freedomblue a medicare advantage ppo from highmark blue shield in association with blue cross of...
TRANSCRIPT
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FreedomBlue
A Medicare Advantage PPO From Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania
April 26, 2006
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FreedomBlue
• What is Medicare Advantage?
• Who is eligible ?
• Number of enrolled Members
• Radiology Management Program
• Cost-sharing
• Overview of BCNEPA Provider Center
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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.)
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FreedomBlue Member ID Cards
Sample Medical ID Card
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FreedomBlue Member ID Cards Cont.
Sample Prescription Drug ID Card
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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)
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FreedomBlue Membership
• The current membership in Luzerne and Lackawanna counties is:– Luzerne – 349– Lackawanna – 254
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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.
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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.
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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.
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Cost-Sharing
• FreedomBlue Value Option incorporated cost-sharing 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
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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
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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).
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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.
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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.
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BCNEPA Provider Center
• Medicare Advantage PPO Building– Bulletins and Articles– Reference Materials– Administrative Guides– Medical Policy– Radiology Management Program– Forms– Pharmacy Information
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BCNEPA Provider Center Cont.
– Electronic Tools– Provider Directory
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BCNEPA Provider Center Cont.
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QUESTIONS???