Medicare, Medicare Advantage, and BCBS Updates

1
Medicare, Medicare Advantage, and BCBS Updates

• Revenue Integrity Specialist Team
• February 22, 2006

2
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).

3
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

4
Traditional Medicare Card
5
Checking Eligibility

• Omnipath
• a.k.a.
• BCBS Mochasoft
• Florida Shared Files
• MEDAAR
• Interactive Voice Response System
• 1-877-908-8434
• 6am-6pm
• Monday through Friday

6
Medicare Eligibility
HIQACRO 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

PF1INQ SCREEN PF3/CLEAREND
PF8NEXT
7
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

8
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.

9
Medicare Advantage Plan Codes

• Financial Class Code VSterling 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 CCommercial
• Q99 Medicare Advantage

10
Arkansas Community Care
11
Arkansas Community Care

• Plan Codes
• S08 Part A equivalent
• S09 Part B equivalent
• Financial Class Code
• VSterling Option
• https//arcadianonline.arcadianhp.com/littlerock/
  
• See Managed Care Database for username password

12
Humana Choice PPO
13
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

14
Plan Code Q99

• Q99Medicare Advantage
• Financial Class Code CCommercial
• It is EXTREMELY IMPORTANT to answer the MSPQ
• Special Form 2577

15
Q99
16
Q99
17
Q99
18
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

19
Humana Gold Plus
20
Medicare Advantage Eligibility
HIQACRO 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

PF1INQ SCREEN PF3/CLEAREND
PF8NEXT
www.uams.edu/rist/online_resources
21
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
• Dont COB Medicare
• These are not Medicare Part D prescription only
  plans

22
Medicare Part DPrescription 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.

23
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.

24
Plan Code I30
25
Plan Code H32
26
NIANational Imaging Associates

• Radiology Prior Authorization Service for AR Blue
  Cross Blue Shield
• Procedures requiring prior authorization
• CT Scan
• MRI/MRA
• Nuclear Cardiology
• PET Scan

27
NIA Continued

• The ORDERING PHYSICIAN is responsible for
  obtaining prior authorization
• Emergency room, observation, and inpatient
  imaging procedures do NOT require prior
  authorization

28
NIA Contact Information

• 1-877-642-0722
• Monday-Friday 7am-7pm
• www.radmd.com
• AHIN

29
RIST Contact Information

• RIST 686-5102
• Admissions-RevenueIntegritySpecialist_at_uams.edu
• Holly Jones 526-7794
• joneshollyr_at_uams.edu

30
Questions?