Arkansas Blue Cross Blue Shield

Provider Manual
Updated March 24, 2025

00984.02.03-v032425-1307
 Contents
Section 1: Arkansas Blue Cross and Blue Shield.............................................................................. 7
Welcome to the Arkansas Blue Cross and Blue Shield Provider Manual.....................................................................8
Regional Offices...............................................................................................................................................................10
Medical Directors............................................................................................................................................................. 11
Network Development Representatives........................................................................................................................ 13
Dental Network Managers.............................................................................................................................................. 14

Section 2: General Information......................................................................................................... 15

How to contact Arkansas Blue Cross and Blue Shield................................................................................................. 16
Definitions.........................................................................................................................................................................19
Helpful Reminders...........................................................................................................................................................23
My BlueLine......................................................................................................................................................................24
Helpful Web Sites.............................................................................................................................................................26

Section 3: Avalon................................................................................................................................ 27
Avalon: What You Need to Know...................................................................................................................................28

Section 4: BlueCard............................................................................................................................ 30
What is BlueCard?............................................................................................................................................................31
BlueCard Claims...............................................................................................................................................................34
Special Note.....................................................................................................................................................................36
BlueCard Coordination of Benefits (COB) and Remittance Advice (RA)....................................................................37
BlueCard: Corrected Claim Submission........................................................................................................................40
Durable medical equipment, lab and specialty pharmacy..........................................................................................42
BlueCard: Inpatient claims financial responsibility policy revision............................................................................45
BlueCard: Medicare Claims.............................................................................................................................................46
Duplicate claims handling for Medicare crossover......................................................................................................47

Section 5: Claims Filing and Information......................................................................................... 49

Accidental Injuries & Subrogation.................................................................................................................................50
Arkansas Blue Cross and Blue Shield Partners with Availity...................................................................................... 51
Assignment of Benefits...................................................................................................................................................52
Claims Filing Rule Reminders for Durable Medical Equipment, Lab and Specialty Pharmacy...............................53
Contiguous Counties.......................................................................................................................................................56
Coordination of Benefits.................................................................................................................................................57
Corrected Claims..............................................................................................................................................................58
Electronic Corrected Claims Are Accepted...................................................................................................................59
Filing Claims Electronically.............................................................................................................................................60
Provider Changes.............................................................................................................................................................61
Initial hospital visits billed by multiple physicians.......................................................................................................62
Medical Facts Letter.........................................................................................................................................................63
Member Cooperation......................................................................................................................................................64
Member Fraud or Misrepresentation.............................................................................................................................65
Most Common Claim Denials.........................................................................................................................................66

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 2
 Paper Claims.....................................................................................................................................................................67
Paper Claims: Step-By-Step Instructions......................................................................................................................70
Prepay Review of High-Dollar Inpatient Claims Changes for 2021 Services.............................................................76
Provider “Third Party Liability” or “Subrogation” Activities and Member Claims..................................................77
Splitting claims.................................................................................................................................................................79
Cloned Medical Record Documentation Policy............................................................................................................80
Timely Filing Guidelines..................................................................................................................................................81
Timely Filing Requirements............................................................................................................................................82
UB-04 Facility Claims.......................................................................................................................................................84
Rule and Regulation 43, Clean Claims, and Section 14 Claims...................................................................................85

Section 6: Claims Payment, Refunds, & Offsets............................................................................. 87

Appeals and Re-reviews..................................................................................................................................................88
Claims Payment Issues....................................................................................................................................................90
Copayments, Coinsurance, and Deductibles................................................................................................................93
Electronic Funds Transfer (EFT)......................................................................................................................................94
Member Financial Obligations........................................................................................................................................97
Refunds.............................................................................................................................................................................98
Remittance Advice...........................................................................................................................................................99
Reimbursement..............................................................................................................................................................100

Section 7: Coding and Coding Edits................................................................................................101

Billing Codes...................................................................................................................................................................102
CodeReview ®..................................................................................................................................................................105
Different Types of Edits and Logic CodeReview ®:......................................................................................................106
Ancillary Code Editing – Claims Xten (CXT)................................................................................................................107
Medically Unlikely Edits (MUE’s)..................................................................................................................................108
Not Otherwise Classified/Unlisted Procedure Codes................................................................................................109
National Drug Codes Required..................................................................................................................................... 110
Place of Service Codes.................................................................................................................................................. 111
Transitional care management code amendment...................................................................................................... 112

Section 8: Provider Accessibility and Availability.........................................................................113

Consolidated Appropriations Act (CAA) update......................................................................................................... 114

Section 9: Coverage Policies & Procedures....................................................................................118

Coverage Policy.............................................................................................................................................................. 119

Section 10: COVID-19........................................................................................................................126

Section 11: Availity Essentials Portal.......................................................................................................129

Terminology....................................................................................................................................................................130
Using Availity to Send Electronic Attachments.......................................................................................................... 131

Section 12: Health Insurance Marketplace Exchange.................................................................. 133

Avalon: Laboratory Benefit Management...................................................................................................................134
What is the Health Insurance Marketplace?................................................................................................................135
Affordable Care Act redefines out-of-pocket cost for health plan members..........................................................136

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 3
 Enrollment update for Federal Health Insurance Marketplace and ARHOME.........................................................137
Essential health benefits at the core of new health plans on the Health Insurance Marketplace.........................138
ARHOME Coordination of Benefit Claims...................................................................................................................145
Frequently asked questions about the health care law..............................................................................................146
Opting out of individual metallic benefit plans*.........................................................................................................148
Metallic Benefits Requiring Prior Approval.................................................................................................................149
Habilitative care and modifier SZ................................................................................................................................. 151
Virtual prenatal and postpartum support programs..................................................................................................152

Section 13: Hospital and Inpatient Information............................................................................ 153

Policies and Procedures for Hospital Reimbursement...............................................................................................154
Hospital Reimbursement...............................................................................................................................................159
Hospital Appeals Issues................................................................................................................................................165
Inpatient Claims Financial Responsibility Policy........................................................................................................166
Revenue Code Claims Filing Changes.........................................................................................................................167
UB-04 Claims..................................................................................................................................................................169

Section 14: ICD-10..............................................................................................................................171

ICD-10 Claims Coding.................................................................................................................................................... 172
ICD-10 guidelines for paper claim submissions.......................................................................................................... 173

Section 15: Medical Records Review..............................................................................................174

Terminology.................................................................................................................................................................... 175
Cancel Request...............................................................................................................................................................177
Troubleshooting............................................................................................................................................................. 178

Section 16: Member / Patient Information.....................................................................................179

Case Management.........................................................................................................................................................180
Member ID Cards...........................................................................................................................................................182
Member Appeals............................................................................................................................................................183
Member Eligibility Inquiries..........................................................................................................................................185
Member Financial Obligations......................................................................................................................................187
My BlueLine for Eligibility and Benefits.......................................................................................................................188
Waiver of Health Plan Liability...................................................................................................................................... 191

Section 17: Mental Health Services................................................................................................ 193

Lucet (formerly New Directions)..................................................................................................................................194
Autism: Applied Behavior Analysis Coverage............................................................................................................195
Dedicated Website Launch for Behavioral Health Providers.....................................................................................196
Residential Treatment Centers.....................................................................................................................................197

Section 18: Modifiers....................................................................................................................... 198

Modifiers.........................................................................................................................................................................199
Modifier Usage...............................................................................................................................................................202
Modifier billings with ClaimsXten................................................................................................................................207

Section 19: Network Terms and Conditions.................................................................................. 209

Network Terms and Conditions and Credentialing Standards.................................................................................. 210

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 4
 Network Participation Guidelines................................................................................................................................ 211
Accreditation Accepted for Network Durable Medical Equipment Providers......................................................... 212
Revision to Payer Policies and Procedures and Terms and Conditions................................................................... 213
Imaging Centers Purchased by Hospitals.................................................................................................................... 214

Section 20: Patient Protection and Affordable Care Act (PPACA)................................................215

Preventive services covered under the Affordable Care Act..................................................................................... 216
Preventive Care Services Update................................................................................................................................. 217
Habilitative care and modifier 96 and modifier 97.....................................................................................................220

Section 21: Pharmacy....................................................................................................................... 221

Pharmacy........................................................................................................................................................................222
Specialty Drugs..............................................................................................................................................................224
The following medications and supplies are not covered:........................................................................................225
Prescription Safety and Monitoring Solution Program.............................................................................................226
Exclusions.......................................................................................................................................................................227
Medical Pharmacy Prior Approval Program ...............................................................................................................228

Section 22: Products........................................................................................................................ 229

A Word about Our Affiliated Companies.....................................................................................................................230
Preferred Provider Networks of Arkansas...................................................................................................................231
HMO Partners, Inc. or “Health Advantage”.................................................................................................................232
Arkansas’ FirstSource® PPO.........................................................................................................................................233
Comprehensive Major Medical.....................................................................................................................................235
Dental..............................................................................................................................................................................236
Federal Employee Program (FEP).................................................................................................................................237
Federal Employee Program - Dental............................................................................................................................238
Medi-Pak ®.......................................................................................................................................................................239
Medicare Advantage PFFS Information.......................................................................................................................240
New Medicare Advantage Networks........................................................................................................................... 241
True Blue PPO.................................................................................................................................................................242
Workers’ Compensation................................................................................................................................................243

Section 23: Provider Information.................................................................................................... 246

Billing..............................................................................................................................................................................247
Fraud and Abuse............................................................................................................................................................248
Changes/Updates of Information.................................................................................................................................250
Forms for Providers....................................................................................................................................................... 251
Providers’ News.............................................................................................................................................................252

Section 24: Ambulance Providers................................................................................................... 253

Ambulance Providers....................................................................................................................................................254

Section 25: Special Billing and Coding Issues.............................................................................. 256

Anesthesia Billing..........................................................................................................................................................257
Nerve Block.....................................................................................................................................................................260
Discograms.....................................................................................................................................................................261
HCPCS: K Codes.............................................................................................................................................................262

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 Immunoassay for Analytes...........................................................................................................................................266
Molecular Diagnostics and Cytogenetic Testing........................................................................................................268
Pathology Consultation.................................................................................................................................................269
Postoperative Global Period.........................................................................................................................................270
Transitional care management services......................................................................................................................271
Treatment of Temporomandibular Joint Disease.......................................................................................................272

Section 26: Utilization Review........................................................................................................ 273

Introduction.................................................................................................................................................................... 274
Basis for Determining Medical Necessity (vs. using primary coverage criteria in benefit)...................................275
Arkansas Blue Cross Exchange Population Prior Approval Requirements..............................................................277
Behavioral Health Admissions and Services..............................................................................................................281
Outpatient Services.......................................................................................................................................................282
Pharmacy........................................................................................................................................................................283
High Tech Radiology Prior Approval............................................................................................................................284
Out of State/Out of Area................................................................................................................................................285
Transplant Facilities and Procedures...........................................................................................................................286
Carelon (formerly AIM Specialty Health).....................................................................................................................287
Radiology Management Reference Guide...................................................................................................................291
Utilization Determination Timeframes........................................................................................................................298
Peer to Peer and Appeals..............................................................................................................................................299
Claims Received Without Prior Approval....................................................................................................................300
Enhancement for Prior Approval Submissions...........................................................................................................301

Section 27: Miscellaneous............................................................................................................... 302

Advanced Practice Registered Nurses - Certified Nurse Midwives, Clinical Nurse Specialists and Certified
Nurse Practitioners........................................................................................................................................................303
Allergy Injections...........................................................................................................................................................306
Allergen immunotherapy - provision of antigens.......................................................................................................307
Durable Medical Equipment, Prosthesis and Orthotic Appliances and Medical Supplies.....................................308
Imaging centers.............................................................................................................................................................. 311
Laboratory Services...................................................................................................................................................... 312
Do not use out-of-network laboratories...................................................................................................................... 313
Outpatient Hospital and Ambulatory Surgery Center (ASC) Surgery Payments.................................................... 314
“Never Events” Policy Reminders................................................................................................................................ 315
Physical Therapy, Occupational Therapy, and Speech Therapy............................................................................... 317
Payment reduction for multiple therapy services performed on the same day...................................................... 318
Physician Assistants......................................................................................................................................................320
Sleep Study Centers......................................................................................................................................................322
Telemedicine coverage update.....................................................................................................................................323
Incident-to Services for PTA and COTA.......................................................................................................................324

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 6
SECTION 1

Arkansas Blue Cross

and Blue Shield
Section 1 | Arkansas Blue Cross and Blue Shield

Welcome to the Arkansas Blue Cross and Blue Shield Provider Manual
Welcome! Thank you for becoming a participating provider with Arkansas Blue Cross and Blue Shield. Arkansas
Blue Cross and Blue Shield is the largest health insurer in Arkansas. Established by a group of physicians in
1948, Arkansas Blue Cross has provided its members with quality health coverage for more than 75 years. A
mutual insurance company, Arkansas Blue Cross is owned by its policyholders and operated as a not-for-profit
organization.

What This Manual Is Intended to Do

Arkansas Blue Cross recognizes that, at times, the administrative requirements of managing a patients’ health
care can be complex. The intent of this Provider Manual is to serve as a source for answers to some of the most
common questions providers have about health plan coverage and claims filing procedures, policies and other
facts related to administering care to Arkansas Blue Cross members.

This Provider Manual is not intended as a complete statement of all provider-related policies, procedures, or
standards of Arkansas Blue Cross and Blue Shield. The Provider Manual outlines certain, but not all, policies
and procedures adopted by Arkansas Blue Cross with respect to provider participation, claims filing, and related
subjects. Other policies and procedures, not reflected in this Manual, are published regularly in the Providers’
News, on the Arkansas Blue Cross website for providers and members, in our member benefit certificates
or health plans, or in other special publications, letters, or notices, including but not limited to credentialing
standards, appeals policies and procedures, network terms and conditions, and provider contracts.

A Word about Our Affiliated Companies

This Provider Manual is created and published by USAble Mutual Insurance Company, d.b.a Arkansas Blue Cross
and Blue Shield headquartered in Little Rock, Arkansas at 601 Gaines Street. It is intended to be a guide for
providers participating in the Arkansas Blue Cross and Blue Shield Preferred Payment Plan (“PPP”) Network.

At the same time, however, this Provider Manual contains numerous references to networks, products or
services of other companies that are affiliated with but separate and distinct from Arkansas Blue Cross and
Blue Shield. Most of the participating providers are already familiar with these affiliated companies and their
networks, products, and services; nevertheless, to be sure that all providers understand the references in
this Manual to affiliated companies and their networks, products and services, a summary of the affiliated
companies and their relationship to Arkansas Blue Cross and Blue Shield is in Section 15: Products.

Arkansas Blue Cross wants providers to understand that while these companies are affiliated with us, they
are separate organizations with their own Boards of Directors, officers, and operations, as well as policies and
procedures. Providers, who wish to participate in any network of these separate, but affiliated companies, must
meet the terms and conditions, and execute the participation agreements, required by these separate, affiliated
companies.

Disclaimer
Arkansas Blue Cross and Blue Shield makes no representations or warranties with respect to the content hereof.
Further, Arkansas Blue Cross reserves the right to revise this publication without obligation of Arkansas Blue
Cross to notify any person of such revision or changes.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 8
Section 1 | Arkansas Blue Cross and Blue Shield

Updates to any part of this Manual may be made by Arkansas Blue Cross at any time. Arkansas Blue Cross may
give notice of such updates in a variety of ways, depending on the nature of the update, including issuance of a
letter to providers, publication in the Providers’ News newsletter or other publications of Arkansas Blue Cross,
or posting to the Arkansas Blue Cross website, arkansasbluecross.com.

Special Note: This Manual is provided for the convenience of providers participating in any Arkansas Blue Cross
network. Nothing in this manual shall be interpreted as guaranteeing coverage of any service, treatment, drugs
or supplies because coverage or non-coverage is always governed exclusively by the terms of the member’s
health benefit plan. Accordingly, in case of any question or doubt about coverage, providers should always
review the member’s particular health benefit plan.

Any five-digit physician’s current procedural terminology (CPT) codes, descriptions, numeric modifiers,
instructions, guidelines and other material are copyright by the American Medical Association. All
Rights Reserved.

Unless otherwise indicated, any reference in this Manual to “company,” shall be deemed to refer to Arkansas
Blue Cross and Blue Shield.

Last update: October 25, 2023

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 9
Section 1 | Arkansas Blue Cross and Blue Shield

Regional Offices
The main office of Arkansas Blue Cross and Blue Shield is located at Sixth and Gaines streets in downtown
Little Rock. Arkansas Blue Cross operates full-service regional office Retail Centers serving seven designated
geographic areas of the state. The Regional Offices (headquartered in, Hot Springs, Little Rock, Jonesboro, Pine
Bluff, and Springdale offer sales and provider relations services to counties in their parts of the state.

View the regional map.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 10
Section 1 | Arkansas Blue Cross and Blue Shield

Medical Directors
Arkansas Blue Cross and Blue Shield Corporate Office
Medical Director Address Phone & Fax

Chief Medical Officer Arkansas Blue Cross

(501) 378-2309
Dr. Mark Jansen 601 South Gaines St.
(501) 378-5699 fax
mtjansen@arkbluecross.com Little Rock, AR 72201

Arkansas Blue Cross

Dr. Patty Gibson (501) 502-1049
5 Allied Drive
plgibson@arkbluecross.com (501) 378-2855 fax
Little Rock, AR 72202

Arkansas Blue Cross

Dr. Randal Hundley (501) 688-0716
5 Allied Drive
rfhundley@arkbluecross.com (501) 378-2720 fax
Little Rock, AR 72201

Health Equity and Public Programs Arkansas Blue Cross

Dr. Creshelle Nash 601 South Gaines (501) 399-3986
crnash@arkbluecross.com Little Rock, AR 72201

Medicare Advantage and Senior Products Arkansas Blue Cross

Dr. Thomas Becker 5 Allied Drive (501) 502-1362
tebecker@arkbluecross.com Little Rock, AR 72202

Central Region Little Rock

Medical Director Address Phone & Fax

Arkansas Blue Cross

Dr. John Brineman (501) 502-1330
601 South Gaines
jrbrineman@arkbluecross.com (501) 379-4664 fax
Little Rock, AR 72202

Northeast Region Jonesboro

Medical Director Address Phone & Fax

Arkansas Blue Cross

Elaine Gillespie 501-974-5790
2110 Fair Park Blvd, Ste 1
eagillespie@arkbluecross.com 501-974-5713 fax
Jonesboro, AR 72401

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Section 1 | Arkansas Blue Cross and Blue Shield

Northwest Region Springdale

Medical Director Address Phone & Fax

Arkansas Blue Cross

Dr. Cygnet Schroeder-Bise 501-527-2305
5288 W. Don Tyson Parkway
caschroeder-bise@arkbluecross.com 501-527-2323 fax
Springdale, AR 72762

Vice President
Arkansas Blue Cross
Clinical Strategy and Population Health (479) 973-6623
5288 W. Don Tyson Parkway
Dr. Joanna Thomas (501) 378-2855 fax
Springdale, AR 72762
jmthomas@arkbluecross.com

Arkansas Blue Cross

Dr. Mark Enderle (479) 973-6619
5288 W. Don Tyson Parkway
maenderle@arkbluecross.com (501) 378-2304 fax
Springdale, AR 72762

Arkansas Blue Cross

Dr. Joseph Rose
5288 W. Don Tyson Parkway (501) 378-2311
jrose@arkbluecross.com
Springdale, AR 72762

West Central Region Fort Smith

Medical Director Address Phone & Fax

Arkansas Blue Cross 3501 Old

Dr. Cygnet Schroeder-Bise Greenwood Road, (479) 379-5159
caschroeder-bise@arkbluecross.com Suite 3 (479) 648-6311 fax
Fort Smith, AR 72903

Remote
Medical Director Address Phone & Fax

Dr. Michael Martin (501) 399-3942

Remote
mrmartin@arkbluecross.com (870) 974-5713 fax

Dr. Kristin Lower (479) 379-5159

Remote
kflower@arkbluecross.com (479) 648-6311 fax

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 12
Section 1 | Arkansas Blue Cross and Blue Shield

Network Development Representatives

The network development representatives (NDR) serve as the point of coordination for the provider network
activities in the assigned region and supports on-going network operations. The NDR is accountable for
maintaining a good effective working relationship with providers in the assigned regions, which includes
contracting and education regarding Arkansas Blue Cross and Blue Shield. The NDR is also responsible for
assisting providers with specific inquiries and problems which have not been resolved by other inquiries.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 13
Section 1 | Arkansas Blue Cross and Blue Shield

Dental Network Managers

Effective January 1, 2020, dental administration services moved from Arkansas Blue Cross and Blue Shield to
USAble Life. Your current dental provider network manager is still available to provide the exceptional level
of support you have come to expect from Arkansas Blue Cross, but their contact information has changed.
Although Sheila Ward and Steven Seymour are employees of USAble Life, they will continue to provide dental
provider relations for Arkansas Blue Cross.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 14
SECTION 2

General Information
Section 2 | General Information

How to contact Arkansas Blue Cross and Blue Shield

Provider Service Lines
ID Number begins or
Provider Number
formatted as

501-378-2307 or 800-827-4814
Arkansas Blue Cross Provider (examples) XCA, XCJ, XCP
(Arkansas policies only)

AAA + up to 17 additional
BlueCard® 800-810-BLUE (2583)
alphanumeric characters

800-676-BLUE (2583) AAA + six to nine numeric

The BlueLine
(benefits for all out-of-state policies) digits

XCB, XCG, XCR, XCQ, XCV,

The Enterprise Exchange 800-800-4298
XCY, EXX, AEE, AXC

800-482-6655
FEP R
(federal policies only)

501-378-2364 or 800-482-8416 XCS followed by 960 and a

State and School Employee
(state and school employee policies only) six- digit number

800-843-1329 XCH + K and eight numeric

Health Advantage
(HMO, POS and Open Access policies only) digits

BlueAdvantage AAA + A + eight numeric

888-872-2531
Administrators of Arkansas digits + a two-digit suffix

800-451-7302
Integrated Health
(pre authorization of inpatient admissions only)

Member Service Lines

Line Little Rock Toll Free TTY

Customer Service (main line) 501-378-2010 800-238-8379

State/Public School Employees 501-378-2364 800-482-8416

Federal Employees 501-378-2531 800-482-6655

Medi-Pak® (Current Members) 501-378-3062 800-238-8379

Medi-Pak (Prospective Members) 501-378-2937 800-392-2583

Medi-Pak Advantage Customer Service 877-233-7022 888-844-5530

Medi-Pak Advantage (Pharmacy Customer Service) 866-494-6699 866-236-1069

Medi-Pak Advantage (Caremark Clinical Department

866-494-6699 866-236-1069
Prior approvals and exceptions)

Medi-Pak Rx (Claims) 866-494-5829 866-236-1069

Medi-Pak Rx (Membership) 866-390-3369 800-756-4023

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 16
Section 2 | General Information

Line Little Rock Toll Free TTY

Medi-Pak Rx (Caremark Clinical Department Prior

866-494-5829 866-236-1069
approvals and exceptions)

BlueCard® 800-880-0918

Enterprise Exchange Customer Service 800-800-4298

Health Advantage 501-378-2363 800-843-1329

BlueAdvantage Administrators of Arkansas 501-378-3600 888-872-2531

Email Us
If you have questions about our products or services, you may submit a question to Customer Service.

If you have any questions or comments about our Web site, you may email our Webmaster.

Contact Our Regional Offices

Arkansas Blue Cross and Blue Shield is committed to providing easy access to customers on the local level. We
have seven full-service regional offices to serve you.

Regional Offices: Locate the regional office nearest you.

Network Development Representatives: Service for health-care providers.

News Media Contact

Max Greenwood: 501-378-2131

Our Mailing Address

Arkansas Blue Cross and Blue Shield
P.O. Box 2181
Little Rock, AR 72203-2181

Contact Us to Update your Provider Information

Since it is the responsibility of each provider to inform Plans when there are changes, providers are reminded
to notify Arkansas Blue Cross and Blue Shield and its affiliates and subsidiaries of any changes to their
demographic information or other key pieces of information, such as a change in their ability to accept new
patients, street address, phone number or any other change that affects patient access to care. For Arkansas
Blue Cross to remain compliant with federal and state requirements, changes must be communicated within 30
days so that members have access to the most current information in the Provider Directory.

You should routinely check your current practice information by going to arkbluecross.com and select FIND
CARE near the center of the page. If your information is not correct and updates are needed, please provide the
correct information as soon as possible by completing the Provider Change of Data Form.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 17
Section 2 | General Information

You may also receive a data verification letter from our Provider Network Operations department to provide you
with an additional opportunity to confirm your information as well.

For more information, contact Provider Network Operations at 501-210-7050 or email to

providernetwork@arkbluecross.com.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 18
Section 2 | General Information

Definitions
These definitions are for general reference and convenience only and are subject to modification by the terms of
your provider contract or member health plan or policy which shall control in the event of any conflict.

ALLOWED CHARGES or ALLOWANCE means the fee-per-service agreed upon in a contractual arrangement
between Arkansas Blue Cross and a participating provider or the usual amount charged by the provider,
whichever is less. See your provider contract for complete details.

AMBULATORY SURGERY is any procedure identified on the ambulatory-surgery list which can be done on an
outpatient basis.

BENEFIT CERTIFICATE is the document which Arkansas Blue Cross provides to members that defines the scope
of covered services and the terms, conditions, limitations, or exclusions that apply to such coverage.

BRAND-NAME MEDICATION means any prescription medication that has a patented trade name separate from
its generic or chemical designation, and indicated as such by Medispan.

CASE MANAGEMENT is a collaborative process of assessment, planning, facilitation, care coordination,

evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health
needs through communication and available resources to promote patient safety, quality of care, and cost-
effective outcomes. Case Managers are healthcare professionals who serve as member advocates to support
guide and coordinate care for members, families, and caregivers as they navigate their health and wellness
journeys.

COINSURANCE is the percentage of allowed charges for covered services for which the member is responsible
for payment.

COMPOUND MEDICATION means a medication that is prescribed by the physician and prepared by the
pharmacist using multiple FDA approved-ingredients through any route of administration, including
intravenous therapy.

CONTRACT YEAR means the twelve consecutive month period commencing on the Group Enrollment Contract
effective date and renewing on the anniversary of that effective date.

COPAYMENT is an amount specified that the member is responsible for paying when receiving specified
covered services.

COVERED SERVICES means those services and the attendant drugs or supplies covered under the terms of
a member’s health plan or policy, as amended from time to time. For complete details, see the member’s
applicable benefit plan or policy.

DEDUCTIBLE is the amount of eligible expenses a covered person must pay before payment of benefits is
commenced by the payer under the person’s health plan or policy.

EMERGENCY PRESCRIPTION means any prescription medication prescribed in conjunction with emergency
services and deemed necessary by a physician to be immediately needed by the covered person. See member’s
applicable health plan or policy for complete definition and details.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 19
Section 2 | General Information

EMERGENCY SERVICES are those services that are required when traumatic bodily injury or the sudden,
unexpected onset of an illness would lead a prudent layperson (possessing an average knowledge of medicine
and health) to believe that the condition requires the immediate care and attention of a qualified physician
or when the condition, if not treated immediately, could reasonably be expected to result in serious physical
impairment. See member’s applicable health plan or policy for complete definition and details.

EVIDENCE OF COVERAGE means the certificate of insurance containing the benefits, conditions, limitations and
exclusions of the Group Insurance Contract plus the Schedule of Benefits and any amendments signed by an
Officer of Health Advantage.

FORMULARY means a specified list of covered prescription medications that is maintained by Arkansas Blue
Cross. This list is subject to change.

GENERIC MEDICATION means any chemically equivalent reproduction of a brand-name medication whose
patent has expired.

GROUP CONTRACT is the contract between a health plan or insurance policy payer and an employer which sets
forth the terms of enrollment, membership, payment, coverage, terms, conditions, limitations, and exclusions
under which a group may obtain a health plan or insurance policy coverage for its members.

HOSPITAL means an acute general care hospital, a psychiatric hospital or a rehabilitation hospital licensed as
such by the appropriate state agency. It does not include any of the following, unless required by applicable law
or approved by the Board of Directors of the company: hospitals owned or operated by state or federal agencies,
convalescent homes or hospitals, homes for the aged, sanitariums, long-term care facilities, infirmaries or any
institution operated mainly for treatment of long-term chronic disease. For complete details, see the member’s
applicable benefit plan or policy.

IMPERATIVE CARE means care a member receives while traveling outside the service area for an unexpected
illness or injury that cannot wait until the member returns to the service area. the member can call
800-810-BLUE for participating providers in their area; claims will be reviewed upon receipt to determine if they
meet urgent/emergent guidelines.

INPATIENT STATUS is defined as a hospital stay greater than 24 hours or greater than 12 hours plus an
overnight stay while receiving medically necessary treatment — unless the stay is related to uncomplicated
ambulatory surgery.

MAINTENANCE MEDICATION means a specific prescription medication exceeding a one-month supply that
has been designated as a maintenance medication by the company for ongoing therapy of a chronic illness. For
complete details, see the member’s applicable benefit plan or policy.

MAINTENANCE or SUPPORTIVE CARE means care that is delivered after the acute phase of a condition has
passed and maximum therapeutic benefit has occurred. Maintenance care is treatment to promote optimal
function in the absence of significant symptoms. Supportive care is treatment for a chronic condition for
which recovery has slowed or ceased entirely, and only minimal rehabilitative gains can be demonstrated with
continual care. For complete details, see the member’s applicable benefit plan or policy.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 20
Section 2 | General Information

MEDICAL DIRECTOR is a person trained and licensed as a medical doctor who works for Arkansas Blue Cross
to review medical issues and help establish the Arkansas Blue Cross coverage policy. The medical director does
not practice medicine or give any medical advice or counseling.

MEMBER means any person who satisfies the eligibility requirements and financial obligations to qualify
for coverage of health care services under a health plan issued or administered by Arkansas Blue Cross,
its subsidiaries or affiliates. Member further means and includes any person who satisfies the eligibility
requirements and financial obligations to qualify for coverage of health-care services under a health plan;
including, but not limited to group health, Workers’ Compensation or injury-benefit plans, or any other medical
payments or health-benefit plan, whose sponsor or claims administrator has entered into any PPP Network
access agreement with Arkansas Blue Cross, its subsidiaries or affiliates. Member shall not include individuals
covered solely by other insurance carriers, except for those individuals covered under the BlueCard Program.
See your provider contract for complete definitions and details.

MEMBER APPEAL means a request to change a previous decision made by Health Advantage in which the
Member is financially responsible.

NON-COVERED SERVICES Any service not covered under the terms, conditions, exclusions and limitations of a
Member’s Evidence of Coverage with Health Advantage.

OUT-OF-AREA SERVICES means those services provided outside the Service Area in a location outside the state
of Arkansas where covered medical services are not available through In-Network Providers.

OUTPATIENT is defined as utilization of ambulatory or ancillary services for diagnosis and treatment.

PARTICIPATING HOSPITAL is a hospital with which Arkansas Blue Cross maintains contractual arrangements
to provide comprehensive hospital services to all members. Please refer to the provider directory for the
names of participating hospitals, physicians and providers. See your provider contract for complete definitions
and details.

PARTICIPATING PHARMACY means a licensed pharmacy which has a written agreement to provide pharmacy
services to Arkansas Blue Cross participants as provided in the benefit certificate.

PARTICIPATING PHYSICIAN means a licensed Doctor of Medicine or osteopathy, who has a contract with
Arkansas Blue Cross to provide health services to members. Please refer to the provider directory for the
names of participating hospitals, physicians and providers. See your provider contract for complete definitions
and details.

PARTICIPATING PROVIDER means a health care provider [including durable medical equipment (DME), home
health, etc.] who has contracted with Arkansas Blue Cross to provide or arrange for the provision of health care
services to members. Please refer to the provider directory for the names of participating hospitals, physicians
and providers. See your provider contract for complete definitions and details.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 21
Section 2 | General Information

PHYSICIAN means a Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.) duly licensed and qualified to
practice medicine and perform surgery at the time and place a claimed intervention is rendered. Physician also
means a Doctor of Podiatry (D.P.M.), a Chiropractor (D.C.), a Psychologist (Ph.D.), an Oral Surgeon (D.D.S.) or an
Optometrist (O.D.) duly licensed and qualified to perform the claimed health interventions at the time and place
such intervention is rendered. For complete details, see the member’s applicable benefit plan or policy.

PRE AUTHORIZATION is the process whereby inpatient admissions are reviewed for an initial determination of
whether hospitalization is medically necessary, or whether needed services could be provided in an outpatient
or other alternative setting. Pre authorization does not guarantee payment, but means only that, based on
information provided to Arkansas Blue Cross, coverage for the admission (and for the initial number of inpatient
days authorized for reimbursement), will not be denied solely based on lack of medical necessity for inpatient
treatment. Coverage and payment to all providers is always subject to member eligibility, payment of premiums
and all other terms and conditions of the member’s health plan. NOTE: Pre authorization is not required for most
Arkansas Blue Cross health plans. Check your patient’s ID card or health plan to determine applicability of pre
authorization requirements.

PREFERRED DRUG LIST is an abridged list of covered prescription medications selected by Arkansas Blue
Cross that are subject to lower copayments and coinsurance. For complete details, see the member’s applicable
benefit plan or policy.

PRESCRIPTION means an order for drugs, medicines or medications by a physician to a pharmacy for the benefit
of and use by a covered person of Arkansas Blue Cross. For complete details, see the member’s applicable
benefit plan or policy.

PRESCRIPTION MEDICATION means any medication or pharmaceutical that has been approved by the U.S.
Food and Drug Administration, can be obtained only by a physician order, and bears the label — “Caution:
Federal Law prohibits dispensing without a prescription.” For complete details, see the member’s applicable
benefit plan or policy.

PROVIDER means an advance practice nurse; an athletic trainer; an audiologist; a certified orthodontist; a
chiropractor; a community mental health center or clinic; a dentist, a Hospital; a licensed ambulatory surgery
center; a licensed certified social worker; a licensed dietitian; a licensed durable medical equipment provider;
a licensed professional counselor; a licensed psychological examiner; a long-term care facility; a non-Hospital
based medical facility providing clinical diagnostic services for sleep disorders; a non-Hospital based medical
facility providing magnetic resonance imagining, computed axial tomography, or other imaging diagnostic
testing; an occupational therapist; an optometrist; a pharmacist; a physical therapist; a physician or surgeon
(M.D. and D.O.); a podiatrist; a prosthetist; a psychologist; a respiratory therapist; a rural health clinic; a speech
pathologist and any other type of health care Provider which the Company, in its sole discretion, approves for
reimbursement for services rendered.

SUBSCRIBER means a person who is directly employed by the employer for full-time employment. This person
must reside in the United States and be paid for full-time work in the conduct of the employer’s regular business.
No director or officer of the employer shall be considered a subscriber unless he meets the above conditions.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 22
Section 2 | General Information

Helpful Reminders
To assist physician offices in obtaining proper eligibility, coverage and benefits information regarding Arkansas
Blue Cross members, a list of helpful reminders is provided below:
ƒ When a member calls to schedule an appointment, ask about insurance information.
ƒ When a member arrives at your office, ask to see their Arkansas Blue Cross and Blue Shield
identification card.
ƒ Maintain a current copy of the front and back of the member’s identification card in their medical file.
ƒ When possible, collect any copayments, coinsurance, and deductibles the day services are rendered.
ƒ File claims with Arkansas Blue Cross within 180 days even if Arkansas Blue Cross is not the primary payer.

If a member does not have a valid identification card, providers may call our Customer Service department
or access Availity to obtain the most current membership eligibility information available for Arkansas Blue
Cross, from the employer and/or member. If you are not already registered on Availity, click here to find out how
to register.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 23
Section 2 | General Information

My BlueLine
The Interactive Voice Response System
Arkansas Blue Cross and Blue Shield, Health Advantage and BlueAdvantage Administrators of Arkansas are
happy to announce the availability of My BlueLine, the Interactive Voice Response System (IVR). My BlueLine
recognizes common English to answer questions when you call. When providers call, My BlueLine will
immediately answer. By simply responding to the questions asked by the system – with no buttons to push –
providers can get questions answered quickly and easily without having to wait.

Providers can call 800-827-4814, or locally to the Central Arkansas area 501-378-2307, for access to information
for Arkansas Blue Cross Blue Shield, Blue Advantage Administrators, Health Advantage and Federal Employees
Program (FEP) members.

Note: Continue using the existing telephone numbers for the following:
ƒ Blue Card 800-880-0918

Arkansas Blue Cross believes this is a great enhancement for providers. Providers will no longer have to call
multiple phone lines to get information on a member, depending upon whether the member’s coverage is with
Arkansas Blue Cross and Blue Shield, Medi-Pak ®, BlueAdvantage Administrators, Health Advantage, or FEP
(Federal Employees Program).

My BlueLine will be able to help providers with questions regarding member eligibility, member benefits, and
claims status. During regular business hours, callers can request – at any time during the telephone call – to
speak to the next available customer service representative. At that time, the caller will be given an option
of visiting with a Customer Service Representative with BlueAdvantage Administrators, Health Advantage,
Arkansas Blue Cross Blue Shield, or FEP (Federal Employees Program). Please note that for Blue Advantage
Administrators, there are several phone lines handling self-insured employers. Therefore, it may be necessary
that we direct you to a phone number on the member’s ID card.

My BlueLine is there when you need quick answers to simple questions and is available 24 hours a day, seven
days a week.

Items to Remember:
National Provider Identifier (NPI): A caller must have their 10-digit NPI and the member’s ID number when calling
My BlueLine.

Using My BlueLine
Items to Remember:
ƒ National Provider Identifier (NPI): A caller must have their 10-digit NPI number and the member’s ID number
when calling.
ƒ Clear speech: Speak clearly and avoid conversations with others while using the IVR.
ƒ Speaker phones: Avoid use of speaker phone when using the IVR.
ƒ Headsets: To eliminate problems with the IVR not recognizing what is spoken, avoid the use of headsets.
ƒ Multiple checks: A caller can check on as many claims or members’ eligibility as needed in the same call.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 24
Section 2 | General Information

ƒ Multiple lines of business: Callers can check on Arkansas Blue Cross and Blue Shield, Health Advantage and
Blue Advantage Administrators of Arkansas patient information in the same call.
ƒ Main menu: Say “Main Menu” at any time to be transferred to the main menu section.
ƒ Availability: The IVR system is available 24 hours a day, 7 days a week.
ƒ Customer service: Say “Customer Service” at any time to transfer to Customer Service. Customer Service
Representatives are available during regular working hours.
ƒ Answering questions: Once a caller is familiar with the IVR system, break in and answer the questions before
the IVR is finished speaking the questions.
ƒ Information provided: Eligibility information and any benefit information provided is not a guarantee of
payment or coverage and is only valid if all coverage criteria is verified when we receive the claim

Where to Call for Out-of-State Members

ƒ For benefits on out-of-state Blue Cross and Blue Shield members – 800-676-2583.
ƒ For claims on out-of-state Blue Cross members – 501-378-2127 or 800-880-0918.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 25
Section 2 | General Information

Helpful Web Sites

Name Website
American Chiropractic Association acatoday.org
American Occupational Therapy Association aota.org
Arkansas Medicare Services medicare.com/state/arkansas-medicare
Arkansas Chiropractic Association archiro.org
Arkansas Chiropractic Society archirosociety.com
Arkansas Department of Health healthyarkansas.com
Arkansas Department of Human Services humanservices.arkansas.gov
Arkansas Foundation for Medical Care, Inc. afmc.org
Arkansas Hospital Association arkhospitals.com
Arkansas Medical Society arkmed.org
Arkansas Medicaid https://www.benefits.gov/benefit/1089
Arkansas Physical Therapy Association arpta.org
Arkansas State and Public School -
dfa.arkansas.gov/employee-benefits-division/arbenefits
Employee Benefits Division
Arkansas State Medical Board armedicalboard.org
Availity apps.availity.com/availity/web/public.elegant.login
BlueAdvantage Administrators of Arkansas blueadvantagearkansas.com
arkansasbluecross.com/providers/resource-center/
BlueCard
bluecard-program
Centers for Medicare and Medicaid Services cms.gov
cms.gov/medicare/coordination-of-benefits-and-recovery/
Coordination of Benefits Agreement (COBA) coba-trading-partners/coordination-of-benefits-agreements/
coordination-of- benefits-agreement-page.html
Federal Employee Program (FEP) fepblue.org
Federal Registers online site ofr.gov
GPO (Government Publishing Office) gpo.gov
Health Advantage healthadvantage-hmo.com
Information on Medicare Manuals cms.gov/manuals
Medical Group Management Association mgma.com
cms.gov/outreach-and-education/learn/get-training/get-
Medicare Training
training-page.html
NPPES - National Provider Identifier https://nppes.cms.hhs.gov/#/
OIG (Office of the Inspector General) oig.hhs.gov
SSA (Social Security Administration) ssa.gov

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 26
SECTION 3

Avalon
Section 3 | Avalon

Avalon: What You Need to Know

This policy applies to health plans that utilize a routine laboratory management vendor, which include
Arkansas Blue Cross and Blue Shield, Federal Employee Health Benefit Plan and Postal Service Health Benefit
Plan, Health Advantage, and Octave Blue Cross and Blue Shield fully insured plans, including the Metallic and
ARHOME plans and Complete/Complete Plus plans. Additionally, this policy will apply to the Farm Bureau and
Level Funded plans.

Arkansas Blue Cross and Blue Shield has previously communicated information about our implementation of the
Avalon program in the September 2024 Provides News, the Availity Payer Space, as well as some direct mailing.
Below is another reminder of our February 1, 2025, implementation.

Beginning February 1, 2025, Arkansas Blue Cross and Blue Shield will be implementing a new laboratory
benefit management (LBM) review program that aligns with our existing claims review processes. This
process will apply once lab claims are submitted and entail post-service and pre-payment policies based on
the latest science and clinically accepted, peer-reviewed guidelines for such services. The LBM review will
provide consistent enforcement of laboratory policies via an automated review of 24 sets of high-volume,
low-cost routine laboratory tests. This type of review is already in place for many other lab tests and other
medical services.

We believe this new process, will ensure members and patients receive high-quality, medically appropriate
and affordable laboratory services. Details of this process include new and revised medical coverage criteria,
guidelines and consistent reviews for certain laboratory services. This process will not apply to services
performed in a hospital setting.

ƒ Effective February 1, 2025, new and revised medical coverage criteria and guidelines will take effect that
will affect certain laboratory, services, tests and procedures. These policies and guidelines, which align
with our existing claims review processes, are available for review on the Arkansas Blue Cross website
(https://secure.arkansasbluecross.com/providers/coverage_policy.aspx).
ƒ The affected policies are:
- 2024023 - 2024030 - 2024045 - 2024051 - 2024056
- 2024025 - 2024031 - 2024046 - 2024052 - 2024057
- 2024026 - 2024035 - 2024048 - 2024053 - 2024058
- 2024027 - 2024036 - 2024049 - 2024054 - 2024059
- 2024028 - 2024044 - 2024050 - 2024055
ƒ Arkansas Blue Cross uses these evidence-based policies aligned with the latest scientific research to ensure
the appropriateness of lab testing. The lab policies are reviewed annually, or more often when the science
has changed, to account for the latest evidence and the development of new types of tests.
ƒ Effective for dates-of-service February 1, 2025, and thereafter, Arkansas Blue Cross will apply automated
policy enforcement (post-service and pre-payment) to claims reporting laboratory services performed in
office, hospital outpatient and independent laboratory locations.
ƒ Laboratory services, tests and procedures provided in emergency room, hospital observation and hospital
inpatient settings are excluded from this program.
ƒ Additionally, codes reporting multiple units billed will be reviewed referencing code-specific unit allowances
under Arkansas Blue Cross laboratory policies and guidelines.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 28
Section 3 | Avalon

We value and appreciate you for working to provide high-quality care and produce better healthcare outcomes
for our members. If you have questions about this program, please reach out to your Arkansas Blue Cross
representative.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 29
SECTION 4

BlueCard
Section 4 | BlueCard

What is BlueCard?
BlueCard links participating health-care providers and the independent Blue Cross and Blue Shield Plans across
the country through a single electronic network for professional outpatient and inpatient claims processing and
reimbursement. The program allows participating Blue Cross and Blue Shield providers in every state to submit
claims for indemnity and PPO patients who are enrolled through another Blue Plan to their local Blue Cross and
Blue Shield Plan.

Through the BlueCard program, providers can submit claims for Blue Cross and Blue Shield members (including
Blue Cross only and Blue Shield only) visiting a provider from other areas directly to Arkansas Blue Cross and
Blue Shield. If a provider is an Arkansas provider, Arkansas Blue Cross and Blue Shield is the sole necessary
contact for all Blue Cross and Blue Shield claims submissions, payments, adjustments, services and inquiries.

What services and products are covered under BlueCard?

BlueCard applies to all inpatient, outpatient and professional services. BlueCard does not yet apply to the
following:
ƒ Stand-alone dental and prescription drugs
ƒ Federal Employee Program (FEP)
ƒ Some individual Metallic plans

How do providers identify BlueCard members?

When members from other Blue Cross and Blue Shield Plans arrive at a provider’s office or facility, be sure to
ask for their current membership identification card. The two main identifiers for BlueCard members are the
alpha prefix and the “PPO in a suitcase” logo for eligible PPO members.

Alpha Prefix
The three-character alpha prefix at the beginning of the member’s identification number is the key element used
to identify and correctly route out-of-area BlueCard claims. The alpha prefix identifies the independent Blue
Cross and Blue Shield company (“Plan”) or national account to which the member belongs.

There are two types of alpha prefixes - plan-specific and account-specific:

1. Plan-Specific Alpha Prefixes are assigned to every Plan and start with X, Y, Z, or Q. The first two positions
indicate the Plan to which the member belongs, while the third position identifies the product in which the
member is enrolled.

a. First character: X, Y, Z or Q
b. Second character: A-Z
c. Third character: A-Z

2. Account-Specific Prefixes are assigned to centrally processed national accounts. National accounts are
employer groups that have offices or branches in more than one area, but offer uniform coverage benefits
to all their employees. Account-specific alpha prefixes start with letters other than X, Y, Z or Q. Typically, a
national-account alpha prefix will relate to the name of the group. All three positions are used to identify the
national account.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 31
Section 4 | BlueCard

International Alpha Prefixes:

International alpha prefixes can be seen on identification cards from foreign Blue Cross and Blue Shield
members. These ID cards will also contain three-character alpha prefixes. For example, JIS indicates Blue Cross
and Blue Shield of Israel members. The BlueCard claims process for international members is the same as that
for domestic Blue Cross and Blue Shield members.

What is the “PPO in a suitcase” logo?

Providers should immediately recognize BlueCard PPO members by the special “PPO in a suitcase” logo on their
membership card. BlueCard PPO members are Blue Cross and Blue Shield members whose PPO benefits are
delivered through the BlueCard Program. It is important to remember that not all PPO members are BlueCard
PPO members, only those whose membership cards carry this logo. Members traveling or living outside of their
Blue Plan’s area receive the PPO level of benefits when they obtain services from designated PPO providers.

What about identification cards with no alpha prefix?

Some identification cards may not have an alpha prefix. This may indicate that the claims are handled outside
the BlueCard program. Please look for instructions or a telephone number on the back of the member’s ID card
for information on how to file these claims.

It is very important to capture all ID-card data at the time of service. This is critical for verifying membership and
coverage. Arkansas Blue Cross suggests that providers make copies of the front and back of the ID card and pass
this key information on to their billing staff. Do not make up alpha prefixes. Incorrect or missing alpha prefixes
delay claims processing. Providers who are unsure of their participation status (PPO or non-PPO) should call
Arkansas Blue Cross and Blue Shield.

What about BlueCard limitations on some individual Metallic plans?

Some Arkansas Blue Cross and Blue Shield members may receive new 2018 member ID cards without the small
suitcase in the corner. These health plans do not include out-of-area benefits. For these members, the provider
should only refer to out-of-area providers when Arkansas True Blue PPO network providers are not available.
Prior approval is required for extenuating circumstances and can be obtained by completing a Continuation of
Care form. Please do not fill out a Continuation of Care form for these members unless they meet the approved
parameters.

The Continuation of Care form provides benefits for continuity of care for any member who is receiving prenatal
care or is in active treatment for an acute or chronic condition with a provider not in our area of coverage. This
allows the member to continue through the current period of active treatment or up to 90 days, depending on
the care needs and circumstances of the patient. The patient must then transition to an in-area provider.

Continuation of care only covers:

ƒ Pregnancy in the third trimester and/or
ƒ High-risk, newly diagnosed or relapsed cancer currently receiving chemotherapy, radiation therapy or
reconstruction.
ƒ Transplant candidates or transplant recipients in need of ongoing care due to complications associated with
a transplant, recent major surgeries in the acute phase and follow-up period
ƒ Serious acute conditions in active treatment such as heart attacks or strokes.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 32
Section 4 | BlueCard

Routine exams, vaccinations, health assessments, chronic condition care, minor illnesses and elective surgeries
do not qualify for continuation of care.

How can providers find out more information about BlueCard?

For more information about BlueCard, call Arkansas Blue Cross and Blue Shield’s BlueCard Customer Service
toll free at 800-880-0918 or visit the BlueCard Web site at bcbs.com/healthtravel/finder.html.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 33
Section 4 | BlueCard

BlueCard Claims
How to file claims for BlueCard members
Regardless of where a patient’s Blue Cross and Blue Shield Home Plan is located, providers should follow these
three easy steps to file a claim:
1. Call BlueCard® Eligibility at 800-676-BLUE (2583) to verify the patient’s eligibility and coverage.
2. Give the customer service representative the first three characters of the member’s identification number
(their alpha prefix number).
3. Submit the member’s claim to Arkansas Blue Cross and Blue Shield using regular claims filing procedures
after health care services have been provided to the patient.

While claims on BlueCard® members from out-of-state should be submitted in the first instance to Arkansas
Blue Cross and Blue Shield for processing, the payer of all such claims is the patient/member’s “Home Plan,”
(i.e., the separate Blue Cross and Blue Shield Licensee Company in the patient-member’s home state). Arkansas
Blue Cross and Blue Shield merely transmits the claim to the separate company for processing and payment (or
denial), as appropriate in its discretion.

For questions regarding claims status, please call Arkansas Blue Cross and Blue Shield’s BlueCard® Customer
Service at 800-880-0918.

Note: Providers should not collect payment up front from the member other than the required copayment.

Private room claims filing guidelines for all private facilities

When billing private room charges for an all private facility, value code 02 must be entered in the V002 electronic
record or in the value code fields (39-41) on a UB04 claim form when submitting a paper claim. Using the value
code will ensure the full DRG allowance is passed to the members Home Plan on the BlueCard claims.

Dental Claims
Regular dental claims are not handled through BlueCard® but dental-related services that are covered under
the medical benefits can be filed through BlueCard® using the appropriate dental codes. The member’s Blue
Cross and Blue Shield plan will instruct providers to consult the member’s ID card and file regular dental claims
directly to them.

How to avoid misrouted BlueCard claims

In order to avoid misrouted claims and delays in claims processing, Arkansas providers should submit claims
for out-of-state BlueCard members to Arkansas Blue Cross and Blue Shield for processing. Do not submit
claims directly to the member’s out-of-state Blue Plan as this will cause a delay in claims processing. The only
exception is when an Arkansas Blue Cross provider also contracts with the out-of- state Blue Plan.

Another form of misroute notification can be received directly from a Home plan. When a provider receives a
1050 or 1051 denial notification on a remittance advice, the Home plans are notifying the provider that they hold
no membership for that patient and/or the claim has been routed to them in error. At that time, providers need to
obtain a current copy of the patient’s ID card for correct filing instructions.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 34
Section 4 | BlueCard

How do indirect, support, or remote providers file BlueCard claims?

Health-care provider who offers products, materials, informational reports and remote analyses or services and
are not present in the same physical location as a patient are considered an indirect, support or remote provider.
Examples include, but are not limited to, prosthesis manufacturers, durable medical equipment suppliers,
independent or chain laboratories, or telemedicine providers.

Indirect providers for members from multiple Blue Plans should follow these claim-filing rules:
ƒ Providers who have a contract with the member’s Plan, file with that Plan;
ƒ Providers who normally send claims to the direct provider of care, follow normal procedures;
ƒ Providers who do not normally send claims to the direct provider of care and do not have a contract with the
member’s Plan should file with their local Blue Cross and Blue Shield Plan.

When and how will providers be paid for BlueCard claims?

In some cases, a member’s Blue Cross and Blue Shield Plan may suspend a claim because medical review or
additional information is necessary. When resolution of claim suspensions requires additional information from
providers, Arkansas Blue Cross and Blue Shield may either ask for the information or give the member’s Plan
permission to contact the provider directly.

Whom do providers call about claims status, adjusting BlueCard claims and resolving other issues?

Providers should contact Arkansas Blue Cross and Blue Shield’s BlueCard Customer Service toll free at
800-880-0918, or contact their regional office.

How do providers handle calls from members and others regarding claims status
or payment?
If a member contacts a provider regarding a claim, providers should tell the member to contact their Blue Cross
and Blue Shield Plan. Providers should refer the member to the front or back of their ID card for a customer-
service number.

The member’s Plan should not be contacting a provider directly. However, if the member’s Plan does ask a
provider to send them another copy of the member’s claim, refer them to Arkansas Blue Cross and Blue Shield’s
BlueCard Customer Service toll free at 800-880-0918.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 35
Section 4 | BlueCard

Special Note
Even though Arkansas Blue Cross and Blue Shield will serve as a sole point of contact for BlueCard claims,
please understand that this does not mean that Arkansas Blue Cross and Blue Shield assumes the obligation to
pay or guarantee payment of any claims for services to the members of other Blue Cross and Blue Shield Plans,
i.e., the Home Plans. Sole responsibility for payment of all BlueCard claims for members covered by other Blue
Cross and Blue Shield Plans (non-Arkansas Blue Cross and Blue Shield BlueCard members) shall remain at all
times with the applicable Blue Cross and Blue Shield Plan, i.e., the Home Plan. Arkansas Blue Cross and Blue
Shield acts merely as the Host Plan for purposes of facilitating ease- of-service to the Home Plan’s members,
and assisting in communications with that Home Plan.

All coverage determinations for non-Arkansas Blue Cross and Blue Shield BlueCard members are the
responsibilities and decisions of the Home Plan, not Arkansas Blue Cross and Blue Shield. Providers agree to
look solely to the Home Plan for non-Arkansas Blue Cross and Blue Shield BlueCard members for payment with
respect to any services to such members.

Please note that Arkansas Blue Cross and Blue Shield does not share ownership or governance with any other
Blue Cross and Blue Shield Plan; Arkansas Blue Cross and Blue Shield is an entirely independent, separate
not-for-profit mutual insurance company, organized in the state of Arkansas and owned by its policyholders.
The only association between Arkansas Blue Cross and Blue Shield and other Blue Cross and Blue Shield Plans
is that each separate company has been licensed by the Blue Cross and Blue Shield Association to use the
registered “Cross” and “Shield” service marks in their separate business operations.

The BlueCard Program is a cooperative effort among these separate, independent licensees of the Blue Cross
and Blue Shield Association, but it does not in any way obligate Arkansas Blue Cross and Blue Shield to fund any
benefits or become liable for any activities or omissions of any other Blue Cross and Blue Shield Plan.

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 36
Section 4 | BlueCard

BlueCard Coordination of Benefits (COB) and Remittance Advice (RA)

COB Questionnaire
Providers can obtain and submit Coordination of Benefits (COB) questionnaires to Arkansas Blue Cross and Blue
Shield before filing a claim. Questionnaire responses should not be sent as an attachment to a claim. The two-
page COB questionnaire should be printed as a one-sided document to prevent imaging problems. Do not print
the COB questionnaire on the front and back of the page. If the member belongs to another Blue Plan, Arkansas
Blue Cross will forward the COB questionnaire responses to the member’s Blue Cross and Blue Shield Plan on
the provider’s behalf. The COB questionnaire is available on the Arkansas Blue Cross Web site and through the
Advanced Health Information Network (Availity). Completed forms can be faxed to 501-378-2433 or mailed to:

Arkansas Blue Cross

Attn: Blue Card Support
P.O. Box 2181
Little Rock, AR 72203

Remittance Advice Balancing Instructions and Guidelines Related to COB

There has been an increase in inquiries due to the calculation on the remittance when two or more policies are
involved on a claim. Below are examples of some of the more common calculations used in the coordination of
benefits (COB).

However, due to the differences in COB policies and rules for other Blue Cross and Blue Shield carriers, an
example cannot be provided for all instances. Therefore, when in doubt, bill the member the amount indicated in
Member Liability on the remittance advice. If there is an error in payment, the member’s Home Plan will initiate
any necessary adjustments.

The following examples should assist providers in determining patient liability on claims.

Example 1: Charges Discount Paid Payment

 Total Charges = $ 545.50
 Less Blue Cross Discount = ($ 121.08)
 Less Other Insurance Paid = ($ 126.04)
 Less payment on Remittance Advice = ($ 97.21)
 Equals patient liability = $ 201.17
 Provider bills patient $201.17

Note: The patient responsibility amount on the RA is $327.21, which includes the other insurance paid amount
of $126.04.

 Patient Responsibility on RA = $ 327.21

 Less Other Insurance = ($ 126.04)
 New Patient Response = $ 201.17

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 37
Section 4 | BlueCard

Example 2: Charges Allowed Discount Coinsurance Payment

 Total Charges = $ 1190.85
 Less Blue Cross discount = ($ 538.48)
 Less payment on Remittance Advice = ($ 489.29)
 Difference is coinsurance = $ 163.08

Patient responsibility is $163.08 which is the coinsurance amount. Providers will need to bill the patient for the
coinsurance amount.

Example 3: Charges Discount Paid Payment

 Total Charges = $ 242.00
 Less Blue Cross Discount = ($ 104.68)
 Less Other Insurance = ($ 106.16)
 Payment on Remittance Advice = ($ 0.00)
 Patient responsibility = $ 31.16

No payment was made on this claim to subtract. Providers will need to bill the patient for $31.16.

Note: The patient responsibility amount on RA is displayed as $137.32 which includes the other insurance paid
amount of $106.16. $137.32 - $106.16 = $31.16 current patient responsibility.

Example 4: Charges Discount Paid Payment

 Total Charges = $ 5,444.86
 Less Blue Cross Discount = ($ 3,782.86)
 Less Other Insurance Paid = ($ 1,662.00)
 Patient responsibility = $ 00.00

There is no payment from the patient on this claim. The balance is zero with nothing remaining to bill the patient.
The patient responsibility amount matched what the other insurance paid $1662.00.

Changes to remittance advice

Effective April 13, 2014, the following changes were implemented to the remittance advice

New Message Codes:

The following new message codes will now be displayed when applicable:
ƒ 1294 – Medicare-like rate applied for Native American member with approved purchaser order seen by non-
Indian Health Services Provider.
ƒ 1305 – All diagnostic reports are needed before the claim can be processed.
ƒ 1306 – PET/MRI/CT scan report/results are needed before claim can be processed.
ƒ 1307 – EEG report with analysis is needed before the claim can be processed.

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Section 4 | BlueCard

Discount Code 2- Sequestration Reduction Applied

When discount code 2 is displayed on the remittance advice the amount of that discount is also included in the
total amount above.

New Medical Record Document Types:

There are 10 new medical record document types and three updated medical record document types. The new
medical record document types will provide the capability to order specific records versus requesting ‘complete’
medical records. The new medical record document types are as follows:
ƒ AD - Accident/Onset date
ƒ BG - Blood gases report
ƒ DE - Description of services/supply equipment
ƒ DR - Delivery report
ƒ DT - All diagnostic reports
ƒ ER - EEG report with analysis
ƒ OA - Ordering/referring physician name and address/NPI
ƒ SR - PET/MRI/CT scan report/results
ƒ TN - Tooth number
ƒ VS - Vein study report

The following medical record type descriptions have been updated. They are as follows:
ƒ MD - Medication Record/Administration (current letter #996)
ƒ ST - Occupational, Physical, or Speech Therapy Evaluation/Report (current letter #947)
ƒ TP - Treatment Plan/Notes (current letter #974)

Arkansas Blue Cross Blue Shield Provider Manual | Effective March 24, 2025 39
Section 4 | BlueCard

BlueCard: Corrected Claim Submission

What is a “Corrected Claim”? A “Corrected/Replacement Claim” is a change to a claim that has been previously
submitted for processing and has been finalized and reported on the Provider’s Remittance Advice (RA).
Corrected claims should not be submitted unless the initial filing has been finalized and is listed on their
remittance advice.

Corrected Claim submissions are to be used for claims that have finalized processing and have a claim number
assigned. A Corrected Claim should be submitted when providers are changing data on the claim form such as
a procedure code, diagnosis code, or charge with a thorough description of what has been changed. Corrected
claims may be submitted electronically or by paper.

Electronic submission
Arkansas Blue Cross and Blue Shield, BlueAdvantage Administrators of Arkansas, Health Advantage, the Federal
Employee Program and BlueCard accept electronic corrected claims.

For both facility and professional corrected claims, in order to expedite processing time and identify the actual
corrections and the reason for the correction, Arkansas Blue Cross requires a “total replacement” claim in order
for a complete comparison to the original claim along with the explanation in the NTE segment.

To file corrected claims electronically for the CMS 1500 claim form, the provider must populate 2300/CLM05-3
with a value of 7 and include the ICN number or BlueCard SCCF# of the original claim. The original ICN or SCCF#
(Document Control Number DCN) must be placed in the REF segment of the Loop 2300 with a qualifier of Ref
01=F8. If these are not submitted, the claim will be returned as a duplicate.

To file corrected claims electronically for the UB claim form, facilities will need to use XX7 type of bill.

Paper submissions
To submit corrected claims on paper, the provider is asked to complete the most current Corrected Bill
Submission Form for both the CMS 1500 and the UB04 claim forms and attach the claim as it should have been
filed originally. The claim will be returned to the provider processed, or denied as a duplicate claim, unless the
form is attached. The purpose of this change is to expedite processing time by assisting in identifying the actual
correction and the reason for the correction.

The preferred way to submit a corrected claim is through your clearinghouse or direct data entry on Availity.
Paper claims delay processing and could result in more errors, also causing a delay. A separate form is not
needed when submitting your claim through one of these methods.

The most current Corrected Bill Submission Form can be accessed and printed from the Arkansas Blue Cross
and Blue Shield website at arkbluecross.com. Corrected Claim forms should not be used if providers wish to file
the claim under a new identification number or different member, the claim should be filed as a new claim and
Arkansas Blue Cross notified of the original incorrect submission.

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Section 4 | BlueCard

Corrected Claim forms should not be used to appeal the disposition outcome of a claim or to question the
processing of a claim. If providers wish to appeal a claim based on new medical information or rationale, please
submit a written request with the supporting documentation to:

Arkansas Blue Cross

Attn: BlueCard Customer Service
P.O. Box 2181
Little Rock, AR 72203

Timely filing
As a reminder, Arkansas Blue Cross set a 180-day timely filing limit for first-time claims as well as corrected
claims. When it is necessary to file a corrected claim, please ensure it is done within 180 days of the original paid
date or the corrected claim will be rejected or returned.

If you have questions regarding Corrected Claims, contact Availity Client Services at 800-282-4548.

Filing Original Claim

Providers must submit claims for any service, supply, prescription drug, test, equipment or other treatment
within 180 days after such service, supply, prescription drug, test, equipment or treatment is provided. In the
case of a claim for inpatient services for multiple consecutive days, a written proof must be submitted no later
than 180 days following the date of discharge for that admission.

Re-submitting Claims
Arkansas Blue Cross and its affiliates also require providers to use this 180-day timely filing limit for re-
submitting claims for adjustments, or for submitting additional information on a previously filed claim.

Adjudicated Claims/COB
Arkansas Blue Cross and its affiliates extend the timely filing requirements to include 180 days after the primary
insurer adjudicates the claim. Timely deadline for secondary claims is 180 days from the date processed by the
primary carrier.

Member Responsibility
The 180-day timely filing provision is applicable for both providers and members. When a patient covered by
Arkansas Blue Cross or an affiliate does not provide their provider with proof of coverage until after the 180-day
timely filing has expired, that patient is responsible for the services and the provider should not bill Arkansas
Blue Cross or its affiliates.

All contract holders should have a member identification card and should present their member ID card prior
to each service. Arkansas Blue Cross and its affiliates encourage all providers to have their patients’ complete
insurance coverage update forms at the time of each service. By completing an insurance coverage update form,
patients are given every opportunity to provide up-to-date insurance information.

For questions regarding coverage, providers should refer to Availity for member eligibility and claims status or
call The BlueLine, our voice activated response service, available 24 hours a day, 7 days a week.

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Section 4 | BlueCard

Durable medical equipment, lab and specialty pharmacy

Claims filing rule reminders for durable medical equipment, lab and specialty
pharmacy:
In 2004, the Blue Cross and Blue Shield Association (the Association) revised its “Blue Card” claims filing rules
for providers specializing in independent clinical laboratory, durable/home medical equipment and supply, and
specialty pharmacy. While these revisions are several years old, the Association has only recently tightened
system requirements related to these rules. These rules apply to all provider networks and claims related to
Arkansas Blue Cross and Blue Shield, Blue Advantage Administrators of Arkansas and Health Advantage when
claims are being submitted via the “Blue Card” process of the Association, a process used to facilitate the
efficient processing of claims for members receiving services outside their local service area or state.

Claims for independent clinical laboratory, durable/home medical equipment and supply, and specialty
pharmacy are filed to the local Blue Cross and Blue Shield Plan (sometimes called the “Host Plan”). The local
Blue Cross Plan is usually defined as the Plan in whose service area the services are rendered. The Blue Plan
that issued coverage for a given member, or that contracted with their employer to administer their self-funded
health plan, is referred to as the “Home Plan.” (Please note that “Host Plan” and “Home Plans” are in every
case independent companies so that the “Host Plan” is not responsible for funding of any insurance issued by a
“Home Plan.” The “Host Plan’s” role is limited to a claims processing and customer services assistance function
with respect to the out-of-state provision of services to the “Home Plan’s” member.)

New message codes on remittance advice for misrouted claims based on filing
rules for independent clinical laboratory, durable medical equipment suppliers
and specialty pharmacy
New message codes have been created to handle misrouted claims for providers specializing in independent
clinical laboratory, durable/home medical equipment and supply, and specialty pharmacy. When claims are
not filed according to the previously published filing rules (see the reprinted rules following), the claims will be
rejected for one of the following reasons depending on the provider specialty:
ƒ Independent Clinical Laboratory – Message Code 1290: Claim filed to wrong Plan. File to the Plan in the
state where the specimen is drawn.
ƒ Durable/Home Medical Equipment and Supplies – Message Code 1291: Claim filed to wrong Plan. File to the
Plan in the state where the equipment was shipped to or purchased in a retail store.
ƒ Specialty Pharmacy – Message Code 1292: Claim filed to wrong Plan. File to the Plan in the state where the
ordering physician is located.

Arkansas Blue Cross and Blue Shield Customer Service staff will be monitoring claims denied with these
message codes and will contact the Home Plans for verification of the denial. Once the information is obtained,
Customer Service will reach out to affected providers to determine the steps needed to get the claim processed.

Independent Clinical Laboratory

For clinical lab, the local Blue Cross Plan is defined as the plan in which service area the specimen was drawn.
Example: a blood specimen is drawn at a physician’s office in Little Rock that participates in the Health
Advantage network on a member who has Health Advantage benefit coverage. The lab is sent to New York to
be processed and is billed from North Carolina. This laboratory participates in the Health Advantage network.

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Section 4 | BlueCard

The claim must be billed directly to Health Advantage as the specimen was drawn in Arkansas. The claim will be
processed as in network for covered services.

Another example: A blood specimen is drawn in Hot Springs on a member who has health plan coverage
administered through Blue Advantage Administrators of Arkansas. The clinic where the specimen is obtained
is not in any Arkansas Blue Cross provider networks. The lab specimen is sent to Denver, CO to be processed
and will be billed by the lab from Denver. The lab is also not in any Arkansas Blue Cross or affiliates’ provider
network. The claim must be billed directly to Blue Advantage as the specimen was obtained in Arkansas. The
claim will be processed as out of network for covered services.

The Referring Provider information, Field 17 on CMS 1500 Health Insurance Claim Form or loop 2310A (claim
level) on the 837 Professional Electronic Submission, is required on claims submitted for clinical lab. Arkansas
Blue Cross and its family of companies require the referring provider on all professional service claims. Any
outpatient claim submitted with a laboratory service must contain the referring provider name and NPI. The
referring provider will need to be a provider registered/enrolled in the provider database of Arkansas Blue Cross
or its family of companies. Listing a referring provider who is not registered with Arkansas Blue Cross will result
in claim rejection or denial.

Durable/Home Medical Equipment and Supply

For durable/home medical equipment and supply, the local Blue Cross Plan is the plan in which service area the
equipment was shipped to or purchased at a retail store. For example: a member with Arkansas Blue Cross and
Blue Shield insurance living in Fort Smith, AR orders diabetic supplies from a mail order supplier in Ohio. The
supplier participates in the Host Plan’s network in Ohio but not Arkansas. The claim must be Filed directly to
Arkansas Blue Cross because Arkansas is where the supplies were shipped. The claim will be processed as out
of network for covered services.

The following information is required on claims submitted for durable/home medical equipment:
ƒ Patient’s Address, Field 5 on CMS 1500 Health Insurance Claim Form or in loop 2010CA on the 837
Professional Electronic Submission.
ƒ Referring Provider, Field 17 on CMS 1500 Health Insurance Claim Form or loop 2310A (claim level) on the 837
Professional Electronic Submission.
ƒ Place of Service, Field 24B on the CMS 1500 Health Insurance Claim Form or in loop 2300, segment CLM05-1
on the 837 Professional Electronic Submission.
ƒ Service Facility Location Information, Field 32 on CMS 1500 Health Insurance Form or in loop 2310 A (claim
level) on the 837 Professional Electronic Submission.

Specialty Pharmacy
For specialty pharmacy, the local Blue Cross Plan is defined as the plan in which service area the ordering
physician is located. For example: a physician whose clinic is in Pine Bluff orders specialty drugs for a Health
Advantage member who lives in Stuttgart. The specialty pharmacy is located in Jackson, MS and is in the
Mississippi Blue Cross and Blue Shield provider networks, but not in any Arkansas Blue Cross or affiliates’
networks. The claim must be filed directly to Health Advantage as the ordering physician’s practice location is in
Arkansas. The claim will be processed as out of network as the specialty pharmacy is not in any Arkansas Blue
Cross or affiliates’ provider networks. Referring Provider, Field 17 on CMS 1500 Health Insurance Claim Form

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Section 4 | BlueCard

or loop 2310A (claim level) on the 837 Professional Electronic Submission is required on claims submitted for
clinical lab.

The Blue Card program has always relied on the provider agreement status and pricing of the local Blue Cross
and Blue Shield Plan and that is still true. The mere fact that a claim is required to be submitted directly to
certain Blue Cross Plan does not obligate any local Blue Cross Blue Plan to offer contracts to any lab, durable
medical equipment supplier or specialty pharmacy.

However, the Association’s rules for BlueCard have been revised to allow Blue Cross Plans to contract with out
of state clinical labs, durable medical equipment suppliers and specialty pharmacies. Each local Blue Cross will
make its own decisions related to provider contracting and pricing.

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Section 4 | BlueCard

BlueCard: Inpatient claims financial responsibility policy revision

The Blue Cross Blue Shield Association is taking steps to ensure consistency among all Blue Plans regarding
inpatient pre-service review (also known as pre-authorization or pre-certification). Beginning July 1, 2014,
inpatient facilities that fail to obtain pre-authorization or pre authorization when it is required, will be financially
responsible for any covered services not paid and the member will be held harmless.

Not all health plans require inpatient pre-authorization or pre-certification, but where it is required, inpatient
providers who fail to obtain it will be financially responsible for any covered services not paid and the
member will be held harmless. It will become very important for facilities to check member eligibility and pre-
certification requirements, whether it be via a HIPAA 270 transaction or by calling the phone number on the
member’s ID card.

In order to implement the Blue Cross Blue Shield Association mandate, our provider agreement language must
be revised. Please consider this notification as an amendment to the Arkansas Blue Cross and Blue Shield
Preferred Payment Plan, Health Advantage HMO and PPO Arkansas’ (formerly USAble Corporation) True Blue
PPO and Arkansas’ FirstSource® PPO provider network participation agreements.

The following sections in the Hospital and PHO provider network participation agreements will now contain the
additional language:

Prior Approval and Eligibility Inquiries

Non-emergency admissions
Facility understands and agrees that for Health Plans that require prior approval and Facility fails to obtain prior
approval that Facility will hold Member harmless of any amounts not paid for Covered Services.

Emergency admissions
Facility understands and agrees that for Health Plans that require prior approval within 24 hours after admission
or by the end of the next working day, if on a weekend or holiday and Facility fails to obtain pre-authorization or
pre-notification, that Facility will hold Member harmless of any amounts not paid for Covered Services.

Electronic provider access

The Blue Cross and Blue Shield Plans offers Electronic Provider Access (EPA) to give providers the ability to
access out-of-area member’s Blue Plan (Home Plan) provider portals to conduct electronic pre-service review.
The term pre-service review is used to refer to prior approval, amongst other pre-claim processes. Electronic
Provider Access (EPA) will enable providers to use their local Blue Plan provider portal to gain access to an
out-of-area member’s Home Plan provider portal, through a secure routing mechanism. Once in the Home Plan
provider portal, the out-of-area provider will have the same access to electronic pre- service review capabilities
as the Home Plan’s local providers.

The availability of EPA will vary depending on the capabilities of each Home Plan. Some Home Plans will be
fully implemented and have electronic pre-service review for many services, while others will not yet have
implemented electronic pre-service review capabilities. Local access to the EPA is found on the Advanced Health
Information Network (Availity) under the “Members” menu option.

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Section 4 | BlueCard

BlueCard: Medicare Claims

Pricing claims for Medicare statutorily excluded services
The following Medicare crossover servicing updates became effective October 13, 2013 for all Blue Plans to
more accurately price and process these claims:
ƒ For services that are statutorily excluded by Medicare (i.e., home infusion therapy and hearing aids),
providers should submit only those statutorily excluded services to Arkansas Blue Cross and Blue Shield
with a GY modifier on each line for the service that is excluded or not covered by Medicare. The GY modifier
should be used to indicate that the item or service is statutorily excluded. This will allow Arkansas Blue Cross
to apply the contracted rate with the provider to accurately process the claim according to the member’s
benefits. Also, by submitting statutorily excluded services with a GY modifier directly to Arkansas Blue
Cross, providers will receive payment for these services in a timelier manner.
ƒ When a provider submits a claim to Medicare and the services were statutorily excluded and not covered
by Medicare, however the member has benefits for those services; providers will receive notification from
the Blue Plan with instruction to submit those statutorily excluded services directly to Arkansas Blue Cross.
Instructions will be included in either a paper or electronic RA or in a letter from the Blue Plan.
ƒ Paper RAs and Letters: When receiving paper RA’s or letters, providers will receive instructions similar to
the message below:
“This service is excluded or not covered under Medicare. However, the service may be eligible for benefits
under other coverage. Please submit this service to your local Plan.”
ƒ Electronic RAs (835): the following HIPAA claim adjustment reason codes and remark codes will be
included on the 835 responses:
– Claim Adjustment Reason Code (CARC) 109: “Claim not covered by this payor/contractor.”
– RA Remark Code (RARC) N837: “Alert: submit this claim to the patient’s other insurer for potential
payment of supplemental benefits. We did not forward the claim information.”
– Group Code: OA

Commonly Asked Questions:

How do providers know if a service is statutorily excluded or not covered by Medicare?
Providers are responsible for including the GY modifier on only those services which are statutorily excluded
by Medicare.

Where on the claim do providers put the GY modifier?

The GY modifier should be used with the specific, appropriate HCPCS code when one is available. In cases
where there is no specific procedure code to describe services, a “not otherwise classified code” (NOC) must be
used with the GY modifier.

The GY modifier is located in the line level procedure code modifier field(s) and the modifier can be:
ƒ Present position 1, 2, 3 or 4.
ƒ On the paper 1500 form, the GY modifier is located in field 24D.
ƒ On the paper UB04 form, the GY modifier is located in field 44.
ƒ On the 837P, the GY modifier is found at level 2400, Service Line Loop in SV101-3, SV101-4, SV101-5 or SV101-6.
ƒ On the 837I, the GY modifier is found at level 2400, Service Line Loop in SV202-3, SV202-4, SV202-5
or SV202-6.

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Section 4 | BlueCard

Duplicate claims handling for Medicare crossover

Since January 1, 2006, all Blue Plans have been required to process Medicare crossover claims for services
covered under Medigap and Medicare Supplemental products through the Centers for Medicare & Medicaid
Services (CMS). This has resulted in automatic submission of Medicare claims to the Blue secondary payer to
eliminate the need for provider’s office or billing service to submit an additional claim to the secondary carrier.
Additionally, this has also allowed Medicare crossover claims to be processed in the same manner nationwide.

Effective October 13, 2013, when a Medicare claim has crossed over, providers are to wait 30 calendar days from
the Medicare remittance date before submitting the claim to Arkansas Blue Cross and Blue Shield.

The claims providers submit to the Medicare intermediary will be crossed over to the Blue Plan only after they
have been processed by the Medicare intermediary. This process may take approximately 14 business days to
occur. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing
about the same time a provider receives the Medicare remittance advice. As a result, upon receipt of the
remittance advice from Medicare, it may take up to 30 additional calendar days for a provider to receive payment
or instructions from the Blue Plan.

Providers should continue to submit services that are covered by Medicare directly to Medicare. Even if
Medicare may exhaust or has exhausted, continue to submit claims to Medicare to allow for the crossover
process to occur and for the member’s benefit policy to be applied.

Medicare primary claims, including those with Medicare exhaust services, that have crossed over and are
received within 30 calendar days of the Medicare remittance date or with no Medicare remittance date will be
(returned or rejected) by Arkansas Blue Cross.

Commonly Asked Questions:

How do providers submit Medicare primary / Blue Plan secondary claims?
ƒ For members with Medicare primary coverage and Blue Plan secondary coverage, submit claims to your
Medicare intermediary and/or Medicare carrier.
ƒ When submitting the claim, it is essential that providers enter the correct Blue Plan name as the secondary
carrier. This may be different from the local Blue Plan. Check the member’s ID card for additional verification.
ƒ Be certain to include the alpha prefix as part of the member identification number. The member’s ID will
include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and
coverage, and key to facilitating prompt payments.

When a provider receives the remittance advice (RA) from the Medicare intermediary, look to see if the claim has
been automatically forwarded (crossed over) to the Blue Plan:
ƒ If the RA indicates that the claim was crossed over, Medicare has forwarded the claim on behalf of the
provider to the appropriate Blue Plan and the claim is in process. There is no need to resubmit that claim to
Arkansas Blue Cross.
ƒ If the RA indicates that the claim was not crossed over, submit the claim to Arkansas Blue Cross with the
Medicare RA.
ƒ In some cases, the member identification card may contain a COBRA ID number. If so, be certain to include
this number on the claim.

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Section 4 | BlueCard

ƒ For claims status inquiries, contact Arkansas Blue Cross Customer Service at 800-880-0918 or 501-378-2127.

When should providers expect to receive payment?

The claim a provider submits to the Medicare intermediary will be crossed over to the Blue Plan only after they
have been processed by the Medicare intermediary. This process may take approximately 14 business days to
occur. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing
about the same time the Medicare RA is received. As a result, upon receipt of the RA from Medicare, it may take
up to 30 additional business days for providers to receive payment or instructions from the Blue Plan.

What should providers do in the meantime?

If a provider submitted the claim to the Medicare intermediary/carrier and hasn’t received a response to the
initial claim submission, they should not automatically submit another claim. Instead, providers should:
ƒ Review the automated resubmission cycle on the claim system.
ƒ Wait 30 calendar days from receipt of the Medicare Remittance advice.
ƒ Check claims status before resubmitting.

Sending another claim, or having a billing agency resubmit claims automatically, slows down the claim payment
process and creates confusion for the member.

Filing Medicare Advantage Home Health Request for Anticipated Payment Claims
The Center for Medicare and Medicaid Services (CMS) allows Revenue Code 0023 for Medicare Advantage home
health request for anticipated payment (RAP) claims that contain a service line with zero as the total charge, of
which Medicare pays 60% of their normal allowance. Total Charges must be entered as zero on the RAP claim.
This field cannot be left blank.

The claims are then re-submitted later with the actual charges. Medicare then adjusts the claims when the re-
submitted bill is received and pays the remaining difference. These are identified when Medicare home health
care claims are submitted with a bill type 322 or 332 along with zero charges. When the final bill is submitted,
it will initiate a void only adjustment on the RAP Claim. The final bill should contain bill types 329 or 339 and
actual charges.

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SECTION 5

Claims Filing and

Information
Section 5 | Claims Filing and Information

Accidental Injuries & Subrogation

Accidental Injuries
If an Arkansas Blue Cross and Blue Shield member is involved in an accident, bill in the usual manner, adding the
place, date, time and cause of injury. Arkansas Blue Cross needs to know the cause of injury to process injury
claims. By adding the cause of injury and date of injury to the original claim submission, the provider facilitates a
timely and expedited claim process.

If benefits are payable under the terms of any automobile medical, automobile no-fault, homeowners, premises
liability, personal injury protection or similar contract of insurance, benefits may be coordinated at the point of
final determination of liability.

Subrogation
Subrogation rights are included in all Arkansas Blue Cross members’ health plans or contracts. This means that
if Arkansas Blue Cross pays claims for an injury or illness (whether or not it was the result of an accident or some
other cause) that was caused by another person who is liable to the member for that injury or illness, Arkansas
Blue Cross is entitled to recover our payments from the responsible third party or their insurance carrier.

Arkansas Blue Cross members are obligated to cooperate and to furnish all information needed to identify
and pursue a third party or subrogation. If the member fails to cooperate, Arkansas Blue Cross has the right to
recover claim payments and deny benefits. This means a provider’s claims may be affected if the member fails
to promptly return the C-110 form or otherwise fails to cooperate or seeks to avoid our subrogation interest.

Note: Subrogation investigation and recovery services may be pursued for Arkansas Blue Cross by a separate
subrogation vendor, known as Optum.

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Section 5 | Claims Filing and Information

Arkansas Blue Cross and Blue Shield Partners with Availity

Arkansas Blue Cross and Blue Shield and its family of companies entered into a strategic partnership with
Availity in 2020. As part of the alliance, Availity serves as the designated EDI Gateway providing portal and
clearinghouse services for Arkansas Blue Cross and Blue Shield.

Availity is the nation’s largest real-time health information network with connections to more than 2,000
payers nationwide, including government payers like Medicaid and Medicare. With a full range of provider
clearinghouse and revenue cycle management options, Availity may also offer ways to consolidate
clearinghouse endpoints. Visit availity.com/ediclearinghouse for more information.

Arkansas Blue Cross and Blue Shield offers many transactions on Availity, such as eligibility and benefits, claim
submission, remit viewer, claim statuses, a dedicated payer-space with payer-specific apps and documents on
a dedicated payer space, and more. Visit apps.availity.com/availity/web/public.elegant.login to access Availity
registration.

Availity has created a landing page consisting of helpful information and training opportunities to assist
providers through the registration and the getting started process. Providers can access the Availity landing
page at availity.com/arkansasbluecross.

Providers are encouraged to become familiar with Availity chat, ticketing functions and the Availity client
services team at 800-282-4584 (282-AVAILITY).

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Section 5 | Claims Filing and Information

Assignment of Benefits
Providers may elect to require that members, before receiving services, execute an assignment whereby any
benefits under the member’s health plan or contract are assigned to the provider. Granted that a provider is a
participating provider in good standing with Arkansas Blue Cross and Blue Shield (not in violation of the provider
agreement, the Arkansas Blue Cross billing and coding guidelines or this Provider Manual) on the date of such
assignment, and on the date of the services in question, Arkansas Blue Cross will honor such assignments and
any payments due for the services will be paid directly to the provider rather than to our member.

If providers cease to be a participating provider for any reason, however, Arkansas Blue Cross reserves the right
to decline to accept the assignment; and in such case Arkansas Blue Cross may, in our discretion, make payment
to the member rather than to the provider. Whether or not providers elect to require and receive an assignment
from an Arkansas Blue Cross member, providers agree to release the member from all financial responsibility
with respect to that assigned claim, except for applicable copayment, coinsurance and deductible; i.e., providers
agree to look exclusively to Arkansas Blue Cross for payment for all services to the member, except for
copayment, coinsurance and deductible (or non- covered services permitted to be billed to members under the
terms of your participation agreement).

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Section 5 | Claims Filing and Information

Claims Filing Rule Reminders for Durable Medical Equipment, Lab and
Specialty Pharmacy
In 2004, the Blue Cross and Blue Shield Association (the Association) revised its “Blue Card” claims filing rules
for providers specializing in independent clinical laboratory, durable/home medical equipment and supply,
and specialty drugs not covered on the pharmacy benefit. While these revisions are several years old, the
Association has only recently tightened system requirements related to these rules. These rules apply to all
provider networks and claims related to Arkansas Blue Cross and Blue Shield, Blue Advantage Administrators
of Arkansas and Health Advantage when claims are being submitted via the “Blue Card” process of the
Association, a process used to facilitate the efficient processing of claims for members receiving services
outside their local service area or state.

Claims for independent clinical laboratory, durable/home medical equipment and supply, and specialty drugs
not covered on the pharmacy benefit are filed to the local Blue Cross and Blue Shield Plan (sometimes called
the “Host Plan). The local Blue Cross Plan is usually defined as the Plan in whose service area the services are
rendered. The Blue Plan that issued coverage for a given member, or that contracted with their employer to
administer their self-funded health plan, is referred to as the “Home Plan.”

Please note that “Host Plan” and “Home Plans” are in every case independent companies so that the “Host
Plan” is not responsible for funding of any insurance issued by a “Home Plan.” The “Host Plan’s” role is limited
to a claims processing and customer services assistance function with respect to the out-of-state provision of
services to the “Home Plan’s” member.

New message codes on remittance advice for misrouted claims based on filing
rules for independent clinical laboratory, durable medical equipment suppliers
and specialty pharmacy:
New message codes have been created to handle misrouted claims for providers specializing in independent
clinical laboratory, durable/home medical equipment and supply, and specialty pharmacy. When claims are
not filed according to the previously published filing rules (see the reprinted rules following), the claims will be
rejected for one of the following reasons depending on the provider specialty:
ƒ Independent Clinical Laboratory – Message Code 1290: Claim filed to wrong Plan. File to the Plan in the state
where the specimen is drawn.
ƒ Durable/Home Medical Equipment and Supplies – Message Code 1291: Claim filed to wrong Plan. File to the
Plan in the state where the equipment was shipped to or purchased in a retail store.
ƒ Specialty Pharmacy – Message Code 1292: Claim filed to wrong Plan. File to the Plan in the state where the
ordering physician is located.

Arkansas Blue Cross Customer Service staff will be monitoring claims denied with these message codes and will
contact the Home Plans for verification of the denial. Once the information is obtained, Customer Service will
reach out to affected providers to determine the steps needed to get the claim processed.

Independent Clinical Laboratory

For clinical lab, the local Blue Cross Plan is defined as the plan in which service area the specimen was drawn.
Example: a blood specimen is drawn at a physician’s office in

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Section 5 | Claims Filing and Information

Little Rock that participates in the Health Advantage network on a member who has Health Advantage benefit
coverage. The lab is sent to New York to be processed and is billed from North Carolina. This laboratory
participates in the Health Advantage network. The claim must be billed directly to Health Advantage as the
specimen was drawn in Arkansas. The claim will be processed as in network for covered services.

Another example: A blood specimen is drawn in Hot Springs on a member who has health plan coverage
administered through Blue Advantage Administrators of Arkansas. The clinic where the specimen is obtained
is not in any Arkansas Blue Cross provider networks. The lab specimen is sent to Denver, CO to be processed
and will be billed by the lab from Denver. The lab is also not in any Arkansas Blue Cross or affiliates’ provider
network. The claim must be billed directly to Blue Advantage as the specimen was obtained in Arkansas. The
claim will be processed as out of network for covered services.

The Referring Provider information, Field 17 on CMS 1500 Health Insurance Claim Form or loop 2310A (claim
level) on the 837 Professional Electronic Submission, is required on claims submitted for clinical lab.

Durable/Home Medical Equipment and Supply

For durable/home medical equipment and supply, the local Blue Cross Plan is the plan in which service area the
equipment was shipped to or purchased at a retail store. For example: a member with Arkansas Blue Cross and
Blue Shield insurance living in Fort Smith, AR orders diabetic supplies from a mail order supplier in Ohio. The
supplier participates in the Host Plan’s network in Ohio but not Arkansas. The claim must be Filed directly to
Arkansas Blue Cross because Arkansas is where the supplies were shipped. The claim will be processed as out
of network for covered services.

The following information is required on claims submitted for durable/home medical equipment:
ƒ Patient’s Address, Field 5 on CMS 1500 Health Insurance Claim Form or in loop 2010CA on the 837
Professional Electronic Submission.
ƒ Referring Provider, Field 17 on CMS 1500 Health Insurance Claim Form or loop 2310A (claim level) on the 837
Professional Electronic Submission.
ƒ Place of Service, Field 24B on the CMS 1500 Health Insurance Claim Form or in loop 2300, segment CLM05-1
on the 837 Professional Electronic Submission.
ƒ Service Facility Location Information, Field 32 on CMS 1500 Health Insurance Form or in loop 2310 A (claim
level) on the 837 Professional Electronic Submission.

Specialty Pharmacy
For specialty pharmacy, the local Blue Cross Plan is defined as the plan in which service area the ordering
physician is located. For example: a physician whose clinic is in Pine Bluff orders specialty drugs for a Health
Advantage member who lives in Stuttgart. The specialty pharmacy is located in Jackson, MS and is in the
Mississippi Blue Cross and Blue Shield provider networks, but not in any Arkansas Blue Cross or affiliates’
networks. The claim must be filed directly to Health Advantage as the ordering physician’s practice location is in
Arkansas. The claim will be processed as out of network as the specialty pharmacy is not in any Arkansas Blue
Cross or affiliates’ provider networks. Referring Provider, Field 17 on CMS 1500 Health Insurance Claim Form
or loop 2310A (claim level) on the 837 Professional Electronic Submission is required on claims submitted for
clinical lab:

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The Blue Card program has always relied on the provider agreement status and pricing of the local Blue Cross
and Blue Shield Plan and that is still true. The mere fact that a claim is required to be submitted directly to
certain Blue Cross Plan does not obligate any local Blue Cross Blue Plan to offer contracts to any lab, durable
medical equipment supplier or specialty pharmacy.

However, the Association’s rules for BlueCard have been revised to allow Blue Cross Plans to contract with out
of state clinical labs, durable medical equipment suppliers and specialty pharmacies. Each local Blue Cross will
make its own decisions related to provider contracting and pricing.

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Section 5 | Claims Filing and Information

Contiguous Counties
Claims filing rules for counties bordering Arkansas
This is a reminder on the claims filing rules for health care providers located in counties of states that
border Arkansas.

If a member has insurance coverage with Arkansas Blue Cross and Blue Shield and if that member receives
services from a healthcare provider located in a bordering county who is contracted to be in the provider
networks of Arkansas Blue Cross or its affiliates, the provider must submit the claim directly to Arkansas Blue
Cross or its affiliates, as applicable. In this scenario, Arkansas Blue Cross essentially fills both the “Host”
and “Home” Plan function, based on the peculiar circumstances of border county proximity and the network
participation agreement in place with the out-of-state provider. This rule also applies to Health Advantage, its
members and contracted providers, as well as to health plans administered by Blue Advantage Administrators
of Arkansas.

An example would be a physician in Memphis, TN, who provides care to a patient with health plan coverage
from Health Advantage. If that physician is in the Health Advantage provider network, the claim must be
submitted to Health Advantage in Little Rock. If a health care provider in a bordering county is not in the
provider networks of Arkansas Blue Cross and its affiliates but is participating in the networks of the Blue
Cross and Blue Shield plan where the provider is located, and that provider renders services to a member with
coverage from Arkansas Blue Cross and its affiliates, the provider must file claims to the local Blue Cross Blue
Shield plan as the “Host Plan.”

An example would be a physician in Memphis, TN, who provides care to a patient with health plan coverage
from Health Advantage. This physician is NOT in the Health Advantage provider network but is in the Blue
Cross Blue Shield of Tennessee provider networks. This claim must be submitted to Blue Cross Blue Shield of
Tennessee. If a health care provider located in a county bordering Arkansas, who participates in the provider
networks of Arkansas Blue Cross and its affiliates renders care to a member with insurance from a Blue Cross
Blue and Shield Plan other than Arkansas Blue Cross and its affiliates, the provider must file the claim to the local
Blue Cross and Blue Shield Plan, as the “Host Plan.”

An example would be a physician in Branson, MO (located in a county bordering Arkansas) who provides care
to a member with insurance coverage from Blue Cross Blue Shield of Montana. This claim must be submitted to
the local Blue Plan which, for a place of service location in Branson, MO is Anthem Blue Cross and Blue Shield
of Missouri. It does not matter whether the physician is in the Anthem Blue Cross and Blue Shield of Missouri
provider networks, the claim still must be submitted to the local or “Host Plan.”

The exceptions to these rules apply to health care providers for lab, durable medical equipment/medical supplies
and specialty pharmacy.

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Coordination of Benefits
When Arkansas Blue Cross is the secondary carrier, the benefits will be reduced by the amount paid by the
primary carrier. The allowable expense is a service that is covered in full or in part by any of the plans covering
the person. Non-covered expenses are not coordinated.

Ultimately, it is the member’s responsibility to ensure delivery of the EOB from the primary carrier to Arkansas
Blue Cross. However, if the provider receives the EOB from the primary carrier, he or she may forward it to
Arkansas Blue Cross for processing.

When Arkansas Blue Cross is secondary, a provider has the right to collect the copayment deductible, or
coinsurance and then coordinate benefits with the other carrier.

Please note: If Arkansas Blue Cross and Blue Shield is the secondary payer, providers should not submit a claim
until they have received the primary payer’s payment.

If the provider receives payment in excess of actual charges and has collected a copayment, deductible or
coinsurance from the member, the provider should reimburse the member up to but not exceeding the amount
of the copayment, deductible or coinsurance. Any additional overpayment for that date of service should be
refunded to the secondary carrier.

If the provider contractually participates with other health plan(s), the privilege to collect a copayment may be
affected by the agreement with the other health plan(s).

To file secondary claims electronically, reference Filing Claims Electronically.

Dual Arkansas Blue Cross Coverage

When a member has two Arkansas Blue Cross policies, the copayments and coinsurance amounts are paid by
the secondary plan. If one plan has a pre-existing clause, the member could have an amount that would not be
paid in full. Services that are not covered by both the primary and secondary carriers are not coordinated.

If the provider does not participate with the primary carrier but does participate with Arkansas Blue Cross, all
secondary payments will be made directly to the provider as opposed to paying the member.

Secondary Paper Claims Submission

When filing secondary paper claims, a copy of an explanation of benefits (EOB) or remittance advice (RA)
showing primary payment must be attached to each individual claim. Multiple claims attached to one copy of an
EOB or RA will be returned. The electronic submission of secondary claims is preferred. For assistance in filing
secondary electronic claims, please contact your software vendor or contact EDI Operations is 501-378-2336.

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Section 5 | Claims Filing and Information

Corrected Claims
The Arkansas Blue Cross definition of a corrected claim is a claim that has been processed, whether paid or
denied, and was refiled with additional charges, a different diagnosis, or any information that would change the
way that claim was originally processed. Placing the “Corrected Claim” indication on the claim form when it has
not been previously processed will cause a delay in claim adjudication.

Claims returned requesting additional information are NOT to be refiled as corrected claims. These claims have
been processed; however additional information is needed to finalize payment. Inappropriate usage of the
Corrected Claim form will result in information being returned to the provider.

Do not use the Corrected Claim form for the following:

ƒ New claims
ƒ Appeals
ƒ Medical records
ƒ Invoices
ƒ Inquiries
ƒ Adjustments

Corrected Claims can be used for all lines of business including BlueCard and FEP. For a Corrected Claim form,
click on the following link: Provider Forms. Filing claims electronically or by using direct data entry on Availity
prevents the need for an additional form and is the preferred method for submitting a corrected claim.

To file corrected claims electronically, reference the Filing Claims Electronically section of this manual.

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Electronic Corrected Claims Are Accepted

Arkansas Blue Cross and Blue Shield, BlueAdvantage Administrators of Arkansas, Health Advantage, FEP and
BlueCard accept electronic corrected claims.

Electronic Submission: To file corrected claims electronically for the CMS 1500 claim form, providers should
enter the number 7 in 2300/CLM05-3 and include the ICN number or BlueCard SCCF# of the original claim. The
original ICN or SCCF# (Document Control Number - DCN) should be placed in the REF segment of the Loop 2300
with a qualifier of Ref01=F8. If these are not submitted, the claims will be returned as a duplicate.

Providers need to ask their software vendor to open an area within the 2300 loop for the remarks in the NTE
segment as to what was corrected on the claim. Arkansas Blue Cross would appreciate receiving a total
replacement claim in order for a complete comparison to the original claim along with the explanation in the
NTE segment. This will expedite processing time and identify the actual corrections and the reason for the
correction for both facility and professional corrected claims. To file corrected claims electronically for the UB
claim form, the facility will need to use XX7 type of bill.

If you have questions regarding corrected claims, please contact Availity Client Services at 800-282-4548
(292-AVAILITY).

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Section 5 | Claims Filing and Information

Filing Claims Electronically

EDI is the acronym for Electronic Data Interchange. EDI is the exchange of information using routine business
transactions in a standardized computer format; for example, data interchange between an insurance carrier and
a provider. Electronic Data Interchange will save providers time and money. Providers may reach Arkansas Blue
Cross and Blue Shield EDI Services at 501-378-2336 or via e-mail at edi@arkbluecross.com.

How to Enroll
Providers must have appropriate software to transmit claims electronically. Software for the transmission of
electronic claims may be included in the provider’s current practice management or EHR system. If a provider

currently has a practice management system, contact the software vendor. Otherwise, providers must choose
a HIPAA compliant software vendor, billing agent or clearinghouse. Availity also has solutions for providers.
Providers can contact Availity to inquire: 800-282-4548 (282-AVAILITY).

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Section 5 | Claims Filing and Information

Provider Changes
Changes within a provider’s office are both necessary and inevitable. As an electronic submitter, providers
will need to notify EDI Services of any changes that may occur at a provider’s office by sending an e-mail to
edi@arkbluecross.com or faxing the information to 501-378-2265.
ƒ Address Changes – Address changes for electronic submitters must be reported to Provider Enrollment
Services (to update a provider number address) and EDI Services (to update an electronic submitter
file address).
ƒ Changes in Contact Person – EDI must know who to speak to in a provider’s office regarding
electronic claims.
ƒ Changes in Physician Staff – Please notify EDI Services, as well as Provider Network Operations, when a
doctor leaves a practice so that he/she can be deleted from the electronic billing information retained in a
provider’s office. Likewise, if new physicians are added, please let EDI know so the doctor may be added to
the electronic billing information retained in the provider’s office.

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Section 5 | Claims Filing and Information

Initial hospital visits billed by multiple physicians

In March 2012, Arkansas Blue Cross and Blue shield sent notice to providers that only the admitting physician
could bill the hospital admission CPT Codes 99221-99223. All other physicians seeing the patient, even if for the
first time, were instructed to bill the subsequent hospital CPT Codes 99231-99233. However, most physicians
continue to bill the hospital admission codes.

After data analysis and understanding that the consult CPT Codes are not available for providers to use,
Arkansas Blue Cross agrees that the physicians providing ‘consults’ to the hospital patient may bill the first visit
using the hospital admission CPT Codes 99221-99223 provided the service meets the requirements set forth by
the Centers for Medicare & Medicaid Services (CMS) for this use.

The admitting physician should add Modifier A1 for reporting purposes only. Consulting physicians and
subsequent attending physicians should not use the Modifier A1.

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Section 5 | Claims Filing and Information

Medical Facts Letter

Certain claim submissions trigger a front-end claim edit that creates a request for additional information. This
information is obtained using a medical facts letter that is sent to the provider. Listed below are guidelines for
completing the medical facts letter.

Guidelines
ƒ Complete all questions on the medical facts letter regarding pre-existing conditions and answer all questions
on our form letter.
ƒ Use the appropriate diagnosis procedure codes and try to avoid using vague or unspecified diagnosis
and V codes.
ƒ Use the appropriate E&M code for the service rendered and avoid upcoding.
ƒ Do not use modifier 25 with office visit codes unless there is really a separate identifiable service provided.
ƒ Provide both operative reports if billing as cosurgery.
ƒ Provide the lab results with neutrophil count or a formula to calculate the neutrophil count when we request
information for the use of Neupogen.
ƒ Psychiatrists’ and psychologists’ office staff should enter the correct number of services on the claim
depending on the service provided. Some “psych” codes do not have time units and entering the incorrect
number of services will result in incorrect payment.
ƒ Submit ALL requested information when requested.

Note: Arkansas Blue Cross and Blue Shield relies on the accuracy, truthfulness and completeness of all
information supplied to us on the medical facts letter to properly adjudicate the claim and the member’s
benefits. Failure to supply Arkansas Blue Cross with full, accurate information may constitute fraud. The person
completing the medical facts letter is required to sign the form. The signature on the medical facts letter is
required and is looked upon by Arkansas Blue Cross as an assurance that the information provided is true and
correct in all respects and does not present a misleading picture.

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Section 5 | Claims Filing and Information

Member Cooperation
How Member Cooperation Affects Provider Reimbursement
Arkansas Blue Cross and Blue Shield’s member health plans and contracts outline certain areas in which we
need the member’s cooperation to adequately process their claims or provide good customer service. If the
member fails to provide that cooperation, in some instances Arkansas Blue Cross will not be able to determine
benefits or may decide to deny benefits for lack of cooperation. The charges for services would then become the
member’s responsibility.

Because provider reimbursement by Arkansas Blue Cross is always subject to the terms of the member’s health
plan or contract, providers should be aware of the terms of the health plan or contract, including those terms
that require member cooperation. Providers should encourage our members who are your patients to fully
cooperate in furnishing all information needed to properly evaluate and adjudicate their claims.

When Members Fail to Cooperate

If the member fails to cooperate and Arkansas Blue Cross must deny claims on that basis, providers will not
be entitled to any reimbursement from Arkansas Blue Cross for the services in question. Areas in which we
commonly need and request member cooperation include but are not limited to:
ƒ Obtaining medical records or other claims-related information
ƒ Obtaining information regarding other coverage the member may have (coordination of benefits)
ƒ Obtaining information regarding the status of a dependent, such as a disabled child or a college student
ƒ Obtaining information regarding third party liability (e.g., auto accident), subrogation or work- related injuries

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Section 5 | Claims Filing and Information

Member Fraud or Misrepresentation

If Arkansas Blue Cross and Blue Shield discovers that a member obtained coverage initially by means of an
application that misrepresented the member’s past medical history or other relevant background, or that a
member has filed fraudulent insurance claims, Arkansas Blue Cross may elect at our discretion to terminate the
member’s health plan coverage or insurance contract, or to rescind the coverage.

If coverage is rescinded, that action is retroactive to the first date that the member’s coverage became
effective, even if that date was months or even years before Arkansas Blue Cross discovered the fraud or
misrepresentation. This means that the member, in effect, never had any coverage because the coverage was
obtained through fraudulent or material misrepresentation.

Accordingly, providers may be asked to refund prior claims payments made with respect to such a member, and
any pending claims with respect to such a member will be denied by Arkansas Blue Cross on grounds that no
coverage existed on the date of service.

Therefore, it is in a provider’s best interest to assist Arkansas Blue Cross in identifying any member fraud or
misrepresentation as early as possible, not only to protect all members and the public at large from the costs of
such improper activity, but also to protect providers.

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Section 5 | Claims Filing and Information

Most Common Claim Denials

Of all the claims submitted to Arkansas Blue Cross and its affiliates, almost twenty-five percent are denied
on the first submission because of a problem with the way the claims are filed or due to the lack of necessary
information. The top denial reasons are listed below. To help prevent these types of denials, please review the
suggestions with each reason for denial:
ƒ Additional information requested from another provider to verify completion/accuracy of enrollment
information – Failure to return any information requested in a timely manner may result in a denial.
ƒ Duplicate charge - Providers should check each EOP/RA when received. If a provider resubmits the same
claim without any changes or corrections, the resubmission will cause a duplicate-claim error. Before
resubmitting a claim, check the claims status by calling My BlueLine or check Availity online.
ƒ Information requested from policyholder not received - Providers should have the member call customer
service to provide requested information.
ƒ Medical information required to determine benefits - For some claims, providers may receive a Bar-Coded
fax or letter requesting additional information. Please refer to the bar-coded fax or letter for details on what
information is needed. Fax the Bar-Coded letter along with the requested information to Arkansas Blue
Cross. The claim will remain closed for the reason noted on the EOP/RA until Arkansas Blue Cross or its
affiliates receive the requested information.
ƒ No prior approval on file – Services that require prior approval must be authorized prior to the delivery of
services. Approval numbers must be indicated in Block 23 of the CMS 1500 claim form.
ƒ Patient account number missing – The patient’s account number must be listed on the claim, or the
submission will fail in Availity.
ƒ Service not submitted within required filing period - All claims for services must be submitted within 180
days of the date the service is rendered to be eligible for reimbursement. NOTE: If providers fail to file a
claim within the required 180-day period, providers cannot bill the member for that claim and providers will
not receive payment from Arkansas Blue Cross.
ƒ If the member fails to provide insurance information within the required 180-day fining period, providers
should not file the claim. Providers should hold the member responsible for the payment of the services.
ƒ Service part of an allowance on this or a previous claim – If the claim for service is considered part of an
allowance acknowledged on the claim or a previous claim, the claims will be denied for fragmented charges.

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Section 5 | Claims Filing and Information

Paper Claims
Providers are encouraged to utilize the much faster, easier electronic claims processing capabilities available
through Availity. However, if a provider must use paper claims, the following guidelines apply.

Guide to CMS-1500 Paper Claim Form for Professional Providers

These guidelines will help providers prepare claims for Optical Character Recognition (OCR) scanning when filing
paper claims for Arkansas Blue Cross and Blue Shield, Health Advantage, and Blue Advantage Administrators.
ƒ Align the Form: Please align the claim form carefully so that all data falls within the blocks on the claim form.
The provider will be able to keep the form aligned if they center an “X” in the boxes at the top right and left
corners of the claim. Please be sure that all line-item information appears on the same horizontal line. Claims
will be returned if they are not properly aligned.
ƒ Dates: Use an 8-digit format for all dates on the claim. For example, enter June 1, 2006 as 06012006. All dates
must be valid dates. Some fields require an entry such as DOS, while others are optional.
ƒ Dollars and Cents: Please do not use dollar signs ($) in any block. Separate dollars and cents with a blank
space. For example, enter $1,322.00 as 1332 00.
ƒ Forms: Please don’t fold, staple, or tape claims. Please separate all forms carefully. Forms must be original
red and white forms. Copies of forms or forms with light print cannot be accepted and will be returned to
the provider.

For providers using bursting equipment, adjust the splitters to precisely remove the pin feed edges. Claims must
be submitted on the 08/05 version of the CMS-1500 claim form printed with red “drop out” ink.

Providers may obtain copies of the CMS-1500 claim form through various vendors such as the American Medical
Association or the U.S. Government Printing Office.
ƒ Keep It clean: Don’t print, write, or stamp extra data on the claim form. When correcting errors, use white
correction tape only and not white correction fluid.
ƒ Lines of Service (block 24): Limit the lines of service to six lines on each claim filed. Placing information in
the shaded areas as shown on the NUCC site should be as “FYI” only since the data may not image properly.
Arkansas Blue Cross and Blue Shield does not recommend the use of this free form line. However, if it is
used, it is critical that the right qualifiers be used.
ƒ Names: For all blocks requiring names, please omit any titles, such as Mr. or Mrs. Enter the last name first,
followed by a comma, and then the first name - Last Name, First Name. (For example: Doe, James).
ƒ Print quality: Providers can help ensure that paper claims are accurately processed by checking the quality
of the print carefully. Faint printing can cause scanning problems. Please replace printer ribbons or toner
regularly and be sure to use the highest quality print setting available.
ƒ Ribbons and Fonts: Use only black ribbons in typewriters or printers and change the ribbons frequently.
Although claims can be accepted using a 12-pitch setting, please use a 10-pitch setting. If software supports
fonts, please use Courier 10 Monospace font.

By following these guidelines, providers will assist Arkansas Blue Cross and Blue Shield in meeting its goal of
efficient, accurate claims processing.

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Section 5 | Claims Filing and Information

Rejected Claims
As part of the change in claims processing, all paper claims are now processed through “front-end” edits that
verify eligibility information. Claims that cannot be scanned by OCR will be returned to the provider with an
accompanying explanation. Providers will receive a letter for claims that the OCR rejects. Please verify the
information on the patient’s insurance card prior to submission.

Submit the unacceptable claims as New claims. Do not resubmit unacceptable claims as “corrected” claims.
Unacceptable claims are rejected prior to acceptance into Arkansas Blue Cross adjudication system(s), therefore
there is no “original” claim to correct on the Arkansas Blue Cross systems.

Common causes of paper claim delays or returns

ƒ National Provider Identifier missing in blocks 17B, 32A and 33A
ƒ Invalid Place of Service and Type of Service Codes
ƒ Invalid CPT or ICD–9 codes
ƒ Misaligned information on the form. Make sure your information is inside the form blocks
ƒ Narrative text in numeric fields on the CMS-1500 (HCFA) form
ƒ Hand-written claims
ƒ Alpha characters in numbers fields
ƒ Invalid member number
ƒ Un-scannable forms or copied forms that are not of good print quality

Reminder of printing guidelines for paper claims

Arkansas Blue Cross and Blue Shield, BlueAdvantage Administrators of Arkansas, and Health Advantage
encourage providers to file claims electronically since electronic claims are processed faster and more
accurately than paper claims. However, in the event that a paper claim form is used, certain guidelines must be
followed before the paper claim can be accepted. To ensure the paper claim is accepted and the claims data is
read accurately, providers should adhere to the following guidelines:
ƒ Use only red Form CMS-1500 08/05 and red Form UB-04 that conform to CMS guidelines.
ƒ Align the form carefully so that all data falls within the blocks on the claim form. Please be sure that all line-
item information appears on the same horizontal line.
ƒ Do not hand write claim information. Claim information must be printed or typed with black ink. Remember
to regularly change your printer ribbon or ink cartridges.
ƒ Keep the form clean by not printing, writing, or stamping extra data on the form. Please refrain from using
correction fluid or correction tape. If an error occurs while completing the claim, please complete a new, red
claim form for submission.
ƒ Use only UPPERCASE letters for alphabetical entries. Don’t mix fonts or use italics, script, percent signs,
question marks or parentheses.
ƒ The recommended font for Form CMS-1500 08/05 is 12-point Courier New set at 10 characters per inch (10-
pitch), 6 lines per inch. The recommended font for Form UB-04 is 10-point Courier New set at 10 characters
per inch (10-pitch) and 6 lines per inch.

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Section 5 | Claims Filing and Information

ƒ Please separate all forms carefully. Do not fold, staple, or tape claims. Do not place any stickers on the claim
form. Remove any pin-feed edges from any continuous feed forms.

Since Optical Character Recognition (OCR) technology is used to convert paper claims to electronic data, paper
claim forms that do not comply with these guidelines or are printed too light to be successfully read by OCR
equipment may be rejected.

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Section 5 | Claims Filing and Information

Paper Claims: Step-By-Step Instructions

The following information is designed to help providers complete the new CMS-1500 claim form which is
mandated by the National Uniform Claim Committee (NUCC) to meet the requirement for all providers to have a
NPI number. Only submit paper claims if electronic claim submission isn’t possible.

Note: Effective January 1, 2007, all fields indicated as REQUIRED in the following guide must be completed or
the claim will be returned to the provider.

Block 1 – Type of Insurance:

Indicate the type of health insurance coverage applicable to this claim: Medicare, Medicaid, TRICARE,
CHAMPVA, Group Health Plan, FECA Black Lung, or Other.

Block 1A - Insured’s I.D. # (REQUIRED):

Enter the patient’s current identification number exactly as it appears on their identification card, including the
appropriate three letter alpha prefix. Please don’t list any extra data, such as the name of the plan. Transposed
or incomplete contract numbers will cause a delay in the processing or denial of the claim.

Block 2 - Patient’s Name (REQUIRED):

Enter the patient’s last name followed by a comma and the first name in all capital letters. An entry in
this block is required. Do not include any apostrophes, hyphens, suffixes (like Jr. or Sr.), or titles (such as
Mr. or Mrs.) any other marks of punctuation besides the comma. For example, enter Mrs. Mary O’Hara as
“OHARA, MARY.”

Block 3 - Patient’s Date of Birth and Sex (REQUIRED):

Enter the patient’s birth date (MM DD CCYY) and sex. A space must be reported between month, day, and
year. Entry in both the date of birth and sex is required.

Block 4 - Insured’s Name (REQUIRED):

Enter the last name of the policyholder or subscriber, followed by a comma and the first name. Please enter
this name exactly as it appears on their card. Do not include any apostrophes, hyphens, suffixes (like Jr. or Sr.),
or titles (such as Mr. or Mrs.) any other marks of punctuation besides the comma. For example, enter Mary
O’Hara as “OHARA, MARY.” Using the terms “same” or “self” may result in a claim being rejected.

Block 5 - Patient’s Address (REQUIRED):

Fill out this block only if the patient’s address is different from the insured’s address, in Block 7, and please
enter no more than 28 characters in this field.

Block 6 - Patient’s Relationship to Insured (REQUIRED):

Check the appropriate box for patient’s relationship to insured. Enter an “X” in one of the following boxes:
ƒ Self - the patient is the subscriber or insured
ƒ Spouse - the husband or wife or qualified partner as defined by the insured’s Plan.
ƒ Child - minor dependent as defined by the insured’s Plan.
ƒ Other - stepchildren, student dependents, handicapped children, & domestic partners.

Block 7 - Insured’s Address and Telephone (REQUIRED):

Enter the Insured’s address and telephone number.

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Block 8 – (reserved for NUCC use).

Block 9 - Other insured’s Name (REQUIRED):

If the patient is covered under another health benefit plan including Arkansas Blue Cross and Blue Shield,
BlueAdvantage, or Health Advantage, please enter the full name of the policyholder.

Block 9A - Other insured’s Policy or Group Number (REQUIRED):

Enter Other Insured’s Policy or Group Number (Note: Do not use a hyphen or space within the policy or
group number.)

Block 9B - (reserved for NUCC use)

Block 9C - (reserved for NUCC use)

Block 9D - Other Insured’s Plan Name or Program Name (REQUIRED):

Enter the other insured’s plan name or program name. If recipient has Medicare coverage, enter the word
Medicare followed by the Medicare plan name (e.g., Medicare Senior Dimensions, Medicare Senior Care Plus).

Block 10 (A - C) - Patient’s condition related to?

For each category (employment, auto accident, other), insert an “X” in either the YES or NO fields. If any
“YES” fields are selected, Block 14 must be populated with the accident date. The appropriate postal
abbreviation for the STATE must be supplied if an AUTO ACCIDENT.

Block 10D - This field is reserved for local use

Block 11 - Insured’s Policy, Group, or FECA Number (REQUIRED):

Enter the insured’s current identification number exactly as it appears on their identification card, including the
appropriate three-letter alpha prefix. Please don’t list any extra data, such as the name of the plan. Transposed
or incomplete contract numbers will cause a delay in processing or denial of the claim.

Block 11A - Insured’s Date of Birth, Sex (REQUIRED):

Enter the 8-digit date of birth (MM/DD/CCYY) of the insured and an “X” to indicate the sex of the insured.

Block 11B – Other Claim ID (Designated by NUCC). Block 11C – Insurance Plan Name of Program Name:
Enter the insured’s plan name or program name as it appears on their identification card.

Block 11D - Is there another health benefit plan?

Enter an “X” in the appropriate box. If marked “Yes”, complete 9 and 9 A-D.

Block 12 – Patient’s or Authorized Person’s signature.

Block 13 – Insured’s or Authorized Person’s signature.

Block 14 - Date of Current Illness, injury or Pregnancy:

Injury - Enter date the accident occurred; if any YES fields are marked with an “X” in Block 10 (A - C) then Block
14 must populated with the accident date.

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ƒ Illness - Enter for acute medical emergency only and include onset date of condition;
ƒ Injury – Enter the date of the accident
ƒ Chiropractic – Enter the date of the first treatment.
ƒ Pregnancy - Enter date of the last menstrual period (LMP) as the first date.

Block 15 – Other Date:

If patient has had the same or similar illness, enter the date of the onset of illness.

Block 16 – Dates Patient Unable to Work in Current Occupation:

Enter the date range where patient is unable to work in current condition.

Block 17- Name of Referring Physician or Other Source (REQUIRED):

Enter the name (First Name, Middle Initial, and Last Name) and credentials of the professional who referred or
ordered the service(s) or supply(s) on the claim. Do not use periods or commas within the name.

Block 17B - National Provider Identifier (NPI) (REQUIRED):

Enter the NPI of the referring provider, ordering provider, or other source in 17B. (Note: Now required for
claims filed May 23, 2007 or later.)

Block 18 - Hospitalization Dates Related to Current Services:

Enter admission and discharge dates (MM DD YY format) for inpatient hospitalization related to
current services.

Block 19 – Additional Claim Information (Reserved for local use). Block 20 - Outside lab charges:
If laboratory work was performed outside a provider’s office, enter the laboratory’s actual charge to the
provider. If the laboratory bills Arkansas Blue Cross directly, enter an “X” in the “NO” box.

Block 21(A-L) - Diagnosis and/or Nature of Illness or Injury (REQUIRED):

Enter the appropriate ICD-9 diagnosis code (up to five digits) for the services performed. Enter up to twelve (12)
ICD-9 codes in the spaces indicated A through L. Enter the codes across each line, not down Do NOT use any
punctuation such as a decimal.

Block 22 – Resubmission Code:

Complete the field to adjust or void a previously paid claim. Otherwise, leave this field blank.
ƒ In the Code area, enter an adjustment or void reason code
ƒ In the Original Reference Number area, enter the last paid Internal Control Number (ICN) of the claim.

Block 23 – Prior Approval Number:

Enter only one approval number per claim form. Enter any of the following as assigned by the payer for the
current service:
ƒ Prior approval number,
ƒ Referral number, or
ƒ Mammography prior approval number.

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Block 24 - Supplemental Information:

The following are types of supplemental information that can be entered in the shaded areas of Item
Number 24.

National Drug Codes (NDC) for drugs – must have N4 qualifier followed by 11 digit NDC code – do not put a
space between the qualifier and code; do not use hyphens in the code.

Placing the following information in the shaded areas as shown on the NUCC site should be as “FYI” only
since the data may not image properly. Arkansas Blue Cross does not recommend the use of this free form
line. However, if it is used, it is critical that the right qualifiers be used.

Narrative description of unspecified codes must have a “ZZ” qualifier followed by the code description – do
not put a space between the qualifier and the code.

From the NUCC website:

“To enter supplemental information, begin at Block 24A by entering the qualifier and then the information.
Do not enter a space between the qualifier and the number/code/information. Do not enter hyphens or
spaces within the number/code.”

Block 24A-Date(s) of Service (REQUIRED):

Enter date(s) of service, from and to. If only one date of service, enter that date under “From.” Leave “To”
blank or re-enter “From” date. If grouping services, the place of service, procedure code, charges, and
individual provider for each line must be identical for that service line. Grouping is only allowed for services on
consecutive days. The number of days must correspond to the number of units in 24G.

Block 24B - Place of Service (POS) Code (REQUIRED):

Enter the appropriate two-digit code from the “Place of Service” list from the CMS web site for each item used
or service performed. The “Place of Service” identifies the location where the service was rendered. POS
11 = Office

Block 24C - EMG Emergency Indicator:

Enter “N” for NO and “Y” for YES in the bottom, unshaded area of this field.

Block 24D - Procedures, Services or Supplies (REQUIRED):

Enter the CPT/HCPCS code(s) and applicable modifier(s) from the appropriate code set in effect on the date of
service. This field accommodates the entry of up to four two-digit modifiers. The specific procedure code(s)
must be shown without a narrative description unless it is an ‘unlisted’ procedure code. If ‘unlisted’ an NDC or
description must be shown in the shaded area for that line.

Block 24E - Diagnosis Pointer (REQUIRED):

Enter the line-item diagnosis code pointer(s) referencing the appropriate diagnosis code(s) reported in Block
24D. Do not use a range, list primary diagnosis for the service line first. (1, 2, 3 not 1-3).

Block 24F - Charges (REQUIRED):

Enter the charge for each listed service.

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Block 24G - Days or Units (REQUIRED):

Enter the units of service rendered for the procedure. Anesthesia services and “special” procedure codes
require time units format. (Note: Must be whole number).

Claims submitted for anesthesia services by anesthesiologists or CRNAs must indicate the actual total number
of minutes that anesthesia was administered. For example, if anesthesia was performed for 1 hour and 22
minutes, this would be indicated as 82 minutes in block 24G of the CMS-1500 claim form. If no units are
indicated on the claim, the claim will be denied.

Block 24H – EPSDT/Family Plan (Situational):

For providers that bill Family Planning services, enter “Y” if services were family planning and “N” if
they were not.

Block 24I – ID Qualifier (REQUIRED):

ƒ Using NPI in field 24J: Enter “ZZ” in the top, shaded half of the claim line.
ƒ Using API in Field 24J: Enter “N5” in the top, shaded half of the claim line.

Block 24J - Rendering Provider ID Number (REQUIRED):

The individual provider rendering the service should be reported in Block 24J. The original fields for Block 24J
and 24K have combined and re-numbered as Block 24J. Enter the NPI number in the un- shaded area of the
field. (Note: NPI is required on claims filed on May 23, 2007 or later).

Block 25 - Federal Tax ID Number:

Enter the provider of service’s or supplier’s federal tax ID (employer identification number) or Social Security
number. Enter “X” in the appropriate box to indicate which number is being reported. Only one box can
be marked.

Block 26 - Patient’s Account Number (REQUIRED):

Enter the patient’s account number assigned by the provider of service’s or supplier’s accounting system.

Block 27 - Accept Assignment? (REQUIRED):

Enter an “X” in the correct box. Only one box can be marked. “Accept Assignment” indicates the provider
agrees to accept assignment under the terms of the Medicare Program.

Block 28 - Total charge (REQUIRED):

Enter the sum of all line charges.

Block 29 - Amount Paid:

Enter the total amount the patient or other payers paid on the covered services only. Attach a copy of the other
insurer’s explanation of benefits (EOB) and complete Block 9.

Please note: If Arkansas Blue Cross is the secondary payer, providers should not submit a claim until payment
is received from the primary payer.

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Block 30 – Balance Due (reserved for NUCC use):

Block 31 - Signature of Physician / Supplier:

Enter the legal signature of the practitioner or supplier, signature of the practitioner or supplier representative,
“Signature on File,” or “SOF.” Enter the eight-digit date (MM/DD/CCYY), or alphanumeric date (e.g. January 1,
2006) the form was signed.

Block 32 - Service Facility Location:

Enter the name, address, city, state, and zip code of the location where the services were rendered. Providers
of service (namely physicians) must identify the supplier’s name, address, zip code, and state when billing for
purchased diagnostic tests. When more than one supplier is used, a separate CMS-1500 claim form should be
used for each supplier. Leave blank if this is a sub-part of the location entered in Block 33.

Block 32A National Provider Identifier (NPI) (REQUIRED):

Enter the National Provider Identifier (NPI) number of the service facility. (Note: NPI is required for claims filed
on May 23, 2007 or later).

Block 33 - Physician’s or Supplier’s Billing Name, Address, and Phone:

Enter the provider’s or supplier’s billing name, address, zip, and phone number. The phone number is
to be entered in the area to the right of the field title. Enter the name and address information in the
following format:
ƒ 1st line – Name
ƒ 2nd line – Address
ƒ 3rd line – City, State, and Zip Code

Block 33A - National Provider Identifier (NPI) (REQUIRED):

Enter the “pay to” National Provider Identifier (NPI) number of the billing provider in Block 33A. (Note: The NPI
is required for claims filed May 23, 2007 or later).

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Section 5 | Claims Filing and Information

Prepay Review of High-Dollar Inpatient Claims Changes for 2021

Services
The Blue Cross Blue Shield Association made changes to the high-dollar inpatient claims review for 2021.
These changes were adopted by Arkansas Blue Cross and Blue Shield and its family of companies effective
January 1, 2021.

The Association, in 2019, began requiring itemized bills for high dollar inpatient claims that were $250,000 or
greater. Arkansas Blue Cross was required to adopt that policy and subsequent updates to the policy. For 2020
the amount was lowered to $200,000, and upon reviewing the findings and results of this policy, the Association
lowered the threshold for 2021 to $100,000. Therefore, please remit itemized bills for all inpatient claims of
$100,000 or more if the claim will have a payment that is tied to the billed charge (i.e., not paid wholly by per
diem, case rate or diagnosis-related group). To avoid unnecessary delays or interruption of payments of these
claims, providers are asked to submit an itemized bill with any claim that meets these criteria.

Arkansas Blue Cross and its family of companies use the CMS Provider Reimbursement Manual and the UB
Editor for guidance, as well as the services of Optum (formerly known as Equian) to conduct this prepay review.
Arkansas Blue Cross and the Blue Cross Blue Shield Association will continue to evaluate the results of the
prepay review to determine whether the billed amount subject to review should be adjusted.

To minimize the administrative work this change will create for the providers, Arkansas Blue Cross is working to
automate an electronic submission format to allow the providers to bill the electronic claim and other supporting
documentation simultaneously.

Please contact your network development representative for specifics about submitting itemized bills with
the claims.

Note: For questions involving a report’s findings, we ask that providers work with Equian/Optum directly. Please
review the report and contact Equian/Optum to discuss any inquiries regarding review findings and/or the
documentation and explanation necessary to clarify the questioned charges:

Claims Resolution
Email: claimsresolution@equian.com
Direct: 888-895-2254

Additionally, providers may formally dispute a report’s findings. Please identify the correspondence as a formal
dispute, include the documentation and explanations necessary to clarify the questioned charges, and send the
formal written dispute to:

Claims Disputes / Reconsiderations

Email: reconsiderations@equian.com
Fax: 866-700-5769
Mail: Equian, LLC / Attention: Claims Disputes / 600 12th St / Suite 300 / Golden, CO 80401

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Section 5 | Claims Filing and Information

Provider “Third Party Liability” or “Subrogation” Activities and

Member Claims
Arkansas Blue Cross and Blue Shield would like to provide the following notice regarding applicable claims
filing policies and procedures of Arkansas Blue Cross and its affiliate, Health Advantage, in situations in which
a third party or their liability carrier are responsible for the injuries an Arkansas Blue Cross or Health Advantage
member sustains (generally referred to for shorthand convenience as “Third Party Liability” or “Subrogation”
matters). These policies and procedures have been in place for many years but are being restated for emphasis
due to increasing Third Party Liability or Subrogation activities of some providers.

Providers are reminded that their network participation agreements obligate them to comply with all claims
filing policies and procedures, including those published in Providers’ News.
1. Arkansas Blue Cross and Blue Shield and Health Advantage encourage providers to file all claims, rather than
holding such claims to pursue Third Party Liability or Subrogation. Filing the claim allows quick provision of
any available health plan or insurance contract benefits to our members and provides the fastest payment to
providers.

2. Although filing of claims is strongly encouraged and preferred, Arkansas Blue Cross and Health Advantage
provider contracts do not require that claims be filed with them and recognize that state law specifically
grants a lien to providers for Third Party Liability (i.e., providers can claim a part of any third party recovery
the member may otherwise seek or be entitled to recover).

3. While Arkansas Blue Cross and Health Advantage understand this state lien law, and do not purport
to change or challenge it, Arkansas Blue Cross and Health Advantage do require as an express term of
their network participation agreements that participating providers must not pursue the member for any
amounts in excess of the Arkansas Blue Cross or Health Advantage payment (“Excess Amounts”) although
participating providers may collect applicable member deductible, coinsurance or copayments. This means
that while a provider can go after the third party or their carrier without violating their network participation
agreement, the provider cannot attempt to recover “Excess Amounts” from the member. Any attempt to bill
the member or collect against the member or their assets for Covered Services will be deemed a violation of
the network participation agreement.

4. Providers are reminded that network participation agreements impose a 180-day timely filing requirement
for all claims, and expressly bar collection – either from Arkansas Blue Cross or Health Advantage or
the member – on claims not filed within 180 days. Thus, if a provider elects not to file a claim in favor of
exclusively pursuing Third Party Liability or Subrogation, if that effort causes a delay in filing the claim past
the 180-day filing deadline, providers cannot thereafter bill either the member or Arkansas Blue Cross or
Health Advantage for any amount on such claims.

5. Providers are also reminded that while they may elect not to file a claim, members may still file the claim
with Arkansas Blue Cross or Health Advantage based on the provisions of their member certificate or
evidence of coverage. If the member files a claim that a provider has withheld, Arkansas Blue Cross or Health
Advantage will attempt to develop and process that member- submitted claim. Providers are contractually
obligated in such circumstances to provide to Arkansas Blue Cross and Health Advantage information
needed to evaluate and process the claim. Any payments determined due on such claims will be paid to the
provider. Providers may not decline to accept the Arkansas Blue Cross or Health Advantage payment in such

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Section 5 | Claims Filing and Information

situations. If a provider does breach the participation agreement by declining to accept payment, Arkansas
Blue Cross or Health Advantage will then make payment to the member. In either case, whether the payment
is accepted or declined, and whether payment is made to the provider or the member (following provider
refusal to accept), the provider cannot pursue collection against the member for Excess Amounts.

6. Arkansas Blue Cross and Health Advantage do not take a position regarding a provider’s option to

a. File claims and receive the Arkansas Blue Cross or Health Advantage payment and also
b. Pursue Third Party Liability or Subrogation for the remaining portion of their bills (the Excess Amounts).

The only interest for Arkansas Blue Cross and Health Advantage is in ensuring that providers understand
that once they become a participating provider in these networks, they cannot pursue the member for
amounts beyond the Arkansas Blue Cross or Health Advantage payments.

7. To the extent that any of the preceding rules of network participation have not been clearly understood
or interpreted by any provider or party, this Providers’ News article shall be deemed to constitute notice
of an amendment to the network participation agreement of Arkansas Blue Cross and Health Advantage
participating providers.

With respect to Arkansas’ FirstSource® PPO and True Blue PPO networks of PPO Arkansas, the same
policies and procedures as referenced above shall apply, with the only variation being that PPO Arkansas
is not a payer of any claims of self-funded groups that access these networks; accordingly, payment of all
such self-funded group claims is always subject to funding and direction of the employer-sponsor as Plan
Administrator of such plans.

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Section 5 | Claims Filing and Information

Splitting claims
Providers should submit all codes for one place of service on one date of service for payment on one claim.
Providers should not submit multiple claims for payment for the same date of service by splitting the codes
billed on separate claims. Splitting the claims may cause the claim(s) to pend for manual processing and
possibly delay payment.

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Section 5 | Claims Filing and Information

Cloned Medical Record Documentation Policy

All Arkansas Blue Cross and Blue Shield, Health Advantage and PPO Arkansas (“ABCBS”) network provider
participation agreements require that all providers create and maintain a standard, contemporaneous
medical record for each Member receiving services. The medical records shall be created and maintained in
compliance with, and shall contain the information required by state and federal laws and regulations, including
requirements of the Medicaid and Medicare programs, and shall be retained for such time periods required by
law or regulation, but in any event not less than seven years after the date of service.

All documentation in the medical record must be specific to the individual patient and specific to the individual
encounter.

The word ‘cloning’ refers to documentation that is worded exactly like previous medical record entries. Cloned
documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic
Health Record (EHR). The United States Department of Health and Human Services, Office of Inspector General
strongly discourages cloning of medical records and continues to monitor it closely.

Cloning of documentation which fails to consider patient specific variations will be considered a
misrepresentation of the medical necessity requirement for coverage of services. In other words, it will be
considered a breach of the required terms of each ABCBS provider agreement. Any claim connected to medical
record cloning described herein may be denied, and further, providers will not be allowed to bill or seek to
collect from the Member any charges described in the cloned medical records.

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Section 5 | Claims Filing and Information

Timely Filing Guidelines

As a reminder, the following information regarding timely claims filling applies to Arkansas Blue Cross and Blue
Shield, BlueAdvantage Administrators of Arkansas and Health Advantage and includes claims for members of
other Blue Cross Plans.

Filing Original Claim

Providers must submit claims for any service, supply, prescription drug, test, equipment or other treatment
within 180 days after such service, supply, prescription drug, test, equipment or treatment is provided. In the
case of a claim for inpatient services for multiple consecutive days, a written proof must be submitted no later
than 180 days following the date of discharge for that admission.

Re-submitting Claims
Arkansas Blue Cross and its affiliates also require providers to use this 180-day timely filing limit for re-
submitting claims for adjustments, or for submitting additional information on a previously filed claim.

Adjudicated Claims/COB
Arkansas Blue Cross and its affiliates extends the timely filing requirements to include 180 days after the primary
insurer adjudicates the claim. Timely deadline for secondary claims is 180 days from the date processed by the
primary carrier.

Member Responsibility
The 180-day timely filing provision is applicable for both providers and members. When a patient covered by
Arkansas Blue Cross or an affiliate does not provide their provider with proof of coverage until after the 180-day
timely filing has expired, that patient is responsible for the services and the provider should not bill Arkansas
Blue Cross or its affiliates.

All contract holders should have a member identification card and should present their ID card prior to each
service. Arkansas Blue Cross and its affiliates encourage all providers to have their patients complete insurance
coverage update forms at the time of each service. By completing an insurance coverage update form, patients
are given every opportunity to provide up-to-date insurance information.

For questions regarding coverage, providers should refer to the tool on Availity f or call The BlueLine, our voice
activated response service, available 24 hours a day, 7 days a week.

(This information does not apply to the Federal Employee Program (FEP)).

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Section 5 | Claims Filing and Information

Timely Filing Requirements

Members covered under health plans sponsored by Arkansas Blue Cross and Blue Shield usually have
limitations to the time for which benefits are available after services are rendered. This stipulation, called a
“timely-filing” provision, makes prompt submission of claims critical to getting the claim paid.

In most cases, to be eligible for benefits, a claim must be submitted within 180 days of the date services are
rendered. Corrected claims must be submitted within 180 days of the original payment date.

Timely Filing Requirements

ƒ COB - In the case of coordination of benefits when Arkansas Blue Cross is the secondary payer, the claim
must be filed within 180 days of the primary payer’s determination.
ƒ Medi-Pak ® - The claim must be filed within 180 days from the date Medicare paid.
ƒ BlueCard® - Timely filing requirements are determined by the home plan.
ƒ Medicare Advantage - Timely filing requirements are the same as Medicare.

Proof of Timely Filing

Documents submitted as proof of timely filing will only be accepted if computer generated and contain the
following information:
ƒ Physician or facility name
ƒ Patient’s name and member ID#
ƒ Date of service
ƒ Charged amount
ƒ CPT code
ƒ Date claim was originally filed/resubmitted
ƒ Insurance acceptance or 999 report is the preferred documentation and should be submitted for best
practice to qualify for timely filing review.
ƒ If the insurance filed shows a plan other than Arkansas Blue Cross, a memo should be attached indicating
when the provider was notified that the member had other insurance and any circumstances that caused the
delay in filing with the correct or the delay in checking the status of the claim. These cases will be reviewed.
If the member did not notify the provider of the correct insurance plan within the timeframe to comply with
timely filing, the claim should not be filed and the member can be billed.

If a provider attached a claim correction form to a paper claim with proof of timely filing, this can expedite the
process since the scanning system should halt the claim for review.

The following will not be accepted as proof of timely filing:

ƒ Hand-written notes indicating date the claim was filed
ƒ Computer notes with incomplete information
ƒ Insurance codes with no explanation
ƒ Proof of timely filing with a date of service past 180-days from the current date; (Extenuating circumstances
may be reviewed by attaching a memo.)

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Section 5 | Claims Filing and Information

ƒ Dates on the bottom of the claim submitted as proof

If Arkansas Blue Cross and Blue Shield is secondary, the 180-day timely filing starts from the primary carrier’s
Remittance Advice date of payment or denial.

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Section 5 | Claims Filing and Information

UB-04 Facility Claims

Information regarding the national uniform billing data element specifications manual as developed by the
National Uniform Billing Committee (NUBC) can be found by accessing their web site at nubc.org.

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Section 5 | Claims Filing and Information

Rule and Regulation 43, Clean Claims, and Section 14 Claims

The Arkansas Insurance Department Rule and Regulation 43 sets standards for timely processing of health
insurance claims. Rule and Regulation 43 establishes the maximum number of days that insurance carriers have
to process “clean claims” and “non-clean claims” or “Section 14 Claims” without incurring penalties. All claims
to insurance carriers are subject to this regulation.

Rule and Regulation 43

Rule and Regulation 43 requires that:
1. All clean claims submitted electronically must be processed (paid or denied with notification to provider or
member) within 30 days. Clean claims submitted on paper must be processed within 45 days.
2. For Section 14 Claims, the claim must be determined to be non-clean and returned to the provider or
member within 30 days. After the correct information has been provided to the insurance carrier, the
insurance carrier then has 30 days to process the claim.

If the insurance carrier does not process a clean claim within 60 days, the insurance carrier must then pay a
penalty beginning on the 61st day after the claim was filed. The penalty is the amount of the claim multiplied by
12 percent per annum multiplied by the number of days delinquent divided by 365.

If the insurance carrier does not process a Section 14 Claim within 45 days of receipt of necessary information,
the insurance carrier must then pay a penalty beginning on the 46th day after the correct information is received.
The penalty is the amount of the claim multiplied by 12 percent per annum multiplied by the number of days
delinquent divided by 365.

For information and guidelines on filing the CMS-1500 claim form and CMS-1500 anesthesia claim form and for
filing guidelines for Wellness services, please read the following information.

R&R 43 Exceptions: This rule does NOT apply to the Federal Employee Program and some groups administered
by BlueAdvantage Administrators of Arkansas.

Clean Claims
Clean Claims are claims submitted with all information necessary for payer adjudication and that do not
require further investigation. A “Clean Claim” does not include claims on expenses incurred during a period
of time when premiums were delinquent or for benefits under a Medicare supplement policy if the claim is not
accompanied by an explanation of Medicare benefits or the Explanation of Medicare Benefits (EOMB) has not
been otherwise received by the insurance carrier.

Section 13 Claims
Section 13 Claims are claims that have been submitted but must be suspended from processing until the
insurance carrier receives more information. They are called “Section 13 Claims” because the rules for
processing these claims are found in Section 13 of Rule and Regulation 43. Under the terms of Rule and
Regulation 43, an insurance carrier must notify the claimant (provider or member) within 30 days of receiving
a Section 13 Claim of the need for additional information to process the claim correctly. Necessary information
may include any of the following:
ƒ Information to determine if contract limit or exclusion applies

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Section 5 | Claims Filing and Information

ƒ Medical information to determine price of medical procedure

ƒ Information to determine eligibility of claimant
ƒ Information to determine if claim is covered by another carrier, government program, workers’ compensation
or third party
ƒ Information to determine coordination of benefits (COB) obligation
ƒ Information to determine if there is fraud or material misrepresentation
ƒ Payment of premiums that were delinquent at the time of claimed services

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SECTION 6

Claims Payment,
Refunds, & Offsets
Section 6 | Claims Payment, Refunds, & Offsets

Appeals and Re-reviews

All re-review and appeal requests should be submitted in writing within 180 days of the denial of benefits on a
claim and should include: the issue being appealed, the date of service, the patient’s name and ID number, the
provider’s name, and reasons why the provider/member believes that the claim was incorrectly denied in whole
or in part. The request should also include any medical records relevant to the appeal. For greater efficiency,
providers are encouraged to pursue resolution with customer service prior to filing a re-review or appeal with
Arkansas Blue Cross. An appeal or re-review request should not be submitted with a Corrected Claim form; this
will only delay the appeal or re-review response.

1. Appeals and Re-review requests on Arkansas Blue Cross and Blue Shield Covered Members:

a. Provider Re-reviews: Arkansas Blue Cross and Blue Shield requires providers to request a re- review
of a denied claim (in whole or in part) prior to the submission of an appeal. Re-reviews should be
submitted to:
Arkansas Blue Cross and Blue Shield
Attn: Medical Re-Review
P.O. Box 3688
Little Rock, AR 72203

b. Provider Appeals: If the denial of the service continues to be disputed after the re-review is completed,
an appeal may be submitted within 180 days of the original denial of the service. An appeal request on
an Arkansas Blue Cross and Blue Shield member should be submitted to:
Arkansas Blue Cross Blue Shield Appeals Department
Attn: Appeals Coordinator
P.O. Box 2181
Little Rock, AR 72203

Fax: 501-378-3366
Email: appealscoordinator@arkbluecross.com

c. Member Appeals: Members should submit appeal requests in writing to the Appeals Coordinator at the
above referenced address within 180 days of the denial of the service. The same information listed above
under provider appeals is required for a member appeal.

2. Appeals and Re-review requests on out-of-state Blue Cross and Blue Shield Plan Members (BlueCard):
Each Blue Cross Blue Shield Plan is an independent licensee of the Blue Cross and Blue Shield Association.
Therefore, each Plan develops their own certificates and policies and controls benefits for their members.
Arkansas Blue Cross and Blue Shield acts as the Host Plan for other Blue Cross Plans when Arkansas
Providers are used for services. Arkansas Blue Cross and Blue Shield only prices the claim when the member
is covered under a Blue Cross Plan other than Arkansas Blue Cross, and the provider is in Arkansas. The
member’s Home Plan determines if benefits are due. Providers who disagree with the way a claim was
processed or paid may contact BlueCard Customer Service at 800-880-0918 for assistance.

a. Provider Re-review of the allowance for a service: Providers should send their request in writing to:
Arkansas Blue Cross and Blue Shield
Attn: Medical Re-review
P.O. Box 3688
Little Rock, AR 72203

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If the provider continues to dispute the allowance for a service after the re-review response, a written
appeal may be filed with the Arkansas Blue Cross and Blue Shield Appeals Coordinator. (Address
listed above.)

b. Provider Appeals related to benefits available under another Blue Cross Plan: The provider should send
their written appeal to:
Arkansas Blue Cross and Blue Shield
Attention: BlueCard Correspondence 601 Gaines St.
Little Rock, AR 72203

Arkansas Blue Cross and Blue Shield will forward the appeal to the member’s correct Home Plan for
response by the other Blue Cross Plan.

c. Member Appeals: Members should submit their appeals directly to their own Blue Cross Plan.

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Claims Payment Issues

While one of Arkansas Blue Cross’s ongoing goals is to minimize the number of claims paid incorrectly, errors
are occasionally made. Some of these errors can affect a provider’s 1099 earnings and/or a patients’ claim
history, deductibles, and benefit limits. These situations can result in incorrect information being reported to the
IRS and/or incorrect patient benefit determination. Please note:
ƒ Amounts of issued provider payee checks are recorded as increases to the 1099 earnings.
ƒ Amounts of voided provider payee checks are recorded as decreases to the 1099 earnings.
ƒ Amounts received from providers (claims refunds) are recorded as decreases to the 1099 earnings.
ƒ 1099 earnings are accumulated under the Tax Identification Number (TIN) of the payee, as recorded in our
files at the time of the transaction.

Changes in Name or EIN (Employer Identification Number)

Providers must notify Arkansas Blue Cross and Blue Shield promptly with changes in their EIN or name to
ensure accurate reporting to the IRS. If the IRS sends Arkansas Blue Cross a “B-Notice” indicating that the
Taxpayer Name and EIN does not match the IRS records, Arkansas Blue Cross will be required to withhold,
and remit to the IRS, 28% of future amounts payable to providers if corrected data is not received within the
mandated time frame. Once withheld amounts are remitted to the IRS, they cannot be refunded to providers but
will be reported on the 1099 as “Federal Income Tax Withheld.”

Deductibles, Benefit Limits, Out-of-Pocket Maximums, and Lifetime Maximums

Deductibles, benefit limits, out-of-pocket maximums, and lifetime maximums are accumulated by individual
members. If erroneous claims are not adjusted appropriately and promptly, subsequent claims may be
incorrectly adjudicated.

Please verify that the payee is correct on all checks received prior to negotiating them.

Examples of Payment Errors

Listed below are examples of some payment situations that can occur, along with procedures recommended to
facilitate correction of the data:
ƒ If a provider receives payment for a claim for services that they did not perform: Please refund the amount
paid in error. Even if you know to whom the payment should have been made, do not forward the amount to
that party. A provider’s 1099 can only be corrected if the money is returned and the claim reprocessed to the
appropriate party.
ƒ If the patient was paid, and payment should have been made directly to the provider: Please advise the
patient to return the check, or refund the amount paid, along with a request to reprocess the payment to the
provider. If a provider accepts payment from the patient, Arkansas Blue Cross could subsequently discover
the error and send a request for refund to the member since our records will reflect the member received
the payment.
ƒ If a provider was paid, and payment should have been made to the patient: Please refund the payment
to Arkansas Blue Cross and Blue Shield (rather than to the patient) along with a request to reprocess the
payment to the patient. A provider’s 1099 can only be corrected if the money is returned and the claim
reprocessed to the appropriate party.

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ƒ If a check is made payable to an individual physician but should have been made payable to the clinic: Please
return the check to Arkansas Blue Cross (rather than depositing the check in the clinic’s account) with a
request to reprocess the payment to the appropriate provider. A provider’s 1099 can only be corrected if the
money is returned and the claim reprocessed to the appropriate party.

Note: If the check is made payable to an individual physician, the 1099 will be generated in the physician’s name,
even if they are an employee of the clinic.

Arkansas Blue Cross and Blue Shield recommends providers endorse and deposit all checks as soon as possible
after confirming that the payee is correct. Most of the checks from Arkansas Blue Cross have a preprinted
stale-date message indicating that the check will be void if not cashed within a specific time frame (usually six
months). After that time, the check must be reissued or, in some cases, the claim must be reprocessed.

As a deterrent to fraud and to enhance the quality of copies of cleared checks that might be requested in the
future, Arkansas Blue Cross also recommends that provider endorsements be made in BLACK ink and include
the bank account number into which the deposit is being made.

Minimize the Time Required to Process a Claim Refund

To minimize the time required to process a claim refund and to ensure that your 1099 earnings are adjusted
accurately:
ƒ When sending us a requested refund: Please return the remittance copy of the refund request letter along
with the check.
ƒ When sending us an unrequested refund: It is not necessary to return the original check and the entire
explanation of payment if just one or two patient claims are paid incorrectly. Please enclose copies of the
remittance advice/explanation of payment pages with the claims paid in error highlighted and a notation of
the reason for the refund or enclose the following information for each claim paid in error:
1. Reason for the refund
2. Patient name
3. Patient ID number
4. Date of service
5. Amount
6. Provider name (pay to)
7. NPI (pay to)
8. TIN (pay to)

If the provider is not returning the original check, a separate refund check for each line of business is preferred.

A provider’s 1099 earnings can only be corrected if Arkansas Blue Cross has the specific provider name, NPI, and
EIN. If a provider uses the services of a third party for these financial transactions, please instruct the third party
administrator to provide this information on each refund.

Please do not combine refunds for Arkansas Blue Cross, Health Advantage, BlueAdvantage, USAble
Administrators, and Medicare. Please do not issue refund checks payable to Arkansas’ FirstSource®. Refund

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checks pertaining to FirstSource members should be made payable to the appropriate check issuer (which may
sometimes be a third party administrator for a self-funded plan): Arkansas Blue Cross and

Blue Shield, BlueAdvantage, USAble Administrators, Health Advantage or another outside carrier that accesses
the FirstSource® PPO Network with a copy of the remittance advice/explanation of payment.

Note: Federal Employee Program (patient ID# begins with “R”) refunds should not be combined with others to
Arkansas Blue Cross in order to comply with new timeliness standards even though the refunds are sent to the
same processing location.

The following are the correct addresses to use for claim refunds:

Arkansas Blue Cross and Blue Shield

P.O. Box 2099
Little Rock, AR 72203

Health Advantage
P.O. Box 8069
Little Rock, AR 72203

BlueAdvantage Administrators of Arkansas

P.O. Box 1460
Little Rock, AR 72203

USAble Administrators
P.O. Box 1460
Little Rock, AR 72203

Medicare (part A or B)
P.O. Box 8075
Little Rock, AR 72203

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Copayments, Coinsurance, and Deductibles

Copayments, coinsurance and deductibles are all vital components of not only actuarial calculations of premium,
but also cost incentives to the member. As required by our provider participation agreements, providers should
always bill and collect all copayments, coinsurance and deductibles directly from the member. As the provider
looks solely to Arkansas Blue Cross and Blue Shield for payment of covered services, providers should not bill
or collect any amount in excess of the Arkansas Blue Cross payment except for the applicable copayments,
coinsurance and deductibles.

Providers may collect any amount from members for services that are deemed not meeting the Primary
Coverage Criteria (e.g., deemed experimental/investigational) if, and only if, the provider obtains a written
statement from the member before any services are provided, acknowledging that the services are not covered
by the member’s health plan or contract, and the statement specifies the amount of charges for the services.
This statement must be signed by the member in advance of any applicable services. This statement will be
referred to as a waiver of health plan liability.

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Electronic Funds Transfer (EFT)

All applicants (excluding dental) are required to enroll in EFT, regardless of whether this is a new or an
existing practice, to receive claim payments. This payment method is effective for Arkansas Blue Cross and
Blue Shield, Health Advantage, BlueAdvantage Administrators of Arkansas, Federal Employee Program
(FEP), USAble Administrators and USAble Life Group Health payment types inclusively. Contact your local
Network Development Reps (NDRs) - Arkansas Blue Cross and Blue Shield for an EFT enrollment package.

A separate appendix - Provider’s Bank Information - is required for each of the assigned provider/ NPI numbers
to whom payments are routinely directed: individual doctor / sole practitioner, facility, clinic, emergency room,
etc. This is true even when the same bank information applies to all providers in the ‘group.’ For example, if a
new physician is applying to participate in any of the networks mentioned above, and the physician is applying
to join an already established clinic, that clinic must be paid via EFT.

After receipt of the EFT information, there is a waiting or pre-notification period during which time Arkansas
Blue Cross and Blue Shield performs a validation process to ensure bank routing and account information
is valid.

In the event a provider changes banking information to which claim payments should be directed, a new
Appendix – Provider’s Bank Information - is required and a new pre-notification period is established. During this
pre-notification period, the provider will receive paper checks. A single contract may be completed for affiliated
entities such as a facility which also maintains an outpatient clinic and the like.

Claim payments are validated by Financial Services daily and released to a servicing bank for transfer through
the Automated Clearing House (ACH) Network to the provider’s bank. Payments are released two days prior to
the effective date of the EFT which is the same as the paper check date. Consequently, with EFT payments, your
payments reach you faster.

Remittance information is posted to Availity no later than the EFT effective date. If you are registered on
Availity, paper remittances will not be mailed. Otherwise, a cover sheet indicating that funds have been sent
electronically to the provider’s financial institution accompanies the paper remittance. The electronic remittance
advice (835) is available by accessing Availity Essentials remittance viewer.

For additional information see the “Claims Payments, Refunds & Offsets” section of the Arkansas Blue Cross
and Blue Shield Provider Manual at arkansasbluecross.com/providers.

Electronic Funds Transfer (EFT) Requirements

EFT submissions may come through Availity or submitted via email to your local
Network Development Rep (NDR). EFT requirements include the following:
1. A complete EFT agreement packet which includes the following:
a. Authorized signature on the agreement page
b. Authorized signature on the Electronic Funds Transfer (EFT) Form

2. Valid bank letter which includes the following:

a. Bank letterhead

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b. Provider name
c. Bank routing and account numbers
d. Signature of bank official

An e-mail notification is sent to the provider advising the approximate start date of EFT payments. The EFT
notice does not guarantee network approval. If provider has applied for network participation, a separate
welcome letter will be sent once approved through the credentialing process at which time, claims should be
submitted. Please avoid submitting claims before the welcome letter is received. Included in this notice is the
current “Payment Address” to which the paper remittance will be sent. If this address is incorrect, please submit
a Provider Change of Data Form . A copy of your EFT contract will be returned after being executed by the Vice
President of Financial Services.

The Availity platform has much better security processes than email and paper. While Arkansas Blue Cross
and Blue Shield realizes some providers may not have Availity, we encourage you to sign up as we believe the
Availity platform offers more protective measures in this day and time of cybercrime.

Arkansas Blue Cross and Blue Shield endeavors to maintain the privacy of the provider’s financial information
and, to that end, has limited all screens containing such information to selected Provider Network Operations
and Financial Services staff.

If you have questions about EFT enrollment or changes, contact your local NDR (Network Development
Representative).

Electronic Funds Transfer (EFT) Identifiers

The following is a reference for check / EFT identifiers and payment frequencies to assist providers in identifying
where EFT payments originate.

Arkansas BlueCross BlueShield (EFT Payments)

Identifier Line of Business Payment Schedule

IT 01 BlueCard Weekly

BC 01 Arkansas Blue Cross and Blue Shield commercial business Twice weekly*

Arkansas Blue Cross and Blue Shield Medicare Supplement (Medipak)

MP 01 Twice weekly*
business

Arkansas BlueCross BlueShield (Hard Copy Check Payments)

Identifier Line of Business

HO BlueCard

GA Arkansas Blue Cross and Blue Shield commercial business

MA Arkansas Blue Cross and Blue Shield Medicare Supplement (Medipak) business
*Includes scheduled adjustments for holiday and month-end processing.

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BlueAdvantage Administrators of Arkansas

Identifier Line of Business Payment Schedule

US 01** Cross & Shield branded self-funded groups Weekly*

US US USAble Administrators (non-branded self-insured groups) Weekly*

US CH Arkansas Comprehensive Health Insurance Plan Weekly*

US 55 USAble Life Group Health Weekly*

US WM Walmart Twice weekly

*Includes scheduled adjustments for holiday and month-end processing.
**Since each self-insured group generates a separate EFT, there could be multiple US 01 transactions on any
given day.
Note: The EFT codes for BlueAdvantage are the same as on hard copy check payments.

BlueAdvantage Administrators of Arkansas

Identifier Line of Business Payment Schedule

HA SI Self-insured Weekly*

HA AR Arkansas State Employees and Public-School Employees Weekly**

HA ST Commercial Weekly*
*Includes scheduled adjustments for holiday and month-end processing.
**Payments for Arkansas State Employees and Public-School Employees are released upon receipt of funding.
Note: The Health Advantage EFT codes are the same as on hard copy check payments.

Federal Employee Program (FEP)

FEP (EFT Payments)
Identifier Line of Business

ES FEP Standard Option

EB FEP Basic Option

EF FEP Blue Focus Option

FEP (Hard Copy Check Payments)

Identifier Line of Business

FS FEP Standard Option

FB FEP Basic Option

FF FEP Blue Focus Option

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Member Financial Obligations

In most situations, Arkansas Blue Cross members will be responsible for part of a provider’s bill for services;
and, as the provider agreement with Arkansas Blue Cross outlines, providers will not waive these member
financial responsibilities, (i.e., the member copayment, coinsurance and deductible) as specified in the member’s
health plan or contract.

Non-Covered Services
Members will generally be exclusively responsible for any non-covered services provided. As specified in
the provider agreement, providers may not bill members for services that do not meet Primary Coverage
Criteria (e.g., experimental/investigational), unless a member waiver is first obtained. See Provider Rights and
Responsibilities for instructions on member waivers and the documentation required before billing members for
such non-covered services.

Please note that except for applicable copayment, coinsurance or deductible, providers are not permitted
to request or require payment in advance by any of Arkansas Blue Cross members or from anyone else as a
condition of providing services to members.

Billing
Providers are not permitted to balance bill a member for amounts in excess of the Arkansas Blue Cross and Blue
Shield allowance (member copayment, coinsurance and deductible are deemed part of the allowance for this
purpose and should be billed to the member) for covered services. Providers are also responsible for any billing
or collection service activities that they may engage, or to whom a provider may assign any accounts receivable
or other claims against Arkansas Blue Cross members.

If Arkansas Blue Cross finds that a provider, billing service, collection agency, or other agent engaged by a
provider has improperly attempted to bill any member or collect any amounts from members in violation of
the provider agreement or the guidelines in this Provider Manual, providers are obligated to promptly take
all necessary steps to halt any such activity, to ensure that it is not repeated, and to reimburse Arkansas Blue
Cross and the member for any expenses or losses incurred in responding to or defending against the claims or
collection actions of any such billing service, collection agency or other agent. Providers may also be excluded
from the network for failure to adhere to the member “hold harmless” agreement.

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Refunds
While all parties strive for accurate claim adjudication on the first pass, occasionally adjudication mistakes are
detected that result in the need to adjust the amount paid. When the adjustment results in a reduction of the
claim payment amount, Arkansas Blue Cross and Blue Shield sends the provider notice of any overpayments
through a refund request letter as well as on the remittance advice (RA) in the section called “Adjustments.” The
notice contains patient and claim information including the patient account number for ease of tracking.

While Arkansas Blue Cross request refunds within 30 days from the date of the letter or RA, Arkansas Blue Cross
prefers that providers allow recover of the overpayment from a future remittance if the provider agrees with
the overpayment determination. This will take place after the 30-day period assuming the provider has claims
payments to cover any, or all, of the overpaid amount. This requires less administrative work for the provider
and Arkansas Blue Cross.

In order to close patient accounts more timely, providers may return the letter with a notation “Recoup
Immediately,” and Arkansas Blue Cross will initiate the recovery within approximately 10 days assuming the
provider has claims payments to cover any, or all, of the overpaid amount. If the provider does not have claim
payments sufficient to cover the overpayment during a 90-day period, Arkansas Blue Cross will send a follow-up
requesting a check for the overpaid amount.

Please note that if Arkansas Blue Cross must offset to recoup duplicate or erroneous payments (overpayments)
made to providers, providers are not allowed to pursue collection of such offset amounts from the members
against whose claims such offsets are made.

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Remittance Advice
A hardcopy Remittance Advice (R/A) will accompany the reimbursement check from Arkansas Blue Cross and
Blue Shield for services rendered to our members. If a provider uses a billing service, please send copies of the
Remittance Advice to the billing company.

Most of the column headings on the RA are self-explanatory. Those columns labeled “Service” code (type and
place), “Remarks” code, and “Payment” code will contain a numerical character.

There are multiple ways to receive a remittance advice:

ƒ Electronic Remittance Advice (ERA) - HIPAA ANSI 835 via Availity
ƒ Viewing and printing a report via the Availity website (ANSI 835 type of report)
ƒ Availity’s remit viewer
ƒ Paper remittance advice

Examples of remittance advice:

ƒ Arkansas Blue Cross and Blue Shield
ƒ Federal Employee Program (FEP)

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Reimbursement
Subject to Member Health Plan or Contract:
Provider reimbursement is subject to the terms of our member’s applicable health plan or contract. This means
that Arkansas Blue Cross and Blue Shield will pay for any services, supplies, drugs or equipment provided to our
members only as provided in the member’s health plan or contract.

If coverage is denied for any reason under the member health plan or contract, providers will not be entitled to
reimbursement from Arkansas Blue Cross for any services to the member. For this reason, providers should be
aware of the terms of the health plan or contract of Arkansas Blue Cross member.

Each member is issued a copy of their health plan or contract, so providers may request a member bring a copy
to appointments. Providers may also request a copy of the member’s health plan or contract from Arkansas
Blue Cross. Providers may also obtain information regarding specific Arkansas Blue Cross Coverage Policies by
accessing our web site at arkbluecross.com.

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SECTION 7

Coding and
Coding Edits
Section 7 | Coding and Coding Edits

Billing Codes
Physician Responsibility in Selecting the Appropriate Billing Code for Medical
Procedures
As additional medical techniques become available, it becomes more important for providers to ensure proper
billing and coding of claims for such services.

Choose the Correct Code

When choosing new ways to bill a procedure or when incorporating medical innovations, providers are
responsible for billing a procedure code whose name AND relative work under Resource Based Relative
Value Scale matches the service performed. In addition, providers should not fragment services from global
procedures (e.g., billing for closing the artery in addition to the cardiac catheterization), nor should physicians
choose codes out of context from their CPT section. It is the physician’s responsibility to code correctly
regardless of whether or how they utilize any manufacturer’s or billing consultant’s advice.

Note: Arkansas Blue Cross relies on the proper coding to process provider claims and adjudicates the member’s
benefits. The codes providers select and enter on claims are representations to Arkansas Blue Cross that the
member’s treatment (and the provider’s bill) was for the coded diagnosis, not others, and that the provider,
in fact, performed the procedures as described in the American Medical Association Current Procedural
Terminology (CPT) Manual or the Health Care Procedural Coding System Manual (HCPCS). Miscoded or
improperly billed claims may constitute fraud and could be the basis for denial of claims, termination of
provider’s network participation or other remedial action.

Coding strokes correctly

Stroke is an acute medical emergency that requires urgent attention and can only be accurately diagnosed by
confirmation with a CT scan or MRI of the brain. Acute stroke codes (ICD-10 category I63.-) should only be used
during the acute inpatient encounter and until discharge of that encounter. Therefore, a coder is unable to use
the acute stroke codes (I63.-) in an office setting due to the nature of the event and the inability to accurately
diagnosis in the office.1

Once discharged from an acute-care facility, the patient now has a history of stroke (ICD-10 code Z86.73) and this
code should be used after the initial stroke encounter. Z86.73 is a billable ICD-10 code used to specify a diagnosis
of personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. (icd data).
Any late effects should be documented and coded with ICD-10 category I69.-.

In the office setting, suspect conditions cannot be coded according to ICD-10 coding guidelines. As a result, an
active stroke should not be coded in the office because it is still suspected and there has been no work-up on the
patient to confirm the diagnosis.

Correct Complete Coding & Payer Policy Reminder

The need for correct and specific diagnosis and procedure coding has never been more important. It’s not
just a matter of ensuring claims contain a payable diagnosis, it now includes proving to our state and federal
regulators that Arkansas needs additional funding to improve the state’s health status.

1 Yew, Kenneth and Cheng, Eric. Diagnosis of acute stroke. Am Fam Physician. 2015 Apr 15;91(8):528-536

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Because Arkansas Blue Cross and Blue Shield and its family of companies are involved in state federal
government programs, we must submit our claims data to regulators in order for them to gather health
statistics. Coding your claims to the very most specific diagnosis codes is very important in this endeavor.
Gone are the days of always using “unspecified” or “not otherwise specified coding.” In addition, the clinical
documentation of these diagnoses within your medical records is also critical, as these regulators may choose
your particular patient in an audit, thereby requiring our request and review of these medical records.

As a reminder, all of our provider network agreements indicate that facilities and providers agree “to accept
and comply with the claims filing and coding policies or procedures established by the applicable payer for
health plan claims.” Most of our policies have been placed in the online provider manual as well as this quarterly
newsletter, Providers’ News.

Our agreements also state that facilities and providers agree “that all reimbursement is subject to all terms,
conditions, limitations and exclusions of the member’s health plan, and to the application of a payer’s coverage
policy and coding, billing and claims processing and appeals policies and procedures (Payer Policies and
Procedures) as established by payers and as modified from time to time.” Our payer policies and procedures and
claims filing and coding polices use various coding criteria and protocols including, but not limited to, the CPT
Manual published by the American Medical Association, the National Correct Coding Initiative, Specialty Society
guidelines and industry coding standards from the Centers for Medicare & Medicaid Services (CMS).

The agreements require that facilities and providers follow these noted industry coding standards.

Refer to the Current CPT Manual

The Current Procedural Terminology (CPT) manual is a listing of descriptive terms and identifying codes for
reporting medical services and procedures performed by physicians. The CPT Manual instructs providers to
“select the name of the procedure that most accurately identifies the service performed.”

Refer to the Current HCPCS Manual

The Health Care Procedure Coding System (HCPCS) manual is designed to offer the basic information regarding
coding and billing of medical services, supplies, and procedures using the HCPCS coding system. Do not submit
claims using C, H, K, or T codes.

Note: The CPT and HCPCS manual are commonly used as standardized medical services classification and
reporting systems. Arkansas Blue Cross relies on providers’ accurate use of these systems. However, neither
these systems nor any associated manual or guidelines shall be interpreted to govern claims payment or require
reimbursement for any code or related service. Coverage or non-coverage of all claims remains subject to the
terms and conditions of each member’s health plan or policy.

Category III CPT Codes

Current Procedural Terminology (CPT), the official code book with rules and guidelines from the American
Medical Association’s CPT editorial panel, includes a section of Category III CPT Codes. Category III codes are
temporary codes created to identify emerging technology services and procedures.

Unlike unlisted or deleted codes, the Category III codes allow data collection for specific emerging technology
services. If a Category III code is available, providers must use that code instead of an unlisted or deleted
Category I code. The services or procedures represented by Category III codes may not have FDA approval, may

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not be performed by many health care professionals across the country, and the service or procedure may not
have proven clinical efficacy.

Claims filed for services using Category III codes will be denied unless the code is addressed as a covered
service in an Arkansas Blue Cross Medical Coverage Policy.

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CodeReview®
Arkansas Blue Cross and Blue Shield employs the latest in proven computer technology to process claims in a
timely and efficient manner.

What is CodeReview®?
CodeReview ® is a system that assists the claims processor in evaluating the accuracy of submitted CPT codes by
using its clinical knowledge base to detect, correct and document coding inaccuracies on CPT- 4/HCPCS coded
claims. It provides consistent and objective claim review by accurately applying coding criteria for the areas of:
medicine, surgery, laboratory, pathology, radiology and anesthesiology.

CodeReview ® is based upon the American Medical Association (AMA) CPT-4 guidelines. CodeReview ® has
achieved wide national acceptance among HMOs and other third-party payers. CodeReview ® results in one of
eight types of medically based recommendations to the claims processor:
1. Accept the code(s) as billed.
2. Consider changing the submitted code(s) to comply with generally accepted coding practices that are
consistent with the CPT-4 Manual and the opinion of prominent physicians within the specialty. (Including
addition of modifier 51 for multiple surgeries provided on the same date.)
3. To seek additional information from the physician’s office because of inconsistent information in the claim.
4. Add a code(s).
5. Deny a code(s).
6. Revise a code(s) with a more correct code(s).
7. Exclude a code(s) from a claim.
8. Supersede a code(s) with a correct code(s).

CodeReview ® assists the claims processor in evaluating the accuracy of the coding of the procedure(s), not the
medical necessity of the procedure(s). Current coverage policies and contractual requirements will still apply.
When a change is made to your submitted code(s), a medical explanation of the reason for the change will be
provided. In a few instances where a change is made, it is usually because the CPT- 4 Manual indicates that one
of the submitted codes should not be used separately when submitted with another code on the claim. This does
not mean that the procedure/service was unnecessary; it means that according to generally accepted coding
practice, the procedure/service is not coded separately under this circumstance.

Arkansas Blue Cross and Blue Shield believes CodeReview ® will assist in processing claims more accurately and
consistently. In addition, claims will be paid more quickly and efficiently.

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Different Types of Edits and Logic CodeReview®:

There are several different types of edits and logic CodeReview ® contains. Below are several examples.
CodeReview ® edits and logic includes:

Unbundling: When claims are submitted with a global procedure code along with multiple incidental procedures
or codes that are an inherent part of performing the global procedure.

Fragmentation: Occurs when a claim includes all the incidental codes separately without listing the more global
code. (Note: We do not pay separately for such fragmented charges when applicable CPT codes provide a global
code that encompasses the “fragmented” charges.

Duplicate Procedures: CodeReview ®’s knowledge base contains a list of valid procedures that are allowed more
than once on the same date of service. Codes not contained on this list are excluded, or replacements are made.

Unlisted Procedure: CodeReview ® always questions unlisted services (those codes generally ending in “99”
because they are not specific enough to determine what service was actually performed. A description of the
code will be requested from the provider through the Medical Review Request System.

Modifier Processing: Modifiers are added to the main procedure code to indicate that the services or procedures
have been altered or are different in some way. CodeReview ® processes all CPT-4 modifiers and a few HCPCS
modifiers, as part of their modifiers edits. A modifier edit is a modifier check based on date of service and
appropriateness. For the most part, the way you include modifiers will not change; it is consistent with both
AMA and CMS guidelines. However, some may require submission in a different format. An example is modifier
50. CodeReview ® is designed to accept bilateral procedures in the following format:
ƒ Line 1 - CPT-4 code (primary or one site)
ƒ Line 2 - CPT-4 code 50 (additional or a secondary site)

Age Edit: If a CPT-4 code is defined as age-specific, CodeReview ® checks the date of birth or age (whichever is
entered) to determine whether or not the appropriate codes are being used.

Gender Edit: CodeReview ® checks gender for gender-specific CPT-4 codes to determine whether the code is
appropriate.

Place of Service Edit: CodeReview ® checks certain procedures to determine where they are performed.

Evaluation and Management Logic: These edits deal primarily with global procedures and E&M services
performed as part of these global procedures. These edits follow the current Arkansas Blue Cross policies.

Clear Claim ConnectionTM: Clear Claim Connection™ is a disclosure tool that will enable providers to access
the editing rules and clinical rationale existing in McKesson’s CodeReview ® auditing product. Clear Claim
Connection™ is designed to “mirror” how CodeReview ® evaluates code combinations during claims processing.
Through this capability the CodeReview ® auditing rules, edit clarifications and associated clinical rationale are
made available for Blue Cross, Health Advantage and BlueAdvantage Administrators claims.

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Ancillary Code Editing – Claims Xten (CXT)

Arkansas Blue Cross and Blue Shield updated some of the editing with ClaimsXten in December 2018. As a part
of this editing, an additional edit will be implemented for claims effective May 1, 2019.

The additional editing that will be implemented is for the ancillary services surrounding a non-covered service.
Certain procedures are deemed to be non-covered based upon their medical and/or payment policies. When
procedures related to those non-covered services are submitted, they should be denied as non-covered, as well.

This editing will look at the following five types of ancillary services: anesthesia, assistant surgeon, pre op
testing, pathology or radiology. If no other payable major surgical service was performed on the same date of
service, the ancillary services will also be denied.

Example: A provider submits procedure 15820 (Blepharoplasty), which is considered a non-covered procedure
for Arkansas Blue Cross on 08/01/2019. The anesthesiologist bills procedure 00103 (Anesthesia for reconstructive
procedures of eyelid ((i.e., blepharoplasty, ptosis surgery)). Due to the 15820 being a non-covered procedure, the
00103 procedure will also be denied.
ƒ 15820 – Blephorplasty, lower eyelid;
ƒ 00103 – Anesthesia for reconstructive procedures of eyelid (i.e., blepharoplasty, ptosis surgery)

Arkansas Blue Cross has always performed this type of review, and this edit will allow us to do so in a much
more consistent and efficient way.

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Medically Unlikely Edits (MUE’s)

The National Correct Coding Initiative (NCCI) includes a set of edits known as Medically Unlikely Edits (MUE’s).
An MUE represents a maximum number of units-of-service that would be expected to be included in any specific
CPT or HCPCS code, and therefore could be medically necessary.

The major purpose for the MUE’s is to prevent incorrect payment resulting from erroneous unit entries on claims
(for example, it is not rare to receive claims with the number 999 in the units field). The ClaimsXten (CXT) claims
auditing software contains the MUE’s, which do not require manually adding medically necessary units-of-
service edits for each CPT/HCPCS code.

If more services are submitted than allowed for one date of service for a specific CPT or HCPCS code, the entire
line item will be denied. For example, if a claim is for two appendectomies for the same member on the same
day, that line item on the claim will be denied.

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Not Otherwise Classified/Unlisted Procedure Codes

Effective immediately, when billing procedure codes that are defined as not otherwise classified or unlisted
procedure in the CPT and/or HCPCS coding manuals, a description must be indicated on the claim form and/or
electronic record for each code billed. As noted in the December 2009 Providers’ News, if the description is not
present on the claim form and/or electronic record, it will result in the claims being returned for this information.
When the claim is re-filed, including the descriptions, it will be considered a new claim and a corrected claim
form does not need to be attached.

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National Drug Codes Required

Effective Oct. 1, 2020, Arkansas Blue Cross and Blue Shield, Blue Advantage Administrators of Arkansas and
Health Advantage began requiring the National Drug Code (NDC) when billing for drugs. This requirement was
already in place with the Blue Federal Employee program. We are seeing an increased amount of front-end
rejections due to this requirement. Below are some ways to prevent common billing errors:
ƒ Bill in the correct format (5-4-2 format per NDC guidelines).
ƒ Don’t add NDC to the line item on the claim for an office visit, administration code, lab or x-ray code.
ƒ Bill for the appropriate HCPCS/NDC combination when available instead of a not otherwise specified
(NOC) code.
ƒ Don’t bill with expired NDC/HCPCS combination, expired NDC code or expired HCPCS code.
ƒ Make sure compounded drugs are covered by the member’s plan. Most plans do not cover
compounded drugs.

The edit will validate the correct NDC/procedure code/effective date combination and reject the claim if it is
not a valid combination. If the line on the claim containing the NDC cannot be validated the entire claim will
reject, and the provider must correct the error and resubmit the claim. See June 2020 Providers’ News for more
information.

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Place of Service Codes

Place of Service (POS) codes are numeric codes on professional claims that identify where a service was
rendered. A list of Place of Service codes is located in the Current Procedural Terminology (CPT) manual.

Place-of-service code for urgent care centers

This is a reminder that urgent care centers should use place-of-service code “20” for claims submission.
Arkansas Blue Cross and Blue Shield, BlueAdvantage Administrators of Arkansas and Health Advantage require
all providers to use appropriate claims coding guidelines.

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Transitional care management code amendment

The Transitional Care Management (TCM) codes (CPT codes 99495 and 99496) are intended to report
management of a transition of a complex patient from one care setting to another, generally from an inpatient
to outpatient status. The TCM codes are now reimbursable for any provider who meets the requirements as
specified in the CPT manual, specifically including managing transition of the entire patient.

Please note, this service includes communication, medication management, reviewing the discharge records,
interaction with other involved professionals, education, and assistance with scheduling follow-up with other
providers and community services for all the patient’s medical and psychosocial issues. This would generally fall
in the purview of the patient’s primary care provider.

The CPT code description states:

“The reporting individual provides or oversees the management and/or coordination of services, as
needed, for all medical conditions, psychosocial needs, and activities of daily living support by providing
first contact and continuous access.”

The CPT code manual provides other important details regarding these codes, which includes both an office visit
and contact with the patient outside of the office visit with time frames for the face-to-face visit and for initial
contact after discharge. These codes are payable to only one provider per discharge and it are not payable to a
surgeon during the global period following surgery. These TCM codes are subject to post-pay review.

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SECTION 8

Provider Accessibility
and Availability
Section 8 | Consolidated Appropriations Act

Arkansas Blue Cross and Blue Shield is certified as a Qualified Health Plan (QHP), which is required to be a payer
in the Affordable Care Act (ACA) metallic business (AR HOME and Exchange). As part of that QHP certification,
we are accredited by URAC. Network adequacy of various specialties and provider types has always been a
required measurement, but availability and accessibility are being added. It will be important for you to track
how quickly patients are able to get in to see providers. We plan to capture measures in a new or recredentialing
provider/facility site visit or provider surveys that will ask about the maximum wait times for appointments with
practitioners. Specifically, we will be required to report wait times for the following provider types:
ƒ Primary care
ƒ Specialty care
ƒ Behavioral Health
ƒ Hospitals
ƒ Non-hospital inpatient facilities
ƒ Outpatient facilities

Consolidated Appropriations Act (CAA) update

The Consolidated Appropriations Act (CAA) contains many requirements that have implications for health
insurers, health plans, healthcare providers and consumers. We fully anticipate being able to meet our obligation
to comply with any of the applicable effective dates of the law’s provisions.

Arkansas Blue Cross is analyzing and relying on the legislation’s text to guide our preliminary assessments,
planning and compliance activities. We continue to closely monitor for additional regulations from the
Department of Health & Human Services (HHS) related to the requirements put forth under the CAA so that we
will be prepared to comply on the effective dates put out under the forthcoming rules’ release(s).

Note: While Arkansas Blue Cross and Blue Shield strives to be helpful, we do not provide legal or regulatory
advice or services to third parties. If providers have questions about whether or how a law or regulation applies
to them, they should consult with their own legal counsel. We can provide background information and offer our
business perspective where we believe it would be helpful – but not legal, regulatory or compliance advice.

We very much appreciate the quality care you provide to the people who count on us for their health coverage.
As final rules and guidelines become available, we will be sharing more details about process changes that may
affect you and that are required to implement the law’s requirements.

As background, below are general explanations of some of the items included in the CAA that may impact
healthcare providers in some way:
ƒ Price comparison tools – This rule is similar to the 2020 Transparency Rule which applied to certain
providers/facilities. The CAA requires group health plans and health insurance issuers to provide price
comparison tools. It requires group health plans and health insurance issuers to maintain a “price
comparison tool” available via phone and website that allows enrolled individuals and participating
providers to compare cost-sharing for items and services by any participating provider.

The Tool must be available for 500 covered items and services by January 1, 2023, and for all covered items
and services by January 1, 2024.

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To align the enforcement date of the CAA Price Comparison Tool with the enforcement date of the
Transparency in Coverage Tool, enforcement of [the CAA price comparison tool] requirement was deferred
until January 1, 2023.

Effective: January 1, 2023

ƒ Advance Explanation of Benefits (EOB) – CAA requires group health plans and health insurance issuers to
provide an advance explanation of benefits (EOB) for scheduled services. Requires individual and group
health plans to provide a detailed estimate prior to services that are scheduled at least three days in
advance. Estimates will be based on mandated notice from providers or members and must be created in
three business days or less.
ƒ Effective for providers and facilities: Enforcement of the Advanced EOB requirement has been deferred,
pending a rule-making process.
ƒ Surprise billing – CAA establishes requirements to protect patients from surprise medical bills received
from out-of-network hospitals, free-standing emergency facilities, out-of-network providers at in-network
facilities, and out-of-network air ambulance carriers. Provides for patients to be responsible for only in-
network cost-sharing amounts, including deductibles, in emergency situations and certain nonemergency
situations in which patients do not have the ability to choose an in-network provider. This does not apply
where the member chooses to receive services from an out-of-network provider.
ƒ Out-of-network providers and facilities who have provided emergency services or out-of-network
providers offering services in an in-network facility where the member would not have the opportunity to
know in advance that services would be provided by an out-of-network provider will have requirements to
provide notice and receive consent to allow for balance billing.

Providers and facilities are encouraged to work with their legal representatives to ensure that they will be in
compliance with this new law and its requirements.

Effective for plan years: beginning on or after January 1, 2022

ƒ Air ambulance – As a part of the Surprise Billing protections, members who unknowingly receive services
from out-of-network (OON) air ambulance providers are protected from out-of-network (OON) cost-sharing
and balance billing.
ƒ Contains requirements for air ambulance providers and plans to both report and submit to the Tri-Agencies
several metrics on air ambulance services within 90 days of the end of a plan year.

Effective for plan years: starting January 1, 2022

ƒ Provider directories – CAA impacts:

ƒ Requires providers to update directory information and provide refunds to enrollees if OON costs are
inappropriately applied (in certain circumstances).

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– To ensure accurate provider directory information, the CAA requires group health plans and issuers
offering group and individual health plans to establish a verification process to confirm directory
information at least every 90 days.

Accordingly, it is very important that healthcare providers respond in a timely manner to inquiries
about their provider information. This includes attesting to the information’s accuracy to avoid possible
network termination from our provider networks due to noncompliance with the requirements of the law.

Provider Data Management implementation –Per the Consolidated Appropriations Act (CAA), all
providers MUST attest to their information every 90 days. CAA is very serious about the accuracy
and timely updates of provider data. If providers do not attest to the accuracy of their data every 90
days, the CAA recommends that payers remove these providers from paper and on-line directories. If
providers continue to be noncompliant, more severe action can be taken, such as termination from the
provider networks.

Effective for plan years: starting January 1, 2022

ƒ Mental health parity – CAA requires group health plans and health insurance issuers offering individual
or group coverage to perform and document comparative analyses of the design and application
of nonquantitative treatment limitations (NQTL) when applicable to mental health/substance use
disorder benefits.
Effective: February 10, 2021

ƒ Changes to ID Cards – Requires group and individual health plans to identify on insurance cards the
amount of the in-network and out-of-network deductibles, the in-network and out-of-network out-of-pocket
maximum, and a phone number and website address for consumer assistance information.

Effective: Compliance enforcement deferred to January 1, 2023.

ƒ Continuity of care provisions – The CAA contains provisions on continuity of care. For plan years beginning
January 1, 2022, or thereafter, health plans are required to facilitate continuity of care for covered members
who have qualifying conditions.

An individual is considered a continuing care patient if they are:

ƒ Undergoing a course of treatment for a serious and complex condition that is life-threatening, potentially
disabling or congenital and requires specialized medical treatment to avoid death or permanent harm.
ƒ Undergoing a course of institutional or inpatient care.
ƒ Scheduled to undergo nonelective surgery (including postoperative care).
ƒ Pregnant and undergoing a course of treatment related to the pregnancy.
ƒ Terminally ill and receiving treatment for that illness.

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Health plans are required to:

ƒ Notify members in writing of any significant changes in the availability or location of covered services,
provider terminations, cessation of services or any other significant changes.
ƒ Allow members to notify the health plan or issuer of their need for transitional care.
ƒ Allow members to elect to continue to receive care from the originating provider (under the same terms
and conditions that would have applied had the termination not occurred) for the previously covered
services for up to 90 days.

Effective for plan years: starting January 1, 2022

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SECTION 9

Coverage Policies &

Procedures
Section 9 | Coverage Policies & Procedures

Coverage Policy
(Specific to Discrete Procedures or Technologies)

The medical director of Arkansas Blue Cross and Blue Shield has established specific coverage policies
addressing certain medical procedures or technologies.

The purpose of a Coverage Policy is to inform members and their physicians why certain medical procedures
may or may not be covered under Arkansas Blue Cross and Blue Shield health plans. In addition to these specific
Coverage Policies, all Arkansas Blue Cross and Blue Shield health plans or contracts also include more generally
applicable coverage standards known or the Primary Coverage Criteria. The Primary Coverage Criteria apply to
ALL benefits members may claim under their plan, no matter what types of health intervention may be involved
or when or where members obtain the intervention. For more specifics on Primary Coverage Criteria, click on the
Primary Coverage Criteria link below.

Search for a Policy

You can search by keyword, title, coverage policy number or procedure code at
secure.arkansasbluecross.com/providers/coverage_policy.aspx.

What You Will See

When you select a policy, you will see its title, category and effective date at the top of the page. A description of
the treatment and the actual policy, which explains what is covered, follows. At the bottom of the page, you will
see related CPT codes and references.

Additional Information
What Is a Coverage Policy?
Coverage Policy means a statement developed by Arkansas Blue Cross and Blue Shield that sets forth the
medical criteria for coverage under an Arkansas Blue Cross Evidence of Coverage. Some limitations of benefits
related to coverage, drug, treatment, service equipment or supply are also outlined in the Coverage Policy.

The existence of an affirmative Coverage Policy does not certify coverage, nor does it override or replace
specific coverage language listed in an individual policy or group health plan. While a procedure, technology or
drug may be medically necessary, it still may be specifically excluded under the terms of a member’s contract
or benefit plan, or the use may be an investigational or experimental use of the service and therefore excluded
under the experimental or investigational language of the member’s benefit contract or plan.

The absence of a specific coverage policy does not indicate that a service is covered. For example, a new device
or a new use of an old device may not have been proven safe and effective, but coverage may also have not
been previously requested, thereby providing us an opportunity to study the information on the safety and
effectiveness of the new use of the device.

A copy of a specific Coverage Policy is available from Arkansas Blue Cross and Blue Shield upon request
at no cost, or a Coverage Policy can be reviewed on the Arkansas Blue Cross and Blue Shield website at
arkansasbluecross.com.

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How are Coverage Decisions Made?

The Arkansas Blue Cross and Blue Shield medical directors, including the regional medical directors, review
each Coverage Policy before the policies are implemented. Input is requested from local physicians on each new
Coverage Policy. Each existing coverage policy is reviewed for accuracy every two years if the policy restricts
coverage of a service, procedure, device or drug.

The following sources of information are consulted for the development of Coverage Policies regarding new or
emerging treatments, procedures, devices or drugs:
ƒ Member’s Benefit Certificate or Summary Plan Description: Is the service, procedure, device or drug
specifically excluded?
ƒ FDA Status: Does the service, device or drug require FDA approval?
ƒ Assessment of the effectiveness and safety published by:
ƒ Agency for Healthcare Research and Quality
ƒ American Hospital Formulary Service and/or United States Pharmacopoeia Drug Information (USP DI®)
Compendia: Has the drug been recommended for off-label use?
ƒ Blue Cross and Blue Shield Association Technology Evaluation Center
ƒ Cochrane Library of Systematic Reviews
ƒ Formal technology assessment committees of national medical societies
ƒ Hayes, Inc. Technology Assessment
ƒ National Institutes of Health (NIH)
ƒ Results of Phase III clinical trials as published in peer-reviewed, mainstream medical journals
ƒ Position papers of major medical organizations
ƒ Consultation with national medical experts

A similar process is followed for additional new uses of established procedures, devices or drugs to establish
Coverage Policies.

What is a CPT Code?

Current Procedural Terminology (CPT) is a five-digit code for reporting of treatment and diagnostic services
performed by physicians. CPT is protected by copyright and trademark owned by the American Medical
Association (AMA). Physicians use CPT codes in billing for their services.

What is primary coverage criteria?

The Primary Coverage Criteria apply to all benefits you may claim under your Plan, no matter what types of
health intervention may be involved or when or where you obtain the intervention. Health Intervention or
Intervention means an item or service delivered or undertaken primarily to:
ƒ Diagnose, detect, treat, palliate or alleviate a medical condition; or
ƒ Maintain or restore functional ability of the mind or body.

Purpose and Effect of Primary Coverage Criteria

The Primary Coverage Criteria are designed to allow Plan benefits for only those health interventions that are
proven as safe and effective treatment. Members will receive an Explanation of Benefit (EOB), and Providers

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will receive an Explanation of Payment (EOP) with claims processing remarks that indicate that a claim was not
eligible for benefits since the Primary Coverage Criteria was not met.

Another goal of the Primary Coverage Criteria is to provide benefits only for the less invasive or less risky
intervention when such intervention would safely and effectively treat the medical condition or to provide
benefits for treatment in an outpatient, doctor’s office or home-care setting when such treatment would be a
safe and effective alternative to hospitalization. Examples of the types of health interventions that the Primary
Coverage Criteria exclude from coverage include such things as the cost of a hospitalization for a minor cold
or some other condition that could be treated outside the hospital or the cost of some investigational drug or
treatment, such as herbal therapy or some forms of high-dose chemotherapy not shown to have any beneficial
or curative effect on a particular cancerous condition.

Finally, the Primary Coverage Criteria require that if there are two or more effective alternative health
interventions, the member’s health plan or policy should limit its payment to the Allowable Charge for the most
cost-effective intervention.

Regardless of anything else in a member’s health plan or policy, and regardless of any other communications or
materials received in connection with a member’s health plan or policy, the member will not have coverage for
any service, prescription drug, treatment, procedure, equipment, supplies or associated costs unless the Primary
Coverage Criteria set forth are met. At the same time, just because the Primary Coverage Criteria are met does
not necessarily mean the treatment or services will be covered under a member’s health plan or policy. For
example, a health intervention that meets the Primary Coverage Criteria will be excluded if the condition being
treated is a Pre-Existing Condition excluded by the member’s health plan or policy.

Elements of the Primary Coverage Criteria

To be covered, medical services, drugs, treatments, procedures, tests, equipment or supplies (interventions)
must be recommended by the member’s treating physician and meet all of the following requirements:
1. The intervention must be a health intervention intended to treat a medical condition. A health intervention is
an item or service delivered or undertaken primarily to diagnose, detect, treat, palliate or alleviate a medical
condition or to maintain or restore functional ability of the mind or body. A medical condition means a
disease, illness, injury, pregnancy or a biological or psychological condition.
2. The intervention must be proven to be effective (as defined below) in treating, diagnosing, detecting or
palliating a medical condition.
3. The intervention must be the most appropriate supply or level of service, considering potential benefits
and harms to the patient. The following three examples illustrate application of this standard (but are not
intended to limit the scope of the standard):

a. An intervention is not appropriate, for purposes of the Primary Coverage Criteria, if it would expose
the patient to more invasive procedures or greater risks when less invasive procedures or less risky
interventions would be safe and effective to diagnose, detect, treat or palliate a medical condition;
b. An intervention is not appropriate, under the Primary Coverage Criteria, if it involves hospitalization or
other intensive treatment settings when the intervention could be administered safely and effectively in
an outpatient or other less intensive setting, such as the home; and
c. Maintenance Therapy is another example of this standard because under the Primary Coverage Criteria,
chiropractor services or other physical therapy, speech or occupational therapy, are not considered

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appropriate for purposes of coverage if the frequency or duration of therapy reaches a point of
maintenance where the patient remains at the same functional level and further therapy would not
improve functional capacity or ambulation.

4. The Primary Coverage Criteria allows the member’s health plan or policy to limit its coverage to payment
of the Allowable Charge for the most cost-effective intervention. Cost-effective means a health intervention
where the benefits and harms relative to the costs represent an economically efficient use of resources
for patients with the medical condition being treated through the health intervention. For example, if the
benefits and risks to the patient of two alternative interventions are comparably equal, a health intervention
costing $1,000 will be more cost-effective than a health intervention costing $10,000. Cost-effective shall not
necessarily mean the lowest price.

Primary Coverage Criteria Definitions

1. Effective defined.
a. An existing intervention (one that is commonly recognized as accepted or standard treatment or which
has gained widespread, substantially unchallenged use and acceptance throughout the United States)
will be deemed effective for purposes of the Primary Coverage Criteria if the intervention is found
to achieve its intended purpose and to cure, alleviate or enable diagnosis or detection of a medical
condition without exposing the patient to risks that outweigh the potential benefits. This determination
will be based on consideration of the following factors, in descending order of priority and weight:

i. Scientific evidence, as defined below (where available); or

ii. If scientific evidence is not available, expert opinion(s) (whether published or furnished by private letter
or report) of an Independent Medical Reviewer(s) with education, training and experience in the relevant
medical field or subject area; or
iii. If scientific evidence is not available, and if expert opinion is either unavailable for some reason
or is substantially equally divided, professional standards, as defined and qualified below, may be
consulted; or
iv. If neither scientific evidence, expert opinion nor professional standards show that an existing
intervention will achieve its intended purpose to cure, alleviate or enable diagnosis or detection of a
medical condition, then Arkansas Blue Cross and Blue Shield in its discretion may find that such existing
intervention is not effective and on that basis fails to meet the Primary Coverage Criteria.

b. A new intervention (one that is not commonly recognized as accepted or standard treatment or which
has not gained widespread, substantially unchallenged use and acceptance throughout the United
States) will be deemed effective for purposes of the Primary Coverage Criteria if there is scientific
evidence (as defined below) showing that the intervention will achieve its intended purpose and will cure,
alleviate or enable diagnosis or detection of a medical condition without exposing the patient to risks that
outweigh the potential benefits.

Scientific evidence is deemed to exist to show that a new intervention is not effective if the procedure
is the subject of an ongoing phase I, II or III trial or is otherwise under study to determine its maximum
tolerated dose, toxicity, safety, efficacy, or its efficacy as compared with a standard means of treatment
or diagnosis. If there is a lack of scientific evidence regarding a new intervention, or if the available
scientific evidence is in conflict or the subject of continuing debate, the new intervention shall be deemed
not effective, and therefore not covered in accordance with the Primary Coverage Criteria, with one

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exception, if there is a new intervention for which clinical trials have not been conducted because the
disease in issue is rare or new or affects only a remote population, then the intervention may be deemed
effective if, but only if, it meets the definition of effective as defined above.

2. Scientific Evidence Defined. Scientific Evidence, for purposes of the Primary Coverage Criteria, shall mean
only one or more of the following listed sources of relevant clinical information and evaluation:

a. Results of randomized controlled clinical trials as published in the authoritative medical and scientific
literature that directly demonstrate a statistically significant positive effect of an intervention on a
medical condition. For purposes of this Definition A, authoritative medical and scientific literature shall
be such publications as are recognized by Arkansas Blue Cross and Blue Shield, listed in its Coverage
Policy, or otherwise listed as authoritative medical and scientific literature on the Arkansas Blue Cross
and Blue Shield website at arkbluecross.com.

or

b. Published reports of independent technology or pharmaceutical assessment organizations recognized as

authoritative by Arkansas Blue Cross and Blue Shield. For purposes of this Definition B, an independent
technology or pharmaceutical assessment organization shall be considered authoritative if it is
recognized by Arkansas Blue Cross and Blue Shield, listed in its Coverage Policy, or otherwise listed as
authoritative medical and scientific literature on the Arkansas Blue Cross and Blue Shield website at
arkbluecross.com.

3. Professional Standards Defined. Professional standards, for purposes of applying the effectiveness standard
of the Primary Coverage Criteria to an existing intervention, shall mean only the published clinical standards,
published guidelines or published assessments of professional accreditation or certification organizations
or of such accredited national professional associations as are recognized by the Arkansas Blue Cross and
Blue Shield Medical Director as speaking authoritatively on behalf of the licensed medical professionals
participating in or represented by the associations.

Arkansas Blue Cross and Blue Shield shall have full discretion whether to accept or reject the statements
of any professional association or professional accreditation or certification organization as professional
standards for purposes of this Primary Coverage Criteria. No such statements shall be regarded as eligible
to be classified as professional standards under the Primary Coverage Criteria unless such statements
specifically address effectiveness of the intervention and conclude with substantial supporting evidence that
the intervention is safe, its benefits outweigh potential risks to the patient, and it is more likely than not to
achieve its intended purpose and to cure, alleviate or enable diagnosis, or detection of a medical condition.

Application and Appeal of Primary Coverage Criteria

1. The following rules apply to any application of the Primary Coverage Criteria. Arkansas Blue Cross and Blue
Shield shall have full discretion in applying the Primary Coverage Criteria, and in interpreting any of its terms
or phrases, or the manner in which it shall apply to a given intervention. No intervention shall be deemed to
meet the Primary Coverage Criteria unless the intervention qualifies under all of the following rules:
a. Illegality: An intervention does not meet the Primary Coverage Criteria if it is illegal to administer or
receive it under federal laws or regulations or the law or regulations of the state where administered.
b. FDA Position: An intervention does not meet the Primary Coverage Criteria if it involves any device
or drug that requires approval of the U.S. Food and Drug Administration (FDA), and FDA approval for

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marketing of the drug or device for a particular medical condition has not been issued prior to the date
of service. In addition, an intervention does not meet the Primary Coverage Criteria if the FDA or the U.S.
Department of Health and Human Services or any agency or division thereof, through published reports
or statements, or through official announcements or press releases issued by authorized spokespersons,
have concluded that the intervention or a means or method of administering it is unsafe, unethical or
contrary to federal laws or regulations. Neither FDA Pre-Market Approval nor FDA finding of substantial
equivalency under 510(k) automatically guarantees coverage of a drug or device.
c. Proper License: An intervention does not meet the Primary Coverage Criteria if the health- care
professional or facility administering it does not hold the proper license, permit, accreditation or other
regulatory approval required under applicable laws or regulations in order to administer the intervention.
d. Plan Exclusions, Limitations or Eligibility Standards: Even if an intervention otherwise meets the Primary
Coverage Criteria, it is not covered under the member’s health plan or policy if the intervention is subject
to a Plan exclusion or limitation, or if a member fails to meet eligibility requirements.
e. Position Statements of Professional Organizations: Regardless of whether an intervention meets some
of the other requirements of the Primary Coverage Criteria, the intervention shall not be covered if
any national professional association, any accrediting or certification organization, any widely used
medical compendium, or published guidelines of any national or international workgroup of scientific
or medical experts have classified such intervention or its means or method of administration as
experimental or investigational or as questionable or of unknown benefit. However, an intervention that
fails to meet other requirements of the Primary Coverage Criteria shall not be covered, even if any of the
foregoing organizations or groups classify the intervention as not experimental or not investigational, or
conclude that it is beneficial or no longer subject to question. For purposes of this Definition E, national
professional association or accrediting or certifying organization, or national or international workgroup
of scientific or medical experts shall be such organizations or groups recognized by Arkansas Blue Cross
and Blue Shield, listed in its Coverage Policy, or otherwise listed as authoritative medical and scientific
literature on the Arkansas Blue Cross and Blue Shield website at arkbluecross.com.
f. Coverage Policy: With respect to certain drugs, treatments, services, tests, equipment or supplies,
Arkansas Blue Cross and Blue Shield has developed specific Coverage Policies, which have been put into
writing, and are published on the website at arkbluecross.com. If Arkansas Blue Cross and Blue Shield
has developed a specific Coverage Policy that applies to the drug, treatment, service, test, equipment
or supply that a member received or seeks to have covered, the Coverage Policy shall be deemed to
be determinative in evaluating whether such drug, treatment, service, test, equipment or supply meets
the Primary Coverage Criteria; however, the absence of a specific Coverage Policy with respect to any
particular drug, treatment, service, test, equipment or supply shall not be construed to mean that such
drug, treatment, service, test, equipment or supply meets the Primary Coverage Criteria.

2. Members may appeal a determination by Arkansas Blue Cross and Blue Shield that an intervention does not
meet the Primary Coverage Criteria to the Appeals Coordinator using the procedures for appeals outlined in
the member’s policy or certificate.

Important Notice for Members: For any health intervention, there are six general coverage criteria must be met
in order for that intervention to qualify for coverage under a member’s health plan or policy:
1. The Primary Coverage Criteria must be met.
2. The health intervention must conform to specific limitations stated in the member’s health plan or policy.

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Section 9 | Coverage Policies & Procedures

3. The health intervention must not be specifically excluded under the terms of the member’s health plan
or policy.
4. At the time of the intervention, the member must meet eligibility standards.
5. The member must comply with the applicable provider network and cost-sharing arrangements.
6. The member must follow the required procedures for filing claims.

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SECTION 10

COVID-19
Section 10 | COVID-19

The federally declared public health emergency (PHE) related to the COVID-19 pandemic ended May 11, 2023.
This resulted in changes in coverage and cost-sharing requirements for members of Arkansas Blue Cross and
Blue Shield’s and Health Advantage’s fully insured health plans, as described below.

Please note: Coverage and cost-sharing changes for members of self-funded health plans administered by
BlueAdvantage Administrators of Arkansas or Health Advantage are determined by the employers or plan
sponsors who fund those self-funded plans. If you have questions about coverage for such plans, please call the
number on the back of the health plan member ID card.

Member cost-sharing for COVID-19-related services

On May 11, 2023, federal mandates for coverage (without member cost-sharing) of certain healthcare services
ended. Affected services rendered May 12, 2023, and thereafter will be subject to member cost-sharing
requirements of the member’s plan (copays/deductibles/coinsurance, etc.).

This resumption of member cost-sharing requirements for covered services includes:

ƒ Clinical encounters associated with COVID-19, including:
ƒ Office visits.
ƒ Urgent care clinic visits.
ƒ Emergency department visits.
ƒ Telemedicine visits.
ƒ Lab evaluations performed in conjunction with any of the above-listed types of clinical encounters.
ƒ Diagnostic lab testing for COVID-19 performed in a medical setting – including eligible specimen collection.
ƒ Pharmacy-based diagnostic lab testing for COVID-19 performed by pharmacists – including eligible
specimen collection.
ƒ All U.S. Food and Drug Administration-approved therapeutic agents used to treat COVID-19 – e.g., Veklury.

This resumption of member cost-sharing requirements will not include (meaning that members will not be
subject to cost-sharing):
ƒ The cost of COVID-19 vaccines that have been approved by the Centers for Disease Control & Prevention
(CDC) Advisory Committee on Immunization Practices (ACIP).
ƒ Charges for administration of ACIP-approved COVID-19 vaccines – which are covered as preventive services
and therefore do not require cost-sharing for most members.

Coverage for at-home COVID-19 test kits

Coverage for such tests ended May 11, 2023.

Specimen collection codes

Healthcare Common Procedure Coding System (HCPCS) specimen collection codes G2023 and G2024 are no
longer covered after May 11, 2023, and claims containing those codes will be denied.

Monoclonal antibodies
There currently are no monoclonal antibody treatments approved for COVID-19. Accordingly, any related
services rendered May 12, 2023, and thereafter will not be covered.

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High-throughput testing
The following HCPCS codes are no longer covered after May 11, 2023, for any provider at any place of service:
ƒ U0003
ƒ U0004
ƒ U0005

Out-of-network COVID-19 testing

After May 11, 2023, there is no coverage for COVID-19 tests performed by entities that are not contracted
participants in our health plans’ provider networks. Fee schedule pricing will be applied to covered lab
codes only.

Prior authorization/medical management

Laboratory services for which prior authorization requirements were suspended due to the public health
emergency are subject to such prior authorization requirements beginning May 12, 2023.

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SECTION 11

Availity Essentials Portal

Section 11 | Availity Essentials Portal

Availity serves as the designated EDI Gateway providing portal and clearinghouse services for Arkansas Blue
Cross and Blue Shield.

Availity is the nation’s largest real-time health information network with connections to more than 2,000
payers nationwide, including government payers like Medicaid and Medicare. With a full range of provider
clearinghouse and revenue cycle management options, Availity may also offer ways to consolidate
clearinghouse endpoints. Visit availity.com/arkansasbluecross for more information.

Arkansas Blue Cross and Blue Shield offers many transaction options on Availity. Click here to learn more about
functions Availity offers.

Visit apps.availity.com/availity/web/public.elegant.login to access Availity Essentials Portal.

The ability to upload documents (unsolicited and solicited attachments) can be accessed through a convenient
dashboard on Availity Essentials portal. Access the dashboard from Home | Claims & Payments | Attachments.
Please note your user administrator must register your organization for this function.

Training videos are available in the Availity Learning Center. Providers can log in and select Help & Training | Get
Trained to search the Availity Learning Center catalog.
ƒ Attachments (Training demo)
ƒ Attachments Dashboard Intro & Medical Attachments Setup (recorded webinar)
ƒ Medical Attachments Setup (Training demo)
ƒ Arkansas BCBS – Submit attachments with 837 and Direct-Data Entry (DDE) Claims (recorded webinar)

Providers are encouraged to become familiar with Availity chat, ticketing functions and the Availity client
services team at 800-282-4584 (282-AVAILITY).

Terminology
Solicited Attachments – Requests sent electronically from Arkansas Blue Cross to the provider for medical
records related to a specific claim.

Unsolicited Attachments – Any necessary documents for claim adjudication, such as an EOMB or
medical record.

Providers are encouraged to become familiar with Availity chat, ticketing functions and the Availity client
services team at 800-282-4584 (282-AVAILITY).

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Section 11 | Availity Essentials Portal

Using Availity to Send Electronic Attachments

Attachments can be sent electronically, but please note the following to ensure the attachment can be identified
with the appropriate claim. For example, attachments can be sent electronically using Availity in response to
a request (277RFAI) or they can be sent unsolicited by submitting the PWK06 segment on a claim – where the
provider has 3 days to respond in the Availity dashboard. However, to send an unsolicited attachment in the
Attachment Dashboard that is not tied to a request or unsolicited record, you must send certain data elements
for it to be recorded appropriately. To submit a document that needs to attach to a claim or bar-coded request
the following steps must be followed.

From the Attachments Dashboard, select Send Attachment dropdown, next select Medical Attachment.
Predetermination Attachment is not available for Arkansas Blue Cross and Blue Shield. *EOBs, COBs, appeals or
documentation for appeals should not be sent through this process.

ƒ Select your organization and payer from the dropdown menu.

ƒ Enter your NPI from the claim, type in the Organization Name.
ƒ Enter the member/patient information.
ƒ Patient control number is the patient account number.

*Attachment Control Number must be the claim number from the submitted claim OR the control number
from the medical record request letter. This step is very important! If it is not followed, it can result in your
record not attaching to the correct claim and can become lost!

Your attachment will not sync up to the correct claim if you do not enter the Attachment Control Number
correctly!

The attachment control number can be located at the top of your bar-coded request.

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ƒ Enter service from and service to dates.

ƒ Select Reason 1 dropdown to add your attachment.

ƒ Once all documents are attached, Send Attachment.

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SECTION 12

Health Insurance
Marketplace Exchange
Section 12 | Health Insurance Marketplace Exchange

Avalon: Laboratory Benefit Management

New program features automated review of high-volume, low-cost routine laboratory tests

Beginning February 1, 2025, Arkansas Blue Cross and Blue Shield will be implementing a new laboratory benefit
management (LBM) program administered by Avalon Healthcare Solutions. This innovative program includes
policies based on the latest science and clinically accepted, peer-reviewed guidelines for lab services. The LBM
program provides consistent enforcement of laboratory policies via an automated review of high-volume, low-
cost routine laboratory tests.

Providers ordering laboratory services (both referring and performing) will need to be aware of this new
program, as collectively we have an obligation to ensure members and patients receive high-quality,
medically appropriate and affordable laboratory services. The program includes important changes affecting
providers, such as new and revised medical coverage criteria, guidelines and consistent reviews for certain
laboratory services.

Facts for healthcare providers

Below you’ll find details of these program components and important implementation dates.
ƒ Effective February 1, 2025, new and revised medical coverage criteria and guidelines will take effect that will
affect certain laboratory, services, tests and procedures.
ƒ Arkansas Blue Cross will use these evidence-based policies, aligned with the latest scientific research, to
determine the appropriateness of lab testing. The lab policies will be reviewed annually, or more often when
the science has changed, to account for the latest evidence and the development of new types of tests.
ƒ The new program is effective for dates of service February 1, 2025, and thereafter. Arkansas Blue Cross
will apply automated policy enforcement (post-service and pre-payment) to claims that include laboratory
services performed in office, hospital outpatient and independent laboratory locations.
ƒ Laboratory services, tests and procedures provided in emergency room, hospital observation and hospital
inpatient settings are excluded from this program.
ƒ Additionally, codes reporting multiple units billed will be reviewed referencing code-specific unit allowances
under Arkansas Blue Cross laboratory policies and guidelines.

We value and appreciate our dedicated healthcare providers for the vital role you play in working to provide
high-quality care and produce better healthcare outcomes.

If you have questions about this program, please call provider services at 501-378-2307.

Arkansas Blue Cross and Blue Shield is an independent licensee of the Blue Cross Blue Shield Association. Avalon Healthcare Solutions is a
separate company that has been engaged by Arkansas Blue Cross to provide laboratory benefit management (LBM) services on behalf of its
members. Avalon is not affiliated with Arkansas Blue Cross or the Blue Cross Blue Shield Association.

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Section 12 | Health Insurance Marketplace Exchange

What is the Health Insurance Marketplace?

The Health Insurance Marketplace is a website designed to determine if a person is eligible for financial help to
cover their health insurance costs. Some Americans will be eligible for a $0 premium plan or a new kind of tax
credit that lowers their monthly premiums. It also helps people shop for and purchase health insurance. People
also may contact the Health Insurance Marketplace by telephone.

A Health Insurance Marketplace is set up in each state, either by the state itself, by the federal government, or in
Arkansas’ case, in partnership with the federal government. Each marketplace will be responsible for:
ƒ Creating and maintaining a consumer shopping website.
ƒ Providing access to all information necessary to determine if those applying are eligible for help paying for
their premium or if they qualify for free coverage.
ƒ Helping consumers shop for and purchase health plans.
ƒ Making sure all health plans offered on the marketplace meet all the new regulations.

The Health Insurance Marketplace opens annually from November 1–January 15 for people to purchase
coverage with an effective date of January 1 for the following year.

Many people are eligible to receive advance premium tax credits (subsidies) if they purchase a health plan
through the marketplace. An advance premium tax credit is a new tax credit that can lower monthly premium
costs beginning the effective date of the policy.

The amount of the advance premium tax credit that each household will receive is calculated by using their
income, the size of their family and other factors. This new tax credit helps lower- and middle- income families.
Some households, based on their income, will receive additional financial assistance when they receive medical
care, known as cost-sharing reductions.

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Section 12 | Health Insurance Marketplace Exchange

Affordable Care Act redefines out-of-pocket cost for health plan members
Health plan members—whether belonging to a PPO, HMO, or traditional comprehensive major medical plan—are
familiar with cost sharing requirements in the form of copayments, coinsurance, and deductibles. Once a
policyholder meets his/her deductible, a coinsurance amount is paid until an annual out-of-pocket maximum
is reached.

Although no more financial obligation is required by the policyholder for major services, traditionally, cost
sharing in the way of copayments still was expected for services rendered at a clinic or other health care facility,
and pharmacy copayments for medications were required each time a prescription was filled. As of 2014, all new
non-grandfathered individual and group health plans were required to have a single out-of-pocket maximum
that applies to all in-network, covered medical services, including prescription drugs. This amount excludes
premium cost. This is called the True Out-Of-Pocket (TrOOP) maximum.

The intent of this rule is that once the out-of-pocket maximum has been met, the member is not responsible for
additional out-of-pocket cost sharing for in-network covered medical services for the remainder of the plan year.

Out-of-pocket maximums
The Affordable Care Act established a maximum annual out-of-pocket amount, which may be paid for
in-network essential benefits covered under a plan with anticipated increases for inflation. Once a maximum is
reached in a given plan year, any additional costs incurred for in-network essential benefits covered by the plan
will be covered at 100% for the balance of the plan year. Remember that Availity maintains the current status of
member’s out-of-pocket expenses.

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Section 12 | Health Insurance Marketplace Exchange

Enrollment update for Federal Health Insurance Marketplace and

ARHOME
Please be advised that eligibility information for the federal Marketplace and state ARHOME membership
processing, include mailing ID cards to the members at the address provided by either the ARHOME system or
the federal exchange system and Availity, is kept current and up to date.

Due to the many challenges in the enrollment through the federal Health Insurance Marketplace, Arkansas
Blue Cross and Blue Shield continues to receive enrollments that should have been transmitted earlier. Federal
exchange member’s coverage is not activated until their first premium payment is received and processed by
Arkansas Blue Cross.

Arkansas Blue Cross expects high call volumes each year from October 1 through January 31 of the following
year during open enrollment period of November 1–January 15. Additional staff is scheduled in our service
support area; however, for eligibility inquiries, providers are strongly encouraged to use Availity or My BlueLine.
Providers who are unable to locate a patient’s information on Availity or My BlueLine should try the following:

ARHOME
If the member is not found on Availity or My BlueLine but has presented a letter of eligibility from Medicaid,
please check the Medicaid eligibility system. If the patient is on the Medicaid eligibility system, their coverage
has started with Medicaid and their coverage with Arkansas Blue Cross has not started and has not been sent
to eligibility files from the ARHOME system for the patient. If the patient cannot be identified in the Medicaid
eligibility system and the patient states they have enrolled with Medicaid, providers may want to contact their
local Medicaid/DHS office for information.

If the patient’s coverage with Arkansas Blue Cross has not yet started, they may be covered under traditional
Medicaid. Providers should use the patient’s Medicaid number for medical services and also advise the patient
to use his or her Medicaid number for the pharmacy and the pharmacies will handle their prescriptions.

Note: The ARHOME system enrolls members by an auto assignment process if the member does not select a
health plan. The member then has 30 days to decide to enroll in the health plan assigned or select another health
plan. During these 30 days, Arkansas Blue Cross does not have information from the ARHOME. Arkansas Blue
Cross does not receive the member’s information until after the 30 days.

Federal exchange
If the patient cannot be located on Availity or My BlueLine and the patient indicates they enrolled in the federal
exchange (healthcare.gov), please be advised that there is a delay of a day or two from the federal enrollment
and the transmission to Arkansas Blue Cross.

Arkansas Blue Cross continues to receive changes from the federal exchange adjusting the original effective
dates of the enrollments. These are transmitted to Arkansas Blue Cross in a separate transaction which requires
a manual process and may take several days to complete.

If the patient cannot be located on Availity or My BlueLine and the patient indicates they enrolled in the federal
exchange, please have the patient contact the federal exchange.

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Section 12 | Health Insurance Marketplace Exchange

Essential health benefits at the core of new health plans on the Health
Insurance Marketplace
Standardizing Health Plans
Consumers have long complained that choosing a health insurance plan is complicated. They have difficulty
comparing what medical services are covered by each health plan under consideration. In addition, it is difficult
for consumers to compare which plan offers the best financial value.

It is easy to compare monthly premiums from one plan to the next, but more difficult to figure out what total out-
of-pocket costs might be when considering deductibles, copayments, and coinsurance maximums.

To make this process easier for employers and consumers, the Affordable Care Act specifies the medical
services that must be covered by health plans.

Standardizing Covered Medical Services

Non-grandfathered health plans must cover a core set of benefits called “Essential Health Benefits.” This core
set of benefits includes services in the following ten categories:
ƒ Outpatient care
ƒ Emergency services
ƒ Hospitalization
ƒ Mental health and substance abuse treatments
ƒ Prescription drugs
ƒ Rehabilitative and “habilitative” services and devices
ƒ Laboratory services
ƒ Preventive and wellness services
ƒ Pediatric dental* and vision care
ƒ Maternity and newborn care

These services are offered in every plan with no annual or lifetime dollar limits.

Preventive care and many women’s preventive services are offered with no member cost sharing as required by
law. In other words, services like colonoscopy and contraceptives are provided at no charge.

These new health care rules became effective January 1, 2014, for all new fully insured individual and small
group health plans sold, and for non-grandfathered plans at the first renewal date on or after January 1, 2019.

However, grandfathered, and self-insured health plans are exempt. Large group plans (groups with more than 50
employees) are required to meet the cost-sharing limits and the benefit levels but are not required to provide the
full scope of benefits in the essential benefits package.

While the Affordable Care Act requires coverage for each of these categories, the law does not define the
specific services that must be covered or the amount, duration, or scope of services. The Health & Human

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Section 12 | Health Insurance Marketplace Exchange

Services secretary defines the specific benefits within each of these categories and updates the definition over
time to address gaps or respond to changing medical practices in the future.

In defining the essential benefits package, the Health & Human Services secretary must decide not only which
health services to include, but also how much discretion to leave to insurers in coverage decisions. For example,
if the secretary determines that physical therapy to treat lower back pain is a covered benefit, she could
determine the minimum number of physical therapy sessions that must be covered to treat the condition, or she
could leave that to the discretion of the insurers.

*Pediatric Dental is not included in our Metallic Plan since there are stand-alone pediatric dental plans available.

Frequently Asked Questions

Are the Health Insurance Marketplace members’ eligibility and benefits on Availity?
Yes, eligibility, benefit, and claims status information along with the status of applicable deductible and out-of-
pocket accumulators are provided on Availity. Please note, to avoid delays when calling to check new members’
eligibility, which could occur due to the high volume of new enrollments, we encourage that all providers use
Availity for eligibility, benefits and claims status and limit calls to our provider lines for claims processing
questions. If you have any questions regarding Availity, providers may contact Availity Client Services at
800-282-4548.

Are members required to have a PCP and do members need a referral to see a specialist?
Exchange members are encouraged to select a PCP and referrals are not required to see a specialist. Members
should use True Blue PPO providers for all services. If services are provided by an out-of-network provider, the
result will be higher out-of-pocket costs to the member.

Do providers have to see ARHOME patients?

Providers who currently have restricted their practices to “current patients only” and are not accepting any
new patients do not have to accept Health Insurance Marketplace members. If a practice is open, it’s open to all
patients. This would include all Health Insurance Marketplace and ARHOME members. Providers do have the
option to “opt out” of the network.

Where do providers file claims for Blue Cross?

ALL claims should be filed to Arkansas Blue Cross as you do today for BlueCard claims. Please note that
members with member ID card prefixes EXX, AXC, GXH, SXA do not have BlueCard benefits with providers
outside the state of Arkansas, unless the provider is in a contiguous county and is directly contracted with
ABCBS through the TB network. If a service is not available from a participating True Blue PPO provider in
Arkansas or its contracted providers in contiguous counties, a network exception may be requested. An
approved network exception will serve as a prior approval for services needed outside the coverage area. This
does not apply if the service is an emergency.

If an eligible member has elected to receive an advanced premium tax credit (APTC) but fails
to pay their portion of the total premium, will Arkansas Blue Cross request a refund on any
claims paid during the special three- month grace period?
On the Health Insurance Marketplace, members who receive a federal subsidy (an advanced premium tax credit)
that does not cover the full amount of the premium are allowed a three-month grace period beginning on the

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Section 12 | Health Insurance Marketplace Exchange

premium statement due date missed. Note: The grace period is applicable after the member has paid their first
premium payment and therefore effectuated their coverage. The three-month grace period is defined as a period
of three consecutive months, not a rolling period.

Arkansas Blue Cross will pay claims for the first month in which the member is delinquent and will not request
refunds on claims. If the member’s portion of the premium is not paid for month two or three, the member will
be considered uninsured. After the first month, the provider will be notified of the member’s delinquent status
via a message stating “Grace Period” on Availity. Providers should continue to file claims during this time.

Arkansas Blue Cross will suspend claims for months two and three pending the receipt of the member’s
payment. Providers will not receive a remittance advice for suspended claims but will be able to see on Availity
suspended claim status code 766 “Services were performed during a Health Insurance Exchange (HIX) premium
payment grace period.”

Providers should collect payments from members per their usual office policy during the member’s
grace period. It is very important that providers verify coverage on Availity prior to providing services to
these members.

Once the member pays the past due premium, the provider’s claims will be released for payment and any
portions that were collected up front from the member should be refunded to them, minus any applicable
copayment, coinsurance or deductible.

If the member fails to pay their premium within the grace period, after the third month the suspended claims will
be denied, and the member no longer will be considered covered by Arkansas Blue Cross. Please remember,
Arkansas Blue Cross will not request a refund for claims paid to the provider during the first month of
delinquency for non- payment of premium for the special three-month grace period. The grace period does not
apply to ARHOME members, as there is no member portion of premium.

Can our clearinghouse tell us through auto eligibility if a member is in grace period?
Eligibility transactions (270) submitted via your clearinghouse or on the Availity portal will return a (271)
response that the member is in their “grace period” when applicable. Providers will need to check with their
clearinghouse to see how the information will be displayed.

Note: ARHOME members are not subject to the grace period provisions.

What are the services that need prior approval?

The following Metallic Plan benefits require a prior approval:
ƒ Hospital services in connection with dental treatment
ƒ Inpatient medical admissions including, but not limited to, medical and surgical admissions (scheduled
and elective)
ƒ Advanced diagnostic imaging services. (CT/PET scans, Nuclear Cardiology, MRI/MRA).
ƒ Allowable charges for in vitro fertilization and infertility
ƒ Autism spectrum disorder benefits
ƒ Behavioral health admissions and services. (Partial hospitalization, intensive outpatient services, residential
treatment and rTMS)

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ƒ Durable medical equipment with costs greater than $500

ƒ Implantable Osseo-integrated hearing aids / cochlear implants
ƒ Prosthetic devices with costs greater than $5,000
ƒ Reduction mammoplasty
ƒ Certain drugs (pharmacy)
ƒ All transplants other than kidney and cornea
ƒ Neurologic rehabilitation facility services
ƒ Pediatric vision services, vision therapy, developmental testing. Only refers to eye prosthesis
ƒ Enteral feedings
ƒ Gastric pacemaker
ƒ Medical disorder requiring specialized nutrients or formulas
ƒ “Off label” use of medication
ƒ Skilled nursing facility (SNF)
ƒ Hospice/Home health
ƒ Cognitive rehab
ƒ Outpatient services – pain management only
ƒ Hyperbaric therapy
ƒ Wound vac
ƒ Long term acute care (LTAC) excluding LTAC inpatient rehabilitation
ƒ Inpatient mental health
ƒ LVAD – heart mate
ƒ Craniofacial anomaly
ƒ Rehabilitation and habilitation services on occupational therapy, physical therapy, speech therapy, and
chiropractic treatments
ƒ Cardiac and pulmonary rehabilitation
ƒ Non-emergency health interventions by out-of-area providers
ƒ Reconstructive surgery/corrected surgery, and related health interventions
ƒ Pain management
ƒ Infertility testing, artificial insemination, and In Vitro fertilization
ƒ Substance use disorder inpatient and outpatient services
ƒ Pre-notification for maternity and obstetrical care including routine prenatal care and postnatal care

Can a provider pay a member’s premium?

According to a document dated November 4, 2013, from CMS regarding third party payments of premiums for
qualified health plans in the marketplaces, the Department of Health and Human Services has broad authority
to regulate the federal and state Marketplaces (e.g., section 1321(a) of the Affordable Care Act). It has been
suggested that hospitals, other health care providers, and other commercial entities may be considering
supporting premium payments and cost- sharing obligations with respect to qualified health plans purchased by
patients in the Marketplaces.

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Section 12 | Health Insurance Marketplace Exchange

Health and Human Services has significant concerns with this practice because it could skew the insurance risk
pool and create an unlevel field in the Marketplaces. Health and Human Services discourages this practice and
encourages issuers to reject such third-party payments. Health and Human Services intends to monitor this
practice and to take appropriate action, if necessary.

In conjunction with the CMS statement, it is an Arkansas Blue Cross official policy to only accept premium
payment from our members or groups.

To whom do providers direct patients to contact if they have questions about their plans?
Members may call Arkansas Blue Cross Customer Service at 800-800-4298 regarding their new plan. For general
information regarding Health Insurance Marketplace products, members may call 855-625-0451.

What do providers need to do to be in-network for the Metallic Plans?

Providers do not need to do anything if they are participating in the True Blue PPO network. Arkansas Blue
Cross will be using the True Blue PPO network for the individual Metallic Plans sold both on and off the Health
Insurance Marketplace. Participating providers, if appropriate, were mailed a contract amendment notifying
them of a new fee schedule for these new Metallic Plans. Reimbursement for existing products that access the
True Blue PPO network will not change.

What wellness benefits will the Metallic Plans use?

The Affordable Care Act (ACA) wellness benefits are covered at 100% in-network only. The ACA wellness
benefits will be used in the plans sold both on and off the Health Insurance Marketplace. The ACA wellness
benefits are posted in the Availity payer space under Resources, and coverage policies are on the Arkansas Blue
Cross website (arkansasbluecross.com).

What is the difference in an ARHOME plan and a cost sharing reduction plan?
Plans with cost sharing reduction protect lower income people from high out-of-pocket costs when they receive
medical services. Those plans have lower deductibles and copayments and are based upon income.

There are cost sharing reduction plans for both the ARHOME and for people who qualify for an advance
premium tax credit (subsidy). People who qualify for the ARHOME will not owe any premium for their
insurance plan.

ARHOME members who fall below 100% of the federal poverty level and are not eligible for traditional Medicaid
will have no out-of-pocket cost. ARHOME members who fall between 100-138% of the federal poverty level will
have lower out-of-pocket costs.

Consumers whose income falls between 139% and 250% of the federal poverty level may also enroll in a cost
sharing reduction plan on the Health Insurance Marketplace, which also results in lower out-of-pocket expenses.

Are children covered under Arkansas’ ARHOME plan?

The ARHOME is for adults ages 19-64 years old. Children, including newborns, may be eligible for Medicaid
programs such as ARKids First.

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Is pregnancy covered under the ARHOME?

Pregnant enrollees may be entitled to additional benefits under traditional Medicaid. Providers should encourage
their patients to contact the Arkansas Medicaid offices in their county for information of the availability of these
additional benefits. Additional benefits such as transportation services may be available for some enrollees.

Also, if a patient is enrolled in a ARHOME plan with member copayments, the member may be eligible for
traditional Medicaid benefits without copayments. All ARHOME plans have free pregnancy-related services
beginning in 2022. Cost sharing no longer applies to pregnancy deductibles.

What if a patient needs traditional Medicaid services?

State Medicaid is establishing a provider referral process and form by which individuals with exceptional
and predictable need for services that are not covered under the health plan are identified. Providers should
encourage these patients to contact the Arkansas Medicaid offices in their county for information of their
eligibility for additional benefits covered by Medicaid but not covered by their health plan.

In keeping up with all the changes the exchange and ARHOME Metallic Plans will bring to providers, Availity
becomes an increasingly important day-to-day tool. Providers need to remember not only to verify coverage and
benefits, but also to check to make sure members who receive advance premium tax credits are not in the three-
month grace period.

Additionally, the Metallic Plans comply with True Out-Of-Pocket (TROOP) requirements where all out-of-pocket
expenses, including all deductibles, coinsurances, medical copayments, and prescription copayments are
accumulated as a single out of pocket maximum. Once the TROOP max is met, copayments/coinsurance should
no longer be collected. Availity is updated nightly in order to bring the most up-to-date information possible to
providers.

To identify a Metallic plan, providers can look for the word Metallic on the member ID card. Below is a ARHOME
member ID card example. To identify the ARHOME enrollees, providers should reference the Group numbers on
the cards:

ABCBS Exchange ArHome Groups: MS00000009 - MS00000015

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HA Exchange ArHome Groups:

MSH0000003 - MSH0000009

The member ID cards represent members with an alpha prefix of EXX, AXC (ABCBS) and GXH, SXA (Health
Advantage). These members do not have out-of-area benefits for non-emergent care or without prior approval.

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ARHOME Coordination of Benefit Claims

On July 24, 2024, Arkansas Insurance Department released Bulletin 10-2024 advising that all ARHOME plans
must be the payor of last resort by no later than January 1, 2026. This means claims payments for members
with two or more insurance plans may be delayed as insurance companies nationwide identify members and
adapt their systems to reverse payor order appropriately. Arkansas Blue Cross and Blue Shield is making a
concerted effort to identify enrollees with dual coverage so transitions can be completed before January 1, 2025.
Thank you for your patience as we adjust to the new requirement.

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Frequently asked questions about the health care law

What is the health insurance marketplace?
The Affordable Care Act created these health insurance marketplaces (exchange) as a means for consumers to
buy “qualified health plans” from private carriers. People who have not had access to health insurance in the
past now have access to several options. The health insurance marketplace (exchange) is a state run, web-based
service where Arkansas Blue Cross will offer qualified health plans that will access our True Blue PPO network.
The health insurance marketplace also provides financial assistance to eligible insurance purchasers whose
household incomes fall below 400 percent of the federal poverty level.

What is a qualified health plan?

A qualified health plan is an insurance plan that is certified by the federal government, provides essential health
benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum
amounts), and meets other requirements. They may be sold on and off the marketplace.

What are essential health benefits?

Qualified health plans are required to cover 10 essential health benefits at 100 percent; meaning the member
pays nothing out of pocket for the medical service. These health benefits include:
ƒ Ambulatory patient services, such as doctor’s visits and outpatient services
ƒ Emergency services
ƒ Hospitalization
ƒ Maternity and newborn care
ƒ Mental health and substance use disorder services, including behavioral health treatment
ƒ Prescription drugs
ƒ Rehabilitative and habilitative services and devices
ƒ Laboratory services
ƒ Preventive and wellness services and chronic disease management
ƒ Pediatric services including oral* and vision care

What does “on” and “off” the marketplace or exchange mean?

All health plans sold on the health insurance marketplace must be qualified health plans. People who purchase
health plans on the marketplace may receive tax credits and, in some cases, additional financial assistants
paying their medical costs. Insurance companies also may sell the qualified health plans off the marketplace to
people who do not qualify for a tax credit. They also may sell HIPAA-Excepted Benefit (HEB) products, which
include limited duration policies, new self-insurance products and defined contribution products.

What are Metallic Plans?

Qualified health plans must fall within two percent of four value levels, which have been given metallic names to
represent their financial worth. Each level indicates a set percentage of medical costs a health plan would pay for
the average person. For example, a bronze plan will cover 60 percent of the health care costs an average person
might use in a year, while a platinum plan will cover 90 percent. The more the health plan pays, the higher the

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premium will be, and the less out-of-pocket cost there will be when a policyholder receives medical care. (See
the metallic coverage levels chart on the following page.)

Are Medicare health plans affected by the health care law?

No. Medicare patients will not have to make changes to their policies as a result of the health care law. They will
not have to shop on the marketplace for their coverage and most of them will be able to keep their health plans.
People eligible for Medicare, however, are not eligible for tax credits under the health care law.

*Pediatric Dental is not included in our Metallic Plan since there are stand-alone pediatric dental plans available.

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Opting out of individual metallic benefit plans*

Currently, the True Blue PPO network is utilized by several health benefit plans and participation in the True
Blue PPO network has necessitated that providers be in-network for all of these plans. Effective July 1, 2015,
providers who participate in the True Blue PPO provider network will be able to remove their participation (i.e.,
opt out) from being in-network for metallic plans in the individual health insurance Marketplace/Exchange yet
remain in the True Blue PPO network for all other benefit plans.

To opt out of the metallic plans in the individual marketplace, providers must send a written request that
indicates the provider wants to “opt out of the network for members who have the individual metallic benefit
plans.” This written request must be placed on the provider’s official letterhead and must be signed by
the provider making the request. Providers are not required to terminate their True Blue PPO participating
agreement if they wish to opt out from the individual metallic plans. Please remember that if you are contracted
through a physician hospital organization (PHO) or other group arrangement, that you must follow their
respective contracting procedures requirements which may include obtaining their approval.

Requests to opt out of the individual metallic plan provider network should be mailed to:

PPO Arkansas
Attn: PNO - 3 North
P.O. Box 1489
Little Rock, AR 72203-1489

Please understand that opting out applies to all individual metallic plans and all of a provider’s locations. Once
a provider has chosen to be removed from the metallic plans in the individual marketplace, the provider cannot
be reinstated for these benefits plans for at least 12 months. To be reinstated, the provider will need to complete
full application forms and must go through the initial credentialing process. Any provider who opts out will be
designated as out of network for individual metallic plans and all services will be processed at the out of network
benefit levels with any covered services paid to the member. Provider directories will include a notation that the
provider is not participating as an in-network provider for individual metallic plans.

* This notice is considered an amendment to the PPO Arkansas’ True Blue PPO participating provider
agreement. True Blue agreements issued in the future will contain a separate exhibit addressing
participation in the individual metallic plans’ network.

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Metallic Benefits Requiring Prior Approval

To view the prior approval requirements, click Metallic Prior Approval Guide for members with identification
card alpha prefixes:
ƒ ABCBS – XCB, EXX, AXC, XCQ
ƒ Health Advantage – HOG, GXH, EXA, SXA

Autism Spectrum Disorder Benefits

After prior approval, coverage is provided for members with autism spectrum disorder that is diagnosed by a
licensed Doctor of Medicine or a licensed psychologist.

The following coverage is provided annually for applied behavior analysis, when ordered by a medical doctor or
a psychologist for a member under the age of 18, and provided by a board-certified behavioral analyst:
Autism Spectrum Disorder Services Frequency

Applied Behavioral Analysis Treatment Plan Up to one every six months

Applied Behavioral Analysis Assessment Up to three hours once every three months

Applied Behavioral Analysis BCBA services Up to six hours per week for 50 weeks

Applied Behavioral Analysis Treatment by Behavioral

Technician, a Board-Certified Associate Behavioral Analyst, or Up to 40 hours per week for 50 weeks
a Board-Certified Behavioral Analyst (direct or line)

Craniofacial Anomaly
Subject to prior approval from the Company, coverage for corrective surgery and related Health Interventions
for a Covered Person who is diagnosed as having a craniofacial anomaly provided the Heath Interventions
meet Primary Coverage Criteria to improve a functional impairment that results from the craniofacial anomaly
as determined by a nationally accredited cleft-craniofacial team. A nationally accredited cleft-craniofacial team
for cleft-craniofacial conditions shall evaluate Covered Persons with craniofacial anomalies and coordinate a
treatment plan for each Covered Person. Coverage includes corrective surgery, dental care, vision care and the
use of at least one hearing aid.

Requests for prior approval of services other than those noted above must be in writing and faxed to Attn:
Prior Approval 501-378-6647. To access the prior approval form, click on the link or access at arkbluecross.com
under the forms tab.

Please note: Prior approval does not guarantee payment or assure coverage, it means only that the information
furnished to the company, at the time approval is requested, indicates that the services meet the primary
coverage criteria requirements. All services must still meet all other coverage terms, conditions and limitations,
and coverage for these services may still be limited or denied, if, when the claims for the services are received
by us, investigation shows that a benefit exclusion or limitation applies, that the covered person ceased to be
eligible for benefits on the date the services were provided, that coverage lapsed for non-payment of premium,
that out-of-network limitations apply, or any other basis specified in the benefit certificate.

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* If a prior approval is not received, the denied charges result in provider responsibility, except in the case of
DME in which case a denied charge due to no prior approval results in member responsibility.

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Habilitative care and modifier SZ

During January 2014, the Patient Protection and Affordable Care Act (PPACA) began requiring all health
insurance issuers offering small group health insurance coverage (1-50 fulltime employees) and individual
health insurance coverage to include essential health benefits in products offered on and off the Federal Health
Insurance Marketplace. Federal law now requires that individual and small group products include the following
10 categories of essential health benefits:
ƒ Ambulatory patient services
ƒ Emergency services
ƒ Hospitalization
ƒ Maternity and newborn care
ƒ Mental health and substance use disorder services
ƒ Prescription drugs
ƒ Rehabilitative and habilitative services and devices
ƒ Laboratory services
ƒ Preventive and wellness services and chronic disease management
ƒ Pediatric services, including oral and vision care.

Without a way to identify habilitative services and devices, Modifier SZ was created to help identify habilitative
services. Modifier SZ has been deleted as of 12/31/2017. Modifier SZ has been replaced with Modifier 96,
Habilitative Services

For dates of services on or after July 1, 2014 thru December 31, 2017, Modifier SZ should be used for
Habilitative Care.

For dates of services on or after January 1, 2018, Modifier 96 should be used for Habilitative services. For dates
of services on or after January 1, 2018, Modifier 97 should be used for Rehabilitative services.

What are habilitative services?

Arkansas’ definition of habilitative services are services provided in order for a person to attain and maintain a
skill or function that was never learned or acquired and is due to a disabling condition.

Coverage of habilitative services:

Subject to permissible terms, conditions, exclusions and limitations, health benefit plans, when required to
provide essential health benefits, shall provide coverage for physical, occupational and speech therapies,
developmental services and durable medical equipment for developmental delay, developmental disability,
developmental speech or language disorder, developmental coordination disorder.

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Virtual prenatal and postpartum support programs

Maven, a virtual prenatal and postpartum care program, is now available at no additional cost to Arkansas Blue
Cross and Blue Shield and Health Advantage ARHOME and ACA members.

Maven’s program supports women in between their in-person clinic visits. Maven’s trusted care advocates
take a relationship-driven approach to offer coaching and education on topics ranging from mental health
support and birth planning to nutrition and breastfeeding. Members can video chat or message with OB-GYNs,
pediatricians, lactation consultants and infant sleep coaches.

Maven supports expecting parents during pregnancy and postpartum and includes the following across
each track:
ƒ Care advocacy: Navigation to resources on the Maven platform as well as to high-quality, in-person care
for medical and social needs; risk detection and proactive outreach to personalize support, drive healthy
behaviors and improve outcomes.
ƒ Telehealth consultations: Telehealth capabilities with virtual providers and professionals, acting in a
coaching and education capacity.
ƒ Educational materials: A library of articles and video content to educate and guide participants in their
health journeys.
ƒ Content and community: Clinically-approached, engaging content and virtual classes; live community
forums moderated by Maven providers to ensure responses are clinically grounded.
ƒ Diverse coverage: Culturally diverse and conscious providers that speak multiple languages.

Members can sign up on the Maven website.

We can also provide trifolds or posters for your office. Please contact Kimberly Brown
(kdbrown@arkbluecross.com) if you would like further information.

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Hospital and Inpatient

Information
Section 13 | Hospital and Inpatient Information

Policies and Procedures for Hospital Reimbursement

Introduction
The purpose of this portion of the provider manual is to provide information on the Hospital Reimbursement
Program of Arkansas Blue Cross and Blue Shield with the specific objectives of explaining the policies and
procedures of reimbursement as referred to in the contract with member hospitals. (The remainder of this
provider manual continues to apply equally to hospitals, where applicable; this section is meant to address
reimbursement issues specific to hospitals only.)

Diagnosis-Related Groups
These policies and procedures shall be applicable to reimbursement based on diagnosis-related groups
(DRGs). This reimbursement system consists of established payment levels for groupings of claims according
to medically meaningful characteristics. There are six major criteria utilized in assigning a particular claim to a
specific DRG. These consist of:
ƒ The principal diagnosis
ƒ Procedures performed on the patient
ƒ Patient’s age
ƒ Patient’s sex
ƒ Patient’s discharge status
ƒ Multiple diagnosis and complications

Note: Arkansas Blue Cross uses a variety of methods to establish its allowances, including DRG-based methods,
and may change those methods or the or formulas used at any time in its discretion.

Date of Admission versus Member Policy Effective Date

When the date of admission precedes the effective date of the member’s policy, the claim will deny when billed
electronically. The claim will be processed manually where payment will begin for the effective date of the
policy. Admission dates prior to the date of coverage will be the responsibility of the member or the member’s
previous insurance carrier.

Definitions
ADJUSTED DRG AMOUNT - The DRG base rate plus any applicable daily allowance.

CONTRACTUAL ADJUSTMENT - The amount of reported charges in excess of the amount allowed under DRG
reimbursement which may not be collected from Arkansas Blue Cross and Blue Shield or its policyholder.

DAILY ALLOWANCE (DA) - An allowance that is added to the DRG base amount for each day the length of stay
exceeds the high trim point of the applicable DRG.

DIAGNOSIS-RELATED GROUPING (DRG) - A method of classifying hospital patients by similar diagnosis,

procedure, age, sex, and discharge status.

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DRG BASE AMOUNT - The amount as established by Arkansas Blue Cross that will apply to admissions for
selected DRGs where the length of stay is less than the high trim point.

INCENTIVE RATE - A percentage from 0% to 100% which is used in incentive adjustments to those claims where
the billed charges are greater than the adjusted DRG amount. Individual hospital rates are determined by a
formula applied to claims submission history of the particular hospital.

INLIER - Claims that meet the criteria for being assigned a DRG and do not present any of the factors that would
cause it to be considered an outlier.

MAP DETERMINED ALLOWANCE - The maximum amount that will be allowed for reimbursement of inpatient
claims. This is determined by adding the DRG base amount, any applicable daily allowance and incentive
adjustment.

MAXIMUM ALLOWABLE PAYMENT (MAP) - The amounts established by Arkansas Blue Cross as the maximum
payment allowances for services provided to its members.

OUTLIER - Claims that have unique characteristics that are outside established parameters for each DRG. Claims
with any of the following are outliers:
ƒ Length of stay outside the trim points
ƒ Death of patient
ƒ Patients leaving against medical advice
ƒ Patient transferred to another short-term general hospital

REPORTED CHARGES - The amount of charges billed for hospital services that the hospital is willing to accept
as payment in full. If a hospital discounts a percentage of billed charges, these deductions should be reflected in
the reported charges used to determine reimbursement.

TRIM POINTS - A range of days representing the expected length of a hospital stay for which the DRG
base amount is applicable. A claim is considered an “outlier” if the length of stay is greater or less than the
trim points.

Hospital Billing
Hospitals shall submit claims for hospital services provided to Arkansas Blue Cross and Blue Shield
policyholders using the UB-04 paper claim form, magnetic tape or Electronic Media Claim System. All
information necessary to adjudicate the claim shall be provided. Any incomplete claim will be returned for
additional information or correction.

Inpatient Services
ƒ Arkansas Blue Cross does not recognize distinct units of a hospital. Admissions involving transfer of a
patient from one unit of the hospital to another should be billed as a continuous admission on a single
claim form.
ƒ All charges for hospital services provided to Arkansas Blue Cross members that are obtained from another
hospital while an inpatient in the hospital submitting the claim shall be included on the same inpatient

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billing. A patient cannot be considered an inpatient of one hospital and an outpatient of another hospital at
the same time.
ƒ In computing the number of hospital days provided to a member, the date of admission will be counted, but
the day of discharge will not be counted.
ƒ The hospital will not require payment from any Arkansas Blue Cross member prior to or following the
rendering of a service for amounts more than any deductible, coinsurance, and non-covered amounts.
The hospital will look only to Arkansas Blue Cross for payment of approved benefits with the exception of
coinsurance, deductible and non-covered amounts.
ƒ Separate claims for mothers and newborn shall be submitted.
ƒ First interim bills may be submitted by Acute Care hospitals only when the admission extends beyond 60
days. Psychiatric hospitals, Rehabilitation hospitals, Detox Facilities, and Arkansas Children’s Hospital may
submit first interim bills when the admission extends beyond fourteen (14) days.

Outpatient Services
ƒ Reimbursement for outpatient services directly relating to an inpatient stay (e.g., preadmission X-ray or lab
procedures) that were provided 24 hours prior to or 24 hours after the inpatient stay will be included in the
DRG/per diem reimbursement for the same inpatient claim. The admission date and period covered should
reflect only the inpatient dates of services. Outpatient services that are not related to the inpatient stay may
be billed as outpatient even if provided within 24 hours of an inpatient stay.
ƒ Claims submitted for services provided to an outpatient who was not admitted must be completed with all
the required information necessary to adjudicate the charges, including the diagnosis and procedure codes.
ƒ Separate outpatient claims should be submitted for each date of service.

Payment for selected outpatient services will be made on a global fee basis using the procedures and code
number outlined in the Current Procedural Terminology (CPT4). This allowance will include all services
associated with the procedure except physician services, certified registered nurse anesthetist (CRNA) services,
ambulance services, and some implants and prosthetic devices.

Arkansas Blue Cross will notify the participating hospital 30 days in advance of adjustments to the outpatient
maximum payment allowances.

Initial Hospital Visits Billed by Multiple Physicians

In March 2012, Arkansas Blue Cross and Blue shield sent notice to providers that only the admitting physician
could bill the hospital admission CPT Codes 99221-99223. All other physicians seeing the patient, even if for the
first time, were instructed to bill the subsequent hospital CPT Codes 99231-99233. However, most physicians
continue to bill the hospital admission codes.

After data analysis and understanding that the consult CPT Codes are not available for providers to use,
Arkansas Blue Cross agrees that the physicians providing ‘consults’ to the hospital patient may bill the first visit
using the hospital admission CPT Codes 99221-99223 provided the service meets the requirements set forth by
the Centers for Medicare & Medicaid Services (CMS) for this use.

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The admitting physician should add Modifier A1 for reporting purposes only. Consulting physicians and
subsequent attending physicians should not use the Modifier A1.

Observation Beds
Facility charges for observation beds are to be billed under revenue code 762. Coverage guidelines for
observation beds are as follows:
ƒ Observation bed charges will be recognized from general acute care and critical access hospitals only.
ƒ Reimbursement for observation bed charges will be limited to one day’s semiprivate room allowance.
ƒ Hospital outpatient surgery fee schedule amount (global allowance) will encompass observation bed charges
and related services.
ƒ Observation bed services that occur within 24 hours of a hospital admission will be considered part of the
inpatient hospital billing. The admission date will be the day that the patient is first considered an inpatient.
For purposes of pre authorization (if applicable), the admission will be treated as an emergency so that
the 48-hour prior notice requirement will not have to be met. The managed care company following the
admission will post the actual admission date to their records.

Requirements for Outpatient Observation Care

In compliance with the Centers for Medicare and Medicaid Services Medicare Outpatient Observation
Notice (MOON), Arkansas Blue Cross and Blue Shield requires all acute care and critical access hospitals
to provide written notification and oral an explanation of the notification to patients receiving outpatient
observation services for more than 24 hours. For Medi-Pak ® Advantage members, observation stays require
any pre-authorization or pre-notification requirements. The notice and accompanying instructions are
available here.

The notice should explain the following using contemporary language:

ƒ The patient is classified as an outpatient
ƒ Cost-sharing requirements
ƒ Medication coverage
ƒ Subsequent eligibility for coverage for services furnished by a skilled nursing facility
ƒ Advise patients to contact his or her insurance plan with specific benefit questions

Registration of Hospital Room Rates

All room rates including private, semi-private and special-care units are to be registered with Arkansas Blue
Cross and Blue Shield at least annually and when such rates change. These rates should be listed on the
Bed Complement Form. The form is used to calculate the average and most prevalent semi-private room
allowances. The form is available by clicking on Bed Complement Form.

In hospitals with only private rooms, the average semi-private room allowance will be equal to the average,
routine Medical/Surgical Private Room Rate.

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The rates and changes should be sent to:

Arkansas Blue Cross and Blue Shield

Hospital Reimbursement, & Pricing Division
Post Office Box 2181
Little Rock, Arkansas 72203-2181

Note: Hospitals are responsible for sending changes.

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Hospital Reimbursement
The Maximum Allowable Payment (MAP) for:
ƒ Inpatient claims - Based on the lesser of reported charges or a MAP-determined allowance.
ƒ Outpatient claims - Based on the lesser of the reported charges or the maximum payment allowance.

The hospital’s reported charge as submitted on the claim form will be considered the maximum allowable
payment (MAP) when no DRG allowance has been established for a specific DRG or when no MAP has been
established for an outpatient service.

Actual payment amounts will be based on benefits of the member’s health plan or contract. Amounts related
to the policyholder’s deductible, coinsurance or non-covered services will be deducted from the MAP. These
amounts will become the portion of charges delineated as “Patient Responsibility” on the Remittance Advice.

All payments shall be made on the basis of the rates and allowances in effect on date of admission for inpatient
services and date of service for outpatient services. These dates will also be the determining date for changes in
participation status of the hospital and application of member contract benefits.

On-site audits may be conducted to verify that the medical records contain sufficient information to support
the data indicated on the claim that was used to determine reimbursement. Hospitals will be provided advance
notification of the dates and procedures of the audits. The results of the audit will be provided to the hospital
administrator and Arkansas Blue Cross and Blue Shield management to determine if adjustments are indicated.

Outliers
Outliers shall be reimbursed as follows:
1. Length of Stay Below the Low Trim Point — Charges will be recognized for medically necessary services up
to the MAP-determined allowance for the specific DRG.
2. Length of Stay Above the High Trim Point — Charges will be recognized for medically necessary services up
to the MAP-determined allowance.
3. Outlier Due to Death — Charges will be recognized for medically necessary services up to the Map-
determined allowance.
4. Transfers — Charges will be recognized for medically necessary services up to the MAP-determined
allowance.
5. Patient Leaving Against Medical Advice — Charges will be recognized for medically necessary services up
to the MAP-determined allowance.

Claims for admissions involving more than one outlier will be paid using the MAP-determined allowance for the
most significant outlier.

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Outliers Hierarchy
Outlier Type MAP

Death Charges up to MAP determined allowance.

Days above high trim points Charges up to MAP determined allowance.

Transfer Charges up to MAP determined allowance.

Days below the low trim point Charges up to MAP determined allowance.

Example: A claim with a stay above the high trim point when the patient was transferred to another short-term
general hospital will be paid as shown in the second example above.

Daily Allowance
The daily allowance is a method of sharing the extra cost of an extraordinarily long length of stay by adding to
the DRG base amount for each extra day the length of stay exceeds the high trim point.

This allowance is calculated by dividing the DRG base amount by the high trim point for the length of stay. The
DRG base amount, daily allowance and trim points will be provided to the participating hospital.

Incentive Payment Rate

Participating hospitals will be allowed an incentive adjustment for cost-efficient management of inpatient cases.
The incentive rate will be calculated using each hospital’s historical charge data. The participating hospital will
be notified in writing of the incentive rate no later than 30 days prior to the effective date.

The actual method of calculating the incentive payment rate is based on the total differences between reported
charges on inliers and outliers compared to the adjusted DRG amounts. The incentive adjustment will only be
applied to inpatient claim charges that are in excess of the adjusted DRG amount.

Any hospital with insufficient history to establish an incentive rate will have an initial rate of zero percent until
sufficient charge history has been accumulated.

Incentive Rate Calculations

A. For each hospital, divide all claims with a DRG base amount.
1. Normal claims, or inliers, with reported charges over the adjusted DRG amount.
2. Inliers with reported charges below the adjusted DRG amount.
3. Outliers with reported charges over the adjusted DRG amount.
4. Outliers with reported charges below the adjusted DRG amount.

B. The rate will be calculated as a percentage using:

1. Amount of reported charges over the adjusted DRG amount for inliers (Al, above).
2. 50 percent of reported charges below the adjusted DRG amount for both inliers and outliers (A2 and
A4, above).
3. Amount of reported charges over the adjusted DRG amount for outliers (A3, above).

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4. 25 percent of reported charges below the adjusted DRG amount for inliers (A2, above).

C. Add the lower of B1 or B2 to the lower of B3 or B4. Divide this amount by the sum of B1 and B3 and multiply
by 100 percent. This will be the rate.

Examples of Rate Calculation

INLIERS EXAMPLE 1 EXAMPLE 2 EXAMPLE 3

A. Reported Charges over adjusted DRG amount $25,500 $50,000 $60,000

B. Reported Charges under adjusted DRG amount $40,000 $26,000 $16,000

OUTLIERS

C. Reported Charges over adjusted DRG amount $15,000 $5,000 $5,000

D. Reported Charges under adjusted DRG amount $5,000 $44,000 $44,000

Lower of A or 50% (B + D) $22,500 $35,000 $44,000

Lower of C or 25%(B) $10,000 $5,000 $4,000

Sum of Lowers = $32,500 $40,000 $34,000

(Divided by)

Sum of A + C = $40,000 $55,000 $65,000

Rate = 81.25% 72.73% 52.31%

Contractual Adjustment:
A. Information necessary to calculate contractual adjustment:
1. Total amount of reported room charges
2. Total amount of reported ancillary charges
3. Actual length of stay
4. DRG number
5. High trim point
6. DRG base amount
7. DRG daily allowance
8. Average semi-private room allowance

B. The amount of contractual adjustments will be calculated as follows:

1. Add room allowance (the lesser of actual room charges or the length of stay times the average semi-
private room allowance) plus reported ancillary charges on the claim to determine the adjusted charges.
2. Add DRG base amount plus any applicable daily allowance (days above high trim point times daily
allowance) to determine the adjusted DRG amount.
3. Subtract the adjusted DRG amount (#2 above) from the adjusted charges (#1 above) to determine the
amount of any excess charges.

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4. Multiply the excess charges (#3 above) by the hospital’s incentive rate to determine the incentive
adjustment.
5. Subtract the incentive adjustment (#4 above) from the excess charges (#3 above) to determine amount of
contractual adjustment.

Contract benefits will be applied to reported charges on the claim less the amount of contractual adjustment to
determine the Arkansas Blue Cross payment.

If the adjusted DRG amount is equal to or greater than the adjusted charges, there is no contractual adjustment;
and contract benefits will be applied to reported charges on the claim.

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Section 13 | Hospital and Inpatient Information

Example of Contractual Adjustment Calculation:

Contractual Adjustment and Payment Calculation

Category Example Information

HOSPITAL NAME Arkansas Medical Center

PATIENT NAME Jim Public

ADMISSION DATE 1/24/97

REPORTED CHARGES $8,192.92

ROOM $2,250.00

ANCILLARY $5,942.92

LENGTH OF STAY 9 DAYS

AVERAGE SEMI-PRIVATE ALLOWANCE $250.00

DRG 089

BASE AMOUNT $6,650

DAILY ALLOWANCE $475

HIGH TRIM 14 DAYS

Adjusted Charges Adjusted DRG Rate

Room Allowance – Lesser of actual room charges or

DRG Base Amount $6,650.00
(# days x ASP)

Extra Daily Allowance

$2,295 Or $(9 x $250) $2,295.00 N/A
(# days x Daily Allow)

Reported Ancillary Charges $5,242.92 Total Adjusted DRG Rate $6,650.00

Total Adjusted Charges $8,192.92

Contractual Adjustment Payment Calculation

Adjustment Charges $8,192.92 Total Reported Charges $8,192.92

Adjusted DRG Rate $6,650.00

Excess Charges $1,542.92 Less Contractual Adjustment $300.87

Incentive Adjustment (80.5%) $1,242.05

Contractual Adjustment $300.87 Contract Benefits Applied To $7,892.05

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Section 13 | Hospital and Inpatient Information

Hospital Discounts
If a hospital provides discounts below its usual charge for patient services, (i.e., deductibles, copayments,
percentage of charges, etc.) the discount should be clearly indicated on the claim form. The discounted amount
will be used as the reported charges in determining the maximum allowed payment (MAP).

When the Medicare deductible is discounted, no secondary payer should be listed in Locator 57 on the Medicare
UB-04 claim form.

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Section 13 | Hospital and Inpatient Information

Hospital Appeals Issues

Administrative Decisions
Hospital appeals of administrative matters (e.g., peer group assignments, amounts for DRG incentive rates,
etc.) should be submitted to Hospital Reimbursement and Pricing in writing, setting forth the specific issues of
disagreement. Any appeal concerning matters affecting the calculation of incentive rates must be submitted
within 30 days after hospital first receives the incentive rate notice and provider analysis report.

Any unresolved issues will be submitted to the Hospital Committee of the Arkansas Blue Cross and Blue Shield
Board of Directors. The hospital will be informed of the decision within thirty (30) days of the appeal.

Determination of Non-Covered Services

The determination of a non-covered hospital service (e.g., diagnostic admission, pre-existing cosmetic, etc.)
will be made by applying generally accepted medical standards based on documented facts of the case.
When medical records are secured and reviewed, the case may be referred to the hospital’s Utilization Review
Committee for consideration and recommendations.

If the issue remains unresolved the claim will be referred to the ABCBS Medical Director who will either
authorize benefits on the claim or refer it to a recognized medical review entity.

If the Medical Review Committee determines the services are non-covered, the hospital may appeal the decision
by appearing before the review committee to present additional information.

If after the appeal, the review committee still determines the services to be non-covered, their decision will
be binding.

DRG Assignment
Hospital appeals pertaining to the DRG assignment on a particular claim may be submitted as follows:
1. Discrepancies caused by incorrect information on the claim form can be corrected by submitting a
corrected claim form with bill type 117 in form locator 4. Corrected claims may be reprocessed through the
computer system to provide correct member utilization data (e.g., deductible, stop loss, etc.) resulting in the
voiding of the original claims and payment of the corrected claim. This information will be reflected on the
Remittance Advice.
2. Discrepancies caused by erroneous translation of information from the claim form into the computer system
should be submitted to Arkansas Blue Cross and Blue Shield in writing within 60 days of the date of the
Remittance Advice.

DRG Weights Calculation Policy

Each year a copy of the DRG weights is downloaded from the CMS website after the final rule is rendered in
the Federal Register. This file is downloaded into an Excel format and is used to process inpatient hospital
claims. Previously, the weights are carried to only four decimal places. For 2015, CMS has carried the decimal
further than the four decimal places. However, the full calculation is only visible when clicking in the cell on
the downloaded CMS spreadsheet. For purposes of consistency, the DRG weight will be rounded to the fourth
decimal place in all Arkansas Blue and Blue Shield claims systems. For example, DRG 378 has a DRG weight of
1.002061 and will be rounded to 1.0021.

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Section 13 | Hospital and Inpatient Information

Inpatient Claims Financial Responsibility Policy

The Blue Cross Blue Shield Association has taken steps to ensure consistency among all Blues Plans regarding
inpatient pre-service review (also known as pre-authorization or pre-certification). This change took effect
January 1, 2014.

Inpatient facilities that fail to obtain pre-authorization or pre-certification when it is required will be financially
responsible for any covered services not paid and the member will be held harmless. Not all health plans require
inpatient pre-authorization or pre-certification, but where it is required, inpatient providers who fail to obtain it
will be financially responsible for any covered services not paid and the member will be held harmless.

To implement this mandate from the Blue Cross Blue Shield Association, provider agreement language must be
revised. Please consider this notification as an amendment to the Arkansas Blue Cross and Blue Shield Preferred
Payment Plan, Health Advantage HMO and PPO Arkansas’ True Blue PPO and Arkansas’ FirstSource® PPO
provider network participation agreements.

The following sections in the Hospital and PHO provider network participation agreements will now contain the
additional language:

Pre-Certification, Pre-Notification, & Eligibility Inquiries

Non-Emergency Admissions - Facility understands and agrees that for Health Plans that require pre- certification
or pre-notification and Facility fails to obtain pre-authorization or pre-notification, that Facility will hold Member
harmless of any amounts not paid for Covered Services.

Emergency Admissions - Facility understands and agrees that for Health Plans that require pre- certification or
pre-notification within 24 hours after admission or by the end of the next working day, if on a weekend or holiday
and Facility fails to obtain pre-authorization or pre-notification, that Facility will hold Member harmless of any
amounts not paid for Covered Services.

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Section 13 | Hospital and Inpatient Information

Revenue Code Claims Filing Changes

Since March 1, 2011, outpatient institutional claims containing revenue codes 0905, 0906, 0912, 0913 and 0915
have required CPT/HCPCS codes in conjunction with these revenue codes. When submitting outpatient claims
with these revenue codes (both electronic and paper), facilities must also use the appropriate corresponding
CPT codes 90801-90880, 90901, 96101-96120, G0176, G0177, G0396, G0397, G0410 and G0411. Claims submitted
without appropriate CPT/HCPCS codes will be rejected and the member will not be responsible. This revision
applies to all outpatient UB04 claims submitted to Arkansas Blue Cross and Blue Shield, BlueAdvantage
Administrators of Arkansas and Health Advantage.

Also effective March 1, 2011, revenue code 0761 (specialty services – treatment room), have required CPT codes
on outpatient claims. Please use the following appropriate CPT code when submitting revenue code 0761: 99201-
99205, 99211-99215, 97597, 97598 and 97602. Outpatient claims submitted without the appropriate CPT code in
conjunction with revenue code 0761 will be rejected and the member will not be responsible.

Supplies are often used in conjunction with services billed with revenue code 0761. When revenue code 0761 is
billed, supplies in conjunction with 0761 should be billed using revenue codes 0270, 0271 or 0272.

Revenue codes requiring CPT or HCPCS codes

Beginning July 1, 2015, outpatient institutional claims (UB04) containing revenue codes 0480, 0481, 0482, 0483
and 0489 will require CPT/HCPCS codes in conjunction with these revenue codes. The additional CPT/HCPCS
codes will be required on both electronic and paper claims. Claims submitted without the appropriate CPT/
HCPCS codes will be rejected and the member will not be held responsible. This revision applies to all outpatient
UB04 claims submitted to Arkansas Blue Cross and Blue Shield, Blue Advantage Administrators of Arkansas and
Health Advantage.

Injectable Drug Pricing for Hospital Outpatient Departments

An article was published in the September 2004 issue of Provider’s News stating that administration fees for IV
infusions, etc., would not be covered for facilities. The article specifically mentioned revenue codes 940 and 949.

It has come to the attention of Arkansas Blue Cross and Blue Shield that this denial has not been applied
consistently. In an effort to control costs and to be fair to our providers, Arkansas Blue Cross will begin paying a
nominal fee for these services.

Since the reimbursement for the facility practice expense is covered under other revenue codes when provided
in the outpatient hospital setting, the reimbursement for the practice expense portion of these services has been
removed from the fee schedule amount used for physicians.

Additionally, Arkansas Blue Cross will begin paying hospitals for injectable drugs (J0000-J9999, etc.) based on
the Arkansas Blue Cross fee schedule which was developed to reimburse the cost of the medication. Some of
the sources of the reimbursement amounts are Average Sales Price (ASP) plus 10% (with a 10% maximum of
$400), wholesale acquisition cost (WAC), 85% of average wholesale price (AWP), or invoice from the provider.

The fee schedule amounts will be the same as the amounts used to reimburse physicians and will be paid at
100% of the Arkansas Blue Cross fee schedule amount. Unlisted J codes will be listed as BR (By Report) and will
be reimbursed using one of the sources noted for the drug and dosage provided.

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Anytime a valid HCPCS or CPT code is available for the drug given, the HCPCS/CPT code is required to be billed
with the appropriate revenue code.

Clinic Visits and Trauma Revenue Codes Billed by a Facility

Arkansas Blue Cross and Blue Shield, Health Advantage and PPO Arkansas do not recognize facility charges for
clinic visits or trauma revenue codes. Facility charges for services performed in a clinic should be billed under
revenue codes 0510-0519. Trauma revenue codes 0680-0689 will also be denied as non- covered. These services
will be denied and charges for these services should not be collected from Arkansas Blue Cross policyholders.

Covered services performed in a clinic will be reimbursed when billed on a professional claim.

Implant Billing and Invoice Requirement Change

Effective for dates of service on or after January 01, 2018, there has been no allowance for implant revenue
codes 275 or 278 when billing for Outpatient Hospital or Ambulatory Surgical Center (ASC) Surgery.

The provider may appeal this decision to Provider Compensation only if there is more than one device intensive
procedure on the claim or the claim contains one of the limited numbers of pass-through codes. In these
instances, an invoice will be required to price; there will no longer be threshold amounts.

Please note that in case of an appeal, we will still no longer accept a purchase order in place of a
manufactures invoice.

Please contact your Network Development Representative with any questions or email the Provider
Compensation team at providerreimbursement@arkbluecross.com.

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Section 13 | Hospital and Inpatient Information

UB-04 Claims
Arkansas Blue Cross relies on the proper coding to process provider claims and adjudicates the member’s
benefits. The codes providers select and enter on claims are representations to us that the member’s treatment
(and your bill) was for the coded diagnosis, not others, and that the provider, in fact, performed the procedures
as described in the American Medical Association Current Procedural Terminology (CPT) Manual or the Health
Care Procedural Coding System Manual (HCPCS). Miscoded or improperly billed claims may constitute fraud and
could be the basis for denial of claims, termination of provider network participation or other remedial action.

Claims Filing Information

Information regarding the national uniform billing data element specifications manual as developed by the
National Uniform Billing Committee (NUBC) can be found by accessing their web site at nubc.org.

Scanning UB-04 Paper Claim Forms*

Arkansas Blue Cross is now scanning the UB 04 claim form (CMS-1450). From our experience with scanning, the
following items commonly cause claims to be delayed or rejected on UB 04 claims.
ƒ All data must be contained within its defined area.
ƒ All dollar fields should be blank or have real values.
ƒ Do not include $ or decimal points when reporting charges.
ƒ Do not handwrite or put comments on claims.

* Paper claim submission is not the preferred method. Paper claims may be delayed and result in delayed
adjudication due to multiple factors. Paper claims have a higher rate of rejection due to increased errors.
For information on submitting your claims electronically, please contact Availity at 800-282-4548 or
800-282-AVAILITY. Availity allows providers to submit claims using direct data entry (DDE) for free on the
portal for all Arkansas Blue Cross and Blue Shield lines of business.

Most Common Errors

This process has also allowed us to process UB 04 claims through edits on the front end before they enter the
claim system. The most common errors are:
ƒ No Source of Admission Code in Form Locator 15
ƒ No Patient Status Code in Form Locator 17
ƒ No Provider Number in Form Locator 56 & 57

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Section 13 | Hospital and Inpatient Information

Form Instructions
The UB 04 manual is our guide for completing this form.

DATES – Box 6, 10, 12, 31-36, 45, 74-74E. All date fields except Box 10 should be filled out as “MMDDYY.” Do NOT
use “/ -” or spaces to separate month, day or year. Always put a zero in front of single-digit days or months. Box
10 (birthday) should have a 4-digit year.

BOX 1 – Provider’s Name and Address: Do NOT type information above Box 1. Always place phone number
as last line in this box. Format expected: Line 1 – provider’s name; Line 2 – provider’s street address; Line 3 –
provider’s city, state, zip (5 or 9 positions); Line 4 – provider’s phone (7 or 10 positions).

BOX 3a – Patient Control Number: Should start on left side of box. Numbers next to bill type can become part of
bill type.

BOX 8 a & b – Patient’s Name/ID: Enter in 8a the patient’s ID and in 8b the patient’s last, first and middle initial.
No commas, periods or titles.

BOX 9 a-e – Patient’s Address: Enter the patient’s street address (9a), city (9b), state (9c), zip codes (5 or 9 digits)
(9d), and country (9e). Do not use separators such as semi-colons, use spaces.

BOX 38 – Responsible Party’s Name and Address: Line 1 –Name (last name, first name) and initial. No periods,
commas or titles. Line 2 —Address (street or apt, etc.) Line 3 - Can be a second street, box etc. Line 4 –City, state
and zip (5 or 9). Do not enter phone numbers. Phone numbers distort OCR and there is no place to store them on
the NSF records.

BOX 46 – Service Units: Enter whole numbers only up to seven numeric digits. Fractions and decimals are
not allowed.

BOX 50 – Payer Name: Enter payer’s name, left-justified. If Medicare is the primary payer, enter “Medicare” on
the line. (Line A – Primary Payer, Line B – Secondary Payer, and Line C – Tertiary Payer)

BOX 56 – National Provider Identifier (NPI): Please left-justify.

BOX 58 – Insured’s Name: Enter the last, first, middle initial of the insured. Do not use periods, commas or titles.
(Line A – Insured’s Name Primary, Line B – Insured’s Name Secondary, and Line C – Insured’s Name Tertiary)

For complete instructions on the UB-04 form, visit the CMS web site at cms.hhs.gov.

Paper claims submitted on black UB-04 (CMS-1450) claim forms will be returned to the provider. Paper facility
claims should be submitted on the standard UB-04 claim form with red “drop out” ink. These may be obtained
through various print vendors that comply with National Uniform Billing Committee (NUBC) specifications.
Arkansas Blue Cross and Blue Shield recommends providers submit claims electronically and avoid using paper
claim forms whenever possible.

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SECTION 14

ICD-10
Section 14 | ICD-10

ICD-10 Claims Coding

Arkansas Blue Cross and Blue Shield and its family of companies requires the use of ICD-10 claims coding.
Claims without ICD-10 codes will not be paid.

Availity claims acceptance criteria for ICD-10

Availity has the following criteria to comply with the federal regulation related to ICD-10. Claims not meeting this
criterion will be rejected at the time of submission.

Criteria:
All claim types:
ƒ If a claim is submitted with ICD-9 and ICD-10 codes on the same claim, the claim will be rejected.
ƒ ICD codes must have the correct qualifier indicating whether the code is an ICD-9 code or ICD-10 code.
ƒ The October 1, 2015 compliance date applies to both the ICD diagnosis and ICD procedure codes.

Inpatient claims:
ƒ If the discharge date (statement to date) is prior to the compliance date, ICD-9 codes must be submitted for
all service lines on claim.
ƒ If the discharge date (statement to date) is on or after compliance date, ICD-10 codes must be submitted for
all service lines on the claim.
ƒ For interim bills, the same rules will apply.
ƒ For inpatient claims with admission date prior to compliance date but a discharge date (statement to date)
after compliance date, ICD-10 must be submitted on all service lines on the claim.

Professional and outpatient claims:

ƒ If the statement to date or service date is prior to compliance date, ICD-9 codes must be submitted for all
service lines on claim.
ƒ If the statement to date or service date is on or after compliance date, ICD-10 codes must be submitted for all
service lines on the claim.
ƒ If a claim has service dates both prior to and on or after the compliance date, the claim must be split such
that services prior to compliance date are billed on one claim with ICD-9 codes and services on or after
compliance date are billed on second claim with ICD-10 codes.

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Section 14 | ICD-10

ICD-10 guidelines for paper claim submissions

For detailed instructions on how to properly complete the CMS-1500 (02/12) claim form, Arkansas Blue Cross
recommends following the National Uniform Claim Committee (NUCC) guidelines located on their website
at nucc.org.

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SECTION 15

Medical Records
Review
Section 15 | Medical Records Request

Arkansas Blue Cross recently implemented electronic attachments via the Attachments Dashboard in Availity
Essentials to reduce fax/mailed bar-code medical record requests. This electronic process will allow you to
proactively submit ‘unsolicited attachments’ when you file the original claim. It will also enable you and your
team to respond to ‘solicited’ medical record requests electronically.

The ability to upload documents (unsolicited and solicited attachments) can be accessed through a convenient
dashboard on Availity Essentials portal: Access the dashboard from Home | Claims & Payments | Attachments.

Please note your user administrator must register your organization for this function.

Training videos are available in the Availity Learning Center. Providers can log in and select Help & Training | Get
Trained to search the Availity Learning Center catalog:
ƒ Attachments (Training demo)
ƒ Attachments Dashboard Intro & Medical Attachments Setup (recorded webinar)
ƒ Medical Attachments Setup (Training demo)
ƒ Arkansas BCBS – Submit attachments with 837 and Direct-Data Entry (DDE) Claims (recorded webinar)

Terminology
Solicited Attachments – These are requests sent electronically from Arkansas Blue Cross to the provider for
medical records related to a specific claim.

Unsolicited Attachments – Many providers know that the services they are billing require medical records.
When they file the original claim, they can also attach the medical records. These are called Unsolicited
Attachments

Medical Records Requests (MRR) is now referred to as Medical Attachments.

Some things to note about this change:

We will direct the medical record request to the clinic or facility whenever possible instead of the individual
provider so the electronic request will be posted for the appropriate provider organization in Availity. There will
be some instances where the request will be directed to a referring provider if Arkansas Blue Cross is unable to
obtain clinic information.

Moving the request process from paper to electronic requires the use of standard coding known as Logical
Observation Identifiers Names and Codes, or more commonly referred to as LOINC. LOINC is the world’s most
widely used terminology standard for health measurements, observations, and documents. LOINC helps make
health data more portable. To send providers electronic requests Arkansas Blue Cross must map the formerly
faxed letters to a standard LOINC. Some letters have not yet been mapped (i.e. Medical Questionnaires).
Mapping of these requests is an on-going process we are working through. Due to this on-going process, only
a portion of the medical request letters can be sent electronically at this time; the remaining requests continue
to be sent via fax/mail. You may continue to receive a portion of record requests by fax/mail in addition to
electronically until all request letters can be mapped.

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Section 15 | Medical Records Request

The Patient Account number referenced on a Medical Record request may not match your records. Medical
record requests we send to the referring provider will include the patient account number of the provider who
submitted the claim (ie. Ancillary provider). Please use the patient’s name to locate the member’s records.

If a response is not received within 20 days of the original request (electronic or faxed), a follow-up request letter
will be sent through USPS Mail.

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Section 15 | Medical Records Request

Cancel Request
If you receive a request from Arkansas Blue Cross that, in your opinion, does not apply to you:
ƒ The best practice is to respond to all requests.
ƒ Select the request in question.
ƒ Upload a note stating why you cannot respond with records. For example, the patient listed is not your
patient, or unable to locate the date of service in question; in general, why should the request sent to this NPI
be cancelled.
ƒ Select Submit.

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Section 15 | Medical Records Request

Troubleshooting
For primary support of the registration setup, you can:
ƒ Create a support ticket in Availity through Help & Training | Availity Support, then Contact Support
ƒ Call Availity Client Services at 1-800-AVAILITY (800-282-4548)
ƒ Initiate a Live Chat with an Availity Client Services Representative through Help & Training | Availity
Support, then Contact Support

For customer support regarding the request or claims status: Call the number on the back of the member ID
card for specific questions related to the request. For example, was my request sent electronically or by fax.
To inquire on the status of a claim pended for medical record review, please check claim status on Availity
Essentials portal.

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SECTION 16

Member / Patient
Information
Section 16 | Member / Patient Information

Case Management
The Case Management programs are provided through the continuum of care in a manner that allows the
member to have optimal access to the Case Manager to meet the member’s needs. CM services are provided
predominately telephonically. The CM program design allows for utilizing other communication resources such
as postal mail, email dialog, mobile messaging and may occur occasionally onsite through inter-disciplinary
meetings or home visits.

The CM Program has adopted the definition of case management from the Case Management Society of
America’s Standards of Practice as follows: Case Management is a collaborative process of assessment,
planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s
and family’s comprehensive health needs through communication and available resources to promote patient
safety, quality of care, and cost-effective outcomes.

The CM Program goals/objectives are to:

ƒ Promote quality, safe, and cost-effective care through clinical education with identified clinical needs to
support post-discharge plans.
ƒ Maximize efficiencies of available resources to achieve clinical and social determinants of health needs.
ƒ Ensure appropriate access to care by working with primary care providers (PCP) and other clinical care
providers.
ƒ Work collaboratively with the member, family, and/or caregiver(s) as chosen by the member, the physician,
providers of health care, and others to develop and implement a plan that meets the individual’s clinical
needs and goals, to achieve success.
ƒ Support members’ health care choices and promote self-care.
ƒ Improved patient/caregiver, client, caregiver communication that clearly identifies the role of the
case manager.
ƒ Improvements in member satisfaction in case management
ƒ Increased rates in depression screenings.

Arkansas Blue Cross case management nurses are licensed/certified clinical professionals who use their
specialized skills to communicate effectively with members, caregivers, and treating providers. They do not,
however, provide any medical services. All treatment decisions remain exclusively with the member/caregiver
and their treating provider.

The Arkansas Blue Cross Case Management Team consists of a multidisciplinary team of clinical professionals.
Case managers can be reached at 1-800-225-1891.

For more information regarding case management, please see the section on our website:
arkansasbluecross.com/members/individual-and-family/understanding-your-insurance/case- management-services.

Additional Programs under the umbrella of case manage include:

ƒ Complex Chronic Condition Management for members who have Asthma, CAD, CHF, COPD, Diabetes, or
renal disease.
ƒ Catastrophic Case Management

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Section 16 | Member / Patient Information

ƒ High Risk Maternity Program called Special Delivery

ƒ Transition of Care program for members being discharged from an acute inpatient admission.
ƒ Social Worker
ƒ Behavior Health
ƒ Specialty Case Management to assist with site of care steerage for high cost infusions.

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Section 16 | Member / Patient Information

Member ID Cards
Members should present an identification card at the time of service. This card will include certain member
information necessary for claim submission and should be transferred to the claim form exactly as presented on
the ID card (unless you learn or have reason to know that such information is incorrect). Providers can view most
member ID cards on Availity when verifying member eligibility.

Is the ID Card an Authorization for Service?

The ID card is neither an authorization for service nor a guarantee of payment. The ID card is provided for
convenience only. All coverage or eligibility issues must still be decided by referring to the member’s contract or
health plan and must be evaluated and confirmed by Arkansas Blue Cross when a claim is received.

Misuse of the Member ID Card:

Arkansas Blue Cross and Blue Shield is not responsible for any individual member’s misuse of an ID card, nor
do we have any ability to recall ID cards previously issued when an individual ceases to be eligible for coverage.
Members may also mistakenly use outdated ID cards with incorrect information.

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Section 16 | Member / Patient Information

Member Appeals
Members are entitled to appeal claims denials under procedures that are outlined in the member’s applicable
health plan or contract. All appeals are subject to timely filing and other standards as set forth in the member’s
health plan or contract.

Arkansas Blue Cross and Blue Shield welcomes a provider’s input on member appeals in their role as patient
advocate, and Arkansas Blue Cross does not intend this paragraph or any other statement or activity on our
part as discouragement of any advocacy a provider believes is appropriate with respect to member appeals or
access to benefits under their health plan or contract. At the same time, Arkansas Blue Cross does occasionally
encounter situations in which it is clear that the member is being used by a particular provider to pursue the
provider’s own agenda, either to obtain payment for clearly non-covered services, or to simply wage a vendetta
against Arkansas Blue Cross or other payers for perceived grievances or dissatisfaction of the provider.

Fortunately, Arkansas Blue Cross’s relations with providers in general are excellent, so such instances are rare.
However, Arkansas Blue Cross does ask that providers and their staff refrain from upsetting or inciting our
members to file appeals in support of their own, separate agenda or when providers are aware that Arkansas
Blue Cross has previously addressed the same coverage question and that the service in question is not covered
under Arkansas Blue Cross health plans or contracts.

If Arkansas Blue Cross has previously addressed the same coverage issue, it would be appropriate for providers
to offer any new or different information on that topic, but it would not be appropriate to simply encourage or
participate in repeated member appeals presenting the same information or arguments previously addressed.
This situation sometimes has occurred when a particular provider disputes Arkansas Blue Cross’s determination
that a treatment, drug or device is experimental/investigational and persists in encouraging and supporting
multiple member appeals (involving many different members) regarding the precise same treatment, drug or
device, even though Arkansas Blue Cross has fully reviewed the treatment, drug or device and has determined
that it is experimental/investigational under Arkansas Blue Cross guidelines, as reflected in our member health
plans or contracts.

Providers as Authorized Representative for Member Appeals

Arkansas Blue Cross and Blue Shield will recognize a provider as the authorized representative of a member,
thereby permitting the provider to pursue an appeal on behalf of the member, in the following circumstances:

Urgent Care
If the treatment a provider is administering involves urgent care (where delay of immediate treatment would
seriously jeopardize a member’s life or health or the member’s ability to regain maximum function) we will
recognize the provider as an authorized representative to appeal any denial of pre authorization or prior approval
that may be required for coverage under the member’s health plan or insurance policy.

Written Designation by Member

In non-urgent care situations, we will recognize a provider as the authorized representative of the member to
pursue an appeal of a claim denial on behalf of the member if the member has executed a written designation
of the provider on a form that has been approved by us for this purpose. Approved designation forms may be
obtained by contacting Provider Service or a Network Development Representative.

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Section 16 | Member / Patient Information

Re-Reviews
Anytime a provider disagrees with the denial of a code or the payment level of a code on a claim, the provider
should submit a request for reconsideration by the re-review team in the Medical Audit and Review Services
area. Please write Claim Re-review (MARS) on the letter. It is only after the re-review team upholds the denial or
level of payment that it would be appropriate to appeal the denial or payment level to the Appeals Coordinator.

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Section 16 | Member / Patient Information

Member Eligibility Inquiries

A provider may contact the Arkansas Blue Cross and Blue Shield Customer Service Department during normal
business hours to seek available information on whether a patient is eligible under any of the Arkansas Blue
Cross benefit plans. This information can also be accessed through My BlueLine (24 hour Interactive Voice
Response system) or on Availity. Availity is recommended as the preferred method of verifying eligibility and
benefits. Availity is updated nightly.

Member Eligibility
When a customer service representative receives a call regarding eligibility, the customer service representative
will ask for the Arkansas Blue Cross provider number and either the member’s name, member identification
number, or the member’s Social Security number. When member eligibility is determined, the representative
can provide the following information to providers:
ƒ Benefits
ƒ Coordination of Benefits information
ƒ Effective date of coverage
ƒ Effective date of termination
ƒ Family members on policy

Special Note
Arkansas Blue Cross cannot give providers any kind of guarantee regarding eligibility. Arkansas Blue Cross can
only give providers the data available to us and reflected on our computer system at the time a provider calls.
Many factors beyond the knowledge or control of Arkansas Blue Cross may affect the eligibility status of a
member. Therefore, a provider should not rely on the eligibility data Arkansas Blue Cross provides as assurance
of coverage for the services or service date(s) in question. A provider’s best source of the most up-to-date
information on eligibility is the patient, who should know employment status and premium-payment history or
intention on the date of service. Arkansas Blue Cross’s participating provider agreements specifically address
eligibility.

Effects of Pre authorization or Pre-notification Responses

Provider understands and agrees that pre authorization for inpatient treatment, pre-notification and any
“verification of benefits” or other eligibility inquiries made prior to, at or after admission or provision of any
services to members are not a guarantee of payment.

Pre-notification means only that Arkansas Blue Cross (or the applicable payer) has been notified of the hospital
admission. Pre-notification is required for all out-of-state inpatient hospital admissions and in-state admission to
hospitals not in the Arkansas Blue Cross network.

While Arkansas Blue Cross (or the applicable payer) or its designated representative will endeavor in good faith
to report member eligibility information available to Arkansas Blue Cross within its records or computer systems
at the time of admission or provision of services, providers acknowledge and agree that it is not possible to
guarantee accuracy of such records or computer entities.

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Section 16 | Member / Patient Information

Providers understand and agree that the eligibility of all members and coverage for any services shall be
governed by the terms, conditions and limitations of the member’s health plan. The member’s health plan shall
take precedence over any inconsistent or contrary, oral or written representations.

No reimbursement shall be due from Arkansas Blue Cross (or the applicable payer) for services if, following any
inpatient treatment or other services, it is discovered or determined that:
ƒ Premiums had not been paid for a member’s coverage,
ƒ A former member was no longer employed and eligible for participation in the health plan at the time of the
admission, or
ƒ Coverage had lapsed or terminated for any reason.

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Section 16 | Member / Patient Information

Member Financial Obligations

In most situations, Arkansas Blue Cross and Blue Shield members will be responsible for part of a provider’s
bill for services; and, as the Arkansas Blue Cross provider agreement outlines; providers will not waive the
member’s financial responsibilities (e.g., the member copayment, coinsurance and deductible) as specified in the
member’s health plan or contract.

Non-Covered Services
Members will generally be exclusively responsible for any non-covered services provided, except that, as
specified in Arkansas Blue Cross provider agreement, providers may not bill members for services that do
not meet Primary Coverage Criteria or which are experimental/investigational, unless a member waiver is first
obtained. Select the Patient Waiver Form (PDF) link for the physician notice and member agreement information.

Note: Except for applicable copayment, coinsurance or deductible, providers are not permitted to request or
require payment in advance by any of Arkansas Blue Cross members or from anyone else as a condition of
providing services to members.

Billing
Providers are not permitted to “balance bill” a member for amounts more than the Arkansas Blue Cross and Blue
Shield allowance (member copayment, coinsurance and deductible are deemed part of the allowance for this
purpose and should be billed to the member). Providers are also responsible for any billing or collection service
activities that they may engage, or to whom a provider may assign any accounts receivable or other claims
against Arkansas Blue Cross members.

If Arkansas Blue Cross finds that any billing service, collection agency or other agent engaged by a provider has
improperly attempted to bill any member or collect any amounts from members in violation of the Arkansas
Blue Cross provider agreement or the guidelines in this Provider Manual, providers are obligated to promptly
take all necessary steps to halt any such activity, to ensure that it is not repeated, and to reimburse Arkansas
Blue Cross and the member for any expenses or losses incurred in responding to or defending against the claims
or collection actions of any such billing service, collection agency or other agent.

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Section 16 | Member / Patient Information

My BlueLine for Eligibility and Benefits

My BlueLine provides Eligibility and Benefits Information as outlined below:

Eligibility
Arkansas Blue FEP Federal BlueAdvantage
Health
Cross Blue Employees Medipak ®
Administrators
Advantage
Shield Program of Arkansas

Active or Termed X X X X X

Effective Date X X X X X

Termination Date X X X X X

Whether Pre-Existing Applies

X X X X X
& been met

Benefits
Arkansas Blue Cross and Blue Shield
ƒ Deductibles
ƒ Deductibles amount satisfied
ƒ Copays
ƒ Coinsurance
ƒ Stop-loss
ƒ Lifetime maximums
ƒ Pre authorization requirements
ƒ Wellness
ƒ Maternity
ƒ Accident
ƒ Chiropractor
ƒ Durable Medical Equipment
ƒ Ambulance
ƒ Mental health
ƒ Outpatient physical and occupational therapy
ƒ Outpatient speech therapy

BlueAdvantage Administrators of Arkansas

Benefit Information is not available.

Federal Employees Program (FEP)

ƒ Deductibles
ƒ Copays

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Section 16 | Member / Patient Information

ƒ Coinsurance
ƒ Pre authorization requirements
ƒ Outpatient medical services
ƒ Inpatient hospital
ƒ Catastrophic benefits
ƒ Diagnostic X-rays and lab
ƒ Adult preventive care
ƒ Maternity
ƒ Allergy Care
ƒ Physical, occupational, speech and cognitive therapy
ƒ Chiropractor
ƒ Accident

Health Advantage:
ƒ PCP copay
ƒ Specialty copay
ƒ In- and out-of-network deductibles
ƒ Outpatient therapy visits, copay and coinsurance
ƒ DME maximum amounts, copay and coinsurance
ƒ Outpatient coinsurance
ƒ Out-of-network coinsurance

Medi-Pak®:
ƒ Medi-Pak llan
ƒ Deductibles
ƒ Coinsurance
ƒ Copays
ƒ Drug Coverage

My BlueLine provides the following claim status information:

Arkansas Blue FEP Federal BlueAdvantage
Health
Cross Blue Employees Medipak ®
Administrators
Advantage
Shield Program of Arkansas

Allowance X X X X

Check Number X X X X X

Check Status X X X X X

Check Total X X X X X

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Section 16 | Member / Patient Information

Arkansas Blue FEP Federal BlueAdvantage

Health
Cross Blue Employees Medipak ®
Administrators
Advantage
Shield Program of Arkansas

Coinsurance X X X X

Copayment X X X X

Deductible X X X X

Denial Reason X X X X X

Paid Amount X X X X X

Pended Reason X X X X X

RA Date X X X X X

Risk Amount X

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Section 16 | Member / Patient Information

Waiver of Health Plan Liability

Waivers of Health Plan Liability are used to educate members on services that may not meet the Primary
Coverage Criteria of the member’s policy. This applies to all policies under Arkansas Blue Cross and Blue
Shield’s various products. Using waivers allows providers to collect for services that may not be deemed as
meeting the Primary Coverage Criteria particularly for services designated as experimental/ investigational or
which are not for the treatment of a medical condition.

It is the provider’s responsibility to inform the member before a service is provided when the service(s) may be
considered as not meeting coverage criteria (e.g., which may be experimental or investigational). This process
was designed to prevent Arkansas Blue Cross members from unwittingly having and/or paying for services that
do not meet coverage criteria, (e.g., are considered as experimental/investigational under the coverage policy) or
cosmetic services/procedures.

Providers may collect billed charges from members for services that are deemed as not meeting the Primary
Coverage Criteria of the member’s health plan only if the provider obtains a written statement from the member
before any services are provided. Please follow the guidelines below when obtaining a waiver.

A Valid Waiver Must Include

1. The CPT code and/or description of service that may be denied
2. Reason for likelihood of denial: “this procedure does not meet coverage criteria” or “this procedure is
considered experimental and/or investigational”
3. Dollar amount of charges for the service
4. Patient’s signature
5. Signature date

General Guidelines
1. Waivers are only required for services considered not meeting coverage criteria or those considered
experimental/investigational.
2. The patient must sign the waiver before the service is performed.
3. “Blanket” waivers are not acceptable. Providers must not require a waiver routinely or obtain waivers for all
services as a precaution. Waivers should only be used for specific services the provider knows or has reason
to believe Arkansas Blue Cross may deny for failure to meet the Primary Coverage Criteria (e.g., due to the
experimental/investigational nature of the service).
4. Patients should not routinely sign a waiver.
5. Providers should not add information to a waiver after it has been signed by the patient.
6. Members should not be asked to sign a blank waiver of liability.
7. Each date of service will require a separate waiver.
8. The member must understand their responsibility when signing a waiver, and why a waiver is necessary for
the service.
Note: Providers who abuse the waiver procedure or these rules shall be subject to exclusion from the network.

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Section 16 | Member / Patient Information

When a Patient Won’t Sign Wavier

It is the provider’s responsibility to inform Arkansas Blue Cross patients when a service(s) may be considered
not meeting the Primary Coverage Criteria, (e.g., experimental/investigational under Arkansas

Blue Cross coverage policy). This pre-notification process was designed to prevent Arkansas Blue Cross
members from unwittingly having and/or paying for services that do not meet Primary Coverage Criteria (e.g.,
are experimental/investigational under Arkansas Blue Cross coverage policy). Providers have access to coverage
policies through the Arkansas Blue Cross website. Coverage policies may be searched by description, CPT Code,
or title. A drop-down box is also provided listing all coverage policies alphabetically.

When the patient is advised of the likelihood of denial, they have two options:
1. Do not have the service rendered.
2. Sign the waiver and be financially liable for payment of the denied service.

If a patient refuses to sign the waiver, you have two options:

1. Render the service. If it is denied, write off the charge.
2. Do not render the service.

It is important to note that the patient must understand what he or she is signing and why he or she is
signing it. Waivers are only required for services considered as not meeting the Primary Coverage Criteria
(e.g., experimental/investigational services) or those services that are not provided to treat an actual medical
condition (e.g., cosmetic services/procedures).

Sample Waiver
Click here (PDF) to download a sample waiver form.

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SECTION 17

Mental Health Services

Section 17 | Mental Health Services

Please refer to the Coverage Policy for APRNs and PAs who are providing
mental health services. There are edits in place that capture specific services
that require the provider to have certain credentials to bill for, and seek
reimbursement of, these services.

Lucet (formerly New Directions)

The Mental Health Parity (MHP) Act requires that mental health benefits be equal to physical health benefits.
Member ID cards will include the telephone number of Lucet (formerly New Directions) a company assisting with
mental health services on behalf of Arkansas Blue Cross and Blue Shield, PPO Arkansas, and Health Advantage.

Behavioral Health Management

Arkansas Blue Cross, Health Advantage, and Blue Advantage have contracted with Lucet Behavioral Health to
perform behavioral health utilization management services. Lucet is a full-service behavioral health organization
and is accredited as an MBHO by NCQA and has URAC accreditation for utilization management and case
management.

Inpatient, Partial Hospital and Intensive Outpatient Services

ƒ Contact Lucet for pre-notification of all inpatient, partial hospital and IOP services.
ƒ Lucet will conduct concurrent stay reviews and will work with your staff to provide discharge planning.

For pre-authorization or pre-notification of behavioral health services for Arkansas Blue Cross, Health Advantage
and Blue Advantage members, contact Lucet at (877) 801-1159. For Walmart associates, call (877) 709-6822

Lucet WebPass
Lucet now offers a Provider WebPass, allowing providers and office staff to:
ƒ Submit pre-authorization requests
ƒ Submit pre-notification of hospital services
ƒ Submit pre-notification

Click here to access the Provider WebPass, select “Provider Section,” then select “Provider WebPass.”

Before using the Lucet WebPass System, providers must obtain a username and password from Lucet
Behavioral Health at: webpass.ndbh.com/Contact.aspx

The registration should be completed by Lucet Behavioral Health within two business days and new login
information will be e-mailed at that time.

Claims
Continue to submit mental health claims via Availity or through a clearinghouse. Individual policyholders
applying for, or already with Arkansas Blue Cross, also may select MHP benefits.

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Section 17 | Mental Health Services

Autism: Applied Behavior Analysis Coverage

On October 1, 2011, and upon renewal of group insurance policies and HMO contracts for 2012, Arkansas Blue
Cross and Blue Shield and Health Advantage began covering and administering benefits for Applied Behavioral
Analysis (ABA) in accordance with Act 196 of 2011, codified at ACA. §23-99-418, enacted by the General
Assembly of the State of Arkansas which mandates coverage of Early Intensive Behavioral Intervention (EIBI),
with the following conditions:
1. Applied Behavioral Analysis (ABA) must be ordered for a specific individual diagnosed with autism spectrum
disorder (ASD) by a licensed physician or psychologist.
2. ABA must be provided or supervised by a therapist certified by the nationally accredited Behavior Analyst
Certification Board.
3. The individual with ASD must be less than eighteen years of age.
4. ABA shall have an annual limitation of $50,000.

The following HCPCS codes should submitted for ABA services:

ƒ H2012: Day treatment per hour – supervision by board certified behavior analyst (BCBA) limited to six hours
per week; H2019 plus H2012.
ƒ H0031: Mental health assessment by non-physician – ABA testing (initial or reassessment) limited to no more
often than every three months; record of test must be submitted with the claim.
ƒ H0032: Mental health service plan development by non- physician – development of individual treatment
plan (ITP); limited to no more often than every six months; record of ITP must be submitted with claim.
ƒ H2019: Therapeutic behavioral services (fifteen minutes) –supervision by BCBA; limited to six hours per
week; H2019 plus H2012.
ƒ H2020: Therapeutic behavioral services (per diem).
ƒ H0046: Mental health services, not otherwise specified – direct service provider for ABA per hour. These
services may be provided by the BCBA or by an associate trained in direct services for autism. Whether
provided by the BCBA or the associate, these services should be billed with the BCBA’s provider number.
Services are limited to forty hours per week.

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Section 17 | Mental Health Services

Dedicated Website Launch for Behavioral Health Providers

We’re excited to announce the launch of our new website, designed specifically for providers working in the
fields of mental health and substance use. This new resource aims to support you with quick access to essential
tools and information that will simplify your daily practice.

On the site, you’ll find a list of helpful contacts, including credentialing and pharmacy support numbers, to assist
you and your team in providing seamless care. We’ve also included two comprehensive, downloadable guides:
the Mental Health and Substance Use Benefit and Billing Guide and the Residential Treatment Center Billing
Guide. These documents offer clear, up-to-date guidance on benefit utilization and billing processes.

The website also provides a chance to meet our behavioral health team, including our dedicated nurses, social
workers, and peer support specialists. Get to know the people working with you to ensure our members receive
high-quality care.

https://www.arkansasbluecross.com/providers/mental-health-providers

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Section 17 | Mental Health Services

Residential Treatment Centers

Residential Treatment Centers are licensed by the state health department as Residential Substance Abuse
Centers. Arkansas Blue Cross and Blue Shield offers PPP, True Blue, Arkansas First Source and Health Advantage
participating agreements for these providers.

Inpatient claims are billed with bill type 86X and room revenue codes 1001 and 1002. Allowances are based on
global, all-inclusive per diems that are approved by Facility Reimbursement and Pricing. There is no additional
allowance for physician services.

Outpatient Claims will now be allowed from these facilities. Outpatient claims should be billed with bill type 13X
and must contain revenue codes 0905, 0906, 0912, 0913 and 0915 which require CPT/HCPCS codes in conjunction
with the revenue code(s).

HCPCS codes S0201 (Partial hospitalization services, less than 24 hours, per diem) and S9480 (Intensive
outpatient psychiatric services, per diem) are allowed on a global basis and all other services billed with these
codes will be rolled up for pricing. S0201 can only be billed with revenue codes 0912 and/or 0913. S9480 can only
be billed with revenue codes 0905 and/or 0906.

Benefits for residential treatment center are dependent upon any payable member benefits.

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SECTION 18

Modifiers
Section 18 | Modifiers

Modifiers
A modifier allows the reporting physician to indicate that a service or procedure that has been performed has
been altered by some specific circumstance but not changed in its definition or code. For Arkansas Blue Cross
and Blue Shield claims filing, modifiers, when applicable, should be indicated by placing the appropriate two-
digit number in the indicated space in Block 24D after the usual procedure code.

The applicable modifiers are listed by code and defined in each CPT section. Some common modifiers that
always should be considered when filing claims include the following:

Modifier Definition

21 Prolonged evaluation and management services.

22 Unusual procedural services.

23 Unusual anesthesia.

Unrelated evaluation and management service by the same physician during a postoperative
24
period.

Significant, separately identifiable evaluation and management service by the same physician on
25
the day of a procedure or other service.

26 Professional component.

27 Multiple outpatient hospital E/M encounters on the same date.

32 Mandated services.

47 Anesthesia by surgeon.

50 Bilateral procedure.

51 Multiple procedures.

52 Reduced Services.

53 Discontinued procedure.

54 Not recognized. Surgical care only.

55 Not recognized. Postoperative management only.

56 Not recognized. Preoperative management only.

57 Decision for surgery

58 Staged or related procedure or service by the same physician during the postoperative period.

59 Distinct procedural service.

62 Two surgeons.

63 Procedure performed on infants.

66 Surgical team.

73 Discontinued out-patient procedure prior to anesthesia administration.

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Section 18 | Modifiers

Modifier Definition

74 Discontinued out-patient procedure after anesthesia administration.

76 Repeat procedure by same physician.

77 Repeat procedure by another physician,

78 Return to the operating room for a related procedure during postoperative period.

79 Unrelated procedure or service by the same physician during the postoperative period.

80 Assistant surgeon.

81 Minimum assistant surgeon.

82 Assistant surgeon (when qualified resident surgeon not available).

90 Reference (outside) laboratory.

91 Repeat clinical diagnostic laboratory test.

92 Alternative laboratory platform testing.

*96 Habilitative services.

*97 Rehabilitative services.

99 Multiple modifiers.

LT Left side (used to identify procedures performed on the left side of the body)

RT Right side (used to identify procedures performed on the right side of the body)

* Modifier SZ has been discontinued as of December 31, 2017. Please use the following modifiers when billing
habilitative services. Please use the following modifiers for habilitative services for dates of services on or
after January 1, 2018:
ƒ Modifier 96 for habilitative services.
ƒ Modifier 97 for rehabilitative services.

Modifiers Impacting Pricing

Some modifiers impact pricing. Listed below are modifiers and their applicable pricing adjustments in the
Arkansas Blue Cross and Blue Shield fee schedule, subject to medical necessity.
ƒ Modifiers TC and UE point to the technical component fee schedule amounts.
ƒ Modifiers 26 and RR point to the professional component fee schedule amounts.
ƒ Modifier NU points to the total component fee schedule amount.
ƒ Modifier 22: Increased Services 25% of allowable charges based on documentation that the surgical service
provided is greater than that usually required for the procedure.
ƒ Modifier 50: Bilateral Surgery - 50% of allowable charges and services must be billed on two lines.
ƒ Modifier 51: Multiple Surgery - 50% of allowable charges.
ƒ Modifier 52: Reduced Services 67% of allowable charges based on documentation.

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Section 18 | Modifiers

ƒ Modifier 53: Discontinued Procedure - 25% of allowable charges.

ƒ Modifier 62: Co-Surgery - 62.5% of allowable charge.
ƒ Modifier 63: Infant Procedure - 120% of allowable charge.
ƒ Modifier 73: Discontinued Procedure - 50% of allowable charge (limited to facility billings).
ƒ Modifier 78: OR Return - 70% of allowable charge.
ƒ Modifier 80: Assistant Surgeon - 20% of allowable charge.
ƒ Modifier 81: 10% of allowable charge.
ƒ Modifier 82: 20% of allowable charge.
ƒ Modifier AS: 20% of allowable charge (limited to specialties 50 and 89; in combination with specialty
discount of 75%, results in payment of 15% of allowable).

Arkansas Blue Cross and its family of companies do not recognize modifiers 54, 55, or 56. Providers should bill
E&M codes for these services rather than billing the surgery code with these modifiers.

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Section 18 | Modifiers

Modifier Usage
When used appropriately, modifiers provide additional information that aids in the adjudication claims. When
used inappropriately, modifiers will slow the process of a claim, require manual handling, and usually additional
information from a provider’s office.

Modifier 25 - Significant, Separately Identifiable Evaluation & Management Service:

Modifier 25 should only be used with Evaluation and Management procedure codes (99201 – 99499), and only
when a provider has performed an E&M service that is separate and identifiable from the other procedure(s)
provided on the same day.

Modifier 50 – Bilateral Procedure:

Charges must be submitted on two lines. The first line should include a descriptive modifier, i.e., LT (left side)
or RT (Right side). Modifier 50 should be in the first modifier position on the second line, with the descriptive
modifier in the second position.

If a provider bills a bilateral surgery on one line with Modifier 50, the payment will reflect one half of one side. A
corrected claim must be submitted to obtain correct payment. Modifier 50 is for use with surgical procedures.

Modifier 51: Multiple Surgical Procedures

The Arkansas Blue Cross claims systems will automatically assign Modifier 51 to the secondary surgical
procedure(s) based on the relative value units assigned to the procedures. Arkansas Blue Cross will not apply
multiple surgery guidelines to procedures exempt from Modifier 51 based on CPT or to add-on codes. Modifier
51 does not apply to these groups of procedures by definition. Addition of Modifier 59 to these procedures will
result in manual adjudication of the claim with no change in payment.

AI Modifier
Arkansas Blue Cross and Blue Shield has not accepted consultation CPT codes 99241-99241 and 99251- 99255
since April 1, 2010, as stated in the December 2009 issue of Providers’ News. Because Arkansas Blue Cross is no
longer accepting the consultation codes, it is important to be able to identify the principal physician of record.
The principal physician of record should use modifier AI when billing for hospital and nursing home visits,
CPT codes 99218-99336 and 99304-99306. This modifier will identify the admitting or attending physician who
oversees the patient’s care while in an inpatient or nursing facility setting. This is an informational only modifier.
The AI modifier will not make any changes in processing or amounts payable. Therefore, append any payment
modifiers before the AI modifier.

Modifier GT: Via interactive audio and video telecommunication

Modifier GT should be used when billing for telemedicine services except for interpretation of radiology
procedures or interpretation of rhythm strips. Since July of 2004, telemedicine has not been covered based on
member benefit contract exclusions for Arkansas Blue Cross and Blue Shield, BlueAdvantage Administrators of
Arkansas, Health Advantage and USAble Administrators.

Modifier PT versus modifier 33

Modifier PT is used for a colorectal screening test converted to a diagnostic test or other procedure. Modifier
PT provides information that the procedure was scheduled to be a screening but was converted to a diagnostic
procedure.

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Section 18 | Modifiers

Modifier PT should only be used with the codes for the colonoscopy, flexible sigmoidoscopy or barium
enema when initiated as a screening procedure. In these cases, the diagnostic procedure would be billed with
Modifier PT. For contracts with Patient Protection and Preventive Care Act (PPACA) coverage, these procedures
would be paid without deductible or coinsurance. The Modifier PT should never be used with the anesthesia
procedure 00810.

Modifier 33 is used for preventive services. When the primary purpose of the service is delivery of an evidence
based service in accordance with a US Preventive Services Task Force A or B rating in effect and other
preventive services identified in preventive services mandates (legislative or regulatory), the service may be
identified by appending Modifier 33 to the procedure.

Modifier 33 is the appropriate modifier to use with anesthesia CPT code 00810 for a screening colonoscopy
whether it is completed as a screening or is converted to a diagnostic procedure. Please see the preventive
services newsletter item for a complete list of services that may be billed with Modifier 33.

Modifier FX: X-ray taken using film

Effective January 1, 2017, CMS Change Request (CR) 9727 was implemented. HCPCS Modifier FX reduces the
technical component (TC) (including the TC portion of a global service) of X-ray imaging services provided
using film.

The FX modifier must be included for X-ray services using film. A payment reduction of 20% applies to the
technical component for X-ray services furnished using film for which payment is made.

Modifier 59
Modifier 59: Distinct Procedural Service
Modifier 59 continues to be the most misused modifier. Use of modifier 59 should be rare, should only be
used when no other modifier is applicable, and should never be used if there is only one service on a claim.
Inappropriate use of modifier 59 will delay processing of a claim.

An appropriate use of Modifier 59:

ƒ Two procedures are provided. When entered in Clear Claim Connection via Availity, one of the procedures
denies as inclusive in the other procedure billed.
ƒ The two procedures represent distinct services that will be supported by the medical records.

Inappropriate uses of Modifier 59:

ƒ Evaluation and Management services
ƒ Multiple or bilateral surgery where Modifier 50 or 51 is appropriate
ƒ Single line claims

Modifier 59 Billing Instructions

Under certain circumstances, a physician may need to indicate that a procedure was distinct or independent
from other services performed on the same day. Modifier 59 is used to identify procedures/services that are
not normally reported together but are appropriate under the circumstances. This may represent a different
session or patient encounter, different procedure or surgery, different site or organ system, separate incision/

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Section 18 | Modifiers

excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or
performed on the same day by the same physician.

However, when another already established modifier is appropriate, it should be used rather than Modifier
59. Only if no other, more descriptive modifier is available, and the use of Modifier 59 best explains the
circumstances, should Modifier 59 be used.

Arkansas Blue Cross has received a number of claims in which Modifier 59 has been inappropriately used, (e.g.,
in instances where only one procedure code is billed for a given date of service). Because Modifier 59 is intended
to be used where there is a second or separate procedure performed on the same day, Modifier 59 should never
be used when only one procedure code is billed for same date of service,

Modifier 59 is never appropriate for Evaluation and Management (E&M) codes. Modifier 25 is the appropriate
modifier to bill when reported with an E&M service on the same day as a procedure code with a 0, 10, or 90-day
global to identify a separate and distinct E&M service.

E&M services represent “daily services” and the relative value units for E&M services include some RVUs for
the case in which the physician must see the patient more than once in a 24-hour day. In this case, the E&M code
that best describes ALL the evaluation and management services provided on that day should be reported.

As a rule for surgical procedures, if a surgery would be reimbursed based on multiple surgery guidelines
without Modifier 59, no additional reimbursement would be warranted with Modifier 59 appended. The
inappropriate appending of Modifier 59 will result in additional claim processing time and potential requests for
clinical information.

Most billings of Modifier 59 will require the submission of medical records. The medical records should clearly
support the distinct and independent status of the procedure to which Modifier 59 has been appended.

Review of Modifier 59:

ƒ Modifier 59 is used to report distinct and separate procedures performed on the same day.
ƒ Modifier 59 should be used with caution since this modifier affects the processing and reimbursement.
Modifier 59 is not designed to provide reimbursement for separate procedures that are performed as an
integral part of another procedure. Use of Modifier 59 will normally require submission of medical records.
ƒ When a procedure is described in the CPT code descriptor as a “separate procedure” but is carried out
independently or is unrelated to other services performed at the same session, the CPT code may be
reported with Modifier 59.
ƒ Modifier 59 should not be used when another, more descriptive modifier is available.
ƒ Documentation needs to be specific to the distinct procedure or service clearly identified in the
medical record.

There are modifiers available that describe the body location. (i.e., LT and RT, for left and right side. There are
others to describe specific Modifier 59 digits, eyelids, etc.) If a modifier is available that specifically describes the
body location, that modifier should be used INSTEAD of Modifier 59.

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Section 18 | Modifiers

Clear Claim Connection (CCC):

The September 2004 issue of the Providers’ News provided information on Clear Claim Connection (CCC), a
new tool available to Arkansas Blue Cross providers via Availity. This tool should be used to determine the
appropriate use of Modifier 59.

The code combination being billed should be entered into CCC, without Modifier 59. If Modifier 51 applies to the
secondary procedure, the reimbursement for covered services will be based on 50% of the allowance for the
secondary procedure(s). In cases such as this (where CCC indicates that Modifier 59 should be used), Arkansas
Blue Cross will not ordinarily request medical records. While providers may append Modifier 59 to any claim
when warranted, they should be aware that doing so will ordinarily trigger a request for medical records, and
thus may delay the processing of the claim.

If the secondary procedure would be denied based on CCC and it meets the conditions for billing Modifier
59, Modifier 59 should be appended AND Arkansas Blue Cross will require submission of medical records in
MOST cases. When medical records are needed, they will be requested via the automated Medical Records
Request system.

If CCC combines two procedures into one procedure that includes both of the services provided, providers
should bill using the one procedure that includes both procedures. An example is CPT Codes 93501 & 93510
which are more accurately reported using CPT Code 93526. Arkansas Blue Cross receives in excess of 7,500 line
items per month with Modifier 59 appended. Arkansas Blue Cross has reviewed numerous claims submitted
with Modifier 59. Listed below are examples of inappropriate billing of Modifier 59.

Modifier 59 is NEVER appropriate with:

ƒ E&M codes (CPT Codes 99200-99499);
ƒ Anesthesia Procedures (CPT Codes 00100 - 01999 [except 01967] and 99100 - 99140);
ƒ Single procedure on the date of service;
ƒ Administration codes corresponding to injection, immunization or vaccine (the administration is paid
separately from the code for the drug without addition of Modifier 59);
ƒ Injection codes with multiple units (Providers are expected to bill for the appropriate dosage. If the injection
code is for 50 mg and 100 mg is given, providers should bill with 2 units of service. Modifier 59 is not
necessary.); EVERY administration code on a claim;
ƒ E&M, influenza vaccine, and administration (this combination is acceptable without a Modifier 25 on the
E&M and/or without Modifier 59 on the administration code);
ƒ Code Combination in CCC accessed via Availity, allows all services;
ƒ Code Combination in CCC accessed via Availity appends Modifier 51 to the secondary procedure(s) (Modifier
59 may be included in situations where it is necessary to identify a different lesion, session, etc., not defined
by a more specific modifier. Colonoscopy procedures discussed separately in this newsletter is an example.);
ƒ Code Combination in CCC accessed via Availity replaces the two codes with one code that describes both
services (i.e., CPT Code 93501 + 93510 = 93526);
ƒ One upper and one lower GI Endoscopy procedure (The two procedures address different areas of the body
based on definition.);

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Section 18 | Modifiers

ƒ E&M plus radiology plus one surgical procedure (In this scenario, Modifier 59 is not appropriate on the
surgical procedure. If the E&M code meets the conditions described by Modifier 25, then the appropriate
coding is to add Modifier 25 to the E&M procedure.)
ƒ ALL clinical laboratory services billed on one day;
ƒ Line items billed separately with RT and LT modifiers (These modifiers distinguish the different sites without
using Modifier 59.);
ƒ E&M and surgery on the same day (If the E&M service meets the conditions of Modifier 25, Modifier 25
should be appended to the E&M service. It is never appropriate to also bill Modifier 59 with the surgical
procedure.); and
ƒ Outpatient facility claims where only one surgical procedure was performed. (All ancillary, lab and radiology
services will be combined with the surgical procedure and reimbursed.)

Modifiers to replace modifier 59

On January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) added four new modifiers to further
define Modifier 59. These four new modifiers can be used instead of Modifier 59 (assuming the requirements for
Modifier 59 are met.) The new modifiers and their descriptions are noted below. These new modifiers are set up
in ClaimsXten to work in the same manner as Modifier 59, but are not included in C3 (Clear Claim Connection).
Providers utilizing C3 will need to continue using Modifier 59.

Modifier Description

XE Separate encounter Service that is distinct because it occurred during a separate encounter.

Separate
XP Service that is distinct because it was performed by a different practitioner.
practitioner

XS Separate structure Service that is distinct because it was performed on a different organ/structure.

Unusual
The use of a service that is distinct because it does not overlap usual
XU non-overlapping
components or the main service.
service

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Section 18 | Modifiers

Modifier billings with ClaimsXten

ClaimsXten has some very strict edits on procedure versus modifier. If the modifier is not valid for the
procedure, the claim line will be denied. Some examples/guidelines are:
ƒ Modifier 50, bilateral, is not valid on a procedure with bilateral in the description or with PT/OT codes.
ƒ RT or LT is not valid on a procedure with bilateral in the description (i.e. radiology)
ƒ Modifier 26 is not valid with surgical procedures
ƒ Site specific modifiers are not appropriate with Evaluation and Management codes.
ƒ Be sure the modifier is valid by using the CPT and/or HCPCS book.
ƒ Repeat clinical diagnostic lab procedures should be billed with Modifier 91 and NOT with Modifier 76.
ƒ Specific finger modifiers (F1-F9 and FA) are not valid with procedures specific to the hand.
ƒ Specific toe modifiers (T1-T9 and TA) are not valid with procedures specific to the foot.
ƒ Modifier AT is only valid with CPT codes 98940-98943
ƒ Modifiers 24 and 25 are only valid with Evaluation and Management codes.

Modifier 25
Modifier 25: Significant, separately identifiable Evaluation and Management service by the same physician
on the same day of the procedure or other service. It is important to bill Modifier 25 with Evaluation and
Management code IF a provider is performing an unrelated separate procedure. For example, when providing a
minor surgery service, the visit on that day is included in the payment for the procedure.

However, when performing an E&M service unrelated to the minor surgical procedure, providers should append
modifier 25 to the E&M code. If it is appended to the surgery code, the surgery line will be denied for incorrect
coding. The same criterion applies when providing other procedures, including chemotherapy administration,
allergy injections, chiropractic manipulation, etc. The visit is included in the other procedure codes unless it is a
separate and identifiable E&M procedure.

Some criteria for the appropriate use of modifier 25:

ƒ Are there signs, symptoms, and/or conditions that the physician must address before deciding to perform a
procedure or service?
ƒ Was the evaluation and management of the problem significant and beyond the normal preoperative and
postoperative work?
ƒ Is there more than one diagnosis present that is being addressed and/or affecting the treatment or outcome?

Modifier 59
ƒ Modifier 59: Distinct procedural service. A more detailed article regarding modifier 59 was printed in the
September 2010 issue of Providers’ News. Please refer to that article for complete billing instructions.
ƒ Modifier 59 only applies to non-E&M services. If submitted with an E&M service, the E&M service will be
denied as incorrect coding.
ƒ Documentation must support a different session, different procedure or surgery, different site or organ
system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive
injuries) not ordinarily encountered or performed on the same day by the same individual.

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Section 18 | Modifiers

ƒ No other established modifier is appropriate, i.e., multiple or bilateral surgery.

ƒ Modifier 59 should be used with caution.

When a procedure is described in the CPT code descriptor as a “separate procedure” but is carried out
independently or is unrelated to other services performed at the same session, the CPT code may be reported
with modifier 59.

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SECTION 19

Network Terms and

Conditions
Section 19 | Network Terms and Conditions

Network Terms and Conditions and Credentialing Standards

All companies of Arkansas Blue Cross and Blue Shield operate networks that require full, formal credentialing
and also have adopted specific Credentialing Standards and Network Terms and Conditions. These separate
companies and networks include Arkansas Blue Cross and Blue Shield’s Preferred Payment Plan “PPP”, Health
Advantage’s HMO Network, and two PPO networks organized by Preferred Provider Networks of Arkansas “PPN
of Arkansas”, known as True Blue PPO and Arkansas’ FirstSource® PPO.

The admission of any practitioner to the PPP, HMO, or PPO networks is a matter within the discretion of the
affiliate company; accordingly, practitioners should look to the Arkansas Blue Cross and Blue Shield, Health
Advantage and PPN of Arkansas, for complete details and any decisions regarding network participation.
Nevertheless, because the affiliation of Arkansas Blue Cross and Blue Shield with Health Advantage and PPN
of Arkansas is well-known, we provide on this Arkansas Blue Cross and Blue Shield provider website, for the
convenience of providers who commonly participate in the HMO and PPO networks as well as PPP, some
basic information regarding the separate networks and related network standards of Health Advantage and
PPO Arkansas.

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Section 19 | Network Terms and Conditions

Network Participation Guidelines

Practitioners requesting participation in the Arkansas Blue Cross and Blue Shield PPP network, PPN of
Arkansas’ True Blue PPO network, Arkansas’ FirstSource® PPO network and the Health Advantage HMO network
must agree to follow the network Policies and Procedures and Terms and Conditions and meet the network
Credentialing Standards.

Providers who have questions about participation should contact their region’s
network development representative.

Provider Network Operations provides administrative support for the Arkansas Blue Cross and Blue Shield
Preferred Payment Plan, PPN of Arkansas’ True Blue PPO and Arkansas’ FirstSource® PPO and the Health
Advantage HMO network.

Provider Network Operations

P.O. Box 2181
Little Rock, Arkansas 72203-2181

Telephone: 501-210-7050
Fax: 501-378-2465
E-mail: providernetwork@arkbluecross.com

Health Advantage Network Participation Guidelines

True Blue PPO Network Participation Guidelines

Arkansas’s FirstSource PPO Network Participation Guidelines

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Section 19 | Network Terms and Conditions

Accreditation Accepted for Network Durable Medical Equipment

Providers
The following are acceptable accrediting bodies for any Arkansas durable medical
equipment(DME) /home medical supply provider, orthotic, and prosthetic suppliers with “bricks
and mortar” interested in network participation. Contact your respective regional Network
Development Representative for additional details. A list of representatives may be found at
www.arkansasbluecross.com/providers/resource-center/network-development-reps.

Accreditation
ƒ The Joint Commission (TJC)
ƒ American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC)
ƒ Accreditation Commission for Health Care, Inc (ACHC)
ƒ Board of Certification/Accreditation (BOC)
ƒ Community Health Accreditation Program (CHAP)
ƒ Healthcare Quality Association on Accreditation (HQAA)

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Section 19 | Network Terms and Conditions

Revision to Payer Policies and Procedures and Terms and Conditions

In this rapidly changing health care environment, health insurers and network sponsors are faced with the
challenge of meeting market demand for more information about health care providers.

Consumers now expect to find reliable, standardized comparative performance data for health care providers,
procedures, and policies as well as data reflecting the performance of providers, including cost and quality
ranking where available. Arkansas Blue Cross and Blue Shield, as a sponsor of a health maintenance
organization and preferred provider organization networks, (respectively, Health Advantage and PPN of
Arkansas) is not alone in dealing with market pressure for increased transparency around the cost and quality of
medical services our members receive.

To address the needs of our customers in this regard, effective February 1, 2012, the published “terms and
conditions” for participation in Health Advantage’s HMO network and for PPO Arkansas’ True Blue PPO and
Arkansas’ FirstSource® networks will be changed to remove from “Section VII. Publication of Utilization, Quality
and Other Practice Data” any references to a provider “opting out” of or otherwise avoiding publication of the
provider’s utilization, cost, quality, or other practice data. This means that as of February 1, 2012, any provider
who participates in the Health Advantage HMO network or in either of the two PPO networks of PPO Arkansas
will be subject to publication of any and all utilization, cost, quality, or other practice data that Health Advantage
or PPO Arkansas may deem meaningful or helpful to publish to their members.

This means that as of February 1, 2012, any provider who participates in the Health Advantage HMO network or
in either of the two PPP networks of PPO Arkansas will be subject to publication of any and all utilization, cost,
quality or other practice data that Health Advantage or PPO Arkansas may deem meaningful or helpful to publish
to their members.

Please note that except for deleting the option of a participating provider to “opt out” of, veto or avoid data
publication, all other provisions of Section VII. “Publication of Utilization, Quality and Other Practice Data” shall
remain in effect as written, until further notice of any additional modifications.

While “opting out” of data publication is no longer an option for participating providers, physicians will still
receive an advance copy of any utilization, cost, quality, or other practice data that Health Advantage or PPO
Arkansas intend to publish to their membership. Health Advantage and PPO Arkansas will endeavor to provide
their information for review 45 days in advance of publication.

Providers who have questions about their data may contact their respective regional Network Development
Representative. Currently the available cost and quality data of Arkansas Blue Cross, Health Advantage and PPO
Arkansas is only published on Blueprint Portal, which is a password protected member portal.

The quality information published in Blueprint Portal currently is summarized to the overall statewide specialty
level, not at the individual physician level. The cost information is reported per physician but is rolled up to one
overall level, not per procedure.

Effective February 1, 2012, this may switch to individual physician-level reporting, and the cost and quality
ratings reflected there may be published in other formats or places accessible to members, employers or other
stakeholders of Arkansas Blue, Health Advantage or PPO Arkansas.

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Section 19 | Network Terms and Conditions

Imaging Centers Purchased by Hospitals

Per the terms of participation for the Arkansas Blue Cross and Blue Shield Preferred Payment Plan, Health
Advantage HMO network, and PPN of Arkansas’ True Blue PPO and Arkansas’ FirstSource® networks, advanced
imaging centers must be accredited by one of the agencies that meets approval per these networks’ required
accreditation program. This includes advanced imaging centers purchased by another organization, including
hospitals.

In most situations, a currently accredited imaging center can simply notify the accrediting agency (e.g.,
American College of Radiology or Intersocietal Accreditation Commission) and ask for a certificate with the new
organization’s name applied to it. Arkansas Blue Cross, Health Advantage, and PPN of Arkansas will need a copy
of the new certificate.

Please understand that if the imaging center’s new owner is a hospital, the hospital’s Joint Commission
accreditation does not automatically apply. For this to apply, the hospital must be performing both inpatient and
outpatient imaging services and the imaging center must have been part of the on-site review performed by the
Joint Commission when the accreditation was given.

Imaging centers have 180 days from the date of the new owner’s date of purchase to submit the proof of
accreditation required to remain in network. Please submit proof of accreditation to:

Provider Network Operations

P. O. Box 2181
Little Rock, AR 72203

If you have questions, or need additional information, please contact you network development representative.

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SECTION 20

Patient Protection and

Affordable Care Act
(PPACA)
Section 20 | Patient Protection and Affordable Care Act (PPACA)

Preventive services covered under the Affordable Care Act

Subject to change as regulations and further clarifications are received

For non-grandfathered plans

The Preventive Care Services coverage policy with coding for ICD-10 and CPT or HCPC’s codes is listed in the
coverage policy coding instructions for the Preventive Care Services Coverage Policy which can be found in the
“Providers” section of the Arkansas Blue Cross and Blue Shield web site, arkansasbluecross.com/providers.

Coding for Preventive Services

ƒ Correctly coding preventive care services is key to receiving accurate payment for those services.
ƒ Preventive care services must be submitted with an ICD-9 code that describes encounters with health
services that are not for the treatment of illness or injury. Please avoid using general coding such as V70.0.
ƒ These diagnosis codes must be identified as the primary diagnosis code on the claim form.
ƒ If claims for preventive care services are submitted with diagnosis codes that represent treatment of illness
or injury as the primary (first) diagnosis on the claim, the service will not be identified as preventive care
and the patient claims will be paid using their normal medical benefits rather than enhanced preventive
care coverage.
ƒ Use CPT coding designated as “Preventive Medicine Evaluation and Management Services” to differentiate
preventive services from problem-oriented Evaluation and Management office visits (CPT codes 99381-
99397, 99461, 99401-99404, S0610, and S0612). Non-preventive care services incorrectly coded as
“Preventive Medicine Evaluation and Management Services” will not be covered as preventive care.

Modifier 33 - Preventive Service

When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US
Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive
services mandates (legislative or regulatory), the service may be billed with the modifier 33.

The correct coding for ICD-10 and CPT or HCPC code is also required as listed in the coverage policy coding
instructions of the Preventive Care Services coverage policy.

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Section 20 | Patient Protection and Affordable Care Act (PPACA)

Preventive Care Services Update

Non-Grandfathered/PPACA Wellness Summary
March 2013, Version 2, 2013-03-01

Over the last several months we have had calls and questions on the differences between the wellness
benefits for health coverage established before the Patient Protection and Affordability Act (PPACA) and the
PPACA wellness benefits for non-grandfathered health plans. Arkansas Blue Cross and Blue Shield hopes that
the following Preventive Care Services Summary in this Providers’ News will help providers have a clearer
understanding of the preventive services covered (these, of course, are subject to change).

The preventive services component of the law requires all “non-grandfathered” health insurance plans cover
those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task
Force (USPSTF). Arkansas Blue Cross has studied these recommendations and has developed a coverage policy
on each of these preventive medicine services; please refer to arkbluecross.com or healthadvantage-hmo.com.
Arkansas Blue Cross has added a link to the latest PPACA grid in the Availity payer space under Resources.

In order to comply with PPACA, Women’s Preventive Services was added to many health plans. The change was
made to certain employer-sponsored health insurance plans in 2012. The change took place on January 1, 2013
for certain individual health plans.

Arkansas Blue Cross encourages physicians and other providers of preventive services to become familiar with
the USPSTF, Bright Futures, and Women’s Health Initiative recommendations as well as Arkansas Blue Cross
coverage policies. Most of the inquiries we have received are on lab (urinalysis) and other services such as
chest x-rays, electrocardiograms, breathing capacity tests, catheter for hysterography, vitamins, B-12 injections,
cardiovascular stress tests, CT for bone density, CT for head/brain, removing ear wax, consultations, etc., that
are not included in the USPSTF, Bright Futures, or Women’s Health Initiative recommendations for screening.

These are not part of the Arkansas Blue Cross coverage policy for non-grandfathered/PPACA Preventive
Services. Claims for these services, if billed for screening, would be provider write-offs since they do not meet
the Primary Coverage Criteria or are not medically necessary. These claims will not be a member liability if
billed with a preventive diagnosis unless the ordering provider has obtained a signed waiver from the member
specifically stating why the requested service would not be covered.

Summary of Arkansas Blue Cross Blue Shield and Health Advantage Coverage Polices
The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law in
March 2010. The preventive services component of the law became effective September 23, 2010. A component
of the law requires that all “non-grandfathered” health insurance plans are required to cover those preventive
medicine services given an “A” or “B” recommendation by U.S. Preventive Services Task Force (USPSTF).

Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network
providers. Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of
evidence in support of the intervention.
ƒ Grade A: There is good evidence to support the recommendation that the condition be specifically
considered in a periodic health examination.

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Section 20 | Patient Protection and Affordable Care Act (PPACA)

ƒ Grade B: There is fair evidence to support the recommendation that the condition be specifically considered
in a periodic health examination.
ƒ Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a
periodic health examination, but recommendations may be made on other grounds.
ƒ Grade D: There is fair evidence to support the recommendation that the condition be excluded from
consideration in a periodic health examination.
ƒ Grade E: There is good evidence to support the recommendation that the condition be excluded from
consideration in a periodic health examination.

Those preventive services listed as Grade A and B recommendations are covered without cost sharing (i.e.,
deductible, coinsurance, or co-pay) by Health Plans for appropriate preventive care services provided by an
in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive
care services, deductible, coinsurance, or copayment may be applied.

The appropriate office visit code should be used for services typically included as part of a normal wellness visit.
Evaluation and Management codes for preventive services CPT Codes 99381-99397 will always be considered
preventive. CPT Codes 99401-99404, when used to designate a preventive service, must have the applicable
wellness/preventive diagnosis code as the primary reason for visit.

Note: CPT Codes 99401-99404 are considered components of CPT Codes 99386-99387 if billed on the same date-
of- service.

When the primary purpose of the service is the delivery of an evidence-based service in accordance with
a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates
(legislative or regulatory), the service may be billed with Modifier 33. The correct coding as listed for both ICD-9
and CPT or HCPCS codes in this summary is also required along with Modifier 33. CPT Codes Copyright © 2012
American Medical Association.

Summary of Women’s Preventive Services

Effective August 1, 2012, for certain employer-sponsored health insurance plans. The change will take place on
January 1, 2013 for certain individual health plans.
ƒ Well-woman visits: Annual well-woman preventive care visit for adult women to obtain the recommended
preventive services, and additional visits if women and their doctors determine they are necessary.
ƒ Gestational diabetes screening: For women 24 to 28 weeks pregnant, and those at high risk of developing
gestational diabetes.
ƒ HPV DNA testing: Women who are 30 years of age or older will have access to high-risk human
papillomavirus (HPV) DNA testing every three years, regardless of pap smear results.
ƒ STI counseling, and HIV screening and counseling: Sexually active women will have access to annual
counseling on HIV and sexually transmitted infections (STI’s).
ƒ Contraception and contraception counseling: Coverage of prescription contraceptives on the drug list (brand
contraceptives may have a copayment if a generic is available without a copayment), sterilization procedures
and patient education and counseling. Plan B (morning-after pill) when prescribed for members under 18 will
be covered. Any drugs used to cause abortion (e.g. RU 486) are not covered. Over-the-counter birth control
methods, even if prescribed by a doctor, are not covered.

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Section 20 | Patient Protection and Affordable Care Act (PPACA)

ƒ Breast feeding support, supplies and counseling: Pregnant and postpartum women will have coverage for
lactation counseling from applicable health care providers. Manual breast pumps are covered; electric breast
pumps and supplies are not covered. NOTE: Pregnancy services including prenatal, delivery and postnatal
care subject to member copayments, deductibles and coinsurance.
ƒ Domestic violence screening: Screening and counseling for interpersonal and domestic violence will be
covered for all women.

Subject to change as regulations and further clarifications are received, please refer to additional clarifications at
the end of this article.

For Self-funded plans with SPD language

Certain self-funded plans may have a different list of preventive care benefits. Please refer to the enrollee’s plan
specific SPD for coverage. Group specific policy will supersede this policy when applicable. This policy does not
apply to the Walmart Associates Group Health Plan participants.

Note: Please encourage your patients to update their personal Health Record with information gathered during a
preventive visit.

Note: The cost of drugs, medications, equipment, vitamins, or supplements that are recommended but not
prescribed for preventive measures are generally not covered as a preventive care benefit.

Examples include, but are not limited to:

ƒ Aspirin, OTC
ƒ Supplements, including but not limited to, oral fluoride supplementation, and folic acid supplementation
ƒ Tobacco cessation products or medications
ƒ Condoms, diaphragms, sponges, spermicides, etc.
ƒ Electric breast pumps

Aspirin, prescribed by a health care provider with prescribing authority, for prevention of coronary artery
disease is covered (DOL/HHS ruling; effective on date of renewal of policy, following 2013-02-20).

FDA approved cervical diaphragms for contraception, prescribed by a health care provider with prescribing
authority, for prevention pregnancy, are covered (DOL/HHS ruling; effective on date of renewal of policy,
following 2013-02-20).

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Section 20 | Patient Protection and Affordable Care Act (PPACA)

Habilitative care and modifier 96 and modifier 97

In January 2014, the Patient Protection and Affordable Care Act (PPACA) began requiring all health insurance
issuers offering small group health insurance coverage (1-50 fulltime employees) and individual health insurance
coverage to include essential health benefits in products offered on and off the Federal Health Insurance
Marketplace. Federal law now requires that individual and small group products include the following 10
categories of essential health benefits:
ƒ Ambulatory patient services
ƒ Emergency services
ƒ Hospitalization
ƒ Maternity and newborn care
ƒ Mental health and substance use disorder services
ƒ Prescription drugs
ƒ Rehabilitative and habilitative services and devices
ƒ Laboratory services
ƒ Preventive and wellness services and chronic disease management
ƒ Pediatric services, including oral and vision care.

Without a way to identify habilitative services and devices, Modifier SZ was created to help identify habilitative
services. Modifier SZ has been deleted as of 12/31/2017. Modifier SZ has been replaced with Modifier 96,
habilitative services.
ƒ For dates of services on or after July 1, 2014 thru December 31, 2017, Modifier SZ should be used for
habilitative care.
ƒ For dates of services on or after January 1, 2018, Modifier 96 should be used for habilitative services.
ƒ For dates of services on or after January 1, 2018, Modifier 97 should be used for rehabilitative services.

What are habilitative services?

Arkansas’ definition of habilitative services are services provided in order for a person to attain and maintain a
skill or function that was never learned or acquired and is due to a disabling condition.

Coverage of habilitative services

Subject to permissible terms, conditions, exclusions and limitations, health benefit plans, when required to
provide essential health benefits, shall provide coverage for physical, occupational and speech therapies,
developmental services and durable medical equipment for developmental delay, developmental disability,
developmental speech or language disorder, developmental coordination disorder.

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SECTION 21

Pharmacy
Section 21 | Pharmacy

Pharmacy
Pharmacy Program Advantages
Member’s pharmacy benefits are administered through the Arkansas Blue Cross and Blue Shield Pharmacy
Program, which eliminates paper claim forms and employs the latest technology for electronic pharmacy claims
processing. When a member fills a prescription at a participating pharmacy, the Pharmacy Program computer
network instantly alerts the pharmacist to the following:
ƒ Any potential harmful interaction of the medication about to be dispensed with any other medication that the
patient may already be taking.
ƒ Whether this medication may duplicate another medication the patient is taking.
ƒ Whether the prescribed dosage or strength is appropriate for the age of the patient.

These features help members save money and promote good health and safety.

Common Prescription Benefit Structures

2023 Metallic Formulary | List of Covered Drugs (PDF)

The Metallic Drug List corresponds to our Gold, Silver, and Bronze products that are qualified health plans (QHP).
The specific dollar amount of copayment for each medication will vary depending upon the member’s policy
benefits, but the tier assignment for the medication will be the same for all members.
ƒ First tier: Preventive medications defined by Health Care Reform that member can obtain for $0 cost to
the member
ƒ Second tier: Almost all generic medications
ƒ Third tier: Preferred brand-name medications and other lower-cost, brand-name medications
ƒ Fourth tier: High-cost medications or medications classified as non-preferred
ƒ Fifth tier: Specialty drugs that may require either special handling and/or storage and may be only
purchased through a select specialty pharmacy
ƒ Sixth tier: Non-preferred specialty drugs that may require either special handling and/or storage and may be
only purchased through a select specialty pharmacy

2023 Step Therapy and Tier 4 Specialty Formulary (PDF)

The Standard Step Therapy promotes cost savings through using more generic medications and over the
counter products rather than branded prescription drugs. The specific dollar amount of copayment for each
medication will vary depending upon the member’s policy benefits, but the tier assignment for the medication
will be the same for all members.
ƒ First tier: Almost all generic medications
ƒ Second tier: Preferred brand-name medications and other lower-cost, brand-name medications
ƒ Third tier: High-cost medications or medications classified as non-preferred
ƒ Fourth tier: Highest plan member copayment. Specialty products are at Tier 4.

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Section 21 | Pharmacy

How Are Medications Added to the Formulary? (Covered Drug List)

The services of an independent National Pharmacy and Therapeutics Committee (P&T Committee) are used
to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of
experts from across the United States. The P&T Committee’s voting members include physicians, pharmacists,
a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic
expertise regarding prescription drugs.

Prior Approval and Exception Request Form

Some drugs require providers to request prior approval to dispense, review quantity limits.
For those requests and step therapy and non-formulary exceptions, please complete the
Prior Approval and Exception Request form (PDF).

Prior Approvals and Exceptions — Caremark

ƒ Drugs requiring prior approval
ƒ Birth control exceptions
ƒ Dosages in excess of the plan’s quantity limits
ƒ Step therapy

Providers may contact CVS/Caremark directly by calling 877-433-2973 or faxing the Prior Approval and Exception
Request form to 888-836-0730.

Hours are Monday - Friday from 8:00 a.m. - 6:00 p.m. CST

Exceptions — Arkansas Blue Cross and Blue Shield Pharmacy Department

ƒ Prescription drug fertility treatments
ƒ Non-covered drugs

Providers may contact the Arkansas Blue Cross Pharmacy Department at 501-378-3392 or by fax at 501-378-6980.
Hours are Monday - Friday from 8:00 a.m. - 5:00 p.m. CST

Pharmacy Directory
Providers may search for a network pharmacy by using the Network Pharmacy Search.

For More Information

For more information about a member’s prescription drug coverage, call 800-863-5561.

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Specialty Drugs
The Specialty Drug Program addresses treatment for many complex diseases, including:
ƒ Acromegaly ƒ Inflammatory bowel disorder
ƒ Anemia ƒ Iron overload
ƒ Atopic dermatitis ƒ Lipid disorders
ƒ Cryopyrin-Associated Periodic Syndrome (CAPS) ƒ Movement disorders
ƒ Cushing’s syndrome ƒ Multiple sclerosis
ƒ Cystic fibrosis ƒ Neutropenia
ƒ Electrolyte disorders ƒ Oncology
ƒ Hemophilia ƒ Osteoporosis
ƒ Hepatitis ƒ PKU
ƒ Hereditary angioedema ƒ Pulmonary arterial hypertension
ƒ Hormonal disorders ƒ Rheumatoid arthritis
ƒ Idiopathic pulmonary fibrosis ƒ Seizure disorders
ƒ Idiopathic thrombocytopenic purpura ƒ Systemic lupus erythematosus
ƒ Immunologic disorders ƒ Urea cycle disorders
ƒ Infectious diseases

The program provides an efficient, cost-effective way for members to receive coverage of injectable and select
oral medications.

For more information, visit Caremark Specialty RX. Caremark Specialty RX is the Specialty Drug Program
administrator for Arkansas Blue Cross and Blue Shield.

Medications and Supplies Not Covered

The following medications and supplies are not covered under most Arkansas Blue Cross and Blue Shield
contracts or health plans. However, some contracts or health plans may cover an item on this list. The final
authority on exclusions is the member’s specific benefit certificate or health plan. This list is for illustrative
purposes only and is not an exhaustive list.

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The following medications and supplies are not covered:

1. Medications purchased from a nonparticipating pharmacy, except in an emergency situation.
2. Medications used or intended to be used in the treatment of a condition, sickness, disease, injury, or bodily
malfunction, which is not covered by Arkansas Blue Cross, or for which benefits have been exhausted.
3. Medications for use or intended use which would be illegal, abusive, or are not needed to treat an actual
medical condition.
4. Experimental or prescription medications labeled, “Caution: Limited by Federal Law to Investigational Use.”
5. Medications for which, normally (in professional practice), there is no charge.
6. Medications dispensed for use by a covered person while such person is in a hospital, extended- care
facility, nursing home, convalescent or psychiatric facility or any institution or any medication consumed or
administered at the place where it is dispensed.
7. Non-legend over-the-counter medications (except insulin) which do not, by law, require a prescription order
from a physician.
8. Medications dispensed for use by a covered person while such person is in a hospital, extended- care
facility, nursing home, convalescent or psychiatric facility or any institution or any medication consumed or
administered at the place where it is dispensed.
9. Vitamins or food/nutrient supplements unless used to treat a select group of approved conditions.
10. Rogaine, minoxidil or any other drugs, medications, solutions, or preparations used or intended for use in
the treatment of hair loss, hair thinning or any related condition, whether to facilitate or promote hair growth
or replace lost hair.
11. Medications obtained by unauthorized, fraudulent, or abusive use of the identification card.
12. Legend medications that are not approved by the U.S. Food and Drug Administration (FDA) for a particular
use or purpose or when used for a purpose other than the purpose for which FDA approval is given.
13. Fluids, solutions, nutrients, or medications (including all additives and chemotherapy) used or intended to be
used by intravenous or gastrointestinal (enteral) infusion.
14. Medications prescribed and dispensed for the treatment of obesity or for use in any program of weight
reduction, weight loss or dietary control.
15. Medical supplies such as colostomy supplies, bandages, and similar items.

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Prescription Safety and Monitoring Solution Program

Arkansas Blue Cross and Blue Shield encourages physicians to use the Prescription Monitoring Program. The
program focuses on:
ƒ the number of opioid prescriptions,
ƒ emergency department visits related to opioid drug misuse or abuse,
ƒ drug overdose deaths involving opioid pain relievers.

Arkansas Blue Cross has a Prescription Safety and Monitoring Solution Program identifying members who
are potentially abusing or misusing controlled substances. The main focus is to ensure quality patient care
and safety. High-risk members are identified through an algorithm based on pharmacy claims history and are
flagged when:
ƒ there are prescriptions for several controlled substances,
ƒ prescriptions filled at several pharmacies, and
ƒ prescriptions written by several physicians.

When a high-risk member is identified, a letter is sent to each physician who prescribed a controlled medication
in the last nine months to verify and evaluation the patient’s drug therapy.

As a provider, you can assist by verifying patients’ drug therapy and patterns using the Arkansas Prescription
Monitoring Program (AR PMP). All prescriptions for controlled substances, whether paid for by any insurance or
cash, will show up on your patients’ profile. Physicians can delegate a staff member to access the database on
their behalf. Registration and access for the database can be found here.

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Exclusions
Arkansas State Employees (ASE) and Public School Employees (PSE)
Pharmacy benefits for ASE and PSE are administered by MedImpact, which is not affiliated with Health
Advantage; however, all calls go to EBRx for benefits and claims.
ƒ EBRx phone number: 855-757-9526
ƒ EBRx alternate number: 501-526-0384
ƒ EBRx prior approval calls: 866-564-8258

Federal Employee Program (FEP)

Arkansas Blue Cross and Blue Shield’s Federal Employee Program (FEP) has implemented a change in the way
certain specialty drugs are manageed that fall under the FEP medical benefit.

This new program is administered by Magellan Rx Management (Magellan Rx).

Providers should contact Magellan Rx to obtain prior authorizations for applicable drugs for FEP members for
dates of service on or after March 1, 2022.

Providers will be able to complete the prior authorization process via the internet or by phone. Prior
authorization will be required for the medical specialty drugs when they are administered in the
following settings:
ƒ Physician office (CMS Place of Service code 11)
ƒ Patient homes (CMS Place of Service code 12)
ƒ Outpatient facilities (CMS Place of Service codes 19 & 22)

Reference materials such as a Frequently Asked Question (FAQ) document and the list of affected drugs may be
found on the Arkansas Blue Cross and Blue Shield website.

If you have questions, please contact the provider service line at 800-482-6655.

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Medical Pharmacy Prior Approval Program

On April 1, 2018, Arkansas Blue Cross and Blue Shield and its family of companies enacted prior approval for
payment of specialty medications used in treating rare, complex conditions that may go through the medical
benefit. Since then, medications have been added to the initial list as products come to market. A list of
medications that require prior approval through medical benefit can be accessed in the most current issue of
Providers’ News, Availity, and individual medication coverage policies.

ASE/PSE, FEP, and Medicare are not included in this prior approval (PA) program but have their own
PA program.

For more information on how to submit a request for prior approval of one of these medications, please call the
appropriate Customer Service phone number on the back of the member ID card. Customer Service will direct
callers to the prior approval form specific to the member’s group.

Blue Advantage members can find the form at the following link:
blueadvantagearkansas.com/providers/forms.aspx.

For all other members, the appropriate prior approval form can be found at the following link:
arkansasbluecross.com/providers/resource-center/prior-approval-for-requested-services.

These forms and any additional documentation will be faxed to 501-378-7051 for Blue Advantage members. For
all other members, the appropriate fax number is 501-378-6647.

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SECTION 22

Products
Section 22 | Products

A Word about Our Affiliated Companies

This Provider Manual is created and published by Arkansas Blue Cross and Blue Shield, A Mutual Insurance
Company, headquartered in Little Rock, Arkansas at 601 Gaines Street. The Provider Manual is intended to
be a guide for providers participating in the Arkansas Blue Cross and Blue Shield Preferred Payment Plan
(“PPP”) Network.

At the same time, however, this Provider Manual contains numerous references to networks, products or
services of other companies that are affiliated with but separate and distinct from Arkansas Blue Cross and Blue
Shield. Most participating providers are already familiar with these affiliated companies and their networks,
products and services; nevertheless, in order to be sure that all providers understand the references in this
Manual to affiliated companies and their networks, products and services, Arkansas Blue Cross provides below a
brief summary of the affiliated companies and their relationship to Arkansas Blue Cross and Blue Shield.

Arkansas Blue Cross wants providers to understand that while these companies are affiliated with us, they
are separate organizations with their own Boards of Directors, officers, and operations, as well as policies and
procedures. Providers who wish to participate in any network of these separate, but affiliated companies, must
meet the terms and conditions, and execute the participation agreements required by these separate, affiliated
companies.

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Preferred Provider Networks of Arkansas

Preferred Provider Networks of Arkansas (PPN of Arkansas), formerly PPO Arkansas, is a subsidiary of Arkansas
Blue Cross and Blue Shield. PPN of Arkansas does business in several names because it has organized several
different statewide provider networks, and because it offers several distinct types of third party administration
services (claims administration or “TPA” services) for self-funded employee health benefit plans. Participating
providers are generally familiar with these business names rather than the formal corporate name of the
legal entity, PPN of Arkansas. These business names include BlueAdvantage Administrators of Arkansas,
for TPA services inside the state of Arkansas, and USAble Administrators, for TPA services outside the state
of Arkansas.

Two other business names are associated with the operations and activities of PPN of Arkansas —Arkansas’
FirstSource® PPO and True Blue PPO. These two business names signify the two statewide provider networks
that have been organized and contracted by PPN of Arkansas. Arkansas’ FirstSource® PPO network serves only
self-funded employee health benefit plans and employer-sponsors of such plans; True Blue PPO network serves
any customer, self-funded or otherwise, who seeks access to a statewide PPO network open to all providers who
meet True Blue PPO network credentialing standards, terms and conditions.

It is important to note that PPN of Arkansas (whether operating in the name of BlueAdvantage Administrators
of Arkansas, USAble Administrators, Arkansas’ FirstSource® PPO or True Blue PPO) is not an insurer, nor is it a
funding source or payer of any health insurance or health benefit plan claims. PPN of Arkansas’ role is strictly
limited to either:
1. Organizing and providing access to a provider network, or
2. Serving as the TPA to process claims for a self-funded health benefit plan, using money provided by the self-
funded health benefit plan or its employer-sponsor.

Responsibility for funding all claims remains exclusively with the employer-sponsor or self-funded health benefit
plan as PPN of Arkansas assumes no role in underwriting, funding or paying any insurance or health benefit
plan claims.

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HMO Partners, Inc. or “Health Advantage”

Arkansas Blue Cross and Blue Shield has an HMO affiliate company known formally as “HMO Partners, Inc.,” but
known to participating providers by its business name, Health Advantage. While Health Advantage is affiliated
with Arkansas Blue Cross and Blue Shield, its ownership is shared among Arkansas Blue Cross and Blue Shield’s
subsidiary, Preferred Provider Networks of Arkansas, Baptist Health hospital system, and a group of Central
Arkansas physician investors. Preferred Provider Networks of Arkansas (PPN of Arkansas) owns 50% of Health
Advantage, Baptist Health (through one of its subsidiaries) owns 25%, and the remaining 25% is divided among
individual physician investors.

Health Advantage organizes a separate, statewide HMO Network to provide access and services to Health
Advantage’s HMO members. Health Advantage, as an HMO, usually underwrites or funds the claims payments
Health Advantage makes for its HMO plan customers. Thus, Health Advantage, unlike PPN of Arkansas, is
ordinarily the final authority with responsibility for payment (and funding of payment) or denial of provider
claims on Health Advantage members.

At the same time, Health Advantage also provides some HMO-plan TPA services to certain group customers
who choose to self-fund their health benefit plans but wish to structure their plans around HMO concepts or
approaches. In those instances where Health Advantage is serving only as the TPA for a self- funded group
customer with an HMO-style plan, Health Advantage is like PPN of Arkansas in terms of its payment obligations,
i.e., Health Advantage as TPA may render payment on a claim on behalf of its self- funded plan customer, but
Health Advantage as a TPA is not an underwriting or funding source or payer of such self-funded health benefit
plan claims. It is important for providers to understand that Health Advantage does not always serve as the
underwriter or funding source for group business administered through Health Advantage.

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Arkansas’ FirstSource® PPO

Cutting Costs
Arkansas’ FirstSource® is a preferred provider organization (PPO) network organized by Preferred Provider
Networks of Arkansas, formerly PPO Arkansas. FirstSource® is offered to self-funded employers and therefore is
exempt from the provider network requirements of the 1995 Arkansas Patient Protection Act also known as the
Any Willing Provider law.

Responsible Payers for FirstSource® PPO Members

Please note that different FirstSource® PPO members may have different payers because Preferred Provider
Networks of Arkansas (PPN of Arkansas) is not a payer and does not underwrite any health plan benefits of any
kind. Instead, PPN of Arkansas’ function is to organize a network of providers who agree to serve the covered
employees and dependents of various FirstSource® PPO customers who have contracted with PPN of Arkansas
for access to the FirstSource® PPO network.

In effect, PPN of Arkansas’ only role is to serve to link its PPO customers up with providers who have agreed
to provide services at discounted PPO rates, to be paid by the customers. As a provider, you will always look to
the employer-sponsor of the employee health benefit plan or the insurance carrier who insures that employer-
sponsor’s plan for payment of claims, not PPN of Arkansas. Arkansas Blue Cross and Blue Shield is an insurance
carrier that has contracted with PPN of Arkansas to provide FirstSource® PPO network access to Arkansas Blue
Cross and Blue Shield PPO members, so in the case of Arkansas Blue Cross and Blue Shield PPO members,
Arkansas Blue Cross and Blue Shield is the responsible payer, not PPN of Arkansas.

PPN of Arkansas also contracts for FirstSource® PPO access with numerous employer-sponsors who self-fund
their own employee benefit plans. In the case of each of these self-funded employee benefit plans, the various
employer-sponsors of those plans are the payers for all claims of such FirstSource® PPO members, not PPN of
Arkansas. As a provider, you agree to look to the responsible payer, not PPN of Arkansas, for payment or other
responsibility with respect to your claims for services to FirstSource® PPO members.

Relationship of USAble Administrators

Some employer-sponsors of self-funded employee benefit plans administer their own benefit plan claims, and
simply contract for access to the FirstSource® PPO network (these are called “Access-Only” groups). Other
employer-sponsors of self-funded employee benefit plans contract with USAble Administrators for what is
called “third party administration” or “TPA” services. This TPA agreement with USAble Administrators gives
the employer-sponsor’s benefit plan members access to the FirstSource® PPO network, and it means that
USAble Administrators provides the day-to-day claims processing functions for the self-funded benefit plan. It
is important for you to understand that USAble Administrators is not a payer for any of these self-funded benefit
plans. The sole responsibility for funding any claims payment on self-funded benefit plan members remains with
the employer-sponsor of that benefit plan.

USAble Administrators’ only role is to conduct an initial review of claims filed under the employee benefit plan,
and issue an initial claim determination, including, where appropriate, payment in accordance with the terms of
the employee benefit plan. USAble Administrators does not fund such payments and can only pay your claims
if and when the funding for those claims is provided by the employer-sponsor. You should also understand that

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that final authority on claims payment or denial issues for self-funded employee benefit plans always rests with
the designated “Plan Administrator” for that benefit plan.

USAble Administrators is not the same thing as the “Plan Administrator” – in the case of most self-funded
benefit plans for which USAble Administrators serves as TPA, the “Plan Administrator” is the employer who
sponsors and funds that benefit plan. In effect, USAble Administrators merely works for the employer- sponsor,
in accordance with its directions, to perform certain very limited functions. Any dispute over whether the
self-funded benefit plan covers or does not cover any claim, treatment, drug or procedure is the ultimate
responsibility of the employer-sponsor as Plan Administrator (unless that particular employer- sponsor has
designated another specific person or company (not USAble Administrators) to serve as Plan Administrator).

While USAble Administrators will serve to communicate routine claims payments and initial decisions in
accordance with the terms of the benefit plan document, you understand and agree that USAble Administrators
is simply the TPA and is not obligated in any instance to make or guarantee any payments for services you
provide to self-funded benefit plan members, nor will USAble Administrators be liable to you or any other party
for payment or denial of self-funded benefit plan claims.

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Comprehensive Major Medical

Traditional Fee-for-Service Plan
Major Medical coverage is traditional indemnity (“fee-for-service”) health insurance. Major medical coverage
offers the greatest choice of medical providers of any Arkansas Blue Cross and Blue Shield plan. Major Medical
coverage places no restrictions on Arkansas Blue Cross members regarding their choice of physicians, hospitals
or other providers. Arkansas Blue Cross and Blue Shield pays a percentage of allowable charges for health-care
services after a deductible is met.

Preferred Payment Plan (PPP)

Members may choose any provider they wish but can save money by choosing from health-care providers who
participate in the Preferred Payment Plan (PPP) and hospitals that participate in the Hospital Reimbursement
Program (HRP). These providers, listed in our directory represent 95 percent of the doctors and 100 percent of
the hospitals in the state. (Go to arkbluecross.com and select the “MEMBERS” tab to search a complete list of
PPP providers.) Participating health-care providers agree to accept allowances established by Arkansas Blue
Cross as payment in full and collect from the member-only deductibles, coinsurance and non-covered services.

Hospital Reimbursement Program (HRP)

Closely related to the Preferred Payment Plan is the Hospital Reimbursement Program. Under this program,
hospitals agree to a reimbursement system based on maximum allowable payments. For inpatient care, the
allowable payments are based on diagnosis-related groups (DRGs). Hospitals agree to accept as payment-in-
full the lesser of their billed charges or the maximum allowance set by Arkansas Blue Cross and to charge the
member for nothing other than deductibles, coinsurance and non-covered services.

For More Information

Call: 501-378-3070 or 800-421-1112
E-mail: compmjrmed@arkbluecross.com

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Section 22 | Products

Dental
Arkansas Blue Cross and Blue Shield offers several dental products to groups and individuals. All insured dental
products offered utilize the participating dental providers located on the Arkansas Blue Cross and Blue Shield
website. Participating providers are listed in the provider directory available on the Arkansas Blue Cross website
and in a published dental directory.

Dental Participation Advantages

Dental providers that participate in the Arkansas Blue Cross and Blue Shield Preferred Payment Plan (PPP)
network receive direct reimbursement for services. Non-participating providers do not receive direct payment,
rather the member receives reimbursement. Employers and members are encouraged to use participating
providers.

Fee Schedule (Reimbursement Allowances)

The Arkansas Blue Cross and Blue Shield schedule of allowances (fee schedule) utilized for dental provider
reimbursement is based on a review of average amounts billed by Arkansas dental providers, as well as,
the allowances utilized by other Arkansas dental insurers. An attempt is made to revise the Arkansas Blue
Cross fee schedule allowance once a year and also update it with the latest American Dental Association CDT
procedure codes.

Claims Status Inquiry

Using simple and common PC software, providers have instant access to: patient benefits, patient eligibility, and
claims status.

Limitations and Exclusions

National industry standards along with American Dental Association recommendations are applied to policy
limitations and exclusions.

Claims Submission and Payment

Submission of dental claims, pre-determinations and inquiries should be sent to:

Dental Claims Administrator

P. O. Box 69436
Harrisburg, PA 17106-9436

Claims status information: 888-224-5213

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Federal Employee Program (FEP)

The numerous independent Blue Cross and Blue Shield companies across the United States, through their
participation in the Federal Employee Program (FEP), insure 4 million federal government employees,
dependents and retirees. FEP is the largest privately underwritten health-insurance contract in the world.
Sixty-five percent of all federal employees and retirees who receive their health care through the government’s
Federal Employee Health Benefits program (FEHBP) are members of an independent Blue Cross and Blue Shield
company. Arkansas Blue Cross and Blue Shield participates in the FEP program for federal employees located
in Arkansas.

The website at fepblue.org is devoted exclusively to the FEP program. This site explains the benefits of the Blue
Cross and Blue Shield FEP Service Benefit Plan. Because the Office of Personnel Management negotiates the
benefits and premiums of this plan annually on a nationwide basis, the benefit information is updated each year.
A printable PDF file may be downloaded from the Web site for future reference.

Up-to-date information on providers, pharmacy programs and resources, such as Blue Health Connection, a 24-
hour nurse telephone service, also is available on this site. Newsletters provide health and benefit information
for federal employees, including those who are overseas. Links to health-information sites also are listed.

For More Information

Call FEP Customer Service: 800-482-6655 or 501-378-2531

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Federal Employee Program - Dental

Effective January 1, 2006, the FEP Dental Maximum allowances were updated. When dental claims for FEP
members are rendered in the state of Arkansas, claims should be sent to Arkansas Blue Cross and Blue Shield
for processing. Please submit FEP dental claims to:

Arkansas Blue Cross and Blue Shield Attn: FEP

P. O. Box 2181
Little Rock, AR 72203

Arkansas Blue Cross discourages the use of a paper claim form; instead, providers are encouraged to submit all
claims electronically through one of the following methods:
ƒ Secure File Upload to Availity
ƒ Electronically through a third-party clearinghouse
ƒ Direct data entry on the Availity portal. For questions related to registering on Availity, providers should
contact Availity Client Services at 800-282-4548 or 800-282-AVAILITY.
ƒ To ensure proper payment of claims: Obtain the ID number from the member’s identification card. The FEP
identification number beginning with an “R” followed by 8 digits. (Example R12345678).

Note for Standard Option enrollment code 104 or 105: The FEP Dental fee schedule is not intended to be
payment in full, but a benefit to offset the provider’s charge. When the member uses a Preferred network
dentist, the member pays the difference between the FEP fee schedule amount and the (MAC) Maximum
Allowable Charge.

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Section 22 | Products

Medi-Pak®
For Medicare beneficiaries (who have Part A and Part B coverage) residing in
Arkansas
Medi-Pak ® is a Medicare supplement for Medicare-eligible Arkansans. To be eligible to purchase this product,
members must:
ƒ Have Medicare Part A and Part B coverage
ƒ Be a resident of Arkansas

Depending on the particular plan members choose, Medi-Pak ® pays many of the deductibles, copayments and
coinsurance not covered by the federal Medicare program.

Arkansas Blue Cross and Blue Shield has seven different Medi-Pak ® plans. Members can choose the one that fits
their needs and budget.

Go to the federal Medicare website at medicare.gov for more information on these plans.

For a table that compares the benefits and monthly premiums for the seven Medi-Pak ® options offered by
Arkansas Blue Cross and Blue Shield, link on the link below.

arkansasbluecross.com/lookingforinsurance/medicareplans

Medi-Pak: Remittance advice changes

Effective June 1, 2015, changes were made to the Medi-Pak Remittance Advice (RA). The column header named
“Explanation” was changed to “Remarks Codes.” The remark code(s) now displays under the new column
header on the far right side of the RA.

The explanation for each remark code displays on the last page of the RA above the place of service and type of
service codes. This change allows for current and future expansion in the remarks code explanations.

Providers with questions regarding the RA changes should contact the Medicare Customer Service division at
800-238-8379.

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Medicare Advantage PFFS Information

Arkansas Blue Cross and Blue Shield offers two Medicare Advantage private fee-for-service plans: Medicare
Advantage MA and Medicare Advantage MA-PD. A Medicare Advantage Private Fee-For-Service plan works
differently than a Medicare supplement plan. The doctor or hospital must agree to accept the plan’s terms
and conditions prior to providing healthcare services, except for emergencies. If the doctor or hospital does
not agree to accept our payment terms and conditions, they may not provide healthcare services, except in
emergencies.

Provider Manual - Medicare Advantage: Policies and procedures to assist providers in filing claims, referral
requests and other services.

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New Medicare Advantage Networks

Arkansas Blue Cross and Blue Shield will be launching various new and enhanced Medicare Advantage plans
effective January 1, 2021. These new plans have led to the creation of new Medicare Advantage provider
networks that will focus on providing our Medicare Advantage members with optimal and coordinated
healthcare, as well as focus on clinical improvement and accuracy programs such as HEDIS and risk and care
management efforts.

The table below provides a crosswalk demonstrating the flow from the old networks to the new plans and
their networks:
Old Networks New Plan Provider Network

Medi-Pak Advantage PFFS BlueMedicare Value/Preferred Medicare Advantage PFFS

Medi-Pak Advantage HMO Health Advantage Blue Classic Medicare Advantage Health Advantage HMO

BlueMedicare Choice Medicare Advantage PPO (NEW USAble)

Medi-Pak Advantage LPPO
BlueMedicare Premier Medicare Advantage HMO (NEW USAble)

The creation of these new networks will be focused in Central, Northwest, Northeast, and South Central
Arkansas and will be centered around the large and clinically integrated health systems, including individual
primary care and specialty clinics located in these various regions.

Please note that the new Medicare Advantage HMO network is different from the existing Medicare Advantage
Health Advantage HMO network. It will be important to ensure referral patterns stay within the HMO network in
which the member participates. There are no out-of- network benefits.

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True Blue PPO

In 2005, the Eighth U.S. Circuit Court of Appeals made a ruling that implemented the 1995 Arkansas Patient
Protection Act, commonly known as the Any Willing Provider (AWP) law. PPO Arkansas created the True Blue
PPO network to provide an AWP-compliant network option for PPO Arkansas’ current and future customers who
are not self-funded employer groups. Although exempt from AWP, self-funded employers may also choose to
use True Blue provider network.

True Blue PPO is a preferred provider organization (PPO) now under the entity of Preferred Provider Networks of
Arkansas. Product lines using the True Blue Network include Arkansas Blue Cross and Blue Shield fully insured
PPO, Federal Employee Program (FEP), BlueCard, the Arkansas Comprehensive Health Insurance Pool (CHIP),
and Workers’ Compensation.

Freedom of Choice
True Blue members may choose any health care provider from within the statewide network and receive the
benefit of the negotiated fee discounts.

Members who choose a provider outside the network are responsible for a greater percentage (also pre-
determined) of the allowed amount. For example, if a member usually pays 20 percent of the allowed amount
for in-network services, he or she might be required to pay 40 percent of the allowed amount for out-of-network
services. Also, if out-of-network is chosen, the member may be responsible for balance billing by the provider.

Arkansas’ FirstSource® PPO

The Arkansas’ FirstSource® PPO will continue to exist and Preferred Provider Networks of Arkansas will continue
to administer the FirstSource network. However, Arkansas’ FirstSource® PPO will be used exclusively for self-
funded groups exempt from AWP. Reimbursement for the True Blue PPO is generally the same as the current
Arkansas’ FirstSource® PPO reimbursement.

If you have any questions, please contact your region’s Network Development Representative.

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Workers’ Compensation
Health Plan Coverage Issues
All health benefit plans insured by Arkansas Blue Cross and Blue Shield contain an exclusion for coverage of any
treatment, drugs or services if the member in question has filed a workers’ compensation claim, or recovers, or
could have recovered any benefits under workers’ compensation laws, either by settlement with the self-funded
employer or the workers’ compensation carrier, or otherwise.

The reason for this exclusion is to prevent shifting costs for workers’ compensation injuries from the workers’
compensation carrier (or self-funded workers’ compensation plan) to Arkansas Blue Cross. Arkansas Blue
Cross will pick up the costs of covered services for injured employees if it is finally determined by the Arkansas
Workers’ Compensation Commission (and not overturned on appeal) that the workers’ compensation claim is
not “compensable” under workers’ compensation laws.

Right to Payment
A provider’s right to payment for any services rendered to an injured employee is always subject to all terms and
conditions of the member’s health-benefit plan, including the workers’ compensation exclusion in Arkansas Blue
Cross-insured health benefit plans.

It is very important that to provide Arkansas Blue Cross all information with each claim that would identify
whether the claim is work-related and whether the member has filed or intends to file a workers’ compensation
claim with respect to the injury in question. Included on the claim form is a specific field [10-a] for designating
whether the injury is work-related.

As with all information stated by a provider, by a provider’s staff or by a provider’s billing agent on any claim
forms filed with Arkansas Blue Cross, relies on the completeness and accuracy of that information in processing
your claims.

If the workers’ compensation data field is not supplied, or supplied incorrectly, a provider may be responsible for
any incorrect claims adjudication and become liable to refund all such incorrect payments to us.

A provider agrees to refund promptly any payments made to them if it is later determined by Arkansas Blue
Cross that the member’s treatment was for a work-related injury that was a compensable injury under workers’
compensation laws, as referenced in the member’s health-benefit plan.

Workers’ Compensation Insurance and USAble MCO

As noted above, Arkansas Blue Cross-insured health benefit plans do not cover work-related injuries that would
otherwise qualify for coverage under workers’ compensation laws; in fact, all health benefit plans insured by
Arkansas Blue Cross exclude coverage of work-related injuries that are “compensable” injuries under worker’s
compensation, as defined in the member’s health benefit plan. However, a subsidiary company of Arkansas Blue
Cross is involved in some activities on the workers’ compensation insurance side of the equation — not as an
insurer or payer of any workers’ compensation benefits, but as a network organizer, much like the PPO network
organizing conducted by Preferred Provider Networks of Arkansas for the True Blue and First Source PPOs. This
workers’ compensation network is known as “USAble MCO,” also organized by Preferred Provider Networks of
Arkansas.

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The USAble MCO includes all providers who are members of True Blue PPO, as well as the chiropractors,
podiatrists, dentists and optometrists who are members of the Arkansas Blue Cross and Blue Shield Preferred
Payment Plan.

Note: USAble MCO is not a payer of any workers’ compensation or other claim or benefit plan obligations. See
discussion of “Responsible Payers for True Blue® PPO Members,” for an explanation of different payers’ roles,
which applies equally where workers’ compensation networks and Arkansas PPO/USAble MCO are concerned.

Originally enacted in September of 1996, Rule 33 of the Arkansas Workers’ Compensation Commission (AWCC)
was revised in January of 1997. As modified, Rule 33 allows insurance carriers and self-insured employers to
voluntarily join a Workers’ Compensation Managed Care Organization (MCO) in order to manage health care
costs for injured employees.

It is Important to Remember
ƒ Rule 33 [Managed Care] states that once a self-insured employer or insurer has selected an MCO and
employee notice has been posted, all treatment for work-related injuries, with the exception of emergency
treatment, will be provided by MCO network providers.
ƒ Rule 33 [Section III, Part 1] states that all referrals by initial health care providers shall be to providers who
participate in the MCO that the employer/insurer has selected.
ƒ Rule 33 [Section III, Part 2, a, (1)(c)] requires that a change of physician to a participating or nonparticipating
provider must be approved by the employer, insurer, MCO or AWCC prior to delivery of services. (Note:
Nonparticipating providers that have been approved to provide services must agree to all MCO terms
including the AWCC and/or MCO reimbursement rates.)
ƒ Rule 33 [Section III, Part 2, a, (1)(b)] states that participating or nonparticipating providers must refer the
employee to MCO-participating providers for any treatment the employee requires that cannot be provided
by the referring provider.
ƒ Rule 33 [Section IV, Paragraph 4] states that any treatment or services furnished or prescribed by any
physician other than the ones selected according to the above guidelines, except emergency care, shall be at
the claimant’s expense.
ƒ Rule 33 [Section XIII, Part 1] requires that the maximum allowances for services be determined by the AWCC.
If the allowance for services under the USAble MCO is less than the allowance under AWCC, the lesser
amount is applied. In no case will an allowance be greater than the AWCC allowance.

To see AWCC Rule 33 in its entirety go to awcc.state.ar.us/rules/rule099_33.pdf (PDF).

Commonly Asked Questions and Answers

Question: How does the employer’s selection of the USAble MCO network change the way I treat
injured workers?
Answer: Providers who currently obtain hospital preauthorization, meet the reporting requirements of Rule 30
(Medical Cost Containment Program, implement appropriate treatment plans that focus on a return to work,
and who work effectively with MCO case managers should not experience significant changes. Providers
continue to bill the same payers as at present. USAble is not involved in payment of workers’ compensation
medical charges.

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Question: I understand that care is to be provided only by providers who participate with the MCO. How can
I tell which MCO covers a particular injured worker and whether I am a part of that MCO network?
Answer: Providers should contact the employer or insurer to determine MCO network status under Arkansas
Workers’ Compensation law.

Question: As a physician, how can I be assured that I will receive reimbursement for my services and that
the physicians I refer to and facilities where procedures/services are performed will be paid?
Answer: The provider is responsible to ensure that referrals to other physicians and facilities are in- network.
The AWCC (Rule 33) does not require employers or insurers to reimburse for services performed by
nonparticipating providers or for services provided by participating physicians at nonparticipating facilities,
unless these services are for emergency medical care or are authorized by the employer, insurer, MCO or the
AWCC prior to being rendered. If a provider is not reimbursed for services not authorized prior to treatment, it
will not be an acceptable defense for that provider to claim that he or she was not told that there would be no
reimbursement. When providers contact employers and insurers to ask for information on employment and
coverage, the provider or his or her representative should ask whether the employer falls under an Arkansas
Workers’ Compensation Managed Care Plan that has been certified by the AWCC. (Note: USAble MCO is
not a payer of any claims or benefit plan obligations. See discussion of “Responsible Payer for TrueBlue®
PPO Member.”)

Question: How is a physician selected to provide the initial care for an injured worker?
Answer: Under Rule 33 (Section II), the employer has the right to choose a provider from the list of
participating providers in its designated MCO. The AWCC has stated that employers choosing not to
participate in managed care as defined under Rule 33 do not have the legal right to select the initial treating
physician for their injured workers.

Question: Which employers/insurers have selected the USAble MCO network for their injured workers?
Answer: Currently, more than 15,000 employers, representing more than 600,000 employees have selected
the USAble MCO network for their Workers’ Compensation medical services. This represents approximately
75 percent of eligible Arkansas employees. A list of these carriers/employers may be obtained by contacting
the USAble MCO at 501-396-4097, or P.O. Box 2181, Little Rock, Arkansas 72203-2181.

Additional Resources
Systemedic is a Managed Care Organization and longtime business associate of USAble MCO. Systemedic is
the expert in Arkansas Workers’ Compensation and offers multiple services. These services include medical
bill review, utilization review, medical case management, hospital admission preauthorization services,
comprehensive vocational rehabilitation, and return-to-work services as well as other managed care services as
required by the Arkansas Workers’ Compensation Commission’s Rule 33 [Managed Care].

To contact Systemedic or for additional information, please visit their website at systemedic.com.

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SECTION 23

Provider Information
Section 23 | Provider Information

Billing
Billing for services to provider family members prohibited
Arkansas Blue Cross and Blue Shield wishes to remind all providers of a long-standing policy against providers
billing for services they perform for their immediate family members. Arkansas Blue Cross, Health Advantage
and Preferred Provider Networks of Arkansas (formerly USAble Corporation) have published claims-filing
policies and procedures that prohibit a participating provider from billing for services* provided to any
immediate family member. The immediate family, for this purpose, includes a spouse, parent, child, brother,
sister, grandparent or grandchild, whether the relationship is by blood or exists in law (e.g., legal guardianship).

In addition, all underwritten health plans or policies issued by Arkansas Blue Cross and Health Advantage
expressly exclude coverage of services providers perform for immediate relatives. Any claim intentionally or
mistakenly filed and that is subsequently paid for such services, requires the billing provider to immediately
refund all such payments upon notification.

Violation of these policies and procedures and/or failure to make prompt refunds for erroneous payments will
subject the offending provider to termination from the networks sponsored by Arkansas Blue Cross, Health
Advantage and Preferred Provider Networks of Arkansas. Moreover, a provider’s filing of claims for services
rendered to immediate relatives (and receiving payment for such claims), is an abusive claims-filing practice that
also may constitute fraud and could lead to permanent exclusion from the networks.

* Services to immediate family members include not only those personally performed by the provider, but also
any services, equipment, drugs, or supplies ordered by the provider and supplied/ performed by another
party—including any pharmacy charges resulting from prescriptions written by the provider.

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Section 23 | Provider Information

Fraud and Abuse

Fraud: Healthcare fraud occurs when a person, or persons, who intentionally deceives the health care system to
receive benefits or payments.

Waste: The incorrect submission of claims due to factors such as uneducated staff, coding illiteracy, or keying
errors. Wasteful billing can typically be resolved after the provider and their staff are educated on the proper
billing requirements and/or claim submission rules.

Abuse: Practices that are inconsistent with sound fiscal, business, or medical practices, and result in
unnecessary cost to the health plan. In the case of abuse, there is no conspiracy or malicious intent to deceive.

Why is Healthcare fraud a problem?

The healthcare industry loses billions of dollars each year to fraud. Fraud may result in increased premiums,
potential tax increases, and unnecessary medical procedures. Unnecessary medical procedures could result in
physical and/or mental harm to the member.

Common Types of Fraud, Waste, and Abuse

Here are some examples of fraudulent and abusive billing:
ƒ Non-rendered Services: billing for services that never happened; example can be seen in providers billing
the insurance company for services when a patient has cancelled or did not show for their appointment.
ƒ Upcoding: billing for a higher level of services, such as a complex office visit when a lower level of services
was provided; or knowingly ordering unnecessary services for members.
ƒ Misrepresentation of Services: falsifying medical records to support medical necessity or services
never rendered.
ƒ Kickbacks: offering, soliciting, paying, or receiving remuneration (in kind or in cash) or in return for a referral
of patients.
ƒ Unbundling: submitting claims in a fragmented fashion to maximize the reimbursement of various tests or
procedures that are required to be billed together under one code.
ƒ Free Services: offering “free services” that are not really free, because the insurance company is billed for
the service.

There are many other examples, but these are the most common.

What can you do to prevent fraud, waste, and abuse?

Arkansas Blue Cross and Blue Shield relies on the accuracy and completeness of claims submitted for payment.
Here is what you can do to help:
ƒ Document every aspect of the member’s encounter thoroughly according to documentation standards set by
Arkansas Blue Cross and Blue Shield, the appropriate licensing board, state and/or federal agencies, or CMS
guidelines.
ƒ Understand and refer to your provider contract. The provider contract includes any correspondence through
the Provider Manual and/or Provider News. These resources can be found here.

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Reporting fraud is easy. Use one of the following if you suspect fraud is happening by a provider, a member, or
any other entity.
ƒ Fraud Hotline: 800-FRAUD-21 or 800-372-8321
ƒ Email: specialinvestigation@arkbluecross.com
ƒ Speak to your Network Development Representative.

Together we can work towards eradicating healthcare fraud, waste, and abuse in Arkansas.

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Section 23 | Provider Information

Changes/Updates of Information
Please notify the Provider Network Operations (PNO) division of Arkansas Blue Cross and Blue Shield with ANY
changes to provider information. Receipt of updated information will assist Arkansas Blue Cross in providing
current information to referring physicians and its members. Click here for online access to the Provider Change
of Data Form. Members are given false information regarding providers if information is not accurate. The
Centers for Medicare and Medicaid Services requires 100% accuracy for online and print directories. Changes
can be mailed or faxed to the address below, emailed to providersnews@arkbluecross.com, or contact the
Regional Office in your area.

Arkansas Blue Cross and Blue Shield

Attn: PNO Division
601 Gaines Street
P.O. Box 2181
Little Rock, AR 72203-2181

501-210-7050
501-378-2465 (fax)

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Section 23 | Provider Information

Forms for Providers

The forms listed on the menu below are in portable document format (PDF) and allow you to complete the
form online, print, sign and return to the appropriate address with supporting documents. Contact your
Network Development Representative at the Regional Office nearest you for assistance. Additional forms can
be accessed here.

For medical providers

ƒ Authorization Form for Clinic/Group Billing (PDF)
Use for notification that a practitioner is joining a clinic or group.

ƒ Claim Reconsideration Request Form (PDF)

ƒ Designation of Authorized Appeal Representative (PDF)
ƒ Expedited Appeal Request Form (PDF)
ƒ Network Exception Form (PDF)
ƒ Notice of Payer Policies and Procedures and Terms and Conditions (PDF)
ƒ Other Insurance/Coordination of Benefits (COB) (PDF)
ƒ Patient Waiver Form (PDF)
Use to educate members on services that may not meet the Primary Coverage Criteria of the member’s policy. Waivers
allows providers to collect for services that may not be deemed as meeting the Primary Coverage Criteria particularly
for services designated as experimental/investigational or which are not for the treatment of a medical condition.

ƒ Physician/Supplier Corrected Bill Submission Form (PDF)

Use when submitting previously finalized (corrected) bills.

ƒ Prior Approval and Exception Request (PDF)

ƒ Provider Change of Data Form (PDF)
Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.

ƒ Provider Refund Form (PDF)

Use this form to submit a claim refund.

ƒ Termination Form for Clinic/Group Billing (PDF)

Use for notification that a practitioner is leaving a clinic.

For dental providers

ƒ Authorization Form for Clinic/Group Billing (PDF)
Use for notification that a practitioner is joining a clinic or group.

ƒ Provider Change of Data Form (PDF)

Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.

ƒ Member Dental Claim Form (PDF)

ƒ Accident Form for Dental Injury (PDF)
Use this form to file a claim with your medical plan. Accidents are not covered under your dental policy.

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Section 23 | Provider Information

Providers’ News
Communication is an important factor in delivering quality services to members and educating providers.

The Providers’ News is a quarterly publication designed to update providers and their office staff regarding
changes or improvements in Arkansas Blue Cross policies and procedures, provider workshops, plus other
interesting topics. The newsletter is sent to all providers who participate with Arkansas Blue Cross.

The newsletters cover a wide variety of health care topics including:

ƒ Current events relative to Arkansas providers
ƒ Helpful hints for understanding health benefit plans and other coverage options
ƒ Pertinent changes in Arkansas Blue Cross policies and procedures
ƒ Educational meeting schedules and updates
ƒ General topics of interest

It is essential these publications are read by providers and their staff. A provider’s network participation status
could be affected by failure to keep abreast of all notices published in the Providers’ News. This is one way of
assisting providers in accessing available health plan benefits for Arkansas Blue Cross members. To subscribe to
Providers’ News please submit email request to providersnews@arkbluecross.com.

For ideas, comments, or suggestions of topics to be addressed in the Providers’ News, please call Customer
Service at 501-221-3733 or 800-843-1329 or the local Arkansas Blue Cross.

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SECTION 24

Ambulance Providers
Section 24 | Ambulance Providers

Ambulance Providers
Arkansas Blue Cross and Blue Shield and Health Advantage are creating their own ambulance network. It is
highly likely that self-insured groups of Blue Advantage Administrators will choose to use this network, but that
will be up to each employer.

Arkansas Blue Cross has decided to terminate its relationship with Alacura Transportation Benefit Manager
effective July 31, 2023. The 2023 Arkansas Legislative Session resulted with new laws passed making the
Alacura model very difficult to operate.

Arkansas Blue Cross is targeting July 1, 2023 to be the effective date for ambulance provider agreements.

Ambulance Medical Records

The Arkansas Blue Cross provider agreements indicate that medical records, sometimes referred to as run
sheets, must accompany every claim submitted to Arkansas Blue Cross.

Claims that are submitted with modifier combinations RE, RG, RH, RI, RJ, RN, RS, RX, SH, SI, SP, SR, and SX,
will not require the run sheet/ health record.

For further clarification, there will be a diagnosis code system edit on ambulance claims that could result in the
request of records even if these modifier combinations have been submitted.

Credentialing
The contracting packets include standards that must be met. These standards will be placed on the Arkansas
Blue Cross website.

One of the requirements is that ambulance providers must be CMS certified. For most providers, CMS issues
a tie-in notice indicating official addition to the Medicare program. If the ambulance provider does not have an
official tie in notice, please submit documentation from CMS that will prove your company’s Medicare approval.
Documentation will be reviewed for approval.

Arkansas Blue Cross still prefers the $1 million/ $3 million amounts stated in the provider agreements; however,
we understand that this may not be the community standard and will revisit the coverage amount requirements.
For now, if your city or county requires lower amounts through an ordinance or other legal documents, please
submit those documents for review.

Claims Filing – Availity

Ambulance providers or their clearinghouses must enroll with Availity for claims filing.

Contract Questions
Arkansas Blue Cross has received questions about the section in our provider agreements that does not allow
balance billing when a claim does not meet our primary coverage policies. Some might refer to these as medical
policies. An option is for a provider to obtain a waiver stating that the member understands the service may not
be covered and the member will be financially liable. A similar waiver is called an advanced beneficiary notice
(ABN) in the CMS world.

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Section 24 | Ambulance Providers

Arkansas Blue Cross does understand that sounds complicated on the surface. The new laws effective July 30,
2023 have changed those polices substantially. The services not meeting the coverage policies requirements
should be few. Arkansas Blue Cross asks that the EMS community review them again and we believe you will
agree that obtaining the waiver is plausible.

Arkansas Blue Cross has 180-day timely filing requirements for all claims and all providers. If we are in the
secondary position in coordination of benefits, we will use the date the primary carrier paid as the beginning of
the 180-day timely filing calculation.

Electronic Funds Transfer (EFT)

EFT is required. If you are signing new agreements but already have an active EFT contract with Arkansas Blue
Cross, you do not have to complete new agreements.

Hospital Based Ambulance

Hospital provider agreements were never intended to include hospital-based ambulance. Because of the unique
benefits Arkansas Blue Cross had for many years, we needed the ambulance companies to be created separately
from the hospital. That said, we understand that over the years, ambulance claims may have been paid on the
hospital’s NPI. We need to correct this. As we develop the contracted ambulance network in 2023, Arkansas
Blue Cross needs hospital-based ambulance organizations to obtain their own NPI and ensure claims are billed
separately from the hospital on an 837P claim form.

National Provider Identifier (NPI)

On your enrollment form the key number we need is your NPI, but we would prefer to also have any Medicare
provider number different than your NPI.

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SECTION 25

Special Billing and

Coding Issues
Section 25 | Special Billing and Coding Issues

Anesthesia Billing
How to Bill for Anesthesia Time When Filing A Paper Form of CMS-1500
Recently Arkansas Blue Cross and Blue Shield began scanning and imaging paper claims to improve the
processing of claims. If a provider files paper claims for anesthesia services, these guidelines will help the claims
get processed correctly.

Arkansas Blue Cross would prefer providers file electronically; but if a provider must file on paper, please follow
these guidelines.

Claims submitted for anesthesia services by anesthesiologists or CRNAs must indicate the actual total number
of minutes that anesthesia was administered. For example, if anesthesia was performed for 1 hour and 22
minutes, this would be indicated as 82 minutes in block 24g of the CMS-1500. If no time units are indicated on
the claim, the claim will be denied.

Base Units
Base unit values have been assigned to each anesthesia procedure code and reflect the difficulty of the
anesthesia service, including the usual preoperative and postoperative care and evaluation. Arkansas Blue Cross
uses the anesthesia base units recommended by the American Society of Anesthesiologists.

Do not report base units in the units field (block 24g) on your claim submissions, report the actual total minutes
that anesthesia was administered. The Arkansas Blue Cross claims processing system automatically determines
the base units based on the reported procedure code and modifiers. If a provider’s software automatically prints
a comment line below the service line with the base units, it will not interrupt the processing of the claim as long
as no data prints in the date of service or charge fields.

Time Units
Anesthesia time involves the continuous actual presence of the anesthesiologist or CRNA and begins when the
physician or anesthetist begins to prepare the patient for the induction of anesthesia in the operating room or
equivalent area. Anesthesia time ends when the anesthesiologist/CRNA is no longer in personal attendance, i.e.,
when the patient may be safely placed under post-operative supervision. The anesthesiologist/CRNA’s should
report the total anesthesia time on the CMS-1500 claim form as the sum of the continuous anesthesia block
times. The medical record should be documented so that a medical record auditor can see the continuous and
discontinuous periods and that the reported total anesthesia time sums to the blocks of continuous time.

Time units are determined on the basis of total minutes. Providers should report the total anesthesia time
in minutes on the claims. For example, if the total time is 1 hour and 35 minutes, report “95” in the units file
(block 24g) of the CMS-1500.

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Section 25 | Special Billing and Coding Issues

Physical Status Modifiers

The following physical status modifiers are used to give Arkansas Blue Cross additional information about the
level of complexity of the anesthesia service provided. The points are additional units added to the total time.
Providers should bill for only one (1) physical status modifier per procedure.

POINTS

P1: A normal healthy patient 0

P2: A patient with mild systemic disease 0

P3: A patient with severe systemic disease 1

P4: A patient with severe systemic disease that is constant threat to life 2

P5: A moribund patient who is not expected to survive for 24 hours with or without the operation 3

P6: A declared brain-dead patient whose organs are being removed for donor purposes 0

Anesthesia Reimbursement
Anesthesia services are paid based on the Anesthesia Relative Value Units. The customary values for
reimbursement of anesthesia services are based on the sum of the following components:

ƒ Base units for the primary procedure

ƒ Total time
ƒ Physical status

The following formula is used to determine reimbursement:

Total Anesthesia Contractual
(Anesthesia Physical Conversion
+ + time x = fee x allowance
base Unit) modifying factor
(units)) allowance units

For example, 00865P3 performed in total time of 1 hour and 25 minutes:

Total Anesthesia Contractual

(Anesthesia Physical Conversion
+ + time x = fee x allowance
base Unit) modifying factor
(units) allowance units
7 units + 1 unit + 6 units* + 14 units x $50 = $700

Reimbursement would be $700 X Contract Benefit. In other words, if a provider has agreed to accept 90% of the
Arkansas Blue Cross and Blue Shield allowance, their reimbursement would be $700 X 90% = $630.00.

* Partial units are rounded to the next whole unit; 1 unit = 15 minutes. So, 85 minutes/ 15 minutes = 13.67 units,
which = 14 units.

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Section 25 | Special Billing and Coding Issues

Documentation Requirements
Arkansas Blue Cross does not require the anesthesia record with each claim submission. Do not submit
anesthesia records unless it is requested; then follow the instructions in the letter of request. The following are
the most common situations in which Arkansas Blue Cross requests anesthesia notes:
1. Procedures in the Monitored Anesthesia Care policy may require a letter documenting why monitored
anesthesia was necessary for the particular patient.
2. Submission of any miscellaneous procedure codes. Most miscellaneous codes end in “999” (i.e., “01999”).
The record is required to identify the actual procedure performed, because the code does not provide
sufficient information.
3. Anesthesia administered for dental procedures. Since the member’s dental-related coverage may be limited,
the anesthesia record permits us to make a coverage determination on the particular case.
4. If two different anesthesia services are billed on the same claim, the anesthesia record is needed to
document that two different operative sessions occurred on the same day.
5. If a procedure is billed that is not site specific, i.e., removal of a foreign body, Arkansas Blue Cross may
request the anesthesia record to determine the site to ensure coverage should be allowed.
6. If two or more procedures are provided at the same operative session, the anesthesiologist/CRNA should bill
using the related anesthesia procedure with the highest base units.

Anesthesia Billing Reminder

As stated in the Arkansas Blue Cross and Blue Shield provider manual for anesthesia billing:
1. If two different anesthesia services are billed on the same claim, the anesthesia record is needed to
document that two different operative sessions occurred on the same day.
2. If two or more procedures are provided at the same operative session, the anesthesiologist/CRNA should bill
using the related anesthesia procedure with the highest base units

When these situations are identified, a medical records request (MRR) form will be sent to providers to
document different operative sessions on the same day when two anesthesia services are billed for the same
patient on the same day. Arkansas Blue Cross will pay either the anesthesiologist or the CRNA who delivers the
anesthesia service, but not both.

Arkansas Blue Cross does not pay for supervision. Claims for supervision, documented appropriately with
Modifier, QK, QY, or AD, will be denied. In these situations, Arkansas Blue Cross will only pay the CRNA who
provided the anesthesia service.

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Section 25 | Special Billing and Coding Issues

Nerve Block
Billing Information for Nerve Block
If a nerve block is used in the pre or post-operative period as pain management following the procedure,
the appropriate block code should be billed with Modifier - 59 to indicate the pain block was not part of the
anesthesia for the procedure, and Modifier - 51 as multiple procedure rules.

If the nerve block is used as the anesthesia for the procedure, and given along with conscious sedation, the
nerve block would be considered the anesthesia and would be allowed. If the nerve block is given prior to or
during the procedure, along with deep sedation (for which a general anesthesia code is billed), the nerve block
would not be allowed as it would be considered part of the anesthesia for the procedure.

If the nerve block is given in the preoperative setting and only conscious sedation is given during the procedure
(i.e., no general anesthesia code is reported), the nerve block is covered as the anesthesia for the procedure.

Billing for Diabetes Self-Management Training (DSMT)

Arkansas Blue Cross and Blue Shield, Health Advantage, and BlueAdvantage Administrators of Arkansas self-
funded employer groups have covered Diabetes Self-Management Training (DSMT) for quite some time. Per
Arkansas Law ACA 23-79-601, the coverage is for one DSMT program. Additional programs may be covered if a
member’s symptoms or conditions change significantly.

When billing for a DSMT program, providers should bill using HCPCS codes G0108 or G0109. All outpatient
hospital UB04 claims for DSMT should be submitted with revenue code 942 but also must include HCPCS codes
G0108 or G0109. Revenue code 942 always require an HCPCS/CPT code on an outpatient claim; otherwise, the
claim will be rejected. DSMT services from professional providers should be billed on a CMS 1500 claim form
but must also include HCPCS code G0108 or G0109.

Eligible programs for Diabetes Self-Management training must meet the following standards listed below. These
guidelines follow the requirements of Arkansas Law ACA 23-79-601 (also known as Rule 70).

ƒ Compliance: The program must be in compliance with the National Standards for Diabetes Self-
Management Education Program developed by the American Diabetes Association. These standards may be
found at care.diabetesjournals.org/content/diacare/early/2017/07/26/dci17-0025.full.pdf (PDF).
ƒ Required elements: Elements required to meet minimum standards are:
a) Needs assessment
b) Education plan
c) Education intervention
d) Evaluation of learner outcomes
e) Plan for follow-up for continuing learning needs
f) Documentation
ƒ Certification: To qualify for benefits, the provider must provide certification that the insured individual has
successfully completed the diabetes self-management training.

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Section 25 | Special Billing and Coding Issues

Discograms
Correct Billing of Discograms (CPT Codes 72285 and 72295)
There has been some confusion regarding the billing of Discograms. From the CPT Assistant, April
2003, page 27,
“Question: Which CPT codes should be reported for a lumbar discography at L2-3, L3-4, L4-5 and L5-S1
levels? Would the appropriate code be reported more than once since the procedure is performed at four
different levels? Is the radiological interpretation an inclusive component to the primary procedure, or is it
separately reported?”

AMA Comment:
“The discography procedure performed at the L2-3, L3-4, L4-5 and L5-S1 levels may be reported with CPT
code 62290, Injection procedure for discography, each level; lumbar. This code should be reported four
times since four levels were imaged. Also, CPT code 72295, discography, lumbar, radiological supervision
and interpretation, may be reported four times for the radiological supervision and interpretation as this
code can be reported for each lumbar level. If the physician performed only the professional component
of the discography, then Modifier 26, Professional component, should be appended to CPT code 72295 to
indicate this circumstance. There must be documentation of suspected disease at levels in order to receive
payment for numerous provocations.”

If CPT code 72285, discography, cervical or thoracic, radiological supervision and interpretation, is performed on
more than one level, it should be billed in the same manner described above.

The provider who is completing the injection should be billing for CPT code 62290 (Injection procedure for
discography, each level; lumbar). If a radiologist is then sent an X-ray of the position of the needle to provide a
written report for the record, the radiologist should bill code 72295 with Modifier 26 present, not the provider
completing the injection. The provider completing the injection should not bill code 72295.

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HCPCS: K Codes
Effective January 1, 2014 Arkansas Blue Cross and Blue Shield will start accepting some high dollar HCPCS K
codes. The following K codes will be accepted.
HCPCS Code Description
K0010 Standard-weight frame motorized/power wheelchair
Standard-weight frame motorized/power wheelchair with programmable control parameters
K0011
for speed adjustment, tremor dampening, acceleration control and braking
K0012 Lightweight portable motorized/power wheelchair
K0013 Custom motorized/power wheelchair base
K0014 Other motorized/power wheelchair base
K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
K0607 Replacement battery for automated external defibrillator, garment type only, each
K0608 Replacement garment for use with automated external defibrillator, each
Replacement electrodes for use with automated external defibrillator, garment type
K0609
only, each
Power operated vehicle, group 1 standard, patient weight capacity up to and including
K0800
300 pounds
K0801 Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds
K0802 Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds
Power operated vehicle, group 2 standard, patient weight capacity up to and including
K0806
300 pounds
K0807 Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds
K0808 Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds
K0812 Power operated vehicle, not otherwise classified
Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight
K0813
capacity up to and including 300 pounds
Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to
K0814
and including 300 pounds
Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to
K0815
and including 300 pounds
Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and
K0816
including 300 pounds
Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity
K0820
up to and including 300 pounds
Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to
K0821
and including 300 pounds
Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and
K0822
including 300 pounds
Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and
K0823
including 300 pounds

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HCPCS Code Description

Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to
K0824
450 pounds
Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to
K0825
450 pounds
Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity
K0826
451 to 600 pounds
Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to
K0827
600 pounds
Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity
K0828
601 pounds or more
Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601
K0829
pounds or more
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight
K0830
capacity up to and including 300 pounds
Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up
K0831
to and including 300 pounds
Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient
K0835
weight capacity up to and including 300 pounds
Power wheelchair, group 2 standard, single power option, captain's chair, patient weight
K0836
capacity up to and including 300 pounds
Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient
K0837
weight capacity 301 to 450 pounds
Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight
K0838
capacity 301 to 450 pounds
Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back,
K0839
patient weight capacity 451 to 600 pounds
Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back,
K0840
patient weight capacity 601 pounds or more
Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient
K0841
weight capacity up to and including 300 pounds
Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight
K0842
capacity up to and including 300 pounds
Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient
K0843
weight capacity 301 to 450 pounds
Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and
K0848
including 300 pounds
Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and
K0849
including 300 pounds
Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to
K0850
450 pounds

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HCPCS Code Description

Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to
K0851
450 pounds
Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity
K0852
451 to 600 pounds
Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to
K0853
600 pounds
Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity
K0854
601 pounds or more
Power wheelchair, group 3 extra heavy-duty, captain's chair, patient weight capacity 601
K0855
pounds or more
Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient
K0856
weight capacity up to and including 300 pounds
Power wheelchair, group 3 standard, single power option, captain's chair, patient weight
K0857
capacity up to and including 300 pounds
Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient
K0858
weight 301 to 450 pounds
Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight
K0859
capacity 301 to 450 pounds
Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back,
K0860
patient weight capacity 451 to 600 pounds
Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient
K0861
weight capacity up to and including 300 pounds
Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient
K0862
weight capacity 301 to 450 pounds
Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back,
K0863
patient weight capacity 451 to 600 pounds
Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back,
K0864
patient weight capacity 601 pounds or more
Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and
K0868
including 300 pounds
Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and
K0869
including 300 pounds
Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to
K0870
450 pounds
Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity
K0871
451 to 600 pounds
Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient
K0877
weight capacity up to and including 300 pounds
Power wheelchair, group 4 standard, single power option, captain's chair, patient weight
K0878
capacity up to and including 300 pounds

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HCPCS Code Description

Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient
K0879
weight capacity 301 to 450 pounds
Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back,
K0880
patient weight 451 to 600 pounds
Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient
K0884
weight capacity up to and including 300 pounds
Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight
K0885
capacity up to and including 300 pounds
Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient
K0886
weight capacity 301 to 450 pounds
Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient
K0890
weight capacity up to and including 125 pounds
Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient
K0891
weight capacity up to and including 125 pounds
K0898 Power wheelchair, not otherwise classified
K0899 Power mobility device, not coded by DME PDAC or does not meet criteria

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Section 25 | Special Billing and Coding Issues

Immunoassay for Analytes

Proper Billing of Immunoassay for Analytes
There has been some confusion regarding how providers should be billing CPT code 83516. Therefore, this is a
review of the proper billing of immunoassays for analytes. CPT code 83516 is an immunoassay for analyte other
than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method.
CPT code 83516 is a nonspecific code for immunoassay procedures which use highly specific antigen to antibody
binding to identify specific chemical substances (analytes) by immunoassay techniques for immunoassay
procedures that are not specifically identified in CPT. More specific methods reported with these codes include
enzyme immunoassay (EIA), and fluoroimmunoassay (FIA). CPT code 83516 is limited to one unit-of-service
unless performed for a separate analyte.

CPT code 83516 is a nonspecific code and may be reported for anti-mullerian antibody determination. This test
measures a chemical produced in the body called anti-mullerian hormone, or AMH, which has been shown to
provide an accurate snapshot of a woman’s egg count. Cost for this procedure will accrue to the total benefit
allowance for in vitro fertilization, which is a specific member benefit allowance. Arkansas Blue Cross and Blue
Shield’s Coverage Policy #1998041 excludes coverage of blood/serum testing (cytotoxic food allergy testing).
CPT code 83516 is mutually exclusive with CPT Code 83518. If CPT code 83516 is reported with CPT code 83518,
CPT code 83516 is denied as a fragmentation.

If the codes listed below are billed with CPT code 83516, 83516 will be denied as a fragmentation. If CPT code
83516 is performed for an analyte separate from the codes listed below, CPT code 83516 should be reported with
Modifier 59.
ƒ 80101 - (Drug screen, single drug class method [e.g., immunoassay, enzyme assay], each drug class) as each
code represents qualitative immunoassay for an analyte other than infectious agent antibody or infectious
agent antigen
ƒ 86200 - (Cyclic citrullinated peptide [CCP], antibody), a semi-quantitative/qualitative enzyme- linked
immunosorbent assay
ƒ 86602 - CPT 86793, as all of the latter procedures represent qualitative immunoassays for detection of
antibodies for specific infectious agents
ƒ 86021 - (Antibody identification; leukocyte antibodies), a semi-quantitative/qualitative antibody test
ƒ 86022 - (Antibody identification; platelet antibodies), a semi-quantitative/qualitative antibody test
ƒ 86023 - (Antibody identification; platelet associated immunoglobulin assay), a semi- quantitative/qualitative
antibody test
ƒ 86255 - (Fluorescent noninfectious agent antibody; screen, each antibody), a semi- quantitative/qualitative
antibody test
ƒ 86294 - (Immunoassay for tumor antigen, qualitative or semi-quantitative), a semi- quantitative/qualitative
antibody test
ƒ 86318 - (Immunoassay for infectious agent antibody, qualitative or semi-quantitative, single step method
[e.g., reagent strip]), a semi-quantitative/qualitative antibody test
ƒ 86376 - (Microsomal antibodies [e.g., thyroid or liver-kidney], each), a semi- quantitative/qualitative
antibody test
ƒ 86430 - (Rheumatoid factor; qualitative), a qualitative antibody test

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ƒ 86800 - (Thyroglobulin antibody), a qualitative antibody test

ƒ 86850 - (Antibody screen, RBC, each serum technique) a semi-quantitative/qualitative antibody test
ƒ 86870 - (Antibody identification, RBC antibodies, each panel for each serum technique), a semi- quantitative/
qualitative antibody test

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Section 25 | Special Billing and Coding Issues

Molecular Diagnostics and Cytogenetic Testing

Proper Billing
Arkansas Blue Cross and Blue Shield recently has noticed a significant increase in the number of molecular
diagnostic and cytogenetic testing claims received. Many of the claims being filed for these services are filed
incorrectly. Effective immediately, Arkansas Blue Cross and its affiliates no longer will review the denied claims
for these services if the claim is billed with any of the molecular diagnostic or cytogenetic testing codes (83890-
83914 and 88230-88299) when the claims are submitted without a specific genetic modifier, found in Appendix
I of the 2010 Current Procedural Terminology (CPT®) Manual, and the number of probes performed with each
code. The following information is what any facility or lab must include on a claim for molecular diagnostic or
cytogenetic testing:

1. Claims must have the name of the genetic test that was performed along with the reason the test
was ordered.
2. All of the molecular diagnostic codes (codes contained in the series from 83890-83914) and/or cytogenetic
codes (codes contained in the series from 88230-88299) must be included on the claim for that genetic test
ordered. In addition, the exact number of probes performed for each molecular diagnostic or cytogenetic
code must be appended to the claim.
3. The correct genetic modifier, found in Appendix I of the 2010 CPT Manual for the genetic test ordered must
be appended to the claim.

If a review of a denied claim is received and the claim was not submitted correctly, a letter will be sent to the
provider stating the following:

“Please be advised, the claims will not be paid when submitted unless the proper genetic modifier, which
is found in Appendix I of the 2010 CPT Manual, is properly appended to the claim with the molecular
diagnostic/cytogenetic testing codes with each code having the number of probes that was performed with
each code.”

The claim denial also will be changed to the appropriate code per line of business, indicating the claim was
incorrectly coded and the member cannot be held financially responsible.

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Section 25 | Special Billing and Coding Issues

Pathology Consultation
Billing of Pathology Consultation Codes (CPT Codes 88331 and 88332)
Due to some confusion as to the appropriate manner which CPT code 88331 should be billed, the following is a
guideline for the appropriate billing of this code.

CPT code 88331 is the pathology consultation during surgery; first tissue block, with frozen section(s), single
specimen. The CPT Assistant July 2000, Page 4 states, “During the course of a surgical procedure, a pathology
consultation may be required. Pathology consultations during surgery that involve frozen sections are reported
with CPT codes 88331 and 88332.” The phrase, “with frozen section(s), single specimen,” has caused some
confusion over the intent of the code, prompting some to believe that CPT code 88331 can only be used once
per surgery, rather than once per specimen. In fact, multiple separately submitted specimens may be received
during surgery for frozen section examination for diagnosis or immediate evaluation, resulting in the use of
multiple units of 88331.

In order to properly use these codes, the terms “block” and “section” must be defined. A block is a portion of
tissue from a specimen that is frozen or encased in a support medium such as paraffin or plastic, from which
sections are prepared. A section is a thin slice of tissue from a block prepared for examination. The examination
is usually by light microscopy.

When a section from the first block of tissue from a specimen is examined, CPT code 88331 would be used.
When sections from subsequent blocks of the same specimen are examined, the appropriate coding is one
unit of service of CPT code 88332 for each section examined. If more than one specimen is submitted for
consultation, the services for each specimen would be coded as explained above.

Any routine stains (e.g., rapid H&E, Wright) applied to the frozen section are included in CPT codes 88331 and
88332. If other techniques (e.g., fine needle aspiration, touch preparation, examination of a cell sample) are used
in the course of a pathology consultation during surgery, they should be reported using appropriate cytology
codes. When the definitive permanent section examination is performed, subsequent to the frozen section
during surgery, the appropriate surgical pathology code should be reported.

CPT Changes
CPT Changes 2001 Rationale CPT code 88331 was revised to allay confusion regarding the intent of the code.
The descriptor of CPT code 88331, “with frozen section(s), single specimen,” has caused confusion over the
intent of the code prompting some to believe that CPT code 88331 can only be used once per surgery rather
than once per specimen. The addition of “first tissue block” to the code descriptor was necessary to prevent
misinterpretation.

Therefore, CPT code 88331 is restricted to one unit per specimen. If a frozen section is performed on a second
block of tissue, CPT code 88331 should be reported with Modifier 59 or the LT or RT Modifiers.

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Section 25 | Special Billing and Coding Issues

Postoperative Global Period

Arkansas Blue Cross and Blue Shield uses the postoperative global periods used by Medicare. Each surgical
and/or invasive procedure will have a global period of either zero, ten or ninety days. This means that all
usual postoperative services occurring within those respective time frames are included in the Arkansas Blue
Cross allowance and reimbursement of the surgical/invasive procedure. Providers will not receive additional
payments. Only those related postoperative services that are considered significant and separately identifiable
should be billed.

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Section 25 | Special Billing and Coding Issues

Transitional care management services

Arkansas Blue Cross and Blue Shield and Health Advantage cover the new Transitional Care Management
Services (TOC) codes to reimburse for services provided during the critical period of discharge from a facility.
These services are billed using CPT code 99495 and 99496.

These CPT codes are billable when an established patient requires moderate or highly complex medical
decision-making during a transition of care from an inpatient setting (including acute hospital, rehab hospital,
long term acute care, partial hospital, observation status, or skilled nursing/nursing facility).

Reimbursement for these CPT codes requires an attempt to contact the patient within two business days of
discharge, culminating in a successful contact (for example by phone) separate from a face-to-face visit. In
addition, reimbursement requires that a face-to-face visit occur within seven days of discharge (CPT code 99496)
or within 14 days of discharge (CPT code 99495).

This face-to-face visit is part of the TOC service and is not billable separately from the TOC code. The TOC
service is payable only once per 30 days. In the event of overlapping hospitalizations within a 30-day period,
only one discharge is eligible for TOC reimbursement.

The TOC codes are payable only to primary care providers, including general practice/family medicine, internal
medicine, pediatrics, or gerontology. The date of service can be billed either as the date of the face-to-face visit
or the date 30 days after discharge (the latter being the Medicare policy).

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Treatment of Temporomandibular Joint Disease

Treatment of Temporomandibular Joint Disease is only covered if the member’s certificate has a TMJ rider for
coverage. The only exception is for an individual contract issued prior to January 1, 2002. Providers should
contact customer service for information on whether these benefits are in place and what dollar amount of
coverage is available.

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SECTION 26

Utilization Review
Section 26 | Utilization Review

Introduction
Utilization management (UM) has long been used by healthcare purchasers to encourage appropriate use
of services and high-value care. Through UM, health plans, hospitals, physicians and pharmacists share
information to ensure the highest quality of care is provided to members in the most appropriate settings
and from the most appropriate providers. UM programs are designed to identify areas of risk, reduce waste,
improve patient safety and keep healthcare affordable by lowering costs. Health plans pursue UM programs to
avoid over-utilization and under-utilization of healthcare services by making coverage determinations based on
evidence-based guidelines.

Consistent with our five-year plan to improve value, Arkansas Blue Cross and Blue Shield has created a
framework and is implementing several initiatives to enhance sustainability and improve efficiencies. The
Utilization Management Program is coordinating efforts with the provider quality improvement department to
enhance pay-for-performance and quality programs to help support our high-performing providers.

Arkansas Blue Cross encourages the use of preventive and wellness services to improve health and reduce
costs, as such our UM staff will not require prior approval for certain services such as:
ƒ Emergency room services
ƒ Ambulances
ƒ Urgent care
ƒ Primary care
ƒ Specialist visits
ƒ Other practitioner office visits
ƒ Preventive care
ƒ Screenings
ƒ Immunizations
ƒ Diagnostic tests

The goal of the Arkansas UM team is to ensure high-quality, cost-efficient care for our members. There is no
incentive to deny prior approvals through utilization review.

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Section 26 | Utilization Review

Basis for Determining Medical Necessity (vs. using primary coverage

criteria in benefit)
Arkansas Blue Cross reviews are based upon evidence-based guidelines to assess medical necessity, including
Interqual Guidelines and the Arkansas Blue Cross Medical Coverage Policy developed with input from
physicians within our networks and external specialty physicians, in accordance with standards used by national
accreditation organizations and regulatory agencies. These guidelines are reviewed annually and updated to
include new treatments or technologies adopted as generally accepted professional medical practice. Arkansas
Blue Cross strives to ensure that medical necessity guidelines are applied in a way that considers the individual
health needs of each member.

Arkansas Blue Cross may have to change medical necessity guidelines to reflect new findings on effectiveness
for new or existing treatments. Providers are notified 30 days in advance of changes to these guidelines.

Definitions
The general term “prior approval” is used universally at Arkansas Blue Cross to define a process that is used
when medical tests, procedures or services require review by the enterprise before the medical test, procedure
or service meets primary coverage criteria and will be covered by the member’s benefit plan. There are more
specific terms that may be utilized in UM programs. Some of these include:

1. Primary coverage criteria: Criteria established by Arkansas Blue Cross that must be met before benefits are
available for a service. Elements of the primary coverage criteria include:
a. The intervention must be a health intervention intended to treat a medical condition.
b. The intervention must be proven to be effective.
c. The intervention must be the most appropriate supply or level of service considering potential benefits
and harms to the patient.
d. The intervention must be the most cost-effective intervention.

2. Pre-certification: Reviewing inpatient admissions to determine whether hospitalization is medically

necessary, or whether needed services could be provided in an outpatient or other alternative setting.
3. Pre-authorization: Determining (by Arkansas Blue Cross) in advance if a medical service, medication, supply,
test or equipment meets primary coverage criteria for a covered person.
4. Pre-notification: Contacting the health plan prior to admission or other medical service to alert us of the
admission or service.

If you have questions about prior approval and utilization management, you can email your questions to:
abcbspriorauth@arkbluecross.com

For questions regarding prior approval for members on the exchange, email expriorapproval@arkbluecross.com

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Section 26 | Utilization Review

Arkansas Blue Cross and Blue Shield

Product Line Admission Prior Approval Outpatient Prior Approval

Required for select services

Arkansas Blue Cross and Blue Shield Required (see below)
(see below)

Required
(Please note all ID cards
FEP have the Arkansas Blue Not Required
Cross logo and the ID #
begins with an “R”)

Health Advantage
Product Line Admission Prior Approval Outpatient Prior Approval

Not Required
Pre-notification required
Health Advantage Not Required
for out of state or out of
network.

BlueAdvantage Administrators of Arkansas

Product Line Admission Prior Approval Outpatient Prior Approval

Required for Certain Groups

Call the following phone
BlueAdvantage Administrators of Arkansas Required
number to inquire
800-872-2531

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Section 26 | Utilization Review

Arkansas Blue Cross Exchange Population Prior Approval Requirements

Inpatient Medical Admissions
Coverage of all medical inpatient admissions require prior approval. While emergency care does not need
approval, medical* inpatient admissions as a result of emergent situations do require approval. Medical
inpatient admissions include, but are not limited to:
ƒ Medical and surgical admissions (scheduled and elective)
ƒ Inpatient hospice care
ƒ Skilled nursing facilities
ƒ Rehabilitation facility admissions

* In emergent situations, providers should not delay admission while waiting on approval.

When submitting a prior approval request, you should submit relevant clinical information. If you must call in a
request, it should be followed with written documentation. Calls should be made to 800-558-3865, 8 a.m. to 4:30
p.m., Central time, Monday – Friday, except on major holidays. Information also may be submitted through the
Provider Portal in Availity. Requests submitted after hours and on weekends through the Provider Portal will be
processed the following business day.

Prior approval information should include:

ƒ Member name, date of birth and Arkansas Blue Cross member ID
ƒ Provider’s NPI #
ƒ Facility name
ƒ Admitting or primary diagnosis/procedure codes
ƒ Relevant clinical information to support admission and level of service
ƒ Admission type (SNF, inpatient medical, rehab)

Prior approval decisions for medical inpatient admissions are made by our local team in a time appropriate for
the medical exigencies, but no later than one business day of receiving all relevant clinical documentation. That
information is also made available for future, prospective and concurrent review.

Utilization management decisions are determined by the Arkansas Blue Cross Medical Coverage Policy and
Milliman Care Guidelines (MCG). These policies and guidelines are evidence-based and systematically reviewed
and updated by the Arkansas Blue Cross Medical Policy Committee. These guidelines are available on Availity.

Concurrent review will also be utilized to assure the appropriateness of care, the setting and the progress of
discharge plans and to link Arkansas Blue Cross members to care management as needed to improve health
outcomes. The ongoing review is directed at facilitating the right care, at the right time, in the right setting (or
level) appropriate for the patient.

For members not on Exchange policies, out-of-state and out-of-network hospital admissions require
pre- notification by calling the 800 number located on the member’s ID card. In-network and in-state hospital
admissions do not require pre-notification. Please be aware when calling to pre-notify an out-of-state or

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Section 26 | Utilization Review

out-of-network admission that the phone menu has changed. Providers must listen to the entire menu to assure
calls are being transferred to the appropriate location.

For more information, please call your local Arkansas Blue Cross and Blue Shield office.

Admission Pre-notification/Pre-certification Requirements for Out-Of-State or Out-Of-Network 2011

Pre-notification requirements for out-of-network and out-of-state only. Effective Jan.

1, 2011, pre-notification calls are taken by Arkansas Blue Cross Customer Service. Call
Arkansas Blue
the phone number on the member’s ID card, listen to the menu of options, and choose
Cross Blue Shield
the Arkansas Blue Cross option after the tone. Excluding Exchange members on
metallic plans.

BlueAdvantage Precertificaton and Continued Stay Review are required for many groups. Review,
Administrators of carefully, the member’s ID card for pre-certification or pre-notification instructions and
Arkansas the appropriate 800 number to call.

There have been no changes in this process. Pre-certification is requirement for

hospital admissions. Pre-certification services are provided by Health Integrated. Call
FEP
the phone number on the member’s ID card, listen to the menu of options, and choose
the FEP option after the tone.

Pre-notification requirement for out-of-network and out-of-state only. Calls are taken
by Health Advantage Customer Service by calling the phone number on the member
ID card, listen to the menu of options, and choose the Health Advantage option
after the tone.

For Arkansas State and Public School members (ID prefix PXG), Health Advantage
administers prior authorization/pre authorization service requests. Health Advantage is
partnering with Lucet Health Behavioral Health and Carelon.

For Behavioral Health/Substance Abuse, pre authorization will need to be obtained by

Lucet Health at 877-982-8295.

Health Advantage High Tech Radiology services will need to be precertified by Carelon at 877-642-0722.

All other medical services that require prior authorization/pre authorization will need to
be obtained by calling Health Advantage at 800-482-8416 (internal transfer extension
50158). Outpatient service requests can also be submitted by fax or mail using the
form available on the Health Advantage website:

Prior app roval for requested services - Health Advantage

Prior Authorizations for Specialty Medications will continue to go through EBRx, and a
separate list will be updated as changes occur.

Acute medical conditions do not require pre-certification.

Precertificaton and Continued Stay Review are required for many groups. Review,
USAble
carefully, the member’s ID card for pre-certification or pre-notification instructions and
Administrators
the appropriate 800 number to call.

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Section 26 | Utilization Review

Admission Pre-notification/Pre-certification Requirements for Out-Of-State or Out-Of-Network 2011

Pre-notification requirement for out-of-network and out-of-state only. Calls are taken
by the regional Customer Service not Health Integrated. Providers should dial the
USAble Life Group
Customer Service phone number located on the back of the member’s ID card which
Health
directs callers to the appropriate regional Customer Service area. Callers should listen
to the menu of options, and choose the USAble Life Group Health option after the tone.

Additional Services Requiring Prior Approval

The following services will require prior approval (PA) as of April 1, 2022.

Arkansas Blue Cross and Blue Shield Fully Insured

ƒ Home health visits and hospice subject except metallic.
ƒ Mental health inpatient except metallic.
ƒ Inpatient acute, LTAC, rehab: group business only except metallic.
ƒ Prosthodontics services.
ƒ Additional services require PA as part of the Craniofacial Anomaly reconstructive surgery: Sclera contact
lenses, including coatings, ocular impressions of each eye; every two years, two hearing aid molds and a
choice of two wearable bone conductions, two surgically implantable bone-anchored hearing aids or two
cochlear implants including metallics and the US65 individual plans.

Arkansas Blue Cross and Blue Shield Exchange

ƒ Additional services require PA as part of the Craniofacial Anomaly reconstructive surgery: Sclera contact
lenses, including coatings, ocular impressions of each eye; every two years, two hearing aid molds and a
choice of two wearable bone conductions, two surgically implantable bone-anchored hearing aids or two
cochlear implants including metallics and the US65 individual plans.
ƒ Prosthodontics services.

Special Note
Arkansas Blue Cross and Blue Shield cannot give providers any kind of guarantee regarding eligibility —
Arkansas Blue Cross can only give the data available and reflected on our computer system at the time a
provider calls. Many factors beyond the knowledge or control of Arkansas Blue Cross may affect the eligibility
status of a given member; therefore, providers should not rely on the eligibility data provided as assurance
of coverage for the services or service date(s) in question. A provider’s best source for the most up-to-date
information on eligibility is the patient, who should know employment status and premium payment history or
intention on the date of service.

The Arkansas Blue Cross participating provider agreements specifically address eligibility, providing the
following: Effect of Eligibility and Pre-certification or Pre-Notification Responses — Provider understands and
agrees that pre-certification for inpatient treatment, pre-notification or any “verification of benefits” or other
eligibility inquiries made prior to, at or after admission or provision of any services to members are not a
guarantee of payment.

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Pre-certification means only that, based on information provided to Arkansas Blue Cross (or the applicable
payer) or its designated representative at the time of admission, coverage for the admission (and for the initial
number of inpatient days authorized for reimbursement) will not be denied solely on the basis of lack of medical
necessity (as defined by the member’s health plan) for inpatient treatment. Pre-notification means only that
Arkansas Blue Cross (or the applicable payer) has been notified of the admission.

While Arkansas Blue Cross (or the applicable payer) or its designated representative will endeavor in good faith
to report member eligibility information available to Arkansas Blue Cross within its records or computer systems
at the time of admission or provision of services, provider acknowledges and agrees that it is not possible to
guarantee accuracy of such records or computer entries. A provider understands and agrees that the eligibility
of all members and coverage for any services shall be governed by the terms, conditions and limitations
of the member’s health plan, which shall take precedence over any inconsistent or contrary oral or written
representations.

If, following any inpatient treatment or other services, it is discovered or determined that premiums had
not been paid for a member’s coverage, that a former member was no longer employed and eligible for
participation in the health plan at the time of the admission, or that coverage had lapsed or terminated for any
reason specified in the member’s health plan, no reimbursement shall be due from Arkansas Blue Cross (or the
applicable payer) for such services.

For More Information

For more information regarding pre-certification requirements, see the section on the Arkansas Blue Cross Web
site: https://secure.arkansasbluecross.com/providers/mprecertrouter.aspx

Fax number for hospital pre-certification services

Arkansas Blue Cross and Blue Shield’s hospital admission pre authorization fax number is 501-378-2050. Please
make sure all clinics and facilities are using the fax number when sending pre authorization clinical information
for members of BlueAdvantage Administrators of Arkansas, FEP, and USAble Administrators.

Providers who have questions regarding this change should contact their network development representative.

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Behavioral Health Admissions and Services

To better address behavioral healthcare needs in our state, Arkansas Blue Cross will be implementing high
intensity community-based case management and utilization management that will be coordinated with the
patient’s mental health provider and primary care physician. Accordingly, prior approval of coverage for select
behavioral health services will be required. These services include inpatient behavioral health admissions,
intensive outpatient treatment, residential treatment programs, applied behavioral analysis (ABA) and repetitive
transcranial magnetic stimulation treatment (rTMS).
ƒ To obtain prior approval contact Lucet Health directly at 877-801-1159.
ƒ Prior approval may also be requested through Lucet Health’s secure web access portal, WebPass. For
information about WebPass and how to access it, contact Lucet Health at 888-611-6285.
ƒ Requests must include key clinical information such as the patient’s diagnoses, mental status, precipitating
event or events leading to treatment, prior treatment history, current outpatient providers, medications,
proposed treatment plans, risk and safety concerns, family and support systems, tentative discharge plans
and estimated length of treatment.

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Outpatient Services
Utilization management for outpatient services includes prior approval for the following services:
ƒ Durable medical equipment: over $500
ƒ Prosthetics: over $5,000
ƒ Vacuum assisted closure (wound vac)
ƒ Infertility services health plans
ƒ Rehabilitation services (Physical Therapy, Occupational Therapy, Speech Therapy and Chiropractic Services)
do not require prior approval, but have a maximum combined services visit limit of 30 per calendar year.
Additional visits require prior approval.
ƒ Habilitation services
ƒ Home health
ƒ Reconstructive surgery
ƒ Outpatient services: certain outpatient hospital services and ambulatory surgical center procedures are
subject to prior approval. Call customer service for more information.

Pregnancy-related services will be automatically approved but will require prior notification to ensure high- risk
pregnancies may be adequately identified and monitored for optimal health outcomes for mother and child.
ƒ Complete the prior approval form (PDF).
ƒ For efficient service, you should submit prior approval requests via the Provider Portal on Availity. Requests
submitted after hours and on weekends through the Provider Portal will be processed the following
business day.
ƒ You also may fax your request to 501-378-6647. Be sure to include medical records along with the prior
approval form.
ƒ If for some reason you cannot access Availity, contact Availity Client Services at 1-800-AVAILITY (282-4548)
Monday -Friday 8:00 AM - 8:00 PM EST.

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Pharmacy
To ensure the appropriate use of prescription drugs, in terms of both cost-effectiveness
and safety, certain drugs on the formulary for the individual marketplace will require prior
approval, quantity limits, or step therapy. To see which drugs require these measures, visit
arkansasbluecross.com/members/individual-and-family/pharmacy-information and reference the
Metallic formulary.

The pharmacy help desk is available at 800-364-6331 if assistance is needed.

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High Tech Radiology Prior Approval

Ionizing radiation from medical imaging exposes patients to increased risk of radiation induced malignancies
over time. There is also increased utilization of imaging procedures. The cumulative risk of patients undergoing
frequent or repeated studies is now recognized as a growing public health concern and an area of ongoing
research. Coverage of all enhanced high-tech imaging will require prior approval with submission of relevant
medical record documentation. Clinical validation will be required for the following:
ƒ Abdominal and pelvic CT
ƒ Chest/thorax CT
ƒ Head CT
ƒ Sinus CT

As part of the approval process, providers will need to fax or upload on providerportal.com to Carelon certain
pieces of a patient’s medical records and/ or additional clinical information as part of the clinical review for
determination.
ƒ To initiate a request for an approval please contact Carelon via toll-free number 877-642-0722 or
providerportal.com
ƒ To check the status of an approval please contact Carelon via toll-free number 877-642-0722 or
providerportal.com
ƒ Provider will be able to upload requested records on the Carelon website providerportal.com or at
877-642-0722.

If an urgent clinical situation exists outside of a hospital emergency room, please contact Carelon at
877-642-0722 immediately with the appropriate clinical information for an expedited review.

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Out of State/Out of Area

Arkansas Blue Cross and Blue Shield recognizes the value of ensuring our exchange members see True Blue
PPO providers. As of January 1, 2018, coverage for out-of-area/out-of-state services on some exchange polices
will only be provided with prior approval for services not available from a True-Blue provider or in emergency
situations. There are border state providers participating in the True Blue PPO. If the medical service is best
offered by an out-of-state provider (e.g., certain types of transplants), those services will be permitted upon
review of a prior approval request.

Continuity of care will be considered for complex conditions that have been maintained for a significant length
of time by an out-of-state doctor following a prior approval request. You can identify policies with no out-of-
area/out-of-state coverage by no suitcase symbol on the member ID card and by verifying eligibility on Availity.
ƒ For consideration, submit a continuation of care election form, found at
arkansasbluecross.com/providers/resource-center/provider-forms

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Transplant Facilities and Procedures

Prior approval is required for transplant evaluation and treatment. Prior approval is not required for cornea
transplants.

Arkansas Blue Cross and Blue Shield member health plans and contracts require specific coverage approval
procedures (“Prior Approval”) for all transplants except kidney and cornea transplants. Before any transplant
services, including transplant evaluation, are provided, a request for Prior Approval of coverage should be sent
to Arkansas Blue Cross and Blue Shield.

In order to be covered, transplants must meet all terms, conditions and limitations of the member’s health plan
or contract, including but not limited to the Primary Coverage Criteria. In addition, to be covered, a transplant
must be the subject of a specific Arkansas Blue Cross and Blue Shield Coverage Policy and the member must
meet all of the required criteria necessary for coverage, as set forth in the Coverage Policy and the member’s
health plan or contract. Providers may access such specific Coverage Policies on the Arkansas Blue Cross and
Blue Shield website, click on the link under the “Coverage Policy” section of the on-line version of this Manual.

Reimbursement for covered transplants will be affected by whether an in-network or out-of-network facility is
used for the transplant, and member health plans and contracts specify clear limitations on reimbursement.
Arkansas Blue Cross arranges access for its members to the Blue Cross and Blue Shield Association’s Blue
Distinction Centers for Transplant, a nationwide network of participating transplant facilities. Members receive
the maximum health plan or contract benefit by utilizing a participating facility. When an out-of-network facility
is used, members may be liable for charges by the facility in excess of the Arkansas Blue Cross and Blue Shield
Allowance.

Reimbursement includes payment based on a Transplant Global Period and a global payment for all transplant-
related services rendered during the Transplant Global Period. No payment will be made for separately-billed
services related to the transplant because the global payment is deemed to include payment for all related
necessary services (other than non-covered services).

Several other specific coverage rules and criteria apply to transplants, including but not limited to specific
standards for limited coverage of certain donor or harvesting services, autologous transplants, allogeneic
transplants and nonmyeloablative allogeneic stem cell transplantation. For a complete description of those rules
and criteria, please review the transplant provisions of the applicable member health plan or contract, because
coverage and any payments to providers are always subject to the health plan or contract terms.

A Note on “Prior Approval”: Prior Approval does not guarantee payment or assure coverage; it means only that
the information furnished to us at the time indicates that the transplant meets the Primary Coverage Criteria
requirements set out in the member’s health plan or contract. All services, including any transplant receiving
Prior Approval, must still meet all other coverage terms, conditions and limitations, and coverage for any
transplant receiving Prior Approval may still be limited or denied, if, when the claims for transplant are received
by us, investigation shows that a benefit exclusion or limitation applies, that the member ceased to be eligible
for benefits on the date services were provided, that coverage lapsed for non-payment of premium, that out-
of-network limitations apply, or any other basis specified in the member’s health plan or contract. Contact for
Obtaining Prior Approval: For assistance regarding transplants for our members, and related Prior Approvals,
contact Whitney Floyd, RN at 501-212-9837 or Sarah Geary, RN at 501-340-7299.

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Carelon (formerly AIM Specialty Health)

Arkansas Blue Cross members will receive one CT or MRI for every three people. In addition to the increased
financial burden this puts on those paying health insurance premiums, the rapid acceleration in radiological
imaging is exposing patients to worrisome doses of radiation. For example, each cranial CT Scan with and
without contrast delivers the radiation equivalent of 200 chest X-rays, while a chest CT provides 350 chest
X-ray equivalents. For these reasons, Arkansas Blue Cross, BlueAdvantage, Health Advantage, and Arkansas
PPO have entered into an agreement with Carelon Specialty Health, Inc., (NIA) for outpatient imaging
management services.

A prior approval program for outpatient diagnostic imaging procedures began February 1, 2006. The prior
approval program applies to all Arkansas Blue Cross members, including those who access the True Blue PPO
network, as well as all Health Advantage members.

Under terms of the agreement, Arkansas Blue Cross, Health Advantage and BlueAdvantage will retain ultimate
responsibility and control over claims adjudication and all coverage policies and procedures. Carelon will
manage outpatient imaging/radiology services through existing contractual relationships. Claims for imaging
services will continue to be processed based upon the terms of the Arkansas Blue Cross Preferred Payment Plan,
Health Advantage, PPO Arkansas’ True Blue PPO and Arkansas’ FirstSource PPO provider agreement(s).

In August 2018, Arkansas Blue Cross and Blue Shield made the decision to transition the administration of
advanced diagnostic imaging from National Imaging Associates (NIA) to Carelon for its members.

Why the change?

Carelon administers services nationwide, which will allow us to serve members outside the Arkansas service
area through a single vendor. Carelon serves about 50 health plans and related organizations, representing
more than 42 million people. The Carelon staff of 1,000 associates includes 600 healthcare professionals
(licensed in all 50 states, with board certification in more than 20 specialties and subspecialties).

What changes will customers notice?

This transition will be seamless for the vast majority of our fully insured customers. Here are some important
notes on the transition:
ƒ Effective date – The move from NIA to Carelon is effective January 1, 2019.
ƒ Phone number – Arkansas Blue Cross purchased the telephone number listed on the back of some
member ID cards and will redirect it to Carelon. Members or providers calling for diagnostic imaging pre-
authorization will follow the same process as before the vendor change. For questions or inquiries:
ƒ Call Carelon Specialty Health toll-free at 877-642-0722
ƒ Hours: Monday – Friday [7:00 am to 7:00 pm CST]
ƒ For member inquiries to their network plan, please call the customer service number listed on the
member’s ID card.
ƒ ID cards – No member will receive a new ID card solely because of the move to Carelon.
ƒ Websites – All of the networks websites are now redirected to link provider to Carelon’s website.
ƒ Get fast, convenient online service via the Carelon ProviderPortalSM (registration required). ProviderPortal
is available twenty-four hours a day, seven days a week. Go to providerportal.com to begin.

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The following information is needed to submit a request to Carelon:

ƒ Member’s identification number, name, date of birth, and health plan
ƒ Ordering provider information
ƒ Imaging provider information
ƒ Imaging exam(s) being requested (body part, right, left or bilateral)
ƒ Patient diagnosis (suspected or confirmed)

BlueAdvantage Administrators of Arkansas

Customers of BlueAdvantage Administrators of Arkansas can elect to add this program on a group-by- group
basis, which would be indicated on the member’s ID card.

Federal Employee Program

Arkansas Blue Cross and Blue Shield’s Federal Employee Program (FEP) has engaged Carelon, to operate a new
Radiology Utilization Management Program for that health plan’s members, effective April 1, 2022.

As of that date, Carelon will handle medical necessity review of diagnostic imaging services for FEP members.

Carelon works with leading insurers and providers, through evidence-based practice initiatives, to improve
healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to
promote care that is appropriate, safe and affordable.

For services that are scheduled to begin on or after April 1, 2022, all providers must contact Carelon to obtain
pre-service review for the following nonemergency modalities:
ƒ Nuclear imaging (including myocardial perfusion imaging), cardiac blood pool imaging, infarct imaging and
positron emission tomography (PET) myocardial imaging.
ƒ Computed tomography (CT), including CT angiography, structural CT and quantitative evaluation of coronary
calcification.
ƒ Magnetic resonance imaging (MRI).Magnetic resonance angiography (MRA).
ƒ Magnetic resonance spectroscopy (MRS).
ƒ Functional MRI (fMRI).

How to submit a request for review:

Starting March 14, 2022, providers may begin submitting requests for review or verify order numbers, using one
of the following methods:

Online
The fully interactive Carelon ProviderPortalSM is available 24/7 and processes requests in real-time, using clinical
criteria. Register at the Carelon Specialty Health provider portal.

By phone
Call Carelon Specialty Health toll-free at 866-688-1449 (7 a.m. - 7 p.m. Central, Monday - Friday).

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For more information:

Online
Providers may access Radiology Utilization Management Program resources on the Carelon website. The
Carelon website also has more information about the program and provides access to useful information and
tools such as order entry checklists and clinical guidelines.

By phone
Providers who have questions or observations may contact their designated Arkansas Blue Cross network
development representative.

Arkansas Blue Cross and Blue Shield’s Federal Employee Program greatly values the trusted healthcare
providers that serve the members who depend on us for their health coverage, and we look forward to working
with you and Carelon to maintain a high standard of care.

Note: Aim Specialty Health is an independent company that operates separately from Arkansas Blue Cross and
Blue Shield and administers radiology utilization management services for the benefit of Arkansas Blue Cross
Federal Employee Program members. Arkansas Blue Cross and Blue Shield is an independent licensee of the
Blue Cross Blue Shield Association.

Advanced imaging program for Tyson and Walmart

BlueAdvantage Administrators of Arkansas will continue working with Carelon for outpatient diagnostic imaging
procedures for Walmart associates and Tyson team members and their covered dependents throughout the
United States. Walmart associates and Tyson team members residing in Arkansas will be included in this
national care management program.

This is the same advanced imaging review program currently utilized by Arkansas Blue Cross and Blue Shield,
Health Advantage and select employer groups administered by Blue Advantage through Carelon. The imaging
program for Tyson and Walmart, administered by Carelon, includes clinical appropriateness review of advanced
imaging services and assists members in finding a “best value” site for MRI and CT exams using the Blue Cross
and Blue Shield Association’s National Consumer Cost Tool (NCCT) data set.

There are three primary components included in the imaging management program as described below:
1. Clinical appropriateness review: Carelon will provide prospective clinical review for elective, outpatient CT,
MRI, Nuclear Cardiology, PET and Echocardiography exams.
2. Provider transparency: During the clinical review process, Carelon will share NCCT cost information with the
ordering physician’s office.
3. Member transparency: Carelon will make phone calls to members if there is an opportunity for the member
to maximize their benefits by selecting a different facility for their MRI or CT exam. These conversations will
be supported by the NCCT cost information as well.

Clinical appropriateness review

Physicians ordering elective, outpatient diagnostic imaging exams for the members listed above will be asked to
obtain an order number from Carelon before scheduling the procedure. These services include:
ƒ Computed Tomography (CT/CTA)

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ƒ Magnetic Resonance Imaging (MRI/MRA)

ƒ Nuclear Cardiology
ƒ Positron Emission Tomography (PET)
ƒ Stress Echocardiography (SE)
ƒ Resting Transthoracic Echocardiography (TTE)
ƒ Transesophageal Echocardiography (TEE)

Imaging studies performed in conjunction with emergency room services, inpatient hospitalization, outpatient
surgery (hospitals and free standing surgery centers), urgent care centers, or 23-hour observations are excluded
from this requirement.

Physicians in your service area will find discover information about the program when checking benefits and
eligibility through BlueAdvantage. Messaging will instruct the physicians to contact Carelon to request or verify
an order number one of two ways:
ƒ Online through Carelon’s ProviderPortalSM at aimspecialtyhealth.com/goweb or
ƒ Via the toll-free telephone number displayed on the back of the member’s ID card, or direct to Carelon at
866-688-1449. The member also may call Carelon to initiate the process.

Provider transparency
To support national transparency efforts and through partnership with its Blue clients, we are leveraging the
NCCT cost values for Blue imaging providers. During the clinical review process, we will be sharing MRI and CT
costs with ordering providers in an effort to promote transparency and increase awareness.

Member engagement
Using the clinical appropriateness approval as the trigger, we also will be engaging members in their site of
service selection through the Specialty Care ShopperSM program. When a CT or MRI/MRA exam is scheduled, a
customer service specialist will proactively reach out to members to inform them of the imaging facility options
available to them. During this outreach, members will have an opportunity to maximize their health care benefits
by selecting an alternative imaging facility. Members will not be denied access to benefits if they decide to stay
with their existing facility. Our goal is simply to provide members with information to make informed choices
about their health care.

Submitting online request to Carelon

To submit a request for outpatient diagnostic imaging procedures online to Carelon, providers will
first need to create and register a username and password with ProviderPortalSM. To register, visit
aimspecialtyhealth.com/goweb and select “BCBS National Accounts” from the drop down menu under the
heading “To Register, simply select your health plan.” ProviderPortal is available twenty-four hours a day, seven
days a week. Go to providerportal.com to begin.

At the “Member Login” page, select “Register Now” from the right-hand side of the screen under the caption
“New User?” to complete the registration. The registration wizard will walk users through the process step by
step. For further assistance, providers can contact Carelon at 800-252-2021.

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Radiology Management Reference Guide

Prior Approval Fact Sheet
A prior approval program for outpatient diagnostic imaging procedures was implemented on February 1, 2006.
This correspondence serves as notice of change to the Utilization Review Programs under the Arkansas Blue
Cross and Blue Shield Preferred Payment Plan, Health Advantage, PPO Arkansas’ True Blue and Arkansas’
FirstSource provider agreements.

The following outpatient services require the new prior approval*:

ƒ CT Scan
ƒ Nuclear Cardiology
ƒ MRI/MRA
ƒ PET Scan
* A separate approval number is required for each procedure ordered.

ƒ Emergency room, observation department of a hospital, and inpatient imaging procedures do not require
prior approval.
ƒ These services will apply to all Arkansas Blue Cross and Blue Shield members, including those who access
the Arkansas’ FirstSource and True Blue PPO network, as well as Health Advantage members.
ƒ Customers of BlueAdvantage Administrators of Arkansas can elect to add this program on a group- by-group
basis, which would be indicated on the member’s ID card.
ƒ These radiology services do not apply to members of the Federal Employee Program (FEP) at this time.
ƒ The ordering physician is responsible for obtaining the prior approval number for the study requested.
Patient symptoms, past clinical history and prior treatment information will be requested and should be
available at the time of the call.
ƒ Call center hours of operation are Monday through Friday, 7 a.m. to 7 p.m. ·Providers may obtain prior
approval by calling Carelon at 877-642-0722. (Studies ordered after normal business hours or on weekends
should be conducted by the rendering facility as requested by the ordering physician. However, the ordering
physician must contact Carelon within five business days of the date of service and before the claim is
submitted to obtain proper approval for the studies, which will still be subject to review.)
ƒ Average calls are completed within five minutes. Peak call volume occurs between the hours of 1
p.m. to 6 p.m.
ƒ Approvals may be obtained on-line after the user is registered at: providerportal.com.
ƒ Carelon’s guidelines are located on their website at: providerportal.com. The guidelines are available in a
PDF format that may be printed for future reference.
ƒ Prior approval is not a guarantee of coverage. The radiology services are subject to the member’s eligibility
and benefit plan provisions.

Please note: Just because prior approval is obtained it does not mean coverage is guaranteed or even available
for the particular member or service involved. Coverage is always subject to the specific terms and conditions
of the member’s health plan or policy, which must be met when the claim is received and reviewed. Such terms
and conditions may include but are not limited to lifetime maximums, specific benefit limits or caps in some

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cases, out-of-network limitations, eligibility requirements such as the timely payment of premiums, and specific
health plan or policy exclusions. See the “Pre-Certification” section of your participating provider agreement.

The Prior Approval Implementation Recommendations for Ordering Physicians

and Participating Facilities
As a participating provider of diagnostic imaging services that require prior approval, it is essential that
providers develop a process to ensure the appropriate authorization number(s) is obtained. The following
recommendations are offered for review and consideration in developing a procedure that will be effective for
each facility. These recommendations are for informational purposes only.

Ordering Physician
It is the responsibility of the physician ordering the imaging examination to call Carelon for prior approval. A
separate approval number is required for each procedure ordered.

Emergency room, observation department of a hospital and inpatient imaging procedures do not require prior
approval. To expedite the approval process, please have the following information ready before calling the
Carelon Utilization Management staff (*Information is required):
ƒ Name and office telephone number of ordering physician*;
ƒ Member name and ID number*;
ƒ Requested examination*;
ƒ Name of provider office or facility where the service will be performed*;
ƒ Anticipated date of service (if known); and
ƒ Details justifying examination:*
ƒ Symptoms and their duration;
ƒ Physical exam findings;
ƒ Conservative treatment patient already has completed (for example: physical therapy, chiropractic or
osteopathic manipulation, hot pads, massage, ice packs, medications);
ƒ Preliminary procedures already completed (for example: X-rays, CTs, lab work, ultrasound, scoped
procedures, referrals to specialist, specialist evaluation); and
ƒ Reason the study is being requested (for example: further evaluation, rule out a disorder);

If requested, please be prepared to fax the following information: Clinical notes; X-ray reports; Previous CT/MRI
reports; Specialist reports/evaluation; and Ultrasound reports;

Participating Imaging Facilities

It is the responsibility of the ordering physician to ensure that prior approval is obtained. The rendering facility
should not schedule procedures without prior approval. For urgent tests, the rendering facility can begin the
process, and Carelon will follow up with the ordering physician to complete the process. Procedures performed
that have not been properly approved will not be reimbursed, and the member cannot be balance billed. A
separate authorization number is required for each procedure ordered.

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Emergency room, observation department of a hospital and inpatient imaging procedures do not require prior
approval. If an emergency clinical situation exists outside of a hospital emergency room, providers should
proceed with the examination and call Carelon the next business day at 877-642-0722 to proceed with the
normal review process.

To ensure that approval numbers have been obtained, the following recommendations should be considered:
ƒ Communicate to all personnel involved in outpatient scheduling that prior approval is required for the listed
procedures.
ƒ If a physician office calls to schedule a patient for a procedure requiring prior approval request the
approval number.
ƒ If the provider has not obtained prior approval, inform the provider of the requirement and advise them to
call Carelon at the toll-free number, 877-642-0722. Facilities may elect to institute a time period in which to
obtain the approval number (for example, one business day).
ƒ If a patient calls to schedule a procedure that requires prior approval and the patient does not have
the approval number, the patient should be directed back to the referring physician who ordered the
examination.

Frequently Asked Questions

The following are the most common questions with answers regarding the prior approval changes from Carelon.

Q.1. Is prior approval from Carelon required for all radiological procedures?
A.1. No. Only outpatient CT, MRI/MRA, PET and Nuclear Cardiology procedures require prior approval.

Q.2. Who is responsible for obtaining prior approval from Carelon?

A.2. The ordering physician is always responsible for obtaining approval from Carelon prior to scheduling
procedures.

Q.3. Are there situations that do not require prior approval from Carelon?
A.3. Yes, there are three situations that do not require prior approval from Carelon when billed with the
applicable location code:
ƒ When the procedure is ordered as part of emergency room services.
ƒ When the procedure is ordered as part of an observation bed stay.
ƒ When the procedure is ordered as part of an inpatient stay.

Q.4. Is prior approval required for an emergency situations?

A.4. No. Patients who are directed to the emergency room are exempt from prior approval. It is not necessary
for anyone to call Carelon retrospectively to authorize any imaging procedure performed during an
emergency room visit.

Q.5. How is Observation/Rapid Treatment handled?

A.5. Imaging services occurring in the Observation / Rapid Treatment area of a hospital do not require prior
approval nor do these services require the ordering physician to contact Carelon within the next business day
of rendering the service. These services are easily identifiable in the Companies’ claims systems and will be
paid without an approval from Carelon.

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Q.6. What information does the ordering physician need to expedite a prior approval call to Carelon?
A.6. To expedite the process, please have the following information ready before calling the Carelon
Utilization Management staff (*Information is required):
ƒ Name and office telephone number of ordering physician*;
ƒ Member name and ID number*;
ƒ Requested examination*;
ƒ Name of provider office or facility where the service will be performed*;
ƒ Anticipated date of service (if known);
ƒ Details justifying examination:*
ƒ Symptoms and their duration;
ƒ Physical exam findings;
ƒ Conservative treatment patient already has completed (for example: physical therapy, chiropractic or
osteopathic manipulation, hot pads, massage, ice packs, medications);
ƒ Preliminary procedures already completed (for example: X-rays, CT’s, lab work, ultrasound, scoped
procedures, referrals to specialist, specialist evaluation);
ƒ Reason the study is being requested (for example: further evaluation, rule out a disorder).

Q.7. What kind of response time can the ordering physicians expect for prior approval?
A.7. In many cases, especially when the caller requesting the review has sufficient clinical documentation,
authorization can be obtained during the first telephone call. In general, approximately 60-65 percent of the
requests will be approved during the initial telephone call. Generally, within two business days after receipt
of request, a determination will be made. In certain cases, the review process may take longer if additional
clinical information is required to make a determination.

Also, providers can perform authorization requests on line at providerportal.com.

Q.8. Can Carelon handle multiple authorization requests per telephone call?
A.8. Yes.

Q.9. What is the process for obtaining prior approval from Carelon for CT, MRI/MRA, PET or Nuclear
Cardiology procedures ordered outside of normal business hours?
A.9. The rendering facility should proceed with the study. The ordering physician should contact Carelon
within five business days from the date of service and before the claim is submitted and proceed with the
authorization process.

Q.10. What is the process for obtaining prior approval from Carelon for emergency procedures ordered at a
location other than a hospital emergency room?
A.10. The authorization process will be the same. Studies conducted outside an emergency room setting will
require prior approval.

Q.11. Do physicians have to obtain the prior approval before they call to schedule an appointment?
A.11. Yes. Physicians should obtain the prior approval before scheduling the patient.

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Q.12. Does Carelon ask for a date of service when authorizing a procedure?
A.12. At the end of the authorization process, the Carelon authorization representative asks where the
procedure is being performed and the anticipated date of service. The exact date of service is not required.

Q.13. How long is an approval number valid?

A.13. The authorization number is valid for 60 days. When a procedure is authorized, Carelon will use the date
of determination as the starting point for the 60-day period in which the examination must be completed.

Q.14. What if my office staff forgets to call Carelon and then goes ahead to schedule an imaging procedure
requiring prior approval?
A.14. It is important to notify office staff and educate them about this new policy. This policy is effective
January 1, 2019. Claims for CT, MRI/MRA, PET and Nuclear Cardiology procedures that are not prior
authorized will not be paid, and the members must be held harmless if the service is provided by a
participating provider.

Q.15. Can the participating rendering facility obtain approval in the event of an urgent test?
A.15. Yes, if they begin the process, Carelon will follow up with the ordering physician to complete
the process.

Q.16. Who will receive the prior approval number from Carelon?
A.16. On completion of the prior approval process, Carelon will notify the ordering physician of the
authorization status. If the ordering physician is able to provide sufficient clinical and demographic
information at the time of the initial call, a verbal authorization number will be issued. If the authorization
request requires additional review, Carelon will provide an authorization tracking number that will serve as a
means of tracking the status of the process. Once a final determination has been reached, Carelon will notify
the ordering physician of the decision verbally or in writing (fax or letter). If the ordering physician does not
complete the prior approval process, the status will be“transaction denied for prior approval noncompliance,
no member liability.”

Q.17. How can the Carelon approval number be identified?

A.17. The Carelon approval number consists of 11 alphanumeric characters (Example: NYYMMDD####).

Q.18. If two approval numbers are associated with the patient encounter, which one should be printed on
the claim?
A.18. Any of the two approval numbers should appear on the claim form. The authorization number not
entered on the claim form will be captured internally within the claims system.

Q.19. Which provider(s) are responsible for putting a prior approval number on the claim(s)?
A.19. The rendering facility and/or clinic and the provider who reads the test.

Q.20. Is an Carelon prior approval number needed for a CT-guided biopsy?

A.20. No.

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Q.21. Which PET scans require a prior approval?

A.21. All PET scans performed in physician offices or on an outpatient basis (non-ER or observation
departments) require prior approval by Carelon.

Q.22. What happens if a patient is prior approved for a CT of the abdomen, and the radiologist or rendering
physician feels an additional study of the pelvis is needed?
A.22. The radiologist or rendering physician should proceed with the pelvic study. If this occurs, the provider
should notify the patient’s ordering physician of the additional test the same day, as a matter of courtesy and
appropriate medical procedure. The original ordering physician should call Carelon after the study is provided
to proceed with the normal review process to get an additional authorization number.

Q.23. If a patient needs a CT in preparation for radiation therapy, is a prior approval necessary?
A.23. No.

Q.24. After receiving a prior approval from Carelon, can the ordering physician change the planned
procedure, the servicing facility, or the date of the procedure?
A.24. Yes, but the Carelon Call Center must be contacted if the planned procedure or the servicing provider
changes. The date of the procedure can take place on any date within the 60 days that the approval number is
valid. If the date of service is rescheduled beyond the 60 days, the Carelon Call Center must be contacted.

Q.25. Is a prior approval necessary when Arkansas Blue Cross, Health Advantage or BlueAdvantage (if
applicable) is not the member’s primary insurance?
A.25. Yes.

Q.26. How are procedures that do not require an Carelon prior approval handled?
A.26. These procedures should be handled as they are today.

Q.27. Can I speak directly with a clinical reviewer or physician (peer-to-peer) level reviewer?
A.27. Once the initial intake process is complete, you may request to be transferred to the clinical level of
review. Initial intake information is necessary to determine member eligibility and to process the request.

Q.28. What steps will the ordering provider take when the approval is not given during the initial intake
process (level 1)?
A.28. The case will be forwarded to Carelon’s clinical departments who will review the clinical information
submitted. If needed, the clinical staff will request via fax, additional clinical information. This information
can be faxed to Carelon’s dedicated clinical fax line. An ordering office might request a hot transfer to a nurse
clinical review (level 2) during the initial request, however, this should only be requested if the office has a
clinician who can speak with the Carelon nurses and who have additional clinical information that would
support the requested study.

Q.29. If Carelon denies the prior approval of an imaging study, does a provider have the option to appeal
the decision?
A.29. Yes, through normal appeal procedures as directed in the denial letter. If Carelon makes the decision to
deny the request at the end of the telephone call, and the physician does not agree with the decision made by
Carelon, the physician should request an appeal of the decision from Carelon.

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Q.30. Is there a way to bypass the Carelon recorded announcement?

A.30. When dialing into the toll-free number, callers will hear a seven-second system greeting that identifies
the Carelon Imaging Approval Service. The short announcement will instruct callers to press option one to
initiate a new request for authorization on an imaging exam or option two for the status of a case that was
previously called in for approval. The announcement also will provide information that emergency procedures
do not require a prior approval. The entire greeting may be bypassed by immediately pressing the desired
option whenever the announcement starts.

Q.31. If Carelon approves prior approval of an imaging study, does this guarantee payment of the claim?
A.31. No. A prior approval does not guarantee payment or ensure coverage; it means only that the
information furnished to Carelon at the time indicates that the imaging study that is the subject of the prior
approval meets the Primary Coverage Criteria. A claim receiving prior approval must still meet all other
coverage terms, conditions, and limitations. Coverage for any such prior authorized claim may still be limited
or denied if, when the claimed imaging study is completed and Arkansas Blue Cross, BlueAdvantage, and
Health Advantage receives the post service claim(s), investigation shows that a benefit exclusion or limitation
applies, that the Covered Person ceased to be eligible for benefits on the date imaging study services were
provided, that coverage lapsed for non-payment of premium, that out-of-network limitations apply, or any
other basis specified in the patient’s health plan applies to limit or exclude payment of the claim.

Q.32. What is the toll-free telephone number and hours of operation for the Carelon Call Center?
A.32. Providers can reach the Carelon Call Center by calling the toll-free number 877-642-0722, Monday
through Friday, from 7 a.m. to 7 p.m.

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Utilization Determination Timeframes

Type Time Frame

In Patient Out Patient

Prospective/Urgent 24 hours 24 hours

Prospective/NonUrgent 24 hours 2 business days /10 days ACT 815

Concurrent Review 48 hours

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Peer to Peer and Appeals

A written or verbal request for appeal may be requested by a physician, facility, provider or patient contesting an
organizational determination of an adverse benefit determination and requesting a review for correctness.

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Claims Received Without Prior Approval

Failure to submit a pre-service claim for Prior Approval will result in a denial of coverage.

Note: Prior Approval does not guarantee payment or assure coverage. It means only that the information
furnished to the Company at the time indicates that the services meets the Primary Coverage Criteria
requirements and is not subject to a Specific Plan Exclusion. All services receiving Prior Approval must still
meet all other coverage terms, conditions and limitations, and coverage for these services may still be limited
or denied, if, when the claims for the services are received, investigation shows that a benefit exclusion or
limitation applies because of a difference in the Health Interventions described in the pre- service claim and the
actual Health Intervention, that the Covered Person ceased to be eligible for benefits on the date the services
were provided, that coverage lapsed for non-payment of premium, that out-of- network limitations apply, or any
other basis specified in the members policy.

Contact the network development representative for questions or call customer service at the number on the
back of the member’s ID card.

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Enhancement for Prior Approval Submissions

Effective August 24, 2020, prior approval requests initiated through the provider portal located on the Availity
site now provides for the submission of clinical documentation. This applies to Arkansas Blue Cross and Blue
Shield, Blue Advantage and Health Advantage. It does not apply to the Federal Employees Plan (FEP).

This enhancement feature allows uploading of the supporting clinical documentation for the prior approval
request. Accepted document types include Word, PDF, JPEG and PNG files. The allowed file size is 10 MB or less.

Files over the file limit must be faxed to Arkansas Blue Cross and Blue Shield or the applicable company. These
files should include the episode number associated with the request and full member’s name on the included
cover sheet. For medical inpatient PA requests, please fax to 501-210-7032. For outpatient service requests,
please fax to 501-378-6647.

You will continue to receive a Request for Information letter upon your submission. This is a bar coded letter to
be used should you prefer to continue faxing in your clinical documentation supporting your request. This bar
coded letter can also be used for those files over the file limit.

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Miscellaneous
Section 27 | Miscellaneous

Advanced Practice Registered Nurses - Certified Nurse Midwives,

Clinical Nurse Specialists and Certified Nurse Practitioners
Effective October 1, 2005, Arkansas Blue Cross expanded its covered services for Advanced Practice Registered
Nurses. Advanced Practice Registered Nurses (APRNs) are registered nurses with the advanced education and
clinical competency necessary for the delivery of primary health and medical care.

Reimbursement for Advanced Practice Registered Nurses (APRN’s), which includes Certified Nurse Practitioners
(CNP), Clinical Nurse Specialists (CNS) and Certified Nurse Midwives (CNMs), is limited to APRN’s who are
licensed in the state of Arkansas and have met the requirements for and possess a certificate of prescriptive
authority. The APRN must work in collaboration with the physician to deliver health care services within the
scope of the practitioner’s professional expertise, with medical direction and appropriate supervision.

APRN’s providing services for Arkansas Blue Cross members must comply with the following policy to qualify
for reimbursement:
ƒ In the absence of a Certificate of Full Independent Practice, the APRN must have a written and signed
collaborative agreement and quality assurance plan with a supervising medical doctor (MD) or doctor of
osteopathy (DO). A copy of the agreement must be provided to Arkansas Blue Cross and Blue Shield.
ƒ The APRN must have licensure and be in good standing with Arkansas State Board of Nursing, as well as
with all Arkansas Blue Cross and Blue Shield and any networks of its affiliates.
ƒ The APRN must have prescriptive authority.
ƒ The APRN adheres to the collaborative responsibilities by participating as a team member in the provision of
medical and health care, interacting with physicians to provide comprehensive care according to established
and documented protocols.
ƒ Physicians may continue to bill for appropriate APRN services as “incident to” but cannot bill for services
already submitted under the APRN’s NPI. “Incident to” requires direct supervision of the physician.
ƒ APRN services submitted by the supervising physician will be paid at the physician level to the physician.
ƒ Current published guidelines for assigning CPT codes to services and documentation to support the
“medical necessity” of all services must be met.
ƒ Services performed in an inpatient/acute facility will not be paid.
ƒ The APRN may order diagnostic laboratory and x-ray studies that are medically indicated for the level of
service as indicated above in accordance with established and documented protocols.
ƒ The service provided by the APRN must be concordant with the specialty of the supervising physician.
ƒ Physicians may continue to bill for appropriate APRN services as “incident to” but cannot bill for services
already submitted under APRN’s provider number. “Incident to” requires direct supervision of the physician.
ƒ The APRN must present him/herself so the public and other payers are fully aware of the practitioner’s
business operations. This includes items such as signage, letterhead and other marketing elements.
Practitioner cannot be a network participant if services being provided are eligible to be billed by a facility,
institution or other medical entity.
ƒ The APRN must have professional liability coverage as required per network participation agreement ($1
million/ $3 million).
ƒ The APRN must meet all other contractual requirements.

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Physicians wishing to bill for services provided by an APRN to Arkansas Blue Cross members should send
copies of the APRN’s collaborative agreement and quality assurance plan to:

Arkansas Blue Cross and Blue Shield Division of Medical Management

P.O. Box 2181
Little Rock, Arkansas 72201

Emergency Room Evaluation and Management and Assistant Surgery Services

The coverage of lower level Emergency Room Evaluation and Management Services and Assistant at Surgery
Services have been added to the list of payable services provided by Advanced Practice Registered Nurses
effective for dates of service July 1, 2007 or after.

Low level Emergency Room Evaluation and Management codes:

ƒ The normal scenario will be:
ƒ A physician or physician group is employed by the hospital to staff the emergency room;
ƒ The Advanced Practice Registered Nurse is employed by the physician / physician group / hospital and has
a collaborative agreement with the emergency room physicians.
ƒ Payable services are limited to less complex encounters normally provided by a physician;
ƒ Triage services are not covered as triage services are included in the facility payment;
ƒ If the patient is transferred to an emergency room physician, only the emergency room physician may bill for
the ER visit;

Assistant at surgery services:

ƒ Must be billed under the APN/CNS/CMN provider number with modifier AS in the first modifier position.
ƒ Limited to procedures approved for assistant at surgery coverage.

Copayment changes for Advanced Practice Registered Nurses

Arkansas Blue Cross and Blue Shield will begin applying primary care copayments during claims adjudication
for certain Advance Practice Registered Nurses (APRN). APRNs must work in collaboration with a physician to
deliver health care services within the scope of the practitioner’s professional expertise, with medical direction
and appropriate supervision. APRNs must also have a written collaborative practice agreement and quality
assurance plan with a physician.

The distinction between primary care benefits versus specialist benefits will be based on the specialty of the
collaborating physician. For example, if the written collaborative practice agreement that has been supplied to
Arkansas Blue Cross by the APRN during the network enrollment process is signed by a primary care physician,
then that APRN will be considered a primary care APRN for benefit application/claims adjudication purposes.
In most cases, Family Medicine, General Practice, Internal Medicine, and Pediatric Medicine will be considered
primary care.

The copayment change was effective on April 1, 2008 for Arkansas Blue Cross.

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Keep in mind that not all benefit plans make the distinction between primary care services and specialist
services and that self-funded employer health plans have the option to implement or reject this benefit.

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Allergy Injections
Provided all the terms and conditions of coverage are met (including, but not limited to, the Primary Coverage
Criteria), Allergy injections/services are covered in physician’s office, as well as, in an allergist’s office. The
serum for the injection is covered under all Arkansas Blue Cross and Blue Shield plans. Please contact Customer
Service for more specific coverage and reimbursement information.

Please note that Arkansas Blue Cross does not give oral assurance of coverage prior to claims being filed and
received. All coverage is always subject to final claim investigation upon receipt of the claim and all related
information needed to evaluate the claim for whether it meets coverage criteria under the applicable member
health plan or contract.

Coverage for RAST testing requires a documentation and prior approval of coverage by Arkansas Blue Cross.

Up to ten screening RAST tests are covered only for the evaluation of rhinitis, extrinsic asthma, extrinsic allergic
alveolitis, pulmonary eosinophilia, atopic dermatitis, urticaria, anaphylactic shock due to adverse food reactions,
venom or serum. Even then, they are covered only when certain conditions prevent the performance, or
adversely affect the interpretation, of skin tests. Those conditions are:
ƒ Erratic wheezing;
ƒ Hyperreactive skin;
ƒ Urticaria;
ƒ Dermatographism;
ƒ Severe eczema;
ƒ Food anaphylaxis;
ƒ Allergy to latex;
ƒ Patient refuses skin testing;
ƒ Patient taking pharmacological drugs that interfere with the interpretation of skin tests and the drugs cannot
be discontinued (ie, antihistamines, tricyclic antidepressants or beta blockers).

Medical record documentation must state which of the above conditions precludes skin testing.

If the above conditions are present, up to 10 screening RAST tests will be covered. If one or more of these is
unequivocally positive, up to 30 more RAST tests may be covered. A copy of the positive screening RAST test is
normally the only documentation needed with the claim for coverage of the additional 30 RAST tests.

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Allergen immunotherapy - provision of antigens

Arkansas Blue Cross and Blue Shield uses the Centers for Medicare & Medicaid Services (CMS) Relative Value
Units (RVU) to calculate physician fee schedule amounts. The physician fee schedule allowance for CPT code
95165 is $16.06. CMS regulations indicate that:

“…a physician may not bill this vial preparation code for more than 10 doses per vial; paying more than
10 doses per multi-dose vial would significantly overpay the practice expense component attributable to
this service.”

Arkansas Blue Cross is adopting this CMS rule. Providers should limit billing of CPT code 95165 to 10 units per
multi- dose vial, even if providers actually obtain 30 units from the vial.

CPT code 95165 will be subject to medical review. In the event CPT code 95165 is used, medical records will
be ordered. Providers’ office records should document the number of doses per vial and the number of vials
prepared for each member.

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Durable Medical Equipment, Prosthesis and Orthotic Appliances and

Medical Supplies
Coverage for Durable Medical Equipment (DME), Prosthesis, Orthotics and medical supplies will vary for
Arkansas Blue Cross and Blue Shield members, depending upon the benefit plan, and is subject to Medicare
coverage guidelines. All covered services must meet the Primary Coverage Criteria and be obtained through a
participating Provider listed in the current Arkansas Blue Cross and Blue Shield Provider Directory or web site,
unless the member has out of network benefits. Each member’s plan may have different items that require prior
approval of coverage and may also have a annual limitation. Always contact customer service to access this
information.

Any Provider may obtain information about Member benefit coverage by calling the Customer Service
Department. Please note that Arkansas Blue Cross does not give oral assurance of coverage prior to claims
being filed and received. All coverage is always subject to final claim investigation upon receipt of the claim and
all related information needed to evaluate the claim for whether it meets coverage criteria under the applicable
member health plan or contract.

When it is more cost effective, Arkansas Blue Cross (at its discretion) will purchase rather than lease equipment
for Members. Please Note: Arkansas Blue Cross and Blue Shield will not, in any case, be responsible to pay any
lease or rental payments in excess of the purchase price of the applicable equipment.

Coverage for DME and prosthetic devices is limited to initial acquisition and replacement or repair when Primary
Coverage Criteria is met. Most Arkansas Blue Cross plans have a $5,000 calendar year limit on all DME. Check
with customer service to see it the member receiving equipment to has such a plan. It is the DME or Prosthetic
provider’s responsibility to assist in the coordination of the overall provision of health care services to Arkansas
Blue Cross and Blue Shield members. This responsibility will involve the need to communicate with the
member’s attending physician, as well as, other providers of care, such as home health agencies, home infusion
providers, or hospitals.

Reimbursement will be according to the current Participating Provider contract. Any supplies considered by
Arkansas Blue Cross and Blue Shield to be part of the medical service being provided will not be reimbursed
separately.

Rentals of Durable Medical Equipment (DME) should be billed using the beginning date of rental (not a date
range), units of service of 1, and the Modifier RR.
ƒ Ten monthly rental payments of DME equipment will be considered the same as a purchase of the
equipment. Additional DME billings for rental and/or purchase of the item will be denied as duplicate billings.
ƒ Low cost DME items will require purchase rather than rental.
ƒ Satisfaction of the Primary Coverage Criteria is required for high cost DME items.
ƒ Purchase of covered home supplies will be limited to a 90-day supply. The Medicare limitations will be used
as a guide.

Excluded from coverage are:

ƒ Personal comfort items,
ƒ Hygiene items,

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ƒ All over the counter items,

ƒ Disposable items, or
ƒ Any equipment, devices, and supplies that are not primarily intended for medical use, are not covered.

Oxygen and Supplies

Arkansas Blue Cross and Blue Shield and its family of companies would like to remind providers that oxygen
reimbursement is a bundled payment. All options, supplies, and accessories are considered included in the
monthly rental payment for oxygen equipment. Separately billed options, accessories or supply items will be
denied as unbundling.

Oxygen accessories, including but not limited to trans-tracheal catheters (A4608), cannulas (A4615), tubing
(A4616), mouthpieces (A4617), face tent (A4619), masks (A4620, A7525), oxygen conserving devices (A9900),
oxygen tent (E0455), humidifiers (E0555), nebulizer for humidification (E0580), regulators (E1353), and stand/rack
(E1355) are included in the allowance for rented oxygen equipment. The supplier must provide any accessory
ordered by the physician. Accessories used with beneficiary-owned oxygen equipment will be denied as
non-covered.

Oxygen billing codes:

E1390 and E1392 includes the oxygen concentrator, an integrated battery or beneficiary- replaceable
batteries that are capable of providing at least two hours of remote portability at a minimum of 2 LPM
equivalency, a battery charger, an AC power adapter, a DC power adapter, and a carrying bag and/or cart.
(Rental reimbursement for concentrators will be paid for up to 36 months with a maintenance period the
following 24months)

When code K0738 is billed, code E0431 (portable gaseous oxygen system, rental) must not be used. When code
E0433 is billed, code E0434 (portable liquid oxygen system, rental) must not be used.

E1352 is an all-inclusive code consisting of a control unit, flow regulator, connecting hose, and nasal interface
(pillows). For questions or more information, please email providerreimbursement@arkbluecross.com.

Ventilators and Supplies

Arkansas Blue Cross and Blue Shield and its family of companies would like to remind providers that ventilator
reimbursement is a bundled payment. All options, supplies, and accessories are considered included in the
monthly rental payment for ventilation equipment. Separately billed options, accessories or supply items will be
denied as unbundling.

Reimbursement for ventilators is based on patients meeting the necessary clinical criteria.

Ventilator billing codes:

E0465 - Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

E0466 - Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)

For questions or more information, please email providerreimbursement@arkbluecross.com.

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Hearing Aid Billing

Providers always should bill the monaural code (one ear) that applies to the type of hearing aid they are
supplying and bill each ear separately. Providers should use Modifiers LT and/or RT on each line, whatever is
applicable. One unit of service should be used per claim line. Providers should not submit a claim for a hearing
aid until the aid has been placed in the member’s ear — not when the order for the hearing aid is placed.

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Imaging centers
CT dual auto injector equipment
In the September 2014 issue of Providers’ News, Arkansas Blue Cross and Blue Shield and its affiliates, PPO
Arkansas and Health Advantage published updated assessment criteria which applies to all participating
imaging centers that was effective January 1, 2015. Included in the update was a specific requirement for
imaging centers performing CT, CTA and CCTA which outlines the required utilization of dual auto injector
equipment for contrast enhanced studies.

The rationale for requiring dual-syringe power injectors for CTs is to minimize the pooling of contrast in the
injected extremity. This pooling reduces the effective contrast dose to the target organ being imaged while at
the same time exposing the patient to as much as 30 percent unnecessary or non-imaged contrast dose.

As a reminder, Arkansas Blue Cross and its affiliates require all participating imaging centers to have dual-
auto injector equipment in place and operational when performing any CT modality which includes CT, CTA
and/or CCTA.

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Section 27 | Miscellaneous

Laboratory Services
Physicians need to ensure that contracted reference laboratories are used if specimens are sent outside of a
clinic. Arkansas Blue Cross and Blue Shield and all other affiliated companies are receiving claims from labs
that are not contracted. It is a contractual obligation that all contracted providers use other contracted providers
when making referrals or using outside services.

In addition, Arkansas Blue Cross is receiving claims from out-of-state laboratories that are not contracted. The
Blue Cross and Blue Shield Association claims-filing rules require that specimens collected within a Blue Plan’s
service area be filed directly to that local Blue Plan. Therefore, all specimens collected in Arkansas for all Blue
Cross and affiliated companies’ members, must be filed directly to Arkansas Blue Cross or its affiliates and
subsidiaries. Claims for specimens collected in Arkansas should not be filed directly to another Blue Plan.

Ameritox, Berkeley, Genzyme, Myriad and Prometheus Labs are not contracted with Arkansas Blue Cross nor its
local affiliates and subsidiaries.

If a provider needs a higher-level lab service, one that the provider does not believe can be processed within
Arkansas, please first consult with some of the national labs with whom we have provider agreements. Some of
them own other companies that likely may accommodate your service and are contracted with Arkansas Blue
Cross and its family of companies. Please also check our Web sites to ensure that the service being ordered is
covered by meeting our primary coverage criteria.

Payment for claims from out-of-network lab providers, both in state and out of state, may be denied, or at a
minimum, the member will pay a higher portion.

Effective April 1, 2018, Arkansas Blue Cross and its family of companies require the referring provider on all
professional service claims. Any outpatient claim submitted with a laboratory service must contain the referring
provider name and NPI. The referring provider will need to be a provider registered/enrolled in the provider
database of Arkansas Blue Cross or its family of companies. Listing a referring provider who is not registered
with Arkansas Blue Cross will result in claim rejection or denial.

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Do not use out-of-network laboratories

Arkansas Blue Cross and Blue Shield and its affiliates have recently noticed an increase in the utilization of non-
participating laboratory vendors and the performance of novel “cardiovascular risk” panels at an out- of-network
laboratory. These panels include assays which are not covered benefits under the terms of the members’ health
plans or policies.

Many of the claims for novel “cardiovascular risk” panel at an out-of-network laboratory are being submitted
to one out-of-network vendor, Health Diagnostic Laboratory (HDL). As a reminder, using HDL or other out-of-
network laboratory service providers could result in termination of your network participation agreements with
Arkansas Blue Cross and its affiliates, PPO Arkansas (True Blue and Arkansas’ FirstSource® PPO networks) and
Health Advantage (Health Advantage HMO network).

Referral to out-of-network providers—including labs—constitutes a breach of the network participation

agreement except where referral is unavoidable due to an emergency or if a covered service is not available in-
network. Referral to out-of-network providers is not just a business or contract concern of Arkansas Blue Cross
and its affiliates but these violations have adverse financial consequences for members as well if members are
subjected to “balance billing” in excess of the in-network allowance.

Please be aware that if a provider’s network participation agreements are terminated due to breach, including a
breach due to out-of-network lab referrals, then the provider will not be eligible or considered for re-admission
to the networks for three years.

Most out-of-state labs are NOT in the Arkansas Blue Cross or its affiliate’s networks. Claims for specimens
collected in Arkansas cannot be submitted through other Blues Plans via the BlueCard system. The claim must
be filed with a participating Arkansas Blue Cross provider. Other labs that are not in network for Arkansas Blue
Cross or its affiliates include Ameritox, Aegis Sciences Corp, Ambry Genetics, Clarient Diagnostics, Genomics
Health, GenPath, Health Diagnostics Lab, Medical Diagnostic Lab (MDL), PerkinElmer Labs, Sequenom, Veracyte
and Verinata.

For a list of current in network laboratory service providers, visit the Arkansas Blue Cross website at
arkbuecross.com.

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Outpatient Hospital and Ambulatory Surgery Center (ASC) Surgery

Payments
Primary Surgical Procedure
ƒ Reimbursed at 100% of the Arkansas Blue Cross and Blue Shield Outpatient or ASC Surgery Fee
Schedule allowance (correlates to highest APC weight and reflected by the Fee Schedule as the highest
allowance amount)

Additional Surgical Procedure

ƒ Reimbursed at 50% of the Arkansas Blue Cross and Blue Shield Outpatient or ASC Surgery Fee
Schedule allowance

These amounts are reduced by any contractual agreements.

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Section 27 | Miscellaneous

“Never Events” Policy Reminders

“Never Events” are adverse events or errors in medical care that are clearly identifiable, preventable and serious
in their consequences for patients. Identifying and addressing adverse medical events and “Never Events” has
gained more attention throughout the healthcare industry. Industry drivers include the following:
ƒ The National Quality Forum (NQF) has identified a list of 28 “Never Events” that is gaining interest from
various constituencies focused on health-care quality, including health plan organizations, employers and
state hospital organizations.
ƒ Since October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) no longer pays the extra cost
of treating the 12 Hospital Acquired Conditions (HACs) that occur while the patient is in the hospital.
ƒ CMS requires that most hospitals use a Present on Admission (POA) indicator on claims to indicate if the
patient’s specific condition was present when the patient was admitted to the hospital or if it was acquired
during the inpatient stay (e.g., infection or ulcers). In addition, CMS requires all Medicare Advantage plans to
report “Never Events” and claims with the POA indicator.
ƒ The National Business Group on Health, which represents 300 large employers, supports the reporting of
medical errors and continues to apply pressure to all payers for solutions.

As of October 1, 2008, Medicare defined HACs are considered “Never Events” as they relate to this policy.
HACs include:
ƒ Pressure ulcers, Stages III and IV,
ƒ Catheter-associated urinary tract infections,
ƒ Vascular catheter-associated infection,
ƒ Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG),
ƒ Air embolism,
ƒ Blood incompatibility,
ƒ Foreign object retained after surgery,
ƒ Falls and trauma (fracture, dislocation, intracranial injury, crushing injury, burn, electric shock),
ƒ Surgical-site infections following certain orthopedic procedures,
ƒ Surgical-site infections following bariatric surgery for obesity,
ƒ Manifestations of poor glycemic control, and
ƒ Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures.

In addition, “Never Events” include:

ƒ Surgery performed on a wrong body part,
ƒ Surgery performed on a wrong patient, and
ƒ Wrong surgical procedure performed.

The Arkansas Blue Cross “Never Event” policy, effective since January 1, 2010, states:
ƒ All acute care hospitals participating in the Arkansas Blue Cross, USAble Corporation and Health Advantage
provider networks must populate the POA indicator on all acute care inpatient hospital claims for all “Never
Events,” as applicable. Valid POA values include:
ƒ Y = Yes

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ƒ N = No
ƒ U = Unknown/No information in the record
ƒ W = Clinically undetermined
ƒ 1 = exempt from reporting on 837 claim
ƒ Blank = exempt from reporting on paper claim
ƒ This policy applies to all acute care hospitals including critical access hospitals and specialty hospitals.
ƒ All participating acute care inpatient hospitals will not receive or retain reimbursement for inpatient services
related to “Never Events.”
ƒ All participating acute care inpatient hospitals will not bill members (hold harmless) for any inpatient
services related to “Never Events.”

All HACs should be billed normally using the correct diagnosis codes and will be accommodated through
POA indicators. All appropriate E codes should be billed for “Never Events.” All inpatient hospital claims
will be passed through the Arkansas Blue Cross internal DRG grouper. Hospitals will NOT receive a higher
reimbursement rate due to “Never Events” and members will not be responsible for higher deductible,
copayments or coinsurance amounts resulting from “Never Events.”

Arkansas Blue Cross, Health Advantage and PPO Arkansas will not reimburse hospitals, ambulatory surgery
centers or other outpatient settings for surgery performed on a wrong body part, surgery performed on a wrong
patient or the wrong surgical procedure performed. This includes all services related to these “Never Events.”
ƒ All services provided in the operating room or applicable surgical setting when the error occurs are
considered related. These services will not be reimbursed nor will members be liable for their charges.
ƒ All providers in the operating room or applicable surgical setting when the error occurs, who could bill
individually for their services, are not eligible for payment nor will members be liable for their charges.
ƒ All related services provided during the same hospitalization or outpatient setting in which the error
occurred will not be reimbursed nor will members be liable for their charges.
ƒ Providers should note that related services do not include performance of the correct procedure.

“Never Events” discovered through any and all avenues such as post pay audits and customer service calls are
subject to this policy.

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Section 27 | Miscellaneous

Physical Therapy, Occupational Therapy, and Speech Therapy

As a reminder, Arkansas Blue Cross and Blue Shield evaluates all physical and occupational therapy, whether
provided by an independent therapist or by a therapist employed in a physician’s office, to determine where
such services meet Primary Coverage Criteria.

The treatment must significantly improve the condition of the member being treated in a reasonable period of
time, pursuant to nationally established guidelines, not to exceed 60 days of progress without prior approval of
coverage, and periodic assessment reports approved by Arkansas Blue Cross. All services must be furnished
in accordance with a written treatment plan established and certified by the treating physician. Services that
exceed those guidelines are not covered. Any service that exceeds the established guidelines will be reviewed
on an individual basis.

Most Arkansas Blue Cross benefit certificates limit speech therapy to $500 of eligible charges and/or 45 visits per
calendar year.

Coverage of physical or occupational therapy is provided under the member’s certificate up to 45 visits per
year when Primary Coverage limitations are met. The therapy visits are counted in an aggregate fashion.
Maintenance therapy is an exclusion under the member’s certificate. Speech therapy, for all members, is limited
to $500 per calendar year and/or 45 visits.

For Terms and Conditions required to obtain a provider agreement, select the following link:
Network Terms and Conditions.

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Payment reduction for multiple therapy services performed on the

same day
The Centers for Medicare & Medicaid Services (CMS) completed an in-depth analysis of the practice expense
of providing physical therapy, occupational therapy, and speech therapy services. Their analysis found that the
practice expense of providing two or more modalities on the same day is less than the practice expense cost
as reflected by the practice expense RVUs. Arkansas Blue Cross and Blue Shield uses Medicare/CMS RVUs in
calculating payment for physical therapy, occupational therapy, and speech therapy services.

As a reminder, on October 13, 2013, Arkansas Blue Cross, BlueAdvantage Administrators of Arkansas, and Health
Advantage began following the Medicare policy of reducing payment for the second and subsequent therapy
services when multiple therapy procedures are performed on the same day. On April 1, 2013, Medicare reduced
the payment by 50% of the practice expense payment for the second and subsequent modalities.

Arkansas Blue Cross, BlueAdvantage, and Health Advantage will reduce the second and subsequent therapy
procedures by 20% of the practice expense portion of the procedure, whether provided in a facility setting or
a non-facility setting. When these services are provided on multiple days, each line item on the claim for the
modality must be for one day only. Date spans for these procedures will not be accepted. For the most up to
date file of multiple procedure payment reductions, please refer to cms.gov to view the list available under the
Physician Fee Schedule information.

Physical therapy assistants & physical therapy aides

Physical therapy assistants and physical therapy aides are not recognized as providers under the Arkansas
Blue Cross and Blue Shield member benefit contract. Physical therapy codes describing one-on-one contact
or constant attendance are covered only when performed by a registered physical therapist or physician.
Reimbursement for physical therapy codes that do not require one-on-one contact or constant attendance may
be made when services are provided by an assistant working under the supervision of a registered physical
therapist or physician. Physical therapy aides are not a covered provider, even when working under the
supervision of a physical therapist.

Arkansas Blue Cross and Blue Shield and Health Advantage member benefit certificates do not recognize
physical therapy assistants as “providers” as defined in their certificates. However, Arkansas Blue Cross and
Health Advantage have determined that for members covered under certificates insured or underwritten by
Arkansas Blue Cross or Health Advantage, the services of physical therapy assistants may be covered if all the
following conditions are met:
ƒ Services provided by physical therapy assistants must fall within the scope and definition of covered
services under the written terms of the member’s benefit certificate;
ƒ Services provided by physical therapy assistants must not fall within the scope or definition of any exclusion
in the member’s benefit certificate (other than the definition of “provider”);
ƒ All services provided by physical therapy assistants must be supervised by a licensed physical therapist;
ƒ Physical therapy assistants must hold an active and unrestricted license to perform physical therapy
assistant services, in full compliance with applicable state laws and regulations;
ƒ The supervising licensed physical therapist (or hospital employing the supervising licensed physical
therapist) must bill for services provided by physical therapy assistants. Physical therapy assistants may not
bill separately or directly for any physical therapy assistant services;

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ƒ Services provided by physical therapy assistants will not be covered or paid by Arkansas Blue Cross
or Health Advantage for their insured or underwritten members if services include any evaluation or
assessment services1 or if services include the physical therapy assistants making clinical judgments or
decisions regarding the member’s care or treatment;
ƒ Services provided by physical therapy assistants will not be covered or paid by Arkansas Blue Cross or
Health Advantage for their insured or underwritten members if the services include the development,
management or furnishing of any skilled maintenance program services1 or if the services include the
physical therapy assistants taking or asserting overall responsibility for services;
ƒ Services provided by physical therapy assistants will not be covered or paid by Arkansas Blue Cross or
Health Advantage for their insured or underwritten members if the services are not supervised at the
level appropriate to the particular setting involved, meaning that (a) at least general supervision2 by a
licensed physical therapist is always required and (b) direct supervision3 by a licensed physical therapist is
required for any physical therapy assistants services administered outside of a hospital inpatient or hospital
outpatient setting.

Special note with respect to self-funded health plans: The preceding standards may or may not apply where self-
funded health benefit plan members served by Arkansas Blue Cross, BlueAdvantage Administrators of Arkansas,
or Health Advantage are concerned. While some self-funded health benefit plans may choose to adopt the same
approach as outlined above, others may choose to continue excluding coverage for physical therapy assistants
altogether. As with all services to self-funded plan members, providers (and members) must check the terms
of the specific, applicable self-funded health benefit plan’s Summary Plan Description in order to determine the
specific coverage criteria of the self- funded plan with respect to physical therapy assistants or their services.

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Section 27 | Miscellaneous

Physician Assistants
Physician Assistants (PAs) are licensed practitioners with the advanced education and clinical competency
necessary for the delivery of primary health and medical care. Physician Assistants (PAs) must possess a
certificate of prescriptive authority. The PA must work in collaboration with the physician to deliver health care
services with medical direction and appropriate supervision.

PA’s providing services to Arkansas Blue Cross and Blue Shield members must comply with the following policy
to qualify for reimbursement:
ƒ The PA must have a written and signed collaborative agreement with a supervising medical doctor (MD) or
doctor of osteopathy (DO). The collaborative agreement must be with a physician whose specialty mirrors
the practice of the PA (e.g., if the PA is practicing primary care medicine, the collaborative agreement must
be with a Family Medicine physician or General Internist). A copy of the agreement must be provided to
Arkansas Blue Cross upon request.
ƒ The PA adheres to collaborative responsibilities by participating as a team member in the provision of
medical and health care, interacting with physicians to provide comprehensive care according to established
and documented protocols.
ƒ Services provided by PA’s are limited to those patients presenting problems of low to moderate severity and
the medical decision making involved does not exceed that same level. Patients with more severe problems
must be referred to physicians.
ƒ Current published guidelines for assigning CPT codes to services and documentation to support the
“medical necessity” of all services must be met.
ƒ Services, performed in an inpatient/acute facility, are not covered, with the exception of assistant at surgery
services provided when the collaborative physician is present.
ƒ PA’s may order diagnostic laboratory and x-ray studies that are medically indicated for the level of service as
indicated above in accordance with established and documented protocols.
ƒ The service provided by the PA must be concordant with the specialty of the supervising physician.
ƒ The PA must present him/herself so the public and other payers are fully aware of the practitioner’s business
operations. This includes items such as signage, letterhead and other marketing elements.

The following billing instructions apply to PAs licensed in Arkansas:

ƒ No payments may be made directly to the PA based on the Arkansas State Medical Board Arkansas Medical
Practices Acts & Regulations.
ƒ The line item or rendering provider is listed in Block 24J on paper claims and in Loop 2310B, segment NM108
(NPI qualifier) and segment NM109 (NPI number) on electronic claims.
ƒ The billing/pay to provider is listed in Block 33A on paper claims and in Loop 2010AA (Billing) and in loop
2010AB (Pay To) for electronic claims.
ƒ Services provided in the provider’s office and the collaborative physician is present in the office suite:
ƒ Services provided may be billed by the PA or by the collaborative physician (similar to Medicare’s “incident
to” guidelines).
ƒ The collaborative physician’s NPI should be used as the line item provider number on CMS 1500 and 837P.
ƒ Services provided in the provider’s office and the collaborative physician is NOT present in the office suite:

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ƒ Services should be billed by the provider of service.

ƒ The PA NPI should be used as the line item provider number on CMS 1500 and 837P.
ƒ Services provided in the Emergency Room department:
ƒ Lower level ER visits may be billed by the provider of service.
ƒ This excludes triage and services for patients transferred to an ER physician.
ƒ The PA NPI should be used as the line item provider number on CMS 1500 and 837P.
ƒ Services provided to patients designated as “inpatients” in a facility and the collaborative physician is NOT
present or does not see the patient at another time during that day:
ƒ Inpatient services are not covered. All services will be denied.
ƒ The PA NPI used as line item provider on CMS 1500 and 837P.
ƒ Services provided to patients designated as “inpatients” in a facility and the collaborative physician sees the
patient with the PA or at another time of day
ƒ Only one E&M service is covered during a 24-hour day. The collaborative physician must have a brief
note on the chart indicating the patient was seen; this visit should be reported under the collaborating
physician’s NPI.
ƒ Services provided when acting as assistant at surgery in an inpatient or outpatient hospital or ambulatory
surgery center:
ƒ Assistant at surgery is covered only for those CPT surgical codes for which Arkansas Blue Cross Blue
Shield allows coverage for Assistant Surgeon.
ƒ Modifier ‘AS’ should be used on all line items.
ƒ The PA NPI should be used as the line item provider number on CMS 1500 and 837P.
ƒ Services provided to a patient in a home setting, when the PA is NOT employed by or contracted to a Home
Health agency.
ƒ Lower level home visits may be billed by the provider of service.
ƒ The PA NPI should be used as the line item provider number on CMS 1500 and 837P.

Reimbursement to PAs when the PA NPI is submitted as the line item provider is based on 75% of the
corresponding physician reimbursement.

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Section 27 | Miscellaneous

Sleep Study Centers

Freestanding Sleep Study Centers are eligible for payment of the technical component of sleep medicine
services effective January 1, 2007. If the Freestanding Sleep Study Centers meet the credentialing standards,
they will be considered participating. If the Freestanding Sleep Study Centers do not meet the credentialing
standards, they will be considered out of network.

Freestanding Sleep study centers must bill the technical component of sleep medicine procedures for
reimbursement. The physician who interprets the study must bill for the professional component. The total
components of sleep medicine procedures will be denied as incorrect coding.

Effective January 1, 2009, all facility based sleep study centers must meet the same credentialing standards or
be terminated from Network participation.

Home Sleep Studies

Home sleep studies must be billed with the appropriate HCPCS code to distinguish the level of study provided.
The appropriate HCPCS codes are:
Code Description

Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels:
G039 8
EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation

Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2
G039 9
respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation

G040 0 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels

HCPCS Code G0398 is the only level of sleep study covered in the home setting. Home sleep studies billed using
CPT code 95806 will be denied as incorrect coding.

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Telemedicine coverage update

Arkansas Blue Cross and Blue Shield and its affiliates and subsidiaries had a pilot telemedicine policy in place
since April 2014. Effective January 1, 2016, a new policy became effective. With few exceptions, services covered
in a face-to-face setting will be covered when performed via telemedicine. Telemedicine reimbursement requires
that the provider have a professional relationship with the member, and that the member be physically present
in a credentialed facility or office. The Arkansas Blue Cross and Blue Shield coverage policy for telemedicine
covers all telemedicine services provided within the allowable scope-of- practice for the provider type
performing the service. Specific requirements are noted in the Arkansas Blue Cross coverage policy 2015034,
which is available on the Arkansas Blue Cross website. Please refer to coverage policy 2015034 for details.

The professional service allowable for telemedicine is equivalent to the allowable to the same service when
done face-to-face, and this service should be billed with a –GT modifier in the first modifier position. The
originating site (where the patient is located) should bill Q3014 for the same date of service. Q3014 (originating
site fee) is allowed in most clinical locations (as specified in the coverage policy); Q3014 is not be allowed
for other locations (e.g. home, school, pharmacy) where a patient might be located during an encounter.
Providers must use site-of-service 02 on professional claims; on Q3014 claims use the site-of- service where
the member is physically located during the encounter. The telemedicine clinician is responsible for ensuring
that a HIPAA-compliant audio-visual connection is used, and that an appropriate relationship is in place with the
communication service. Email, text (including photographs), or voice-only interactions are not covered.

Telemedicine is allowed only when the service is one which can be performed remotely to the same standard
of care that can be provided in a face-to-face visit. See coverage policy 2015034 for a list of codes which are
covered when done by telemedicine.

Telemedicine is covered when ALL of the following conditions are met:

1. The service is one which is allowed for the specific provider type when done in a face-to-face setting and can
be safely and effectively performed via telemedicine to the same standard of care as with a face-to-face visit.
2. If the originating site is a clinical setting, a Presenter is available at the Originating Site to orient the patient,
operate the equipment, problem solve, and gather clinical data.
3. The encounter is by real-time audio visual communication. (Store-and-forward, asynchronous, audio-only,
email, fax, and telemonitoring services are not reimbursable.)
4. A clinical record of the encounter which contains at least the same elements as are included in a face-to-face
encounter record is maintained; the location of the Originating Site and Distant Site, along with the date and
time of the connection must be recorded in the note.
5. For visits which include a physical exam, the equipment allows for remote examination by the provider (e.g.,
stethoscope, otoscope, etc. giving a diagnostic-quality signal to the provider) OR a qualified, licensed person
capable of performing the exam supplements the examination and relays the findings to the provider.
6. Data transmission must be accomplished using a HIPAA-compliant network, with sufficient bandwidth and
screen resolution to permit adequate interaction with the patient and assessment of behavioral and physical
features. The network must maintain a log of connections, with time, date, and duration. An example of a
compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the
Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
7. The Distant Site provider must be licensed as required by the appropriate state’s Medical Board, and the
service provided must be within the scope of practice for that provider.
Please contact your Network Development Representative with questions or concerns.

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Section 27 | Miscellaneous

Incident-to Services for PTA and COTA

Effective November 1, 2024, “Incident to” services, performed by Physical Therapist Assistants (PTAs) and
Certified Occupational Therapist Assistants (COTAs) under the general supervision of a supervising Physical
Therapist or Occupational Therapist are eligible for separate reimbursement when separately reported by the
supervising provider when the service performed is an otherwise covered service.

Services performed in whole or in part by a PTA or COTA will be required to be billed with the appropriate
modifier CQ or CO and will be subject to the payment policy guidelines. When covered “Incident to” services are
rendered in accordance with the policy, the services will be reimbursed at 85% of the PT/OT calculated allowable.

“Incident to” services must meet the following criteria:

ƒ HCPCS modifiers CQ and CO are required to be used for services furnished In Whole or In Part by a Physical
Therapy Assistant (PTA) or Certified Occupational Therapy Assistant (COTA).
ƒ Services must be part of the patient’s normal course of treatment, during which a physician personally
performed an initial service and remains actively involved in the course of treatment.
ƒ Services provided by PTAs and COTAs must fall within the scope and definition of covered services under
the written terms of the member’s benefit certificate.
ƒ Services provided by PTAs and COTAs must not fall within the scope or definition of any exclusion in the
member’s benefit certificate (other than the definition of “provider”).
ƒ All services provided by PTAs and COTAs must be supervised by a licensed therapist (applicable to the
specific licensure of the assistant) present in the office suite and/or immediately available, when necessary,
via interactive audiovisual telecommunication to provide assistance and direction throughout visit or
rendered service.
ƒ PTAs and COTAs must hold an active and unrestricted license to perform physical therapy or occupational
therapy assistant services, in full compliance with applicable state laws and regulations.
ƒ The supervising licensed physical therapist or occupational therapist must bill for services provided by PTAs
and COTAs. PTAs and COTAs may not bill separately or directly for any services performed.
ƒ The service provided must be one that is included in the CPT/HCPCS section of the payment policy.

The following services are not eligible for reimbursement as “Incident to” services:
ƒ Services performed by auxiliary personnel other than PTAs or COTAs, including physical or occupational
therapy aides.
ƒ Incidental services that are not separately reportable.
ƒ Services provided by PTAs and COTAs will not be covered or reimbursed if services include any evaluation
or assessment services or if services include the PTA or COTA making clinical judgments or decisions
regarding the member’s care or treatment.
ƒ Physical Therapy evaluation codes include CPT codes 97161-97164
ƒ Occupational Therapy evaluation codes include CPT codes 97165-97168.
ƒ Services provided by PTAs and COTAs will not be covered or reimbursed if the services include the
development, management or furnishing of any skilled maintenance program services or if the services
include the PTA or COTA taking or asserting overall responsibility for services.

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ƒ The services of a PTA/OTA cannot be provided incidental to a physician/appropriately licensed other

practitioner as they are not specifically qualified as licensed physical therapists or occupational therapists

Please refer to the Arkansas Blue Cross & Blue Shield payment policy #AR_PC_ 000016 Incident to Services-
Physical Therapist Assistants & Certified Occupational Therapist Assistants for detailed billing guidelines and a
complete list of eligible codes.

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