Primary Care Providers Enhanced Payments Information
In accordance with Section 1202 of the Affordable Care Act, qualified Medicaid primary care providers practicing in family medicine, general internal medicine, pediatric medicine and related subspecialties who meet specified requirements will be eligible to receive enhanced reimbursement rates. This is effective for dates of service on and after January 1, 2013 through December 31, 2014. The actual implementation date is still yet to be determined pending CMS approvals of TennCare¹s State Plan Amendment and the final release of all necessary CMS final rate information.
BlueCare Tennessee has prepared and sent notices to providers that have been identified in one of the eligible specialties/subspecialties that may qualify for the PCP enhanced rate. If you have received one of these notices, PLEASE READ IT CAREFULLY and follow any instructions that are contained therein.
If you have not received a notice from BlueCare Tennessee by May 15, 2013 and think you qualify, complete the attestation form below and return it in order to receive the enhanced rates.
Please note the following key points:
If you are board certified in an applicable specialty, please complete all related fields on the Attestation Form identifying the specific board specialty, dates and signatures. We will also notify our credentialing department accordingly.
If you are attesting based on the 60% claims threshold, please note this requirement applies to your total eligible Medicaid services, statewide, not at the individual MCO level.
If you supervise and are professionally responsible for mid-level practitioners in your office, you must complete all requested information on the Attestation Form for each in order for him/her to be eligible for the enhanced payment.
Continue to provide services to your BlueCare Tennessee members and submit your claims as you do today. You will be reimbursed at your current contractual rates.
Watch for updates published in the BlueCare Tennessee Provider Newsletter. BlueCare Tennessee will communicate the effective date as soon as it is known.
In order to receive the enhanced rates retroactive to dates of service on and after January 1, 2013, we must receive your completed attestation form by July 15, 2013. For forms received after this date, payments will be adjusted retroactively only for dates of service on or after the date the form was received by BlueCare Tennessee. Please note that if we receive incomplete forms, we will notify you; however, we cannot guarantee that you will be notified in time for you to return a completed form by the July 15, 2013 deadline.
For retroactive processing, you will not have to resubmit eligible claims. Once the implementation date is established, BlueCare Tennessee will identify the eligible claims, based on the CPT codes noted in the regulations, and adjust payments to the greater of your contractual rates or the increased rate specified in the regulations and the CMS approved TennCare State Plan Amendment.
Continue to visit www.medicaid.gov for updated information, as well as this website. Please contact your Provider Network Manager if you have any additional questions.
Thank you for your assistance in providing the best quality care for our members.
Additional information may be found at http://www.cms.gov/apps/media/fact_sheets.asp
Volunteer State Health Plan (VSHP) recently introduced its plans to consolidate lab services to Quest Diagnostics in an effort to rein in rapidly escalating lab expenditures within its TennCare business. Based on feedback from our provider community, several changes have been made to the original program design and the Exclusion List has been significantly revised; See the latest here:
5010 Implementation-Changes to Provider Claims Formats
As of January 1, 2012, all BlueCare/TennCareSelect claims must be submitted in the 5010 format. This impacts electronic claims, as well as claims submitted on the CMS-1450 and CMS-1500 paper claim forms. All providers listed on claims must be reported in a manner that is compliant with established guidelines. Additional information may be found in the documents below.
Letters to Providers
Contractor Risk Agreement
Between the State of Tennessee and Volunteer State Health Plan, Inc. d.b.a. BlueCare
Durable Medical Equipment and Medical Supplies Change
CareCentrix® has provided claims administration, utilization management and provider network management services to BlueCare and TennCareSelect members for durable medical equipment (DME) and medical supplies. As of November 1, 2012, provider network management and claims administration will return to VSHP. We are working to finalize an agreement that will allow CareCentrix® (CCX) to continue performing utilization management for these services.
Updated DME Prior Authorization Form Fax Number is 1-866-325-6697 (effective April 15, 2013).
Dual Special Needs Plan (D-SNP)
Effective January 1, 2014, in an effort to help improve the coordination of care for these Medicare Medicaid enrollees, Volunteer State Health Plan (VSHP) is offering a new Dual Special Needs Plan (D-SNP). This plan is a Medicare Advantage HMO managed by VSHP that will only enroll dual eligible members.
Individualized Education Program Process
Prior Authorization is NOT required for payment of TennCare covered therapy services provided in the school setting. These services must meet TennCare medical necessity according to the TennCare Rules. This does NOT affect services performed in the office or outpatient locations external to the school.
In order for TennCare covered therapy services to be approved for payment in the school setting, BlueCare Tennessee requires that the child has an IEP; services meet medical necessity guidelines as defined by the TennCare rules; and the services are provided by an in-network provider.
If there is no IEP, BlueCare Tennessee will not approve the provider’s request for services in the school setting and will assist in redirecting the child to a network provider in the outpatient or office setting. BlueCare Tennessee will coordinate with the parent and PCP for any needs such as transportation, provider appointment, etc. Services provided outside the school setting do not require an authorization when performed by a participating provider.
BlueCare Tennessee must receive the following information:
Claims submission: When services are performed in the school, claims must reflect the proper place of service. If the place of service is the school, use 03. If the services are performed in the office, the place of service 11, if the place of service is an outpatient setting, use 22.
If you have any additional questions, please contact your provider representative.
November 19 Update
The Centers for Medicare & Medicaid Services website has been updated with the NCCI edits that have a 10/01/10 effective date. You may access them at: http://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.
The Centers for Medicare & Medicaid Services released new information regarding the Vaccines for Children (VFC) program. New CPT vaccine administration codes will be used for the VFC vaccines (90460 and 90461). Per the attached memo from the Department of Health, the instructions for reimbursing the VFC administration codes will continue to be based on a per-vaccine (per unit) basis and NOT on a per antigen or per component basis.
For non-VFC services, reimbursement will be on a per component basis.