CNC : BCBSNC : Quick Reference Guide #1

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QUICK REFERENCE GUIDE

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Blue cross and blue shield of North carolina (BCBSNC)

QUICK REFERENCE GUIDE for chiropractic

The BlueCross BlueShield of North Carolina (BCBSNC) Quick Reference Guide provides information specific to BCBSNC concerning BCBS members, BCBS claims, and BCBS policies. The information in this section is in addition to the HNS/Payor Policies, HNS Documentation and HNS Billing Guidelines.

IMPORTANT NOTE:

BCBSNC Corporate Medical Policy for Chiropractic takes precedence over any information you receive from BCBS telephone representatives for BCBS members (excluding members covered under the Federal Employee Program). Always contact your HNS Provider Rep to determine if a particular service is consistent with BCBSNC Corporate Medical Policy. CLICK HERE for the BlueCross and BlueShield Corporate Medical Policy for Chiropractic.

If you have any questions about any BCBS related topic, please contact your HNS Provider Rep at (877) 426-2411.

IMPORTANT:

Changes to NC State EMPLOYEEs health plan

Despite the diligent efforts HNS and the NCCA, co-payments for the state health plan are increasing.

The new bill increases the in-network specialist co-payment to $81.00 per covered individual except for chiropractic services, mental health and substance abuse services, and physical therapy, occupational therapy, and speech therapy services

Effective September 1, 2011, the following changes to the N.C. State Health Plan will take effect.

Standard Plan (80/20):

Co-payments - $52.00 per individual

Deductibles: In-network deductible- $700.00 annually for member-only coverage; $1400.00 out-of-network annual deductible for member-only coverage. The aggregate maximum annual deductible for employee-child and employee-family coverage shall be three times the member-only annual deductibles.

Co-insurance. $3210.00 in-network maximum for member-only coverage and $6420.00 out-of-network maximum for member-only coverage. The aggregate maximum coinsurance for employee-child and employee-family coverage shall be three times the member-only coinsurance maximums.

Basic Plan (70/30):

Co-payments $64.00 per individual

Deductibles: in-network - $933.00 annually for member-only coverage; $1,866 out-of-network annual deductible for member-only coverage. The aggregate maximum annual deductible for employee-child and employee-family coverage shall be three times the member-only annual deductibles.

Co-insurance. $3,793.00 in-network maximum for member-only coverage and $7,586.00 out-of-network maximum for member-only coverage. The aggregate maximum coinsurance for employee-child and employee-family coverage shall be three times the member-only coinsurance maximums.

The BCBSNC Quick Reference Guide contains the following information specific to BCBS and provides you with helpful information regarding your BCBS patients.

gENERAL INFORMATION

PLEASE REMEMBER: Do not send claims directly to BCBSNC!

Please ignore the claims billing address on the member ID card or any address given to you on the telephone when verifying benefits. HNS instructions for filing claims supersede information given to you by BCBSNC Representatives!

With only a few exceptions, all claims for COVERED SERVICES provided to a beneficiary of a HNS contracted payor MUST be submitted to HNS. (This includes any self-funded groups who utilize a HNS contracted payor as a third party administrator.)

BCBSNC Policy for Nerve Conduction (EMG's, etc)

BCBS only provides coverage for Nerve Conduction Studies and EMG's, when performed by physicians who are diplomates of the American Chiropractic Neurology Board (DACNB). This includes out-of-state BCBS plans as well as in-state plans.

In order to bill BCBS for nerve conduction studies and EMG's, you name must be included on the list of certified neurologist on the ACNB web site. If you name is not included on the ACNB web site, you cannot bill BCBS for these services.

If you are not a DACNB, if provided to members whose health care plans process through BCBSNC, these services must be treated as non-covered services and as such, require a waiver that is signed by the patient before such services are rendered. Please remember that all waivers for non-covered services must be maintained in the patient's health care record.

Blue Cross Blue Shield of North Carolina (BCBSNC) offers many different plans and chiropractic benefits vary based on your member's plan. Always verify specific chiropractic benefits for each member.

Eligibility/Benefits

Please remember that the BCBSNC Corporate Medical Policy for Chiropractic must be strictly adhered to by HNS providers when treating any in state "BCBS" patients. This includes the NC State Employees Plan that is administered by BCBSNC.

The customer service representatives for the NC State Employees Health Plan, and BCBSNC are not always familiar with the Corporate Medical Policy for Chiropractic. So please remember that the BCBSNC Corporate Medical Policy for Chiropractic supersedes information that you are given when verifying eligibility and benefits for BCBSNC members and State Employees.

For BCBS out-of-state members - please verify benefits directly with the member's home plan.

Please remember to always verify eligibility and chiropractic benefits prior to providing any treatment. Benefits do vary by employer group. Ask for specific information on chiropractic benefits for each member. CLICK HERE to see a sample Verification of Insurance Form.

Use the HNS/Blue esm web based service to verify eligibility for BCBS members. (If you are not contracted with Blue eSM , please CLICK HERE for information and instructions on how to sign up.)

BCBS in-state members - To verify eligibility and benefits for in-state policies, call the Provider Blue Line at (800) 214-4844. Provider Blue Line Representatives are available 8:00 AM to 5:00 PM, Monday through Friday.

State Health Plan members - BCBSNC is the plan administrator for State Employees. To verify eligibility and benefits for BCBS State Health Plan (SHP) members, please call the Provider Blue Line at (888) 234-2416. Please remember that the BCBSNC Corporate Medical Policy for Chiropractic supersedes ANY information that you are given when verifying eligibility and benefits for State Employees.

Federal Employee Plan members - BCBSNC is the plan administrator for Federal employees covered under the Blue Cross and Blue Shield Service Benefit Plan. To verify eligibility and benefits for Federal Employee Program (FEP) members, please call (800) 222-4739.

Blue Medicare Supplement members - To verify eligibility and benefits for BCBS Medicare Supplement plans, please call (800) 672-6584.

BCBS out-of-state members - To verify eligibility and benefits for out-of-state, Inter-Plan Programs, please call (800) 676-2583, and choose option four.

Please remember that the BCBSNC Corporate Medical Policy does not apply to BCBS out-of-state members. Please contact the home plan to verify eligibility and benefits for BCBS out-of-state members.

Referral system

No referral from a PCP is needed.

When necessary to refer to another health provider, referrals within the network are strongly recommended.

BCbs id cards

All BCBS ID cards have an alpha prefix. The BCBS alpha prefix is a vital part of the member's ID number. The prefix helps identify the specific plan (or state) in which the member is enrolled. For your claims to process correctly, the entire BCBS ID number, including prefix and suffix, must be included on your claim. Please remember that if there are multiple members on a plan (such as family members), you must include the appropriate numeric suffix specific to each plan member.

The BCBS subscriber ID number should appear in box 1a on the CMS 1500 claim form without spaces or hyphens like the example below:

Please note:

The only BCBS HMP/PPO plans that are NOT filed through HNS are the BCBSNC Blue Medicare plans. All others, including the Blue Medicare Supplement plans (YPZ) and out-of-state Blue Medicare plans are filed through HNS.

If you are uncertain about any BCBS ID card, please use your HNS Fax Inquiry Form and fax a clear, legible copy of the member ID card to HNS and we will respond within 24 hours.

CLAIMS SUBMISSION

All claims for BCBS contracted plans must be submitted to HNS through the HNSConnect system, except for secondary claims, corrected claims, or any claim with an attachment.

CLICK HERE for information on filing secondary claims.

CLICK HERE for information on filing corrected claims.

Please ignore any instructions regarding where to submit claims by payor phone representatives. HNS instructions regarding where to submit claims supersede all other instructions given by payor representatives when verifying benefits.

In order for BCBS claims to adjudicate quickly and accurately, please remember:

When filing claims electronically, the claim must be identified as a BCBS claim in the address section at the top of the CMS 1500 claim form (HNS/BCBS is an acceptable format) using the example address listed below:

Example: HNS/BCBS
PO Box 2368
Cornelius, NC 28031

Claims must be identified in box 11c as BCBS

BCBSNC reserves the right to deny payment if a claim is submitted after 180 days. As a participating provider, you may not bill the member for claims submitted after 180 days.

Claims Inquiries

You can now check the status of your claims on Blue eSM

You can now check the status of your claims on Blue eSM. If you have not signed up for Blue eSM, please CLICK HERE for more details.

For tracing outstanding claims (after 30 days from your billing date), complete the HNS Fax Inquiry Form and fax this form, together with the requested information, to HNS. We will gladly trace the claim for you!

When using the automated system, you will need HNS's NPI number (1093773392), the patient’s ID number, patient date of birth, the date of service and the total amount billed from the claim submitted.

Resubmit lost/missing claims through HNS.

For questions relating to payment of a claim, please do not contact BCBSNC. Please use your Blue eSM online service, your
HNS Fax Inquiry Form, or call your HNS Provider Rep for assistance.

Refer to your HNS/BCBSNC Fee Schedule to confirm allowable amounts and CPT codes.

Please remember that the BCBSNC Corporate Medical Policy for Chiropractic must be strictly adhered to by HNS providers, for all BCBS members. This includes in-state plan members, State Health plan members, all self-funded plans and all HSA and HRA plan members. NOTE: For out-of-state members, please contact the home plan to verify benefits. If you have questions about BCBSNC Corporate Medical Policies, please contact your HNS Provider Rep.

Provider Relations

Questions relating to your participation with BCBSNC should be directed to your HNS Provider Representative at (877) 426-2411.