provider training about the plan individual market pbc ak
TRANSCRIPT
Individual Plans
Provider Training
© 2018 Premera. Proprietary and Confidential.050850 (01-11-2021)
© 2018 Premera. Proprietary and Confidential.
Contents 1. Evolent Health
2. Network changes
3. ID cards
4. Primary Care Provider Assignment
5. Medical and payment policies
6. Evolent secure site
7. Online tools and forms
a) Eligibility and benefits
b) Prior authorization
c) Claims
d) Appeals
e) EFT (InstaMed)
8. Evolent directory
9. Training guides and resources
Evolent Health
• Premera partnered with Evolent Health (Evolent) to support administrative
functions for Individual plans.
• This allows us to offer customers access to healthcare and our health plans at a
more affordable price.
Customer Service
Enrollment & Billing
Member Fulfillment
ClaimsComplaints &
Appeals
Payment Reconciliation
Utilization Management
Case Management
Provider Reimbursement
Network Reminders
• The network name for our Premera Blue Cross Blue Shield of Alaska (PBCBS)
individual plans is AK Legacy and Dental Select
• AK Legacy and Dental Select is the same network as AK Heritage–this is a name
change only–and you’ll be reimbursed based on your current PBCBS contract.
• Our PBCBS Individual plans are offered throughout the state.
• BlueCard providers outside of the service area of AK and WA are considered out of
network for non-emergent services and members will have out-of-network cost
shares. Emergency services are always paid at the in-network cost share.
*The only exception is a small handful of non-grandfathered extended Individual
plans that will retain access to the AK Heritage network and BlueCard.
ID cards
Primary Care Providers
• Members can select a primary care provider (PCP) using the Premera “Find a Doctor” tool.
• Members don’t have to select a PCP but they can see their selected PCP for a lower co-pay on most
plans.
• Premera will transfer all current, in-network PCP selections on file for members so they don’t have to re-
select their PCP for the new year plan.
• Members can change PCPs at any point during the plan year effective the first of the following month.
• There isn’t a limit on the number of times a member can change their selected PCP.
Who’s considered a PCP?
Internist Family practice provider
Pediatrician Geriatric practice provider
Gynecologist/Obstetrician Naturopath
Nurse practitioner Physician assistant
Medical and Payment Policies
Provider Training Deck
© 2018 Premera. Proprietary and Confidential.
Medical and Payment Policies
• Evolent uses InterQual® criteria when reviewing certain services.
• You can view the new policies on the Premera medical policy page and on the secure
website.
• Premera payment policies will be used for our Individual plans.
Medical Policies – Premera Website
Go to the Medical
Policies page and
click on ”View
individual plan
medical policies”
Medical Policies – Premera Website
This link will take
you to a page
with important
information about
the Individual
medical plans
and links to the
InterQual criteria
and code list.
Medical Policies – Secure Site
Premera Secure Site + Online Tools
Provider Training Deck
© 2018 Premera. Proprietary and Confidential.
Premera Secure Site
There’s a separate, secure website for Individual health plans managed by Evolent with
the information and tools you need to serve Premera members with an Individual health
plan:
• Eligibility and benefits lookup tool
• Prior authorization code list and submission tool (Identifi)
• Prior authorization submission form (fax option)
• Claims submission tool (HCFA 1500 only)
• Claims list, status lookup, and explanation of payment details
• Medical policies
• PCP roster
• Appeal form (clinical)
• Contact information for customer service and utilization management
Secure Site Access
In OneHealthPort (OHP) click on the
Premera Blue Cross Blue Shield of Alaska
icon.
Secure Site Access
• After you click on the Premera Blue
Cross Blue Shield of Alaska icon, click
on the “Individual Plans” button at the
top of the page.
• This takes you to the new Individual
secure website.
• If you’re looking for Individual plan
information for years prior to 2020, or
the patient's card doesn’t say
"Individual Plan" then log into the “All
Other Plans” site.
All Other Plans**
Secure Site Access
You can also jump to the secure site on the Premera website on the left navigation bar on
the provider homepage.
Eligibility and Benefits
• There’s a new tool available on the secure site to look up eligibility and benefits.
• Providers should NOT enter the member’s alpha prefix when searching for eligibility and benefits.
• Read our detailed guide on how to use the new tool.
Prior Authorization Process
• There’s a new code list code list for Individual plans that you can view on the
Premera website and on the provider secure website.
• You have two ways to submit prior authorizations:
1. Online using Evolent’s prior authorization submission tool, Identifi, available on
the provider secure site.
2. Fax a new prior authorization submission form on the Premera website under
“Forms” and on the provider secure site to 888-584-8081.
o This a different fax number than other Premera group plans.
• Individual market health plans aren’t using eviCore for outpatient prior authorizations.
• Individual plans are using AIM Specialty Health for imaging prior authorizations.
Identifi - Prior Authorization Process
Getting started:
• Providers aren’t required to register with Identifi to start using it.
• Once you sign into your OneHealthPort account, as a new user, and click to access the
Premera Individual Plan secure site. You’ll be granted access to Identifi within 1-5 business
days and will receive a confirmation email once your access is granted. There aren’t any
additional steps you need to take.
• If you need to submit a prior authorization during the 1-5 day waiting period, you can fax your
submission or call our utilization management team directly.
Resources:
• For questions about Identifi, our utilization management staff can answer questions at our
customer service line, 800-809-9361.
• You can also look at our step-by-step guide on how to use Identifi.
Prior Authorization Request Tool (Identifi) + Form
Prior Authorization Request Form (Premera Website)
Claims
• Evolent adjudicates all claims for Individual plans.
• You may notice slight differences in allowed amounts when compared to Premera due to
rounding, edits, or fee schedule update timing, among other factors.
• You have two ways to submit a claim:
✓ Continue to submit claims electronically as you do today.
✓ For paper claims, continue to use the industry standard claims form and mail it to:
Claims mailing address:
Premera Blue Cross Blue Shield of AK
P.O. Box 21762
Eagan, MN 55121
• Claim sequence will start with the calendar year “202X” and there will be a “T” in the center of
the claim number (or a “M” when entered manually).
• BlueCard claims will have “BC” in the beginning of the claim and “B” in the center of the claim
number (instead of “T” or “M”).
Claims – Electronic HCFA 1500 submission
• The online claims submission tool for HCFA (CMS) 1500 claims currently isn’t available on
the individual secure website.
• In the meantime, submit claims by mail to Premera Blue Cross (PO Box 21762, Egan,
MN 55121), through Office Ally, or use your existing software to create and submit
claims electronically.
• Office Ally is a full-service clearinghouse offering a web-based service where providers
can submit claims to Participating Payers (Premera included) at no cost.
• You can check the status of any of your submitted claims and receive a claims list for each
of your patients using available tools on the Evolent secure site.
• Read our step-by-step guide on how to use the Evolent claims tools on the secure site.
Claims – Secure Site
Claims – Premera Website
Appeals
• To submit a clinical appeal on behalf of a patient (denied prior auth):
✓ Submit an appeal form by fax to 844-990-0262. The new form is on the provider secure
site and the Premera Individual Plan Tools web page.
✓ Start an appeal by calling customer service at 800-809-9361.
• To submit an appeal on a claim:
✓ Call customer service at 800-809-9361 and they’ll instruct you on how submit an appeal
letter.
• To request a peer-to-peer review, call customer service at 800-809-9361 and they’ll connect
you with an Evolent medical director.
Appeals Form – Secure Site
Appeals Form – Premera Website
Electronic Fund Transfers (EFT) and Electronic Remittance Advice (ERA)
InstaMed delivers all EFT payments and ERA for our Individual plans.
Already have InstaMed? New to InstaMed?
Great! You’ll automatically receive EFT
payments for our Individual plan claims.
You have 2 simple ways to sign up:
1. Online: www.instamed.com/eraeft
2. Paper: Complete this online form fax it to
877-755-3392.
Electronic Fund Transfers (EFT)
Explanation of Payment
• This an example of an EOP for our
Individual health plans.
• For EFTs, you need to sign up for
InstaMed if you aren’t already
signed up.
• You can also access EOP
statements on the secure site
under “claims.”
• Read our step-by-step guide on
accessing EOPs.
Explanation of Payment – Secure Site
Contact Information + Resources
Provider Training Deck
© 2018 Premera. Proprietary and Confidential.
Contact Information Premera Blue Cross Blue Shield of Alaska Individual Plan
Phone Fax Mailing Address
Customer service 800-809-9361
Utilization (care) management 844-996-0332 888-584-8081
AIM 866-666-0776
EDI/InstaMed 866-467-8263 877-755-3392 [email protected]
EDI 800-435-2715
Provider relations 877-342-5258, option 4
Pharmacy services 888-261-1756
Claims
800-809-9361
Premera Blue Cross Blue
Shield of AK
PO Box 21762
Eagan, MN 55121
Level 1 appeals Premera Blue Cross Blue
Shield of AK
PO Box 21762
Eagan, MN 55121
Level 2 appeals
844-990-0262
Member Appeals
PO Box 91102
Seattle, WA 98111-9202
Resources
Forms and documents:
• Medical policies:
✓ InterQual criteria
✓ Individual plan medical policies
• Prior Authorizations:
✓ Prior authorization code list
✓ Prior authorization submission form
• Appeals
✓ Appeal form
Training guides for Evolent tools:
• Eligibility and benefits lookup
• Claims (submission and list/status lookup)
• Prior authorization request submission
using Identifi
• PCP Roster lookup
Other Resources:
Regular updates in Provider News
Premera Blue Cross Blue Shield of Alaska is an Independent
Licensee of the Blue Cross Blue Shield Association.