Sunday, 25 September 2016

Six steps in Credentialing process

Credentialing Program

Participating providers are expected to cooperate with quality-of-care policies and procedures. An integral component of quality of care is the credentialing of participating providers. This process consists of two parts: credentialing and recredentialing.

Credentialing Process

Credentialing consists of an initial full review of a provider’s credentials at the time of application to our networks.

1. If a provider applies for participation in any of our networks, credentialing is required before being approved for participation. A Louisiana Standardized Credentialing Application (LSCA) and provider agreement are forwarded to the provider upon receipt of the request for  participation in our networks. This form can be found on our website at >Forms for Providers or Credentialing.

2. The form and agreement are completed by the provider and submitted to Blue Cross for approval.

3. Upon receipt of the completed LSCA, credentialing staff verify the provider’s credentials
including, but not limited to, state license, professional malpractice liability insurance, State CDS Certificate, etc., according to the Plan’s policies and procedures and Utilization Review Accreditation Committee (URAC) standards.

4. Blue Cross staff and the Credentialing Committee, review the provider’s credentials to ascertain compliance with the following credentials criteria. All participating providers must maintain this criteria on an ongoing basis:

• Unrestricted license to practice medicine in Louisiana as required by state law
• Agreement to participate in the Blue Cross networks
• Professional liability insurance that meets required amounts
• Malpractice claims history that is not suggestive of a significant quality of care problem
• Appropriate coverage/access provided when unavailable on holidays, nights, weekends and other off hours
• Absence of patterns of behavior to suggest quality of care concerns
• Utilization review pattern consistent with peers and congruent with needs of managed care
• No sanctions by either Medicaid or Medicare
• No disciplinary actions
• No convictions of a felony or instances where a provider committed acts of moral turpitude
• No current drug or alcohol abuse

5. Based upon compliance with the criteria, Blue Cross staff will recommend to the Credentialing Committee that a provider be approved or denied participation in our networks.

6. The Credentialing Committee, comprised of network practitioners, will make a final recommendation of approval or denial of a provider’s application.

Tuesday, 20 September 2016

Locum Tenes Concept

Locum Tenens

A locum tenens is a physician who is hired to temporarily replace another physician. The usual physician may be absent for reasons such as illness, pregnancy, vacation or continuing medical education. The usual physician identifies the reported services as locum tenens physician services by entering code Modifier Q6 (service furnished by a locum tenens physician) after the procedure code on the CMS-1500 claim form. Blue Cross follows the CMS locum tenens billing requirements, which can be found at

Non-participating Providers

Non-participating providers do not have a contract with Blue Cross and Blue Shield of Louisiana, HMO Louisiana, Inc. network, or any other Blue Cross and Blue Shield plan. These providers are not in our networks. We have no fee arrangements with them. We establish an allowable charge for covered services rendered by non-participating providers. We use this allowable charge to determine what to pay

for a member’s covered services when a member receives care from a non-participating provider. The member will receive a lower level of benefit because he did not receive care from a network provider.
Additionally, a 30 percent penalty may apply when the non-participating provider is a hospital.
Members usually pay significant costs when using non-participating providers. This is because the amounts that providers charge for covered services are usually higher than the fees that are accepted by participating and HMO Louisiana providers. In addition, participating and HMO Louisiana providers waive the difference between the actual billed charge for covered services and the allowable charge, while non-participating providers do not. The member will pay the amounts shown in the “Non-Network” column on their schedule of benefits, and the provider may balance bill the member for all amounts not paid by Blue Cross or HMO Louisiana.

Please note: The member’s policy is an agreement between the member and Blue Cross or HMO Louisiana only. Providers cannot waive the member’s cost sharing obligations, such as deductibles, coinsurance (including out-of-network coinsurance differentials), penalties or the balance of the bill.
A claim that is filed that includes any amounts the provider waives may be a fraudulent claim because it includes amounts that the member is not being charged, and will be reduced by the total amount waived.

PPO and HMO Point of Service Members

When a member receives covered services from a non-participating hospital, the benefits that Blue Cross will pay under the member’s benefit plan will be reduced by 30 percent. This penalty is the member’s responsibility.

The member may also be responsible for higher copayments, coinsurances and deductibles when receiving services from non-participating providers.

Monday, 19 September 2016

Identifying bcbs alpha prefix -Suitcase Logo

How to Identify BlueCard Members

When out-of-area BCBS members arrive at your facility, be sure to ask them for their current membership ID card. The two main identifiers for BlueCard members are the alpha prefix and a “suitcase” logo.

Alpha Prefix

The three-character alpha prefix of the member’s identification number is the key element used to identify and correctly route out-of-area claims. The alpha prefix identifies the Blue Plan or the national account to which the member belongs.

There are three types of alpha prefixes: plan-specific, account-specific and international:

1. Plan-specific alpha prefixes are assigned to every BCBS Plan and start with X, Y, Z or Q. The first two positions indicate the Plan to which the member belongs while the third position identifies the product in which the member is enrolled.

2. Account-specific prefixes are assigned to centrally-processed national accounts. National accounts are employer groups with offices or branches in more than one area, but offer uniform coverage benefits to all of their employees. Account-specific alpha prefixes start with letters other than X, Y, Z or Q. Typically, a national account alpha prefix will relate to the name of the group. All three positions are used to identify the national account.

3. Occasionally, you may see ID cards from foreign BCBS members. These ID cards will also contain three-character alpha prefixes. For example, “JIS” indicates a Blue Cross and Blue Shield of Israel member. The BlueCard claims process for international members is the same as that for domestic BCBS members.

ID cards with no Alpha Prefix

Some ID cards may not have an alpha prefix. This may indicate that the claims are handled outside the BlueCard Program. Please look for instructions or a telephone number on the back of the member’s ID card for information on how to file these claims. If that information is not available, call Provider Services at 1-800-922-8866.

“Suitcase” Logo

BlueCard PPO offers members traveling or living outside of their Blue Plan’s area the PPO level of benefits when they obtain services from a provider or hospital designated as a BlueCard PPO provider. Members are identified by the “PPO in a suitcase” logo on their ID card.

Providers should verify benefits for HMO members. The empty suitcase logo does not guarantee that the HMO member has benefits if they see a participating provider in that state. Most HMO members must get an authorization to see a provider outside of their service area. To ensure claims are paid timely and accurately, please use iLinkBLUE or call Provider Services at 1-800-922-8866.

HMO patients serviced through the BlueCard® Program

In some cases, you may see BCBS HMO members affiliated with other BCBS Plans seeking care at your facility. You should handle claims for these members the same way you handle claims for Blue Cross and Blue Shield of Louisiana members and BCBS PPO patients from other Blue Plans — by submitting them through the BlueCard Program. Members are identified by the “empty suitcase” logo on their ID card.

BlueCard members throughout the country have access to information about participating providers through BlueCard Access, a nationwide toll-free number 1-800-810-BLUE (1-800-810-2583) that allows us to direct patients to providers in their area. Members call this number to find out about BlueCard providers in another Blue Plan’s service area. You can also use this number to get information on participating providers in another Blue Plan’s service area.

Sunday, 18 September 2016

Medical billing insurance overview

TYPE Of Insurance

There are two kind of Insurance Companies

There are :

Federal Insurance Companies


Examples : 

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

Commercial Insurance Companies





Who is eligible for Medicare?

People age 65 or older

People under age 65 with certain disabilities.

People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a  transplant).

Decide how to get your Medicare Coverage

Traditional Medicare includes:
Hospital Insurance (Part A)
Medical Insurance (Part B)
You will need a separate plan for your Part D, 
Prescription Drug Coverage.

Medicare Advantage Plan:
Combines Part A, Part B and usually Part D 

Medicare has Two Parts:

Medicare has Two Parts:

Part A (Hospital Insurance)
 Most people don't have to pay for Part A.

Part B (Medical Insurance)
 For Part B benefits patient has to pay monthly premium  of $99.90 in 2012, a $15.50 decrease over the 2011 
 premium of $115.40.

Two type of Providers

Participating provider 
 Non-Participating provider

Two type of Providers

What is the difference between "participating" and "non-participating" providers?

Participating provider :-  

Participating providers have a signed contract with Insurance.

More patients
Assured payment from Insurance Company
Need to follow Insurance fee schedule

Non Participating provider :-  
Non Participating providers will not have any contract with Insurance.

Members are responsible for the total amount billed
High value of billed amount
High Copay from patient
High Reimbursement

Less patients visits.

Saturday, 17 September 2016

Participating Provider Agreements

Your responsibilities and agreements as a participating provider are defined in your provider agreement(s). You should always refer to your agreement when you have a question about your network participation. As a participating provider, you also have the following responsibilities to our members— your patients:

• Submitting claims for Blue Cross and Blue Shield members.

This includes claims for inpatient, outpatient and office services. To ensure prompt and accurate payment, it is important that you provide all patient information on the CMS-1500 claim form (or the UB-04 claim form for certain allied providers) including appropriate Physicians’ Current Procedural Terminology (CPT®) codes and ICD-10-CM diagnosis codes. National Provider Identifiers (NPIs) are required on all claims (Blue Cross-assigned provider numbers are no longer used). The Claims Submission section of this manual gives specific information about completing the claim form as well as CPT and ICD-10-CM coding information. The Allied Health Providers section gives specific
information about completing the CMS-1500 and UB-04 claim forms.

• Accepting Blue Cross’ payment plus the member’s deductible, coinsurance and/or copayment, if applicable, as payment in full for covered services.

Blue Cross’ payment for covered services is based on your charge not to exceed Blue Cross’ allowable charge. You may bill the member for any deductible, coinsurance, copayment and/or noncovered service. However, you agree not to collect from the member any amount over Blue Cross’ allowable charge.

The Provider Payment Register/Remittance Advice summarizes each claim and itemizes patient liability, the amount above the allowable charge and other payment information. Additional information concerning the Payment Register/Remittance Advice is included in the Reimbursement section of this manual.

• Cooperating in Blue Cross’ cost-containment programs where specified in the Member Contract/ Certificate and not billing the member or Plan for any services determined to be not Medically Necessary or Investigational, unless the provider has notified the member in advance in writing that certain not Medically Necessary or Investigational services will be the member’s responsibility.
Generic or all-encompassing notifications to member will not meet the specific notification requirement mentioned here.

Certain Plan Member Contracts/Certificates include cost-containment programs such as prior authorization, concurrent review and case management. The member’s identification card will contain telephone numbers for prior authorization. Also, the member should inform you if his/her benefit program includes cost-containment provisions or incentives.

• Informing Blue Cross of your possible involvement in a concierge or membership program. Such involvement must be communicated in writing to your Network Representative before our members are contacted about this new process. Blue Cross will discuss with you your intentions and plans for the concierge or membership program and how it will impact our members.

Amendments to Provider Agreements

Blue Cross has the right to amend provider agreements by making a good faith effort to notify the provider at least sixty days prior to the effective date of the change.


Participating providers are those physicians and allied health providers who have entered into a provider agreement with Blue Cross and Blue Shield of Louisiana (herein referred to as Blue Cross or Plan). As a participating provider in our networks, you join other providers linked together through a business relationship with Blue Cross.

Our networks emphasize the primary roles of the participating provider and Blue Cross and Blue Shield.

They are designed to create a more effective business relationship among providers, consumers and Blue Cross and Blue Shield. Our participating provider networks:

• Facilitate providers and Blue Cross working together to voluntarily respond to public concern over costs
• Continue to give Blue Cross and Blue Shield members freedom to choose their own providers
• Demonstrate providers’ support of realistic cost-containment initiatives
• Limit out-of-pocket expenses for patients to predictable levels and reduce their anxiety over the cost of medical treatment
As applicable, providers are encouraged to comply with Interoperability Standards and to demonstrate meaningful use of health information technology in accordance with the HITECH Act.

As applicable, provider agrees to maintain a notice of HIPAA privacy practices, as required by HIPAA, at the point where a Plan Member would enter provider’s website or web portal.

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