Deficit Reduction Act legislation impact to Medicare physician fee schedule

Effective July 1, federal Deficit Reduction Act (DRA) legislation will enact a 10.1% reduction in the Medicare physician fee schedule.

We recognize this reduction may cause considerable hardship for physicians and other health care professionals and potentially impact access for Medicare beneficiaries. Therefore, Regence has decided not to implement the reduction. In addition, we will not implement the reduction for the remainder of 2008, regardless of whether or not the legislation is repealed. This applies only to our Regence MedAdvantage plans; we are obligated to implement the reduction for claims that crossover to Regence when we are a secondary payer to Medicare and for Medicare supplement plans. If subsequent legislation passes approving an increase in the physician fee schedule in 2008, we will implement the increase as required by our contracts.  

Please do not submit requests for reprocessing of claims for Medicare Supplement plans or Medicare claims crossed over to Regence for secondary processing. These claims will be paid in accordance with federal requirements as of July 1, 2008.

Participate today in Puget Sound Health Alliance’s Community Checkup report

The Puget Sound Health Alliance’s (PSHA) first Community Checkup report is currently available to the public. The second report is underway and will contain results for all clinics in King, Kitsap, Pierce, Snohomish and Thurston counties with six or more providers, including nurse practitioners and physician assistants, in a number of different specialties. Regence BlueShield supports the efforts of the PSHA and asks for your participation to ensure that accurate and timely results are made available to members in the community.

What should you do by July 1?
Visit www.onehealthport.com/services/communitycheckup.php for instructions and additional details about the following:

1. Designate someone in your organization to confidentially receive your clinic’s draft results. This is done by assigning someone to the quality assurance (QA) Manager Role on OneHealthPort.com.
2. Review and update your clinic structure
3. Review and respond to your clinic’s draft results before they are made public

Need help?
Contact Natasha Rosenblatt at PSHA at (206) 448-2570 extension 123; or via email at nrosenblatt@pugetsoundhealthalliance.org. For more information about PSHA and the Community Checkup report, visit www.wacommunitycheckup.org.

National Provider Identifier (NPI) dual-use period extended

Regence is extending the dual-use period until further notice because many entities are still in varied stages of compliance. You may submit your NPI and tax identification (ID) numbers; or submit your NPI, tax ID and Regence provider identifier. We will notify you at a later date when the Regence identifier will no longer be accepted.

New payment vouchers for InnovaSM, EngageSM and BlueCard®members

By now you should be receiving the new vouchers for our Innova, Engage, and BlueCard business. We hope that you find the improvements in the vouchers helpful. If you are experiencing any issues or difficulties with these new vouchers, or if you have any questions, please contact your Provider Consultant.

January BlueCard^® Claims May be Delayed
We recently announced that beginning December 31, 2007, we are now processing BlueCard claims on our new system. You may experience delays in BlueCard claims submitted in late December through January 16th. During this time, a technical problem caused some transmitted files to be deleted before Regence could process the data. This prevented some of our data transmissions from posting correctly.

In early February, we began processing and mailing payments on a daily basis. At this time, the majority of these files and payments have been received and processed. Beginning March 13, 2008, we will return to our regular weekly payment schedule.

If you have questions or would like more information, contact your provider relations representative or BlueCard Customer Service at 1 (800) 206-1244

New program for Healthy Options members

Effective January 1, 2008 Regence BlueShield implemented a state required Patient Review and Coordination (PRC) program for Healthy Options members. The PRC program is the mechanism utilized by the Health and Recovery Services Administration’s (HRSA) to fulfill both federal and state Medicaid requirements.   

The PRC program focuses on the health and safety of the member and the elimination unnecessary costs. Members who are seen by several different medication prescribers, have a high number of duplicative medications, use several different pharmacies and/or have a high emergency room usage will be identified for placement in the program. The member’s primary care provider (PCP) will receive a letter informing them that one of their patient’s has been placed in the program.

Members placed in the program will be restricted to specific providers including PCP’s, pharmacies, narcotic prescriber’s, mental health providers for controlled substances, and hospital’s for non-emergency services. Members may use any hospital emergency room for emergency services. Once the member is notified that they are included in the PRC program, they are asked to complete a form choosing the providers they will utilize in the program. If the member does not choose a PCP within ten working days of notification, a PCP will be designated for them, which will be effective for 12 months.

The initial restriction period for a member participating in the PRC program is twenty four (24) consecutive months. Prior to the end of the initial restriction period, each member will be reviewed for continued placement in or removal from the program.

Additional information about the program and criteria may be found in the Washington Administrative Code 388-501-0135 on the Washington State Legislature Web site at http://apps.leg.wa.gov/wac. If you have any questions, please contact our Provider Relations department at 1 (800) 562-2156.

Beginning January 1, 2008, there will be two major elements to the new COB rule affecting the way claims are processed in the secondary position.  Regence is applying these changes to comply with a new rule issued by the Office of Insurance Commissioner.  This rule applies to all individual and group plans (except self-insured ERISA groups) with claims date of service on or after January 1, 2008.

What are the two elements?

1. The secondary payer must pay to the highest allowable between two plans.
2. Claims may not be denied for primary payment information.  The secondary payer must estimate the primary payment and complete processing of the claim within 45 days. 

How will the new COB changes affect me?

When claims are submitted without the primary allowed and paid amount Regence will call the primary insurance plan for the claim payment detail.  If we are not able to obtain this information, claims will be pended for that information.  The COB pended claims will show on the back of your weekly voucher in the “Claims Pending Investigation” section. If the primary insurance claim payment detail is not received by the 45th day after receipt of the claim, Regence will estimate the primary payment at 80% of our allowed amount and pay our portion of the claim.

What do I need to do?

For the most timely processing of your claims, please provide the following information on each electronic or paper claim submitted:

1. Charged amount
2. Primary payment
3. Primary allowed amount

How can I submit the primary payment information to Regence for my “pended” claim?

There are three resources available: dedicated COB fax line, send an email to our COB email address or call Provider Customer Service:

• Dedicated COB Fax:  1 (888) 225-4822
• Email to secure email box: cob@regence.com
• Customer service: 1 (800) 322-1737 from 6:00 a.m. to 6:00 p.m.

Contacting TriWest? Let Us Help You

Suggestions from TriWest Healthcare Alliance to improve your experience when calling TriWest:

Call 1-888-TRIWEST (888-874-9378) during off-peak hours (after 1:00 pm in your time zone) for a quicker response time.

• Use the Interactive Voice Response (IVR) system to receive information 24-7 without the necessity of speaking to a customer service representative.
• An IVR guide is available in the Provider Connection of www.triwest.com in the Resource Library.
• Specific sections for TRICARE reimbursement rates, referrals and authorizations, claims and reimbursement, TRICARE programs and benefits, the National Provider Identifier (NPI), Electronic Data Interchange (EDI), the Resource Library are also found in the Provider Connection
• Go to Provider Connection to find E-Seminar links allowing seminars at a time most convenient to you.
  
• Register for the secured Web site to perform functions without calling TriWest. Registered providers have access to a secure portal on www.triwest.com where they can:
• Verify patient eligibility
• Determine status of referrals/authorizations
• Submit claims online, view claims and check claim status
• Download Explanations of Benefits
• See what checks have been issued

ReinventHealthCare.com

Regence is committed to working with members, physicians and employers to create a health care system that works more effectively for everyone. With this goal in mind, we recently launched a web site where anyone interested in health care can share ideas and listen to what others have to say. The site is www.ReinventHealthCare.com.

As a physician, your perspective is essential to an open, honest and productive public conversation. We encourage you to visit the site and join in. Find out more and share your thoughts at ReinventHealthCare.com.

Medicare crossover update

Coordination of Benefits Agreement (COBA) identification number not necessary for secondary crossover claims.

Recently the Centers for Medicare & Medicaid Services (CMS) changed the way in which claim-based crossover information is sent to secondary insurers. (Claim-based crossover occurs when the rendering provider bills Medicare primary, and on that claim, supplies secondary insurance information.)  As of 10/1/07, CMS advised providers to obtain a Coordination of Benefits Agreement (COBA) identification number to add to these claims.

Regence already shares its eligibility files with Medicare, and, as a result,  receives secondary crossover claims directly from Medicare. It is therefore not necessary for a provider to include a COBA ID on these claims. 

If your secondary claims have not been successfully received by Regence, please contact Customer Service at 1 (800) 544-4246 as we may need to add your patient’s Medicare coverage information to our eligibility files.

Important Update Regarding BlueCard^® Claims Processing

We recently announced that BlueCard^® claims would be processed on our new system beginning December 17, 2007. The date has been moved. We will now begin processing BlueCard claims on our new system on December 31, 2007.

After the conversion referenced above, claims for your BlueCard patients will be reported on our new vouchers. Sample vouchers are available in the Billing Information section (PDF) of our Provider Manual.

As a reminder, clinical editing will also apply to your BlueCard patients’ claims.

Questions
If you have questions or would like more information, please contact your provider consultant at 1 (800) 562-2156.

NASCO^® claims migrated to new (updated for Idaho) claims system on 1/1/08

The National Account Service Company (NASCO^®) claims will be migrated to our new system on January 1, 2008. You will receive a Regence Life and Health voucher for any NASCO claims received prior to December 31, 2007 and any adjustments or recoveries to these claims. You will receive our new voucher (the same voucher used for your Innova^SM, Engage^SM and BlueCard^® patients) for NASCO claims received on or after January 1, 2008. Sample vouchers are available in the Billing Information section (PDF) of our Provider Manual.

Nelson Trust moved to different health plan effective 1/1/08

The Nelson Trust cancelled its coverage with Regence effective December 31, 2007. Members of the Nelson Trust with Regence coverage had the alpha prefix NTT. Claims for dates of service through December 31, 2007 will be processed under their coverage with Regence.

As of January 1, 2008, members of the Nelson Trust will be covered by Premera BlueCross under new alpha prefixes NLQ (actives) and NQN (<65 retirees). Claims for dates of service beginning January 1, 2008 and after will be processed under their coverage with Premera BlueCross. Please refer to your patients' new member cards for the appropriate alpha prefix.