December 2019

What’s New

New Health Equity and Social Determinants of Health (SDoH) Page on Provider Website

In our continuous effort to partner with the provider community to help improve member and community health outcomes, we’ve created a page on the Provider website to centralize resources and tools to help you learn and be engaged.

CMO Perspective

Rural Health Priorities: Assessing Disparities Outside of Chicago

Blue Cross and Blue Shield of Illinois (BCBSIL) is committed to addressing health equity and identifying which, and to what extent, SDoH contribute to the health of our members. In this month’s CMO Perspective, our Vice President and Chief Medical Officer, Dr. Derek J. Robinson, M.D., MBA, FACEP, CHCQM, introduces a new clinical initiative to help further address the health and wellbeing of our members in non-metropolitan counties.

Network Updates/Product Innovation

Adding Value: Addressing Health Equity in the HMO

It’s important to have a cohesive plan of action for addressing member needs across the continuum of care. For BCBSIL’s HMO plans, an annual population assessment is conducted to help ensure that the member population and subpopulations have access to all needed services and community resources. This assessment also looks at the impact of SDoH.

Electronic Options

Government Programs: New Claim Status Tool via Availity^® Provider Portal

As of Oct. 31, 2019, a new and improved Availity Claim Status tool is available for you to check status online for claims submitted to BCBSIL for our Medicare Advantage and Illinois Medicaid members.

New Online Enrollment Process for 835 EFT/ERA through the Availity Provider Portal

A new online 835 Electronic Funds Transfer (EFT) and 835 Electronic Remittance Advice (ERA) setup tool is coming soon to BCBSIL. Registered Availity users will be able to use Availity’s Transaction Enrollment tool to submit EFT and ERA enrollments electronically to multiple payers at the same time.

Government Programs: Interpreting the ‘PLB’ Segment on the 835 ERA

Reversals and corrections may occur when claim adjudication results have been modified from a previous claim report. The method for revision is to reverse the entire claim and resend with modified data. Provider level adjustments are reported in the Provider Level Balance (PLB) segment within the 835 ERA from BCBSIL. As of Dec. 5, 2019, some information will change in the 835 ERA PLB segment for claims submitted for Medicare Advantage and Illinois Medicaid members.

Government Programs: Electronic Payment Summary Now Available for 835 ERA Receivers

As of Nov. 18, 2019, for Medicare Advantage and Dec. 13, 2019, for Medicaid, providers enrolled to receive the ERA from BCBSIL for government programs claims will begin receiving electronic provider claim summary (PCS) files, the electronic version of the remittance advice (RA), in conjunction with the ERA. With this transition, ERA receivers will no longer receive paper remittance advices delivered by mail.

Availity Remittance Viewer Tool Upgrade

The Availity Remittance Viewer tool has been upgraded to better assist you with viewing, searching and reconciling the 835 ERA. Remittance Viewer is available to providers who are enrolled to receive ERA files from BCBSIL.

Clinical Updates, Reminders and Resources

Verify Benefit Preauthorization Requirements by Procedure Code via IVR Phone System

If you need to use the Interactive Voice Response (IVR) phone system, as of Oct. 21, 2019, you can now verify procedure code benefit preauthorization requirements for outpatient, office and home services when calling the IVR phone system for most BCBSIL members.

Provider Education

New Health Equity Resources: Toolkits for Hypertension and Diabetes

There are significant disparities between different U.S. population groups when it comes to hypertension and diabetes incidence, prevalence and sequelae. We are committed to collaborating with you to help support improved health outcomes for your patients, our members and their communities. We’ve gathered resources from well-known websites to create two provider toolkits – one for hypertension, and one for diabetes. The toolkits focus on addressing social determinants of health to achieve health equity for all Illinois populations, regardless of ZIP code.

Provider Learning Opportunities

BCBSIL offers free webinars and workshops for the independently contracted providers who work with us. A preview of upcoming training sessions is included in this month’s issue.

Wellness and Member Education

Osteoporosis Management in Women Who Had a Fracture Remains Low

Osteoporotic fractures can reduce patient quality of life, increase morbidity and mortality and lead to higher health care costs.

New Programs Help Members Lead Healthier Lives

Our Wellbeing Management and Health Advocacy Solutions programs help empower our members to improve their own health and wellness.

Pharmacy Program

New Program Notification for Blue Cross Community Health Plans^SM (BCCHP^SM) Members: Opioid Diagnosis Code Required at Pharmacy

BCBSIL has launched a new program to help prevent diversion and inappropriate use of opioids while still providing access for medically necessary purposes.

Inappropriate Antibiotic Use in Outpatient Settings

Overprescription of antibiotics has increased antibiotic resistance. We can work together to combat antibiotic resistance and appropriately prescribe these important medications.

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2020 – Part 1

Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some additions, revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) were made to the BCBSIL drug lists. Changes effective Jan. 1, 2020, are outlined here. 

Claims and Coding

Recommendations and Reminders for Eye Care Professionals

Many primary care providers (PCPs) refer our diabetic Federal Employee Program^® (FEP^®) and other members to eye care specialists for annual eye examinations. PCPs need to know details about the care their patients receive and to receive communications from their patients’ eye care specialists.

2019 Updates in Pre- and Post-Natal Care Information to Support Effective Coordination and Continuity of Care

This article includes important information to help you when providing pre- and post-natal care and services to FEP and other BCBSIL members.

Quality Improvement and Reporting

Hospital Discharge Summaries Contain Important Information for Primary Care Providers

We want to remind you about some important information to help you when discharging FEP and other BCBSIL members after inpatient hospital stays.

CMS Star Ratings Matter: CAHPS Survey Begins First Quarter of 2020

The Centers for Medicare & Medicaid Services (CMS) uses Star measures to rate Medicare Advantage and Part D programs.

Notification and Disclosure

Provider Credentialing Rights and Responsibilities

Applicants applying or reapplying for participation or continued participation in BCBSIL networks have the right to review information submitted to support their credentialing applications and receive the status of their credentialing or recredentialing applications, upon request.

Important Dates and Reminders

Check here each month for a quick snapshot of recent implementations, upcoming changes, special events, important deadlines and other reminders. 

Has your information changed? Let us know!

When seeking health care services, our members often rely upon the information in our online Provider Finder^®. In particular, potential patients may use this online tool to confirm if you or your practice is a contracted in-network provider for their health care benefit plan. Other providers may use the Provider Finder when referring their patients to your practice.

ClaimsXten^TM Quarterly Updates

New and revised Current Procedural Terminology (CPT^®) and Healthcare Common Procedure Coding System (HCPCS) codes are periodically added to, or deleted from, the ClaimsXten code auditing tool software by the software vendor.

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