medicare, medicare advantage, and bcbs u

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Medicare, Medicare Advantage, and BCBS

Updates

Revenue Integrity Specialist Team

February 22, 2006

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Traditional Medicare The federal health insurance program for:

people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).

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Traditional Medicare Plan Codes A20 Medicare Part A A23 Medicare Part B A96 Medicare Part A Railroad A98 Medicare Part B Railroad A55 Medicare Renal Part A A56 Medicare Renal Part B

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Traditional Medicare Card

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Checking Eligibility Omnipatha.k.a.

BCBS Mochasoft Florida Shared Files MEDAAR

Interactive Voice Response System 1-877-908-8434 6am-6pm Monday through Friday

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Medicare EligibilityHIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 07 IP-REC CN 123456789A NM SMITH IT J DB 01011920 SX M IN 00450 PN 040016 APP REAS 1 DATETIME 042502 163112 REQ SNG DISP-CODE 02 MSG UNCONDITIONAL ACCEPT CORRECT 123456789A NM IT DB SX A-ENT 070195 A-TRM 000000 B-ENT 070195 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190 DAYS LEFT FULL-HOSP CO-HOSP FULL-SNF CO-SNF IP-DED BLOOD DOEBA DOLBA CURRENT 50 30 20 80 000 0 021702 040502 PRIOR 57 30 20 80 000 0 061000 061300 PARTB YR 02 DED-TBM 10000 BLD 3 YR 01 DED-TBM 00000 BLD 3 DI 1003000000 FULL-NAME SMITH.JANE.P HMO CURR ID 00000 OPT 0 ENR 000000 TERM 000000 PER 0 PRIOR ID 00000 OPT 0 ENR 000000 TERM 000000 PART A YR BLD 3 CATASTROPHIC A: DED-TBM BLOOD CO-SNF FULL-SNF DOEBA DOLBA DED-APL YEAR 89 0056000 03 008 142 000000 000000 0000000 ESRD: CODE-1 EFF DATE CODE-2 EFF DATE PF1=INQ SCREEN PF3/CLEAR=END PF8=NEXT

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Medicare Name Match Medicare requires an exact name match of

the Demographic and Insurance Name PBS reported over $130,000 in claims

denials for name mismatch since June What can you do?

Letter Script Call SSA

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Medicare Advantage A Medicare program that gives you more

choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.

Prescription drug coverage is a typically part of Medicare Advantage Plans.

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Medicare Advantage Plan Codes

Financial Class Code V—Sterling Option S08 Arkansas Community Care Part A S09 Arkansas Community Care Part B S11 Humana Choice PPO Part A S12 Humana Choice PPO Part B

Financial Class Code C—Commercial Q99 Medicare Advantage

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Arkansas Community Care

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Arkansas Community Care Plan Codes

S08 Part A equivalent S09 Part B equivalent

Financial Class Code V—Sterling Option

https://arcadianonline.arcadianhp.com/littlerock/ See Managed Care Database for username & password

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Humana Choice PPO

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Humana Choice PPO Medicare Advantage Plan Plan Codes

S11 Part A equivalent S12 Part B equivalent

http://www.humana.com/providers/home.asp See Managed Care Database for username & password

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Plan Code Q99 Q99—Medicare Advantage Financial Class Code C—Commercial It is EXTREMELY IMPORTANT to answer

the MSPQ Special Form 2577

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Q99

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Q99

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Q99

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Humana Gold Plus Medicare Advantage Plan UAMS does NOT have a contract Humana Gold Plus IS DIFFERENT FROM

Human Choice PPO Humana Gold Choice = Q99

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Humana Gold Plus

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Medicare Advantage EligibilityHIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 07 IP-REC CN 123456789A NM SMITH IT J DB 01011920 SX M IN 00450 PN 040016 APP REAS 1 DATETIME 042502 163112 REQ SNG DISP-CODE 02 MSG UNCONDITIONAL ACCEPT CORRECT 123456789A NM IT DB SX A-ENT 070195 A-TRM 000000 B-ENT 070195 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190 DAYS LEFT FULL-HOSP CO-HOSP FULL-SNF CO-SNF IP-DED BLOOD DOEBA DOLBA CURRENT 50 30 20 80 000 0 021702 040502 PRIOR 57 30 20 80 000 0 061000 061300 PARTB YR 02 DED-TBM 10000 BLD 3 YR 01 DED-TBM 00000 BLD 3 DI 1003000000 FULL-NAME SMITH.JANE.P HMO CURR ID H5700 OPT 0 ENR 010106 TERM 000000 PER 0 PRIOR ID 00000 OPT 0 ENR 000000 TERM 000000 PART A YR BLD 3 CATASTROPHIC A: DED-TBM BLOOD CO-SNF FULL-SNF DOEBA DOLBA DED-APL YEAR 89 0056000 03 008 142 000000 000000 0000000 ESRD: CODE-1 EFF DATE CODE-2 EFF DATE PF1=INQ SCREEN PF3/CLEAR=END PF8=NEXT

www.uams.edu/rist/online_resources

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Important Tips to Remember Medicare Advantage can be HMO, PPO,

or PFFS It is important to verify benefits!!!!

These are not traditional Medicare Plans or Medicare Supplements Don’t COB Medicare

These are not Medicare Part D prescription only plans

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Medicare Part D—Prescription Plan

Medicare drug plans are offered by insurance companies and other private companies approved by Medicare. There are two types of Medicare plans.

There are Medicare Prescription Drug Plans that add coverage to the Traditional Medicare Plan.

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Medigap A Medicare supplement insurance policy

sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Massachusetts, Minnesota and Wisconsin, there are 10 standardized plans labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan.

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Plan Code I30

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Plan Code H32

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NIA—National Imaging Associates

Radiology Prior Authorization Service for AR Blue Cross Blue Shield

Procedures requiring prior authorization: CT Scan MRI/MRA Nuclear Cardiology PET Scan

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NIA Continued… The ORDERING PHYSICIAN is

responsible for obtaining prior authorization Emergency room, observation, and

inpatient imaging procedures do NOT require prior authorization

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NIA Contact Information 1-877-642-0722 Monday-Friday 7am-7pm www.radmd.com AHIN

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RIST Contact Information RIST 686-5102Admissions-RevenueIntegritySpecialist@uams.edu

Holly Jones 526-7794

joneshollyr@uams.edu

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Questions?