Transcript FreedomBlue - Blue Cross of Northeastern Pennsylvania

A Medicare Advantage PPO From Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania
April 26, 2006
FreedomBlue
FreedomBlue
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What is Medicare Advantage?
Who is eligible ?
Number of enrolled Members
Radiology Management Program
Cost-sharing
Overview of BCNEPA Provider Center
What is Medicare Advantage?
• Program administered by The Centers for
Medicare and Medicaid Services (CMS)
• Formerly Medicare +Choice
• Provides all the same benefits of Medicare plus
supplemental benefits (i.e. Dental, Vision, RX,
etc.)
FreedomBlue Member ID Cards
Sample Medical ID Card
FreedomBlue Member ID Cards Cont.
Sample Prescription Drug ID Card
Who is Eligible?
• Permanent county residence: NEPA - Luzerne
and Lackawanna counties
• Eligible for Part A and enrolled in Part B
• Can not be medically determined to have End
Stage Renal Disease (ESRD)
FreedomBlue Membership
• The current membership in Luzerne and
Lackawanna counties is:
– Luzerne – 349
– Lackawanna – 254
Radiology Management Program
• Privileging
– Effective January 1, 2006 any Medicare Advantage
provider who wants to perform radiology services
must be privileged by Highmark Blue Shield in
order to bill and be reimbursed for services.
– Imaging providers must submit privileging
applications and be approved to offer certain
advanced imaging procedures to FreedomBlue
members.
Radiology Management Cont.
• Prior Authorization
– Effective with dates of service beginning April 1,
2006, and beyond. For selected CT scans, MRI and
MRA scans and PET scans.
– Must be obtained by the ordering physician
– Must utilize Highmark-Sponsored NaviNet
application (if available). If not available can call
NIA via their toll-free number – 1-866-731-2045,
option 5.
Radiology Management Cont.
– Intended to ensure quality and proper use of
diagnostic imaging
– Clinical guidelines available at www.RadMD.com
– Prior authorization only applies to FreedomBlue
Members in 13 county BCNEPA region, not for
any Highmark commercial members.
Cost-Sharing
• FreedomBlue Value Option incorporated costsharing effective January 1, 2006, for outpatient
diagnostic services.
• What services will this impact?
– Advanced Imaging – including but not limited to,
CT and CTA scans, MRIs, MRAs, PET scans,
PET/CT scans
– Standard Imaging Services- i.e. skeletal x-rays and
ultrasound
Cost-Sharing Cont.
• Diagnostic Medical Services – procedures such as
electrocardiograms (ECG), electroencephalograms
(EEG), echocardiograms, pulmonary studies, stress tests,
audiology tests.
• Laboratory and Pathology Services – procedures such as
non-routine PAP smears, blood tests, urinalysis, biopsies
and cultures.
• Allergy Testing Services – allergy testing procedures
such as percutaneous tests, intracutaneous tests and patch
tests
Cost-Sharing Cont.
• How will cost-sharing be applied?
– If the member has coinsurance, cost-sharing will
apply to the total, technical and professional
component, and to services associated with the
actual diagnostic procedure, including any drugs
and/or contrast media.
– If the member has co-pays, they will apply only to
the total and the technical components, (not to the
professional component).
Cost-Sharing Cont.
• Could Multiple Copays or Coinsurance and
Copays be applied on the same date of service?
– YES
• Ex: Member goes to a provider in the morning and
receives a bone density test, then later that afternoon goes
to a different provider for an X-ray. This member will be
required to pay two separate copays if both procedures
codes are identified as cost-sharing services.
Cost-Sharing Cont.
• Can I use NaviNet to Confirm Benefits,
Including Diagnostic Cost-Sharing?
– YES
• What if the Copay Amount is Greater Than the
Allowance?
– In the rare instance the allowance for the service is
less than the members copay, the provider would
have to reimburse the member the difference.
• Ex: Provider collected $20 copay, reimbursement was
$15, the member would be due a $5 refund from the
provider.
BCNEPA Provider Center
• Medicare Advantage PPO Building
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Bulletins and Articles
Reference Materials
Administrative Guides
Medical Policy
Radiology Management Program
Forms
Pharmacy Information
BCNEPA Provider Center Cont.
– Electronic Tools
– Provider Directory
BCNEPA Provider Center Cont.
QUESTIONS???