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Temporary COVID-19 Policy Changes

During this COVID-19 emergency, we’ve made temporary changes related to claims, coding, enrollment and other policies that takes precedence over information in our current PAMs.

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No Surprises Act, Consolidated Appropriations Act, 2021

Learn what we’re doing to meet the Consolidated Appropriations Act, 2021 (CAA) requirements while supporting the needs of affected members and providers. The scope and effective date of these requirements are based on the provisions as we currently understand them and may change with future guidance from the government.

NO SURPRISES ACT DETAILS
Surprise Billing Protections

Starting Jan. 1, 2022, members enrolled in commercial health care coverage offered or administered by BlueCross will have new protections from unexpected medical bills for certain emergency and ancillary services from out-of-network providers. They’ll also have new protections for covered services provided by out-of-network providers at an in-network facility.  (These provisions do not apply to individuals enrolled in Medicare Advantage Plans or Medicaid managed care plans, such as BlueCare.)

Members shouldn’t get surprise medical bills when they get out-of-network care for:

  • Emergency services at an out-of-network hospital ER or freestanding ER
  • Non-emergency, ancillary services from an out-of-network provider furnished at an in-network facility
    • These can include anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist and intensivist services.
  • Non-emergency services furnished by non-ancillary providers unless the member receives notice of, and provides consent to, treatment by the provider and balance billing.
  • Out-of-network air ambulance transport if the services would have been covered if provided by an in-network air ambulance provider.

Please consult your legal representative for a complete list of the services that are protected.

To submit additional claims information electronically, follow the Supplemental EDI Information guidelines and complete the PWK Fax Cover Sheet.

Balance Billing Restrictions

 

The CAA prohibits out-of-network providers from balance billing members for these covered services: emergency services, non-emergency services furnished by out-of-network providers at in-network facilities, and air ambulance services. We’ll refer to these as Protected Services, meaning the member is generally protected from balance billing.

In some instances, providers can balance bill for some of these Protected Services, but only after a provider gives a member a consent form, and the member signs the form. Not all Protected Services are eligible for balance billing after obtaining a member’s consent, such as, but not limited to, covered emergency services (excluding post-stabilization services), covered air ambulance services, anesthesia, pathology, radiology, laboratory, neonatology, and also assistant surgeon, hospitalist and intensivist covered services.

The U.S. Department of Health and Human Services (HHS) has issued additional regulations and information for providers regarding required notice and consent documents, along with instructions on how to provide these documents to patients.

Information we’re required to share with out-of-network providers relating to Protected Services and the Qualified Payment Amount (QPA)

The member’s cost-sharing for Protected Services is calculated based on the “recognized amount,” which is defined by federal regulations. We’ve determined that in Tennessee the recognized amount is the lesser of the QPA and the provider’s billed amount.

When the recognized amount is the QPA, federal law requires us to provide you with certain information about the QPA:

  • The QPA for an item or service is identified on the remittance advice, with an appropriate explanation code.
  • The QPA is defined in federal law and, generally speaking, is considered the median contract rate for an item or service furnished by a similar provider or facility in the same insurance market. These rates were determined as of Jan. 31, 2019, and have been further adjusted by the Consumer Price Index.
  • BlueCross determines the QPA for each item and service in accordance with federal law.
  • A provider who’s not satisfied with their payment from BlueCross for a Protected Service can begin the open negotiation period provided under federal law within 30 business days of the initial payment or notice of denial from BlueCross.
  • A provider must initiate the independent dispute resolution (IDR) process within four days after the end of the open negotiation period.

Open Negotiation and Independent Dispute Resolution

Open Negotiation Process

To initiate open negotiation with BlueCross, you must complete and email the federally required Open Negotiation Notice form to BlueCross at CAA_OpenNegNotice@bcbst.com. In addition, please return the BlueCross Open Negotiation Notice Supplemental Information Form, so we have everything we need to review your request. Links to these forms can be found below.

If you have questions about this open negotiation process, please call Provider Service at 1-800-924-7141 or email us at CAA_OpenNegNotice@bcbst.com.

BlueCross may determine that its initial payment amount to a provider for Protected Services – which is the QPA – is the appropriate amount for the services rendered.

Independent Dispute Resolution (IDR)

To initiate IDR, you must submit the applicable form to the federal government’s IDR Portal, and also submit a copy of the same form to BlueCross on the same day. Please include any attachments and information sufficient to identify the services in the dispute. All information should be sent by email to OON_IDR_Tennessee@bcbst.com.

Here are the links to the forms to initiate the 30-business-day open negotiation period:

Federal Open Negotiation Notice Form
BlueCross Open Negotiation Notice Supplemental Information Form

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Provider Stability Act

In keeping with the Provider Stability Act (PSA), we're giving you advance notice when we make changes to our Commercial policies, procedures and fee schedules. Here's more information about the law and how we're providing your updates.

Provider Stability Act Details
Changes to Manuals, Reimbursement Rules or Policies

When an insurer makes changes to a Commercial provider manual, reimbursement rule or policy, the insurer must disclose or identify that information at least 60 days before the change takes effect. Here’s how we’ll communicate these changes to you:

  • We’ll use bold print or a larger font to identify changes in our Provider Manuals.
  • We’ll send you a separate communication about reimbursement rule and policy changes and their effective dates.

Changes to Fee Schedules

Insurers must give you at least 90 days’ notice about any Commercial fee schedule changes and effective dates. We’ll send the required notice to your dedicated email address or as otherwise mentioned in your BlueCross contract. We cannot make Commercial fee schedule changes more than once in a 12-month period. However, a health insurance carrier and a hospital may agree to changes in writing.

Exceptions include changes to your:

  • Fee schedule effected by the state or federal government
  • Reimbursement for drugs, immunizations, injectables, supplies or devices if you and the health insurance carrier or PBM agreed reimbursement will be based on an index not established by the health insurance carrier
  • Reimbursement for drugs, immunizations, injectables, supplies, or devices if the provider and the carrier or PBM have previously agreed to reimbursement based on maximum allowable cost pricing
  • CPT®, HCPCS, ICD or other code sets recognized or used by CMS that a health insurance carrier used in creating your fee schedule
  • Revenue codes as established by the National Uniform Billing Committee (NUBC)
  • Fee schedule due to one or more of the following if previously agreed to in a provider’s agreement with a health insurance carrier:
    • Payments made to you are based on values or quality measures explicitly described in your agreement and intended to improve the quality of care provided to our members
    • Escalator or de-escalator clauses
    • Provisions that require adjustments to payment due to population health management performance or results
    • Tennessee Healthcare Innovation Initiative (THCII)

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Find our upcoming PAM, see newly approved policies and guidelines, and offer feedback on developing policies and updates.

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All Blue Provider Workshops

We’re based right here in Tennessee and we host the All Blue Workshops to better partner with you as you provide care for our neighbors covered by a BlueCross plan.

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