System issue with member information on web portals (12/09/2013)
We are experiencing a system issue that means you may be unable to access member information regarding eligibility, benefits and claims status on our web portals. This issue also affects our Customer Service staff so they are unable to assist you at this time. We are working to resolve the issue as soon as possible, and will update this status as we learn more.
HMA and RGA claims submitted incorrectly will be returned (11/12/13)
Currently, Healthcare Management Administrators (HMA) and Regence Group Administrators (RGA) claims that are submitted electronically to Regence in error are forwarded to HMA or RGA for proper handling.
Effective in January 2014, Regence will no longer forward these claims. HMA and RGA claims that are submitted incorrectly to Regence, on or after this date, will be returned with instructions to resubmit to the correct payer. HMA and RGA claims should be submitted directly to Availity with Payer Identification Code ID: HMA01.
Member gap reports available (11/05/2013)
We are in the process of distributing updated provider reports that identify Medicare Advantage members who may have a gap in care or diagnosis reporting. The report includes details regarding what intervention is missing for your patient for each gap noted. We ask that you use these reports to close these gaps before the end of 2013.
These reports will be sent to you via secure email. Review our troubleshooting guide if you have any difficulty.
Reminder: Please respond to payment recoupment requests using the current forms and addresses (10/09/2013)
Payments are occasionally recouped due to a duplicate or adjusted claim. In order to expedite the process, please use the current forms and addresses.
Providers are notified of an impending recoupment on the applicable remittance advice (voucher). The notification will include the following details:
- Dollar amount
- Applicable claim number(s)
- Reason for the recoupment
Responding to a recoupment request
Once you have been notified of the recoupment, your office will have 30 days to respond. To expedite the refund process, please respond immediately. If we do not receive a response after 30 days, the recoupment will be released and automatically deducted on a future remittance advice.
To respond to the recoupment request, you can refund the overpayment to us or request a deduction from a future voucher.
View the current forms and a list of addresses to use.
Physician Quality Measurements (PQM) Program scores updated (9/26/13)
The goal of the PQM Program is to provide nationally endorsed physician performance measurement information to Blue Plan members. The information is intended to help members make more informed health care decisions.
Healthcare Effectiveness Data and Information Set (HEDIS®) Physician Measures are displayed for individual physicians or groups/practices on the Blue National Doctor and Hospital Finder.
An updated report indicating the PQM score for participating Regence providers is now available for review in the Reference Library of the Provider Center. The data in this report will be shown on the Blue National Doctor and Hospital Finder on November 8.
Physical Medicine Program training reminder postcard (9/25/2013)
We apologize for any confusion that the title of the Physical Medicine Program training postcard sent on Monday, September 23 may have caused. This program is NOT associated with AIM Specialty HealthTM (AIM). We inadvertently failed to update the postcard title which should have read “Upcoming Physical Medicine Program Training Reminder”. The training dates and other information on the postcard are accurate.
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Vendor Fee Schedules are now available (9/13/2013) (Updated on 10/03/2013 to indicate that the files are now available)
The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Vendor Fee Schedules effective December 1, 2013 are now posted in the Reference Library of the Provider Center.
Pre-authorization for elective inpatient admissions is a requirement (8/30/2013)
Pre-authorization is required for all elective inpatient admissions for the following Pre-authorization Lists:
- Medicare Products Pre-authorization List
- Uniform Medical Plan Pre-authorization List
- Group and Individual Products Pre-authorization List
- Effective November 1: Federal Employee Program Pre-authorization List
An elective admission is an admission of a patient for care or treatment which, in the opinion of the treating clinician, is necessary and admission can be delayed for at least 24 hours. Please note:
- Our Medical Policies, MCG (formerly Milliman Care Guidelines), and CMS criteria may be used as guidelines for service coverage determinations, including length of stay and level of care.
- Authorization of inpatient facility stays, including level of care and length of stay, will be issued at the same time as authorization for the professional service.
- Maternity admissions do NOT require pre-authorization by the delivering provider.
Payment implications for failure to timely notify or pre-authorize services
Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider liability. Our members must be held harmless and cannot be balance billed.
View our pre-authorization lists.
LifeMap now offers reform-friendly (and provider friendly) Group Dental (8/6/2013)
LifeMap Assurance Company’s new group dental coverage is simple and flexible for members and stacks well with plans under health care reform.
Dollar-based Dental is a new kind of dental insurance, similar to the direct reimbursement plans promoted by the American Dental Association (ADA). It lets members use their dental dollars on a schedule that works best for their needs, whether that is a root canal or several cleanings per year. The decision for care and for what is needed is between the patient and the dentist.
Here are a few highlights:
- Members can choose how to spend benefit dollars their way – the choice is between them and their dentists, not a service schedule
- There are no limitations and just a handful of exclusions (really, just cosmetic)
- It works with the existing network of dentists
- Waiting periods for all services range from 0-6 months (as chosen by the employer)
- There’s no deductible
- There’s no age limit
- There’s no lifetime maximum
Provider and Member Simplicity
There are no exclusions (other than cosmetic) and, therefore, no pre-authorization requirements for providing care to your patients. Providers can spend more time focusing on their care for members.
Dollar-based Dental also works very well for coordination of benefits purposes. There are no complicated procedure-based dental benefits to coordinate with, which greatly simplifies work for the provider, HR manager, employee and the insurance producer.
Dollar-based Works with Reform – Simplify Insurance for Your Practice
Reform has a specific definition of what is covered under pediatric preventive dental benefits; it may, or may not include coverage for restorative and major procedures, such as fillings, root canals and crowns. In addition, coverage coordination must work in very different product platforms, including medical plans, a qualified dental plan within an exchange, and/or a standalone dental benefit. Traditional dental products do not work well in this environment because they specify coverage at the procedure level, whereas Dollar-based Dental does not.
In addition, the ACA includes medically-necessary orthodontic (ortho) coverage in the pediatric dental benefit requirement; however, “medically-necessary” is not defined by the law. Currently, only about 30% of care would qualify (according to the National Association of Dental Plans). This may leave a coverage gap and coordination of benefits issue.
Members with Dollar-based Dental without an ortho exclusion, instead of, or in addition to, the pediatric dental essential health benefit (EHB), provides relief in both scenarios. It fills in the coverage gap for the 70% of children who would not otherwise qualify as medically-necessary without the complexity of coordinating with a traditional ortho rider. Or as a replacement option for the EHB requirement, Dollar-based Dental would provide traditional annual max cost controls as a standalone option.
In all scenarios, providers will see a relief from the coming complexity of health care reform with Dollar-based Dental.
For more information regarding the benefits of Dollar-based Dental visit LifeMapCo.com.
For past announcements, please view the What's New archive.