Provider File Management Guide

Transcription

1 Provider File Management Guide March 2018 Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association. Page 1 of 29

2 The Provider File Management transaction allows professional providers to view and submit specific updates to your Independence Blue Cross (Independence) provider record. It is not intended for use by Magellan Healthcare, Inc., an independent company, facilities, skilled nursing facilities, or ancillary providers. If you have questions about the Provider File Management transaction, call the ebusiness Hotline at You may perform the following functions as they relate to your practice: Add/Delete a participating practitioner to/from an existing practice Add/Delete an address (i.e., doing business as [DBA], check, mailing, main, or practice) Add/Delete contact name, title, or communication device type/number Add/Delete office hours Update your Walk-in acceptance status Update your Patient and Appointment Options (i.e., accepting new patients) Update your General Practice Availability (i.e. Urgent, Routine Visits, etc.) Update your Member Access number (i.e., the telephone number that appears on the member s identification card which must be the location-specific telephone number for a patient to make an appointment) Update your Electronic Medical Records (EMR) status Update the availability of other clinical staff (i.e., mid-wife, nurse practitioner, etc.) Update your office accessibility and services (i.e., handicapped, parking, and communication and language services) In addition, you may perform the following functions as they relate to individual practitioner profiles, providing they hold a primary affiliation with your practice: Update gender, race, or ethnicity Update practitioner languages Upload/Remove photos Add/Delete the address (i.e., main, practice, or check) to which a practitioner is affiliated Update Patient and Appointment Options (i.e., accepting new patients) Add additional educational background Add hospital affiliations For PCPs The following functions are not available to primary care physicians (PCP) practices due to possible impacts to capitation and/or incentive programs: Add/Delete an address (i.e., DBA, check, mailing, main, or practice) Update your Patient and Appointment Options (i.e., accepting new patients) Providers can make these changes by ing or faxing Independence: PracticeUpdates@ibx.com Fax: It is important that you include a contact person s name, phone number, fax number, and address in your or fax request. If there are any questions regarding your request, you will be contacted within 72 business hours. If you are not contacted, your request will be completed within 30 business days. Page 2 of 29

3 Change requests submitted using the Provider File Management transaction must include: group practice name and individual physician name, as applicable National Provider Identifier (NPI) and effective date for group practice and individual physician, as applicable effective date of change type of change (e.g., adding office location, telephone/fax, name change only, adding a physician, removing a physician, changing an office location, tax ID number) previous practice/physician information new practice/physician information Note: If any of these changes result in a change on your W-9, you must submit a copy of your W-9 with your change request. Submitting updates to your provider record To submit an update, select the Provider File Management transaction, from the Independence Workflows menu. If more than one provider practice is associated with your NaviNet office, select the provider practice you wish to view or edit from the drop-down menu. Click inside the Billing provider field; make your selection and select Go. If only one provider group is associated with your NaviNet office, the system will continue directly to the Provider File Management home screen. Page 3 of 29

4 Provider File Management home screen We ask that you review and verify your group address information contained within your profile. This review will ensure that our records are up to date and that your information is displayed accurately in our hardcopy and online provider directories. Having accurate demographic information in our provider directories helps members identify and access services from participating providers. Failure to verify your information could result in removal from our provider directories. View group details The provider ribbon at the top of the Provider File Management home screen offers links to view group details, previously submitted changes, and pending changes. Select View group details. Under View group details you will find: NPI (internal) Provider ID Tax ID Network participation Practice locations Practitioners linked to the practice Page 4 of 29

5 Review submitted changes Select Review submitted changes to view and print a copy of the requested provider record changes submitted to Independence. It also indicates the date and NaviNet username of the individual who submitted the requested edits. Note: We recommend you retain a copy for your records, as the report will not be saved after you exit the Provider File Management transaction. Review pended changes Should your submitted provider record changes pend for review by Independence, notification will be provided upon submission and can be viewed through the Review pended changes option. We encourage you to monitor the status of pended requests after submitting provider record additions and modifications through the Provider File Management transaction. Please allow 30 business days for a response to pended requests. Page 5 of 29

6 In order to initiate updates to provider records, you must check the box of the record you would like to edit, select Edit, and then make the necessary changes. Select Submit at the top or bottom of the screen to finalize your changes with Independence. If you do not select Submit, the requested updates will not be considered for processing. To add a new practitioner or to add a new practice location, select the appropriate option to the right in the Locations and Practitioners header. Note: Due to possible impacts to capitation and/or incentive programs, the Add an Address option is not available to PCPs. PCPs can make these changes by ing or faxing Independence as referenced on page 2. Page 6 of 29

7 Add a Practitioner You are permitted to add new practitioners to existing locations only. When adding a new practitioner to an existing location, select the Yes option as shown below and then Continue Adding Practitioner. If both the practitioner and the address are new, select the No option as shown below and submit the request to Independence by or fax using the numbers provided at the beginning of this guide. Note: and fax can be used for PCPs or specialist providers, and in this example, a specialist is adding a new practitioner and a new address; therefore, the request must be sent by or fax and not through the Provider File Management transaction. Page 7 of 29

8 When adding a new practitioner, you will need to submit the request in a single session. Additionally, the new practitioner must have been previously credentialed. To begin, you will first need to search for your practitioner using one of the following: NPI Individual (internal) Provider ID State Medical License Number Once complete, select Search. It is important that the credentialing status of the practitioner is verified with Independence prior to adding a physician to a practice. If a practitioner is added to a practice and they are not participating with Independence, this could result in claim denials, inaccurate reimbursement, and immediate removal of the provider from the provider directories. The added practitioner should hold the same specialty as the practice he or she is being added to; if not, they could experience the same results (i.e., claim denials, inaccurate reimbursement, and immediate removal of the provider from the provider directories.) After locating the appropriate provider, select Add. Page 8 of 29

9 Once you make the selection to add the practitioner to the applicable location(s), you will need to verify whether the practitioner regularly sees patients at the location at least one day per week. When practices elect to submit any location-related changes, practices must confirm that the answers in the Patients Seen section are accurate. The changes will not be saved without confirmation. You must select the box (as shown below) to confirm the accuracy of the Patients Seen section for the practitioner for each practice location. The Patients Seen responses can be viewed once established and then modified by selecting the Edit button. Page 9 of 29

10 Next, you will be prompted to select the network and specialty roles for the practitioner in the Plans and Specialties section. Once complete, select Submit. Add an Address (non-practice location) If the address to be added is not a practice location (e.g., check address), select the first option, This address is not for a practice location, and then select the Continue Adding Address button. To add a non-practice location address, select the Add an Address option to the right of the Locations and Practitioners header. Page 10 of 29

11 Then, select Expand All. Complete the sections entitled Address Characteristics and Contacts. Note: The fields with a red asterisk (*) are required. 1. Address Characteristics Complete the following fields (some are required): Address effective: The date the new location was opened. Street: The street address location. Building/location: An optional building name or building location. Suite/room: An optional suite or room number. City: The city of the practice location. State: The state of the practice location. ZIP: The ZIP code of the practice location. Doing business as: An optional field indicating the name a group uses when doing business in a community. Page 11 of 29

12 Address type: One or more address types can be associated to a location (e.g., Practice and Check). - Check: The address where remittance and its supporting documentation is sent. - Main: The primary physical practice location. - Mailing: The address where administrative documentation is sent. - Practice: The physical location where patients are seen for services. Must be selected to affiliate practitioners to the location. 2. Contacts The following Contacts are only applicable for practice locations and the main location: Contact Name: The first and last name of practice location contact. Note: More than one contact can be associated to a single location. Select Add New Row to enter multiple contacts (see an example on the next page). Title: An optional field denoting the title of the practice location contact. Communication Device Type: Select from one of the options provided in the drop-down menu (e.g., After Hours Phone Number, Cellular Phone, etc.) Communication Device Number: Enter the number associated with the selected communication device type (Note: The phone number format is: [x9999]). Member Access Number: Indicate (Y or N) if this is a phone number used by members to make an appointment. 3. After entering all required information, select Submit. Page 12 of 29

13 Add an Address (practice location)* To add a practice location address, select the Add an Address option to the right of the Locations and Practitioners header. *Due to possible impacts to capitation and/or incentive programs, this option is not available to PCPs. See page 2 for more information. If the address to be added is a practice location, select the second option, Yes, this address will be affiliated with one or more existing practitioners, and then select the Continue Adding Address button. Then, select Expand All. Page 13 of 29

14 Adding an address and editing practice information You will need to complete the following sections: Address Characteristics, Contacts, Office Hours and Appointments, Practitioners and Other Clinic Staff, and Office Accessibility and Services. Note: The fields with a red asterisk (*) are required. 1. Address Characteristics Complete the following fields (some are required): Address effective: The date the new location was opened. Street: The street address location. Building/location: An optional building name or building location. Suite/room: An optional suite or room number. City: The city of the practice location. State: The state of the practice location. ZIP: The ZIP code of the practice location. Doing business as: An optional field indicating the name a group uses when doing business in a community. Page 14 of 29

15 Address type: One or more address types can be associated to a location (e.g., Practice and Check). - Check: The address where remittance and its supporting documentation is sent. - Main: The primary physical practice location. - Mailing: The address where administrative documentation is sent. - Practice: The physical location where patients are seen for services. Must be selected to affiliate practitioners to the location. 2. Contacts The following Contacts are only applicable for practice locations and the main location: Contact Name: The first and last name of practice location contact. Note: More than one contact can be associated to a single location. Select Add New Row to enter multiple contacts (see an example on the next page). Title: An optional field denoting the title of the practice location contact. Communication Device Type: Select from one of the options provided in the drop-down menu (e.g., After Hours Phone Number, Cellular Phone, etc.) Communication Device Number: Enter the number associated with the selected communication device type (Note: The phone number format is: [x9999]). Member Access Number: Indicate (Y or N) if this is a phone number used by members to make an appointment. 3. Office Hours and Appointments As a participating provider in the Independence network, you are required to meet our access and availability standards, which are based on applicable federal and state regulations and accreditation standards. This would include office hours, appointment availability, etc. Use this section to make edits to this information as needed. Note: Detailed requirements are located in the Quality Management section of the Provider Manual for Participating Professional Providers. Office hours are required for practice locations. The Start and Stop times should be entered in the following format: hh:mm. Please review the following fields and edit as needed: Day: Select the appropriate day of the week from the drop-down menu. Start Time: Enter the location start time in the appropriate format and indicate AM or PM. Stop Time: Enter the location stop time in the appropriate format and indicate AM or PM. Page 15 of 29

16 Frequency: Enter Bi-weekly (every other), monthly, none, or weekly. You must select the box (as shown above) to confirm the accuracy of the office hours entered. To indicate walk-in appointment availability, select Edit to the right of the Appointments header. From the following window, edit Walk-in appointment information as necessary, and then select OK when complete. Any other patient and appointment options must be requested by ing or faxing Independence as referenced on page 2. Page 16 of 29

17 Practice availability Select the Edit button to the right of the Practice availability header. Respond to the below questions concerning general practice availability and select OK when complete. 4. Practitioners and Other Clinic Staff You have the option to associate practitioner(s) with the office location in two ways: (1) click Select and make your selection from the list of providers that is returned, or (2) select a location to copy practitioners from by clicking the Select a location button. Note: By clicking the Select a location button and selecting the location to copy practitioners, all practitioners associated with the selected location will be copied to your new location and any individual practitioner selections you have already made will be removed. Page 17 of 29

18 The Patients Seen responses can be viewed once established and then modified by selecting the Edit button. Once you have associated the practitioners with the applicable practice location(s), you will need to verify whether the practitioner regularly sees patients at the location at least one day per week. When practices elect to submit any location-related changes, practices must confirm that the answers in the Patients Seen section are accurate. The changes will not be saved without confirmation. To indicate if this practice location supports other clinical staff and/or electronic medical records, check the appropriate boxes under Other Clinical Staff and E-Records for New Address. Select OK when complete. Page 18 of 29

19 5. Office Accessibility and Services Location Accessibility and Services Select Edit to answer questions related to location conveniences available at the new office location. Check the appropriate radio buttons under Edit Location Conveniences for New Address. Select OK when complete. Communication and language services Select Edit to answer questions related to available communication services and languages spoken at the new office location. Select OK when complete. 6. After entering all required information, select Submit. Page 19 of 29

20 Editing existing practice location information The Provider File Management transaction allows you to modify specific updates to your Independence provider record, including: locations and addresses practitioners affiliated Editing location information First, select the office location that requires changes by checking the box to the left of the location address. Select Edit if you need to modify any of the location details listed. Note: Practice deletions may not be submitted through the Provider File Management transaction. You are requested to contact Independence via or fax when closing a practice location as referenced on page 2. From the following screen, select Expand All to edit additional fields. Page 20 of 29

21 Address Characteristics To modify Address Characteristics, select the Edit button on the right side of the screen. The below screen allows you to modify the DBA name and address type. For additional detail regarding the specific fields, select the icon. DBA name is optional and indicates the name an office uses when doing business in a community. An address can be flagged with one or more types (i.e., check, mailing, main, or practice) Select OK when complete. Note: If any part of the current location address has changed or is incorrect, delete the location in its entirety. After the location is deleted, follow the instructions provided earlier in this user guide and add the location as a new entry. Page 21 of 29

22 Contacts To modify location contact information, first identify the contact line by checking the box to the left of the line item. Then select Edit. Modify the following information as needed: Contact Name: First and last name of practice location contact. Title: Optional field denoting the title of the practice location contact. Communication Device Type: Select from one of the options provided in the drop-down menu (i.e., After-hours phone number, cellular phone, etc.). Communication Device Number: Enter the number associated with the selected communication device type (Note: The phone number format is: [x9999]). Select Submit when complete. Note: You also have the option to delete a communication type or add a new communication type as needed. To delete location contact information, first identify the contact line by checking the box to the left of the line item. Then select Delete. Page 22 of 29

23 To add new location contact information, select Add New Row and follow the instructions provided earlier in this user guide. Note: More than one contact can be associated with a single location. Office hours To modify office hours and/or appointment information, select the Edit button and enter your changes. You also have the option to delete, copy, and add office hours when selecting the appropriate radio button. Practice availability Select the Edit button to the right of the Practice availability header. Page 23 of 29

24 Respond to the below questions concerning general practice availability and select OK when complete. Practitioners and Other Clinic Staff To edit practitioner information, double click the individual practitioner name. The Practitioner Information screen allows you to make changes to: Demographic and Plan Participation Addresses Educational Background Hospital Affiliations You can expand each category individually or select Expand All to access all available categories. Page 24 of 29

25 Demographics and Plan Participation You can only modify information for practitioners associated with the location as a primary affiliation. All recredentialing information is sent to the practitioner s primary practice affiliation. If your office is not listed as the practitioner s primary affiliation but edits are needed, your request must be submitted to Independence via or fax. The Provider File Management home screen indicates the practitioner s Primary Affiliation status: To modify demographic information, select the Edit button to the right of the Demographics header. Select the appropriate responses for each category provided and select OK. Page 25 of 29

26 To modify the languages spoken, select the Edit button to the right of the Languages spoken header. Check the box next to each language spoken and select OK. Addresses Where Practitioner Works To modify the address information where the practitioner works, select the Edit button to the right. Page 26 of 29

27 Note: If the practitioner is the only practitioner affiliated with a specific practice address, as stated in the warning window (as shown below), removing the affiliation could result in the practice also being terminated. This request will result in a pended status for review and approval. Educational Background You are permitted to add new educational levels for the selected provider by selecting Add New Row. If you need to update existing education information on file, you will need to contact Independence via or fax. After selecting Add New Row, a new line with blank fields will display. 1. Type: Indicate the education type by selecting a value from drop-down menu: a. Additional years b. Chiropractic school c. Dental school d. Fellowship e. Graduate f. Internship g. Medical school h. None i. Not applicable j. Optometry school k. Podiatry school l. Post-doctoral Page 27 of 29

28 m. Postgraduate n. Preceptorship o. Professional school p. Residency q. Sleep medicine program r. Undergraduate 2. Institution: Select Lookup to search for the name of the institution. From the following window, use the below options to find the institution: Then select Search. 3. From: Indicate the education start date using the provided calendar icon. 4. To: Indicate the education end date using the provided calendar icon. Hospital Affiliations To add a new hospital affiliation, select Add New Row. Search for the institution name using the Lookup button. Then indicate the Effective Date. Page 28 of 29

29 To terminate a hospital affiliation, first select X to the right of the institution name. You will be prompted to enter a termination date using the calendar icon. If the provider s affiliation is in a pending status and you wish to terminate the request, the termination date must be equal to the effective date. Select OK when finished. When making updates to provider records, you must select Submit at the top or bottom of the screen to finalize your changes with Independence. If you do not select Submit, the requested updates will not be considered for processing. NaviNet is a registered trademark of NaviNet, Inc., an independent company. Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members. Page 29 of 29