Quarterly Provider Insights: March 2024

Message from Tracy Mohn, Manager of UM and Kirsten Duval, Team Leader of Utilization Management

UM is excited to be back in the spotlight again. This time we would like to provide the positive impact of phase one we are seeing on our new PA Checkpoint tool implemented into our BCBSND Prior Authorizations webpage on Jan. 16, 2024.

The PA Checkpoint tool will: 

• Help providers easily look up procedures before scheduling the next appointment to determine if prior authorization is required.
• Help providers notify patients of any precertification requirements connected to their plan of care.
• Provide access to all policies a code may be addressed in.
• Allow providers to spend less time on the phone and more time helping patients.
• Provide a transaction ID reference number.

History of prior authorizations (PA) requests not needing approval

On average before PA Checkpoint implementation, our UM team received over 1,000 PA requests per month that did not require authorization. Requests to UM for Current Procedural Terminology (CPT) codes that do not require authorization may cause delays in your patient receiving or being scheduled for needed services.

PA Checkpoint Impact

In January 2024, the PA Checkpoint search tool requests went from 2,274 searches to 4,320 in February 2024, which has resulted in a decreased amount of PA submissions that do not require review.

We look forward to seeing the numbers of no PA required requests diminish as providers continue to use the PA Checkpoint tool prior to submitting a request.

Phase Two

We are expected to move to phase two of our PA Checkpoint implementation in May 2024. This will integrate PA Checkpoint into the Availity Essentials provider portal and work in conjunction with Predictal (our precertification tool). This will provide a one-stop process for determining whether a prior authorization is required and advance providers directly into Predictal to submit the request for review, if necessary.

Watch HealthCare News for more information and updates coming soon for phase two.

Our Commitment

It is important to Blue Cross Blue Shield of North Dakota (BCBSND) that we continue to meet our timely requirements for PA. When reviewing CPT codes that do not require PA, it becomes harder for our teams to meet those requirements. This impacts the patient from receiving the needed service and causes more work for the provider.

We strongly encourage providers to check out PA Checkpoint if you are currently not using it today.

Thank You-
Tracy and Kirsten

Join our Blue Cross Blue Shield of North Dakota (BCBSND) Provider Relations and other team members for the upcoming in-person Spring Provider Collaboration Session.

Registration is now open. All sessions are in CST, unless otherwise stated.

Session options available April & May 2024

• April 16
  • Dickinson, 2-3:30 p.m. (MST)
• April 17
  • Minot, 8:30-10 a.m.
  • Bismarck, 2-3:30 p.m.
• April 30
  • Grand Forks, 10-11:30 a.m.
• May 1
  • Fargo, 10:30 a.m.-noon

** Note: If you are unable to attend an in-person session, we will be offering one virtual session.

• May 7
  • Virtual Session 10-11:30 a.m.

We look forward to the opportunity to connect with each of you, provide updates, answer questions and hear your thoughts.

Topics include: 

• BCBSND Commercial, Medicaid Expansion and NextBlue of North Dakota Medicare Advantage updates
• Appeals
• Provider Service Center stats
• Quality BlueAlliance and Value Based Programs  
• Availity Essentials
• Other Updates

Update: Policy Application Language Transparency 

We are informing our provider community of clarifying language providers will see to our medical, reimbursement and coding and pharmacy policies related to claim processing based on date of service (DOS) versus date of process (DOP). This will apply to both Commercial and Medicaid Expansion. 

All policies will have a new policy section under the description of policy application. The policy application section is to add clarity to how claims are being processed. This language does not change how claims are processed.

Example:

Application status:

• Policies with only DOP claims logic will be listed under Policy Application as:
  • All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
• Policies with only DOS claims logic will be listed under Policy Application:
  • All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
• Policies with a combination of DOP and DOS claim logic criteria have the claim policy application listed within each section of the policy.  The Policy Application will indicate:
  • Determination whether the policy rules apply to initial and adjustment claims based on date of DOP or DOS.

Based on the number of policies we have on record; our completion target date is February 2025. 

For more information on our policy format, refer to the September 2023 Quarterly Provider Insights article “Understanding the BCBSND Medical, Pharmacy, Reimbursement or Coding Policy Format.”

Questions?

Contact the appropriate Provider Service Center or email prov.partners@bcbsnd.com for policy application questions.

Provider Directory Validation

Is your provider's directory information up to date?

Our members (your patients) rely on the information listed in the provider directory to select in-network providers for health care services.

BCBSND asks our provider community to validate their directory information through the Availity Essentials Provider Portal and continue to submit changes through the Availity Essentials directory maintenance form. Making these timely changes and validating information every 90 days allows for the directory to be the most accurate and assists BCBSND in meeting the No Suprise Act (NSA) Federal Mandate and Utilization Review Accreditation Commission (URAC) requirements.

Your provider information may be suppressed from the directory if validations are not attested at least once per year. Removal from the directory does not change participation status.

Questions?

For assistance follow the Provider Directory Validation process.

Need help with Availity Essentials or login?

• Call Availity Client Services at 1-800-282-4548.
  

For questions about the Provider Directory Validation process, contact Provider Credentialing at:

• Phone: 1-800-756-2749
• Email: prov.net@bcbsnd.com

Reminder: Advance Member Notice (AMN)

Network providers shall notify members when a requested service is not medically necessary or is noncovered (e.g., contract exclusion, not a covered benefit). A member must be informed in advance with an Advanced Member Notice (AMN) indicating service description and associated costs. If the member chooses to be financially responsible for the noncovered service, the member shall sign the AMN agreeing to pay for the service.

The use of the GA modifier is allowed on professional and institutional claims, as indicated below:

• GA modifier: Member has requested a non-covered service and has signed an Advance Member Notice form (AMN, also known as a “waiver”), agreeing to pay for the service. The requested service is not medically necessary for their condition. Charges will be denied, as member liable. 

Medical information will not be requested or reviewed prior to the denial. BCBSND will conduct routine audits of services billed with these modifiers, requesting chart notes (and signed AMNs, if applicable) to verify appropriate usage. Services billed inappropriately will be reprocessed as provider liable. Further actions may be taken if inappropriate usage continues.

Except for benefit reasons, AMNs cannot be used to collect amounts otherwise not payable, including: 

• Medical policy:
  • The AMN is to be used when services are not medically necessary. 
  • The AMN is not necessary for a Medical Policy that indicates the procedure or service is cosmetic or experimental/investigative in nature as claims will continue to deny as member liable. 
• Providers on Corrective Action Plans.
• Services provided outside the scope of the provider’s license. 
• High charges for covered services. 
• Bundled services.
• Items included in a procedure (e.g., surgical trays) 
• Multiple procedure discounts AMNs cannot be used to collect from members for failure to obtain precertification.
• AMNs cannot be required as a condition of providing covered services.

This does not apply to FEP.

Providers can find additional information in our provider manuals and also a fillable Advance Member Notice Form located on our Provider website, or use a form of their own. An Advanced Beneficiary Notice (ABN) can only be used for traditional Medicare Part A & B services and is not accepted as an AMN.

Eliminating Stigma from the Lineup

Blue Cross Blue Shield of North Dakota (BCBSND) Caring foundation is proud to announce we are continuing to support the needs for mental health resources and services in our rural schools.

To keep the mental health benefits and services available in rural North Dakota schools, the BCBSND Caring Foundation is partnering with Sources of Strength to Shut Out the Stigma. Click on the link below to learn more.

Keep an eye on the “Saves Scoreboard” to stay up to date on how much we have donated to mental health resources for rural schools based on saves made by the Bismarck Bobcats, Fargo Force and UND Fighting Hawks.

Together we can make a difference for our youth in the state of North Dakota who struggle with mental illness.