PROVIDER ADMINISTRATION MANUAL

PROVIDER ADMINISTRATION MANUAL

Table of Contents

I. INTRODUCTION

A.

BlueCross BlueShield of Tennessee Statement of Purpose

B.

Description of BlueCare

C.

BlueCare Health Plan

D.

General

Information

1. Interpretation

Services

2. Medical

Referrals

3.

Outpatient/Inpatient Behavioral Health Services

4.

Notification or Prior Authorization

5.

Protected Health Information –allowable disclosures

under Health Insurance Portability and Accountability

(HIPAA)

6.

Fraud and Abuse

E.

BlueCare Appeals Quick Reference Guide

II.

HOW TO IDENTIFY A BLUECARE MEMBER

A. Determining

Eligibility

B.

Member

Liability

C.

ID

Card

D.

How to Use BlueCare/TennCareSelect Provider Service Line

E.

Electronic Data Interchange (EDI)

III.

BLUECARE PRIMARY CARE MEMBER ASSIGNMENT

A.

Care Management Fee

B.

BlueCare Care Management Fee Payment Process

C.

Primary Care Provider (PCP) Membership Listing

D.

Primary Care Provider (PCP) Changes

IV. BLUECARE

BENEFITS

A.

Covered Benefits

B.

Benefit

Exclusions

V.

BILLING AND REIMBURSEMENT

A.

How to File a BlueCare Claim

1.

Electronic

Claims

2.

Paper

Claims

B.

Timely Filing Guidelines

V.

BILLING AND REIMBURSEMENT

(cont’d)

C. Medicare/BlueCare Dual Eligible Members

1. Medicare/Medicaid Dual Eligible Members 2. Uninsured/Uninsurable Dual Eligible Members D. Third Party Liability (TPL)

E.

F. General Billing Information

1. Current Dental Terminology (CDT), Current Procedural Terminology (CPT®), Health Care Financing Administration Common Procedural Coding System (HCPCS), and

International Classification of Disease (ICD) Coding 2. Addition/Deletion CDT Codes

3. Addition/Deletion of CPT® Codes 4. Addition/Deletion HCPCS Codes 5. Addition/Deletion ICD Codes

6.

7.

8.

9.

10.

11.

12.

1. Sample Copy CMS-1500 (08/05) Version Claim Form 2. CMS-1500 Claim Form Block Description

3. Data Elements Required for Submitting CMS-1500 Claims

H.

1.

2.

3.

I.

1. Anesthesia Billing and Reimbursement Guidelines

2. Assistant-at-Surgery Billing Guidelines and Reimbursement Policy

3. Durable Medical Equipment (DME) 4. Prosthetics and Orthotics

5. Reimbursement Guidelines for Immune Globulins, Vaccines, and Toxoids

6. Reimbursement Guidelines for Infusion Therapy,

Immunosuppressive, Nebulizer, Chemotherapy and Other Injectable Drugs

7. Reimbursement Guidelines for Non-Injectable Medications when the Location of Service is the Practitioner’s Office Rev 12/07

V.

BILLING AND REIMBURSEMENT

(cont’d)

I.

Specific CMS-1500 Claim Form Billing and Reimbursement

Guidelines (cont’d)

8.

Reimbursement Guidelines for Self-Administered

Prescription Medications Dispensed and Submitted by a

Licensed Pharmacist

9.

Reimbursement Guidelines for Unusual Procedural

Services

10.

Reimbursement Guidelines for Administration of Regional

or General Anesthesia Provided by a Surgeon

11.

Reimbursement Guidelines for Multiple Procedures

12.

Reimbursement Guidelines for Bilateral Procedures

13.

Reimbursement Guidelines for Procedures Performed by

Two Surgeons

14.

Reimbursement Guidelines for Bundled Services

Regardless of the Location of Service

15.

Reimbursement Guidelines for Bundled Services when the

Location of Service is the Practitioner’s Office

16.

Reimbursement Guidelines for Screening Test for Visual

Acquity

17.

Reimbursement Guidelines for Visual Function Screening

18.

Reimbursement Guidelines for Codes Classified as

Durable Medical Equipment, Medical Supplies, Orthotics

and Prosthetics without an Established Maximum

Allowable

19.

Reimbursement Guidelines for Home Pulse Oximetry

20.

Emergency/Non-Emergency Transportation

21.

Professional and Technical Components for

Radiology,

Laboratory and Other Diagnostic Procedures

22.

OB/GYN Services

23.

Home Infusion Therapy (HIT)

24.

Billing Guidelines and Reimbursement Policy for

Radiopharmaceuticals and Contrast Material

25.

Reimbursement Guidelines for Procedures Performed on

Infants Less than 4kg

26.

Reimbursement Guidelines for Category II CPT

Codes

27.

Reimbursement Guidelines for STAT Services

28.

Reimbursement Guidelines for Online Evaluation and

Management Services

29.

Billing Guidelines and Documentation Requirements for

CPT

Code 99211

30.

Modifiers Requiring Special Handling

V.

BILLING AND REIMBURSEMENT

(cont’d)

I.

31.

32.

33.

34.

J.

K.

L.

1. CMS-1450 Form Locators and Field Description

M.

4. Hospital Outpatient/Ambulatory Surgery 5. CPT® Code with Surgery Revenue Code 6. Emergency/Non-Emergency

7. Observation Room 8. Newborn

9. Clinic Visit (Professional Fees)

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

N.

O.

P.

Q.

1.

2.

R.

VI.

PRIMARY CARE PROVIDER (PCP)

A. PCP

Responsibilities

B.

Primary Care Site/Medical Review Requirements

C.

PCP Access and Availability

VII. MEMBER

POLICY

A. Introduction

B.

Member Rights and Responsibilities

C.

Member Access to Care

D.

Member/Practitioner Relationship Termination

E.

Member Appeals/Revised Consent Decree – Eff. 11/1/00

F.

BlueCross BlueShield of Tennessee Health Information Library

G.

Financial Responsibility for the Cost of Services

VIII. UTILIZATION MANAGEMENT PROGRAM

A.

Program

Overview

B.

Medical Review Requirements

C.

Notification, Prior Authorization, Retrospective Claims Review,

Focused Review

1. Notification

2. Prior

Authorization

3.

Retrospective Claims Review and Focused Review

4. Referrals

D.

Air Ambulance Transport Services

E. Emergency

Services

F. Investigational

Services

G.

Health Department Services

H.

Medical Necessity Policy

I.

Utilization Management Resources

J.

Medical Policy Manual

K.

Utilization Management Provider Appeals Process

1. Reconsideration

2. Expedited

Appeal

3. Standard

Appeal

4.

Appeal to TennCare

IX. OB

SERVICES

A.

Prenatal Standards/Quality Improvement Studies

B. High-Risk

Pregnancies/Disease Management Referral

Guidelines

C.

Women, Infants and Children (WIC) Program

D. Presumptive

Eligibility

X.

CARE MANAGEMENT

A. Components

B.

Care Management Referral Criteria

C.

Care Coordination Team/Process

D.

Catastrophic Medical Case Management Team/Process

E.

Transplant Case Management

F. Disease

Management

G.

Evaluation of Care Management Programs

XI.

QUALITY IMPROVEMENT PROGRAM

A.

Introduction

B.

Scope

C.

Authority and Structure

D.

Medical Management Corrective Action Plan (MMCAP)

XII. HIGHLIGHTS OF PROVIDER AGREEMENT

A. Administrative

Inquiry

1. Administrative Inquiry Description

2. How to Submit Administrative Inquiries

B.

Provider Dispute Resolution Procedure

C.

TennCare Provider Agreement Requirements

XIII. ABORTION, STERILIZATION, HYSTERECTOMY (ASH)

A. Abortion

B. Sterilization

C. Hysterectomy

D.

Additional Information for Filing Sterilization Claims

E.

Associated Anesthesia Services

XIV. PREVENTIVE CARE

A.

Preventive Care Guidelines

B.

Preventive Care Services Billing Requirements

C.

Guidelines of Periodic Health Assessment Records

XV. Quality of Care Monitors

(Information in this section removed)

XVI. PROVIDER NETWORKS

A.

Network Participation Criteria

B.

Changes in Practice

C.

Providers Denied Participation

D.

Participation in BlueCare and TennCareSelect Networks

XVII. CREDENTIALING

A. Introduction

B. Credentialing

Application

C. Credentialing

Policies

1. Credentialing Process for Practitioners

2. Recredentialing Process

3. BlueCross BlueShield of Tennessee Approved Specialties

4. Credentialing Process for Organizational Providers

5. BlueCross BlueShield of Tennessee Recognized

Accrediting Bodies

D.

Practice Site/Medical Record Standards

XVIII. FINANCIAL SETTLEMENT-

(Information in this section removed)

XIX. PROVIDER AUDIT GUIDELINES

XX. TENNderCARE

A. TENNderCARE

Services

B.

TENNderCARE Screening Guidelines

C. Interperiodic

Screening

D.

Coordination of Care

E. TENNderCARE

Billing Guidelines

F.

TENNderCARE Tool Kit

XXI. TENNCARESELECT Network

A. Introduction

B.

How to Identify a TennCareSelect Member

C.

Best Practice Network (BPN)

D. TennCareSelect Specifics

E. TennCareSelect Frequently Asked Questions

XXII. BEST PRACTICE NETWORK (BPN) Provider Manual

I. Introduction

II.

How to Identify BPN Members

III.

BPN Provider Roles and Responsibilities

IV.

Department of Children’s Services (DCS)

V.

Confidentiality, Informed Consent and Medical Records

VI. General

Information

I. Introduction

This BlueCare Provider Administration Manual (“Manual”) contains comprehensive information regarding BlueCare® operating policies and procedures. The information contained in this Manual applies to Providers who care for BlueCare and/or TennCareSelect Members (“Members”).

This Manual replaces any other BlueCross BlueShield of Tennessee, Inc. BlueCare manuals or communications regarding the subject matters discussed in this document. The requirements, policies and processes defined in this Manual are a contractual obligation as stipulated in BlueCross BlueShield of Tennessee’s BlueCare contract with the Provider.

Changes to this Manual will be communicated to Providers at least 30 days prior to

implementation (excludes medical policy changes driven by new technology). Such changes are communicated using one or more of the following resources:

¾ BlueAlert

¾ Quarterly Provider Manual updates

¾ Online updates to Medical Policy Manual at www.bcbst.com ¾ Individual Provider Mailings

No person on the grounds of race, color, religion, national origin, sex, age, or disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or service provided by BlueCross BlueShield of Tennessee, Inc., including its licensed affiliate, Volunteer State Health Plan, Inc.

Furthermore, no person shall be subjected to any form of retaliation to include, threats, coercion, intimidation or discrimination as a result of filing a complaint, testifying, assisting or participating in an investigation, proceeding or hearing.

Volunteer State Health Plan, Inc. (VSHP) is a Health Maintenance Organization and wholly owned subsidiary of BlueCross BlueShield of Tennessee and an independent licensee of the BlueCross BlueShield Association. BlueCare is a product underwritten by VSHP.

A.

BlueCross BlueShield of Tennessee Statement of Purpose

¾

BUSINESS

Our Business is financing affordable health care coverage.

¾

PURPOSE

Our Purpose is

Peace of Mind

.

¾

LONG-TERM CORPORATE GOALS

Our Long-Term Corporate Goals are:

• Affordability

• Sustainability

• Outreach

Code of Business Conduct

BlueCross BlueShield of Tennessee has been a part of Tennessee families and businesses since 1945. We have built a bond of trust with the people we serve, as well as the vendors and suppliers with whom we do business.

To strengthen that bond of trust, the BlueCross BlueShield of Tennessee Board of Directors adopted a set of policies and Code of Conduct that applies to all employees, officers, contracted vendors, and members of the Board of Directors. Additionally, the organization encourages suppliers and third parties with which we do business to adopt and follow a code of conduct particular to their own organization that reflects a commitment to detect, prevent, and correct any occurrences of unethical behavior. Our organization is willing to share our own Code of Conduct, along with related policies and procedures, with these entities in order to relay our commitment to a corporate culture of ethics and compliance.

Included in our Code of Conduct are two sections entitled “Conflicts of Interest” and “Dealing with Customers, Suppliers, and Third Parties”. The primary focus of these sections is to help ensure business decisions are based on the merit of the business factors involved and not on the offering or acceptance of favors. You can review the Code of Conduct in its entirety online at:

http://www.bcbst.com/about/company_profile/code-of-conduct/.

Please share this information with all your employees who interact with our company. If you should have any questions, or wish to report a suspected violation, please call the Confidential Compliance Hotline, 1-888-343-4221 or e-mail us at [email protected].

B. Description of BlueCare

BlueCross BlueShield of Tennessee (BCBST) has a long-standing commitment to provide excellent service to the people who depend on us. The increased emphasis at both federal and state levels for establishing National Health Care Reform resulted in the State of Tennessee’s introduction of the TennCare Program. BlueCross BlueShield of Tennessee, through Volunteer State Health Plan, Inc. (VSHP), is only one of the Managed Care Organizations (MCOs) administering the TennCare Program in the State of Tennessee.

BlueCare is a product underwritten by VSHP and provides medical care for its TennCare Members. BlueCare strives to ensure Members receive the highest quality of care in the most cost-effective manner.

BlueCare is a Primary Care Practitioner (PCP)-driven HMO network focusing on PCPs providing appropriate care to Members in accordance with established clinical guidelines offering its Members and Providers programs in medical management, quality improvement, education and development, as well as quality customer service. The customer service areas are designed to provide efficient access and assistance to our Providers and Members.

A map defining BlueCare and important contact numbers follow:

BlueCare (Eastern Grand Region) TennCareSelect (Statewide)

(See Section XXI for TennCareSelect specifics) Member Service Line 1-800-468-9698 Member Service Line 1-800-263-5479 Provider Service Line 1-800-468-9736 Provider Service Line 1-800-276-1978 Fax Line 1-800-357-0453 1-423-535-7111 Fax Line 1-800-218-3190 1-423-535-6399 Notification or Prior Authorization (State-wide) Phone Fax 1-888-423-0131 1-800-246-1904 1-800-622-8901 1-800-292-5311 Notification or Prior Authorization Phone Fax 1-800-711-4104 1-800-292-5311 Mailing Address: BlueCare P.O. Box 182277 Chattanooga, TN 37422-7277 Mailing Address: TennCareSelect P.O. Box 182277 Chattanooga, TN 37422-7277

C. BlueCare Health Plan

TYPE OF PLAN

Health Maintenance Organization (HMO)

NETWORK

Volunteer State Health Plan, Inc. (VSHP)

COPAYMENT - Effective January 1, 2005

Poverty Levels Copayment Amount 0 – 100% 0 101% - 199%

$25.00 for hospital emergency room (waived if admitted)

$5.00 for primary care practitioner (PCP) and Community Mental Health Agency services other than preventive care

$15.00 for physician specialists

Prescription or refill: $0.00 for generic $3.00 for brand

$100.00 per inpatient hospital admission

200% and above

$50.00 for hospital emergency room (waived if admitted)

$10.00 for primary care practitioner (PCP) and Community Mental Health Agency services other than preventive care

$25.00 for physician specialists

Prescription or refill: $0.00 for generic $3.00 for brand

$200.00 per inpatient hospital admission

Note: Effective August 1, 2005, (unless otherwise directed by TennCare), there shall be no out-of-pocket maximum amounts.

D. General Information

1. Interpretation Services

According to federal and state regulations of Title VI of the Civil Rights Act of 1964, translation or interpretation services due to Limited English Proficiency (LEP) is to be provided by the entity at the level at which the request for service is received. The Executive Order, signed

August 11, 2000, by former President William Clinton, is a guidance tool including specific expectations designed to ensure that LEP clients receive meaningful access to federally assisted programs.

The financial responsibility for the provision of the requested language assistance is that of the entity that provides the service. It is not permissible to charge a BlueCare or TennCareSelect Member for these services. Full text of Title VI of the Civil Rights Act of 1964 can be found online at http://www.usdoj.gov/crt/cor/coord/titlevi.htm.

Providers can use the “I Speak” Language Identification Flash Card to identify the primary language of BlueCross BlueShield of Tennessee Members, including TennCare Members. The Rev 03/08

flash card, published by the Department of Commerce Bureau of Census, containing 38 languages can be found online at http://www.lep.gov/ISpeakCards2004.pdf.

The Department of Health and Human Services can also recommend resources for use when LEP services are needed or Providers can not locate interpreters specializing in meeting needs of LEP clients by calling one of the numbers listed below:

¾ Language Line 1-800-874-9426

¾ Open Communications International 615-321-5858

¾ Institute of Foreign Language 615-741-7579 Providers may also consider:

¾ Training bilingual staff;

¾ Utilizing telephone and video services;

¾ Using qualified translators and interpreters; and ¾ Using qualified bilingual volunteers.

2. Medical Referrals

Effective July 1, 2001, completion of the written referral form was eliminated for Primary Care Practitioners (PCPs) referring to a participating specialist or to any emergency room. PCPs are still expected to direct Members’ care and make the appropriate appointments to participating specialists. Note: The current written referral process is still required when referring a Member to an out-of-network Provider. (See Section VIII for out-of-network written referral instructions.)

3. Outpatient/Inpatient Behavioral Health Services

¾ Premier Behavioral Health 1-800-325-7864

¾ Tennessee Behavioral Health, Inc 1-800-447-7242

4. Notification or Prior Authorization

See the Utilization Management Program section of this Manual for a listing of the selected services requiring notification or prior authorization.

Notification and Prior Authorization services can be arranged by calling the Utilization Management Department Monday through Friday, 9 a.m. through 6 p.m. (ET) at one of the statewide telephone numbers listed below:

BlueCare TennCareSelect

1-888-423-0131 (Option #2) 1-800-711-4104 (Option #2) 1-800-292-5311 (Fax) 1-800-292-5311 (Fax)

5. Protected Health Information-allowable disclosures under HIPAA

Privacy of medical information is important to all covered entities. New federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) may require some changes in the way BlueCross BlueShield of Tennessee operates, however, it will not prevent us from exchanging the information we need for treatment, payment, and health care operations (TPO).

BlueCross BlueShield of Tennessee will continue to conduct business as usual in most

circumstances. HIPAA regulations allow disclosure of certain medical information, and BlueCross BlueShield of Tennessee providers (subject to all applicable privacy and confidentiality

requirements) are contractually obligated to make medical records of BlueCross BlueShield of Rev 03/08

Tennessee Members available to each Physician and/or Health Care Professional treating BlueCross BlueShield of Tennessee Members and to BlueCross BlueShield of Tennessee, its agents, or representatives.

Privacy Regulations should not impact patient treatment and quality of care; it is vital for the benefit of our members and your patients that quality of care is not negatively

impacted due to misconceptions about allowable exchanges of information for TPO. The following offers examples of TPO, which include, but are not limited to:

Treatment - rendering medical services, coordinating medical care for an individual, or even referring a patient for health care.

Payment - the money paid to a covered entity for services rendered whether it is a health plan collecting premiums, a health plan fulfilling its responsibility for coverage, or a health plan paying a provider for services rendered to a patient.

Health care operations - conducting quality assessment and improvement activities, underwriting, premium rating, auditing functions, business planning and development, and business management and general administrative activities.

For complete TPO definitions and a listing of examples, please review the federal regulations at http://www.hhs.gov/ocr/hipaa/finalreg.html.

If you have any questions or concerns regarding privacy matters, you may contact the BlueCross BlueShield of Tennessee Privacy Office at 1-888-455-3824 or e-mail us at

[email protected].

6. Fraud and Abuse

Volunteer State Health Plan, Inc., cooperates with all state and federal agencies in the investigation of fraud and abuse. Reportable fraud and abuse includes fraud and abuse in the administration of the TennCare program, Provider fraud and abuse, and Member fraud and abuse. Such abuse must be reported to the Tennessee Bureau of Investigation Medicaid Fraud Control Unit and the Office of Inspector General. To report any suspected fraudulent activity:

¾ Call BlueCross BlueShield of Tennessee Fraud and Abuse Hotline at 1-800-496-9600; ¾ E-mail BlueCross BlueShield of Tennessee at http://www.bcbst.com/fraud/report.shtml; ¾ Call the Bureau of TennCare from anywhere in Tennessee at 1-800-433-3982; or

¾ Log onto www.tncarefraud.tennessee.gov and follow the prompts that read “Report Fraud Now”.

In 2005, Congress passed The Deficit Reduction Act (DRA), a piece of legislation that impacted many areas of American government and commerce. The DRA included provisions that have an impact on Federal Health Care Programs. Federal Health Care Programs include: (1) Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government; or (2) Any State health care program, as defined in section 1320a–7 (h) of this title. Volunteer State Health Plan, Inc. (VSHP) falls under that definition.

The Deficit Reduction Act (DRA) changes that impacted Federal Health Care Programs became effective on January 1, 2007. Because Volunteer State Health Plan, Inc. (VSHP) is considered a Federal Health Care Program, VSHP is required to be compliant with several new requirements promulgated by the legislation. Specifically, VSHP must train staff on the provisions of the False Claims Act. The False Claims Act provides Liability for certain acts…

In 2005, Congress passed The Deficit Reduction Act (DRA), a piece of legislation that impacted many areas of American government and commerce. The DRA included provisions that have an impact on Federal Health Care Programs. Federal Health Care Programs include: (1) Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government; or (2) Any State health care program, as defined in section 1320a–7 (h) of this title. Volunteer State Health Plan, Inc. (VSHP) falls under that definition.

The Deficit Reduction Act (DRA) changes that impacted Federal Health Care Programs became effective on January 1, 2007. Because Volunteer State Health Plan, Inc. (VSHP) is considered a Federal Health Care Program, VSHP is required to be compliant with several new requirements promulgated by the legislation. Specifically, VSHP must train staff on the provisions of the False Claims Act. The False Claims Act provides Liability for certain acts…

FALSE CLAIMS ACT (Title 31, Section 3729) (a) Liability for Certain Acts. — Any person who—

• Knowingly presents, or causes to be presented, to an officer or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval;

• Knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government;

• Conspires to defraud the Government by getting a false or fraudulent claim allowed or paid;

• Conspires to defraud the Government by getting a false or fraudulent claim allowed or paid;

• Authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and, intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the receipt is true;

• Knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the Government, or a member of the Armed Forces, who lawfully may not sell or pledge the property; or

• Knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government,

Is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person, except that if the court finds that—

• The person committing the violation of this subsection furnished officials of the United States responsible for investigating false claims violations with all information known to such person about the violation within 30 days after the date on which the defendant first obtained the information;

• Such person fully cooperated with any Government investigation of such violation; and At the time such person furnished the United States with the information about the violation, no criminal prosecution, civil action, or administrative action had commenced under this title with respect to such violation, and the person did not have actual knowledge of the existence of an investigation into such violation; The court may assess not less than 2 times the amount of damages that the Government sustains because of the act of the person. A person violating this subsection shall also be liable to the United States Government for the costs of a civil action brought to recover any such penalty or damages.

Important Contact Numbers

Contact

Toll-Free Number

Address/Description

BlueCross BlueShield of Tennessee Provider Relations

Chattanooga Jackson Johnson City Knoxville Memphis Nashville 423-535-6307 731-664-4127 423-854-6036 865-588-4644 901-544-2399 615-386-8630 BlueCross BlueShield of TN ATTN: Provider Relations 801 Pine Street, 1TC Chattanooga, TN 37402 BlueCross BlueShield of TN ATTN: Provider Relations

51 Stonebridge Blvd. Jackson, TN 38305

BlueCross BlueShield of TN ATTN: Provider Relations 801 Sunset Drive, Bldg C Johnson City, TN 37604 BlueCross BlueShield of TN ATTN: Provider Relations 6305 Kingston Pike Knoxville, TN 37919 BlueCross BlueShield of TN ATTN: Provider Relations 85 N. Danny Thomas Blvd-2MD Memphis, TN 38103

BlueCross BlueShield of TN ATTN: Provider Relations 3200 West End Ave., Ste 102 Nashville, TN 37203

Bureau of TennCare 1-866-311-4287

(Family Assistance Service Center)

Bureau of TennCare 310 Great Circle Rd Nashville, TN 37243 Provider Service Line

• Eligibility • Claims Status BlueCare 1-800-468-9736 TennCareSelect 1-800-276-1978

Available Monday - Friday (except between

7 and 9 p.m. when eligibility information is being updated) and Saturday and Sunday from 8 a.m. to 4 p.m. The system is not available on Thanksgiving Day or Christmas Day.

NurseLine

• Health Information and Education

• Health Care Counseling • Telephone Triage BlueCare 1-800-468-9736 TennCareSelect 1-800-276-1978 Direct Line 1-800-262-2873 Available 24-hours-a-day, 7-days-a-week Rev 12/07

Important Contact Numbers

(cont’d)

Contact

Toll-Free Number

Address/Description

BlueCross BlueShield of Tennessee Health Information Tape Library

1-800-999-1658 Health Information Library available 24-hours-a-day.

TennCare Solutions Unit 1-800-878-3192

Fax 1-888-345-5575

TennCare Solutions Unit P.O. Box 593

Nashville, TN 37202-0593

TennCare Pharmacy Program (Prior Authorizations)

1-866-434-5524

Fax 1-866-434-5523

First Health Services Attention: TennCare PA

14955 Heathrow Forest Parkway Houston, TX 77032

Dental 1-888-554-5542 Doral Dental Services of TN

12121 N. Corporate Parkway Meguon, WI 53092 eBusiness Solutions Technical Enrollment Local 423-535-5717 Local 423-535-5174 BlueCross BlueShield of Tennessee eBusiness Solutions 801 Pine Street Chattanooga, TN 37402

Fraud & Abuse Hotline

BlueCross BlueShield of Tennessee

Bureau of TennCare

1-800-496-9600

1-800-433-3982

To report suspected fraudulent activity.

Outpatient/Inpatient Behavioral Health services

Premier Behavioral Health Systems of Tennessee

Tennessee Behavioral Health, Inc.

1-800-325-7864

1-800-447-7242

To arrange mental

health/substance abuse services. Note: All inpatient/outpatient mental health facility care and psychiatric consultations require prior authorization from the BHO.

Case Management 1-800-225-8698

Fax (Local) 423-535-8380

Disease Management 1-888-416-3025

Fax 1-800-421-2885

Transplant Case Management 1-888-207-2421

Fax 1-800-421-2885

E. BlueCare Appeals Quick Reference Guide

BlueCare Provider and Member appeals are processed at separate locations. Using the correct address to file appeals improves handling efficiency and expedites responses. The following matrix is designed to provide direction in determining the correct appeal address:

APPEAL REASON APPEAL REQUESTER APPEAL ADDRESS

Not Medically Necessary denials, e.g., admissions, facility continuation care, and elective surgery for Members residing in these community service areas:

(See Section VIII. L. Utilization Management Provider Appeals Process)

Provider Government Services UM Appeals Department

Attn: BlueCare/TennCareSelect UM Appeals Supervisor - 2G

BlueCross BlueShield of Tennessee P.O. Box 180202

Chattanooga, Tennessee 37402

Fax Number 1-888-357-1916

Issues regarding claims, accounts receivable, denials for non-covered services, denials for no referral, member benefits, Member eligibility, and referral status

(See Section XII. A. Administrative Inquiry)

Provider BlueCare or TennCareSelect Customer Service

PO Box 182277

Chattanooga, TN 37422-7277

Denials that are upheld through the above noted processes may be submitted through the Provider Dispute Resolution process.

(See Section XII. B. Provider Dispute Resolution Procedure)

Provider Provider Appeals Coordinator Provider Network Management Div. BlueCross BlueShield of Tennessee 801 Pine Street

Chattanooga, TN 37402-2555

Denied, reduced, suspended, or terminated benefits of covered service for Members residing in all Regions

Member (Includes provider-assisted with member signature) TennCare Solutions PO Box 593 Nashville, TN 37202-0593 Fax Number 1-888-345-5575 Rev 06/08

II. How to Identify a BlueCare Member

A. Determining Eligibility

BlueCare covers persons eligible for Medicaid under Tennessee’s Title XIX State Plan for Medical Assistance. Persons who meet one of the following criteria are eligible for BlueCare Medicaid:

¾ Tennessee residents determined to be eligible for Medicaid in accordance with Chapter 1240-3-3-.03 of the rules of the Tennessee Department of Human Services – Division of Medical Services;

¾ Individuals who qualify as dually eligible for Medicare and Medicaid;

¾ Uninsured women who are Tennessee residents, under the age of sixty-five (65), U.S. citizens or qualified aliens, are not eligible for any other category of Medicaid, and have been diagnosed as the result of a screening at a Centers for Disease Control (CDC) site with breast cancer or cervical cancer, including pre-cancerous conditions, and whose income does not exceed 250% poverty; or

¾ Tennessee residents determined eligible for SSI benefits by the Social Security Administration. Provides health coverage for Tennessee residents whom:

¾ Are uninsured, do not have access to group health insurance (either directly or indirectly through another family member), and whose income is less than the poverty level for which federal and state appropriations are made available;

¾ Are uninsured, do not have or have access to group health insurance (either directly or indirectly through another family member), and have proven that he/she meets the appropriate Medical Eligibility criteria for his/her circumstances;

¾ Are uninsured children under age nineteen (19), whose family income is less than 200% of the poverty level, and whose parent(s) may have access to group health insurance but because of the cost cannot afford it, and who were enrolled in the TennCare Program as of December 31, 2001; or

¾ Had Medicare as of December 31, 2002 (but not Medicaid) and were enrolled in the TennCare Program as of December 31, 2001, and who continue to meet the definition of “uninsurable” in effect at that time.

Presumptive Eligibility for Breast/Cervical Cancer Group

Temporary Medicaid coverage is extended to uninsured women under age 65 who have been determined to have breast or cervical cancer, including precancerous conditions, through the Centers for Disease Control screening process. Presumptive eligibility grants full TennCare benefits for 45 days, beginning on the day the woman is enrolled in the presumptive eligibility program.

The presumptive eligible member will be given a Presumptive form completed by the Health Department to use as a temporary ID card until the MCO chosen can provide one. This form will state the effective and termination date of the 45-day coverage period as well as the MCO chosen.

In order to continue TennCare coverage beyond the 45-day period, the woman must complete an

application with the Department of Human Services (DHS) and be approved for enrollment into TennCare. When a BlueCare or TennCareSelect presumptive eligible member presents to the office of a participating practitioner covered services should be rendered. Practitioners should send their patients who have been diagnosed with breast or cervical cancer and without health insurance to the local health department to apply for presumptive eligibility.

Eligibility is maintained by the State of Tennessee, Bureau of TennCare. The Bureau of TennCare must approve all additions, deletions, or changes to the BlueCare eligibility file. The Bureau of TennCare updates TennCare eligibility files daily.

Effective July 1, 2001, if BlueCare verifies eligibility of an individual who is subsequently determined to have been ineligible at the time services were rendered, BlueCare shall recover payments made to BlueCare Providers for services rendered to that Member no more than ninety (90) days prior to the date that

BlueCare was notified the individual Member was ineligible. Such recovery will be based upon actual claim payment date. If the Member Benefit Agreement contains a lesser retroactive Member termination clause (e.g. seven (7) days), such clause shall apply. Notice of recovery will be sent to the Provider no more than thirty (30) days from the date BlueCare was first notified of Member ineligibility.

Presumptive Eligibility for Maternity

See Section IX. OB Services for information regarding presumptive eligibility for pregnant women. Verifying Eligibility

Some patients presenting with commercial or Medicare coverage may also have TennCare coverage. TennCare Standard Operating Procedure (TSOP) 14 states in part “providers may not seek payment from a TennCare enrollee if the provider failed to ascertain the existence of TennCare eligibility or pending eligibility prior to providing non-emergency services”.

Based on this rule, TennCare Solutions Unit (TSU) recommends providers conduct an eligibility search on all patients to identify any existence of TennCare coverage prior to rendering services. TennCare eligibility can be verified using the Bureau of TennCare’s online services at http://www.tennesseeanytime.org/tncr/ or by calling 1-800-852-2683. (See also Section IV. D. of this Manual for additional eligibility contact

information.)

Eligibility information for undocumented aliens will not be reflected on the Tennessee Anytime Web site. Providers should call TennCareSelect at 1-800-276-1978 to verify eligibility. Medical emergency services (inpatient and outpatient), along with maternity services are the only benefits available to the

undocumented alien population. Maternity benefits consist of labor and delivery services only.

B. Member Liability

Federal and Tennessee law prohibit Providers participating in the TennCare program from billing or attempting to collect payment from TennCare Enrollees for TennCare-authorized and/or Covered Services other than applicable copayments and special fees permitted by TennCare Rules and regulations 1200-13-12-.08, 1200-13-13-.08 (Medicaid) or 1200-13-14-.08 (Standard), found at

http://state.tn.us/tenncare/forms/pro08001.pdf. As directed by the Bureau of TennCare Office of Contract Compliance and Performance, Volunteer State Health Plan, Inc. (VSHP), as a TennCare Managed Care Contractor, shall ensure that the participating Provider ceases all actions to bill a BlueCare and/or

TennCareSelect enrollee by issuing a “Cease to Bill Notice” to the Provider. In addition, the Provider must confirm, in writing, to VSHP that he/she has stopped or agrees to stop billing the TennCare Enrollee. Providers may seek payment from BlueCare Members only in the following situations:

1. If the services are not covered by the TennCare program, prior to providing the services, the Provider informed the Enrollee the services were not covered. The Provider is required to inform the Enrollee of the non-Covered Service and have the Enrollee acknowledge the information. If the Enrollee still requests the service, the Provider shall obtain such acknowledgment in writing prior to rendering the service (see Section VII. Financial Responsibility for the Cost of Services, for the recommended acknowledgement form).

Regardless of any understanding worked out between the Provider and the Enrollee about private payment, once the Provider bills an MCO for the service that has been provided, the prior arrangement with the Enrollee becomes null and void without regard to any prior arrangement worked out with the Enrollee; or 2. If the Enrollee’s TennCare eligibility is pending at the time services are provided and the Provider informs the

Enrollee they will not accept TennCare assignment whether or not eligibility is established retroactively. Regardless of any understanding worked out between the Provider and the Enrollee about private payment, once the Provider bills an MCO for the service that has been provided, the prior arrangement with the Enrollee becomes null and void without regard to any prior arrangement worked out with the Enrollee; or Rev 06/08

3. If the Enrollee’s TennCare eligibility is pending at the time services are provided, however, all monies collected, except applicable TennCare cost share amounts must be refunded when a claim is submitted to an MCO if the Provider agreed to accept TennCare assignment once retroactive TennCare eligibility was established. (The monies collected shall be refunded as soon as a claim is submitted and shall not be held conditionally upon payment of the claim).

Providers may not seek payment from BlueCare Members when:

1. The Provider knew or should have known about the Member’s TennCare eligibility or pending eligibility prior to providing services.

2. The claim(s) submitted to BlueCare for payment was denied due to Provider billing error or a BlueCare claims processing error.

3. The Provider accepted BlueCare assignment on a claim, and it is determined that a primary plan paid an amount equal to or greater than the TennCare allowable amount.

4. The Provider failed to comply with TennCare policies and procedures or provided a service, which lacks Medical Necessity or justification.

5. The Provider failed to submit or resubmit claims for payment within the time periods required by BlueCare.

6. The Provider failed to ascertain the existence of TennCare eligibility or pending eligibility prior to providing non-emergency services. Even if the Member presents another form of insurance, the Provider must determine whether the Member is covered under TennCare.

7. The Provider failed to inform the Member prior to providing a service not covered by TennCare that the service was not covered and the Member may be responsible for the cost of the service. Services, which are non-covered by virtue of exceeding limitations, are exempt from this requirement. 8. The Member failed to keep a scheduled appointment(s).

9. The Provider failed to follow Utilization Management (UM) notification or prior authorization policies and procedures.

C. ID Card

Each BlueCare Member receives a plastic BlueCare ID card reflecting the Member’s Primary Care Practitioner (PCP) name and effective date. A new ID card is issued each time the Member changes his or her PCP. If the Member is Medicare/Medicaid dual eligible, the BlueCare ID card will reflect the following eligibility information:

• Medicare Part A Only – PCP’s name (reflected in PCP field) and effective date • Medicare Part B Only - “Medicare/Medicaid” (reflected in PCP field)

• Part A and Part B - “Medicare/Medicaid” (reflected in PCP field)

Note: Medicare/Medicaid dual-eligible Members with Part B or Part A and B are not required

to seek care from a BlueCare PCP for their care, except for Medicare non-Covered Services that are BlueCare-covered.

The ID card provides the following information:

Member name; Member ID number;

Effective date (the date the Primary Care Practitioner assignment is effective); Assigned Primary Care Practitioner;

Member liability; Member’s Date of Birth; Prior authorization information; TennCare eligibility classification: and Benefit Package Indicator (BPI)

A sample copy of the BlueCare ID card follows:

Benefit Package Indicators are defined as:

BPI Description

A A child under age 21, who does NOT have Medicare

B A TennCare Medicaid adult age 21 and older who does NOT have Medicare and who does not get long-term care that TennCare pays for

C A TennCare Standard adult age 21 and older

D A TennCare Medicaid adult age 21 and older who does NOT have Medicare and who is Medically Needy (Spend Down)

E A TennCare Medicaid adult age 21 and older who does NOT have Medicare and who gets long-term care that TennCare pays for

F A TennCare Medicaid adult age 21 and older who does NOT get long-term care that TennCare pays for, and who has Medicare

G A TennCare Medicaid adult age 21 and older who gets long-term care that TennCare pays for, and who has Medicare

H A child under age 21 who has Medicare Rev 06/07

Last two digits of ID Number Identifies Eligibility

Classification

Benefit Package Indicator

Identifies Services Member Receives The letter A, B, C, D, E, F, G, or H will be reflected in the "Benefit" field (see legend below)

Identifies Whether Medicaid or Standard Benefits Apply Standard benefits ID card will reflect copayment amounts

TennCare eligibility classification is defined as: Classificatio

n Number

Classification Type Medicaid/Standard

17 Medicare/Medicaid Dual Eligible Medicaid

27 Uninsurable/Disabled Standard

37 Disabled Uninsured Standard

47 Disabled Medicaid Medicaid

67 Medicaid Other Medicaid

77 Uninsured/Disabled with Medicare Standard

87 Uninsured Other Standard

97 Uninsurable Standard

∗

If a Member presents without his or her ID card, Providers should check eligibility by: Checking his or her most recent BlueCare Member Listing (if a Primary Care Practitioner); Calling the BlueCare/TennCareSelect Provider Service Line;

Calling the Automated Information Lines;

Accessing e-Health Services® via BlueAccess on the company Web site, www.bcbst.com; or Calling the toll-free Family Assistance Service Center 1-866-311-4287.

D. How To Use BlueCare/TennCareSelect Provider Service Line

Current BlueCare Member eligibility and claims status information are available by calling the Provider Service Line at BlueCare 1-800-468-9736 or if TennCareSelect Member, 1-800-276-1978. Note: Eligibility information reflects the name of the Member’s assigned PCP and date he/she became effective with that PCP.

These lines are available Monday – Friday, 8 a.m. to 6 p.m. (ET). The automated information line is available to check Member eligibility and claims status. This line is available Monday through Friday (except between 7 and 9 p.m. when eligibility information is being updated) and Saturday and Sunday from 8 a.m. to 4 p.m. (ET). The system is not available on Thanksgiving Day or Christmas Day.

Providers may also verify the following information via the eligibility lines: Copayment amount/Coinsurance percentage;

Maximum out of pocket, if met;

Name of assigned Primary Care Practitioner; Name of Behavioral Health Organization (BHO); Verification of Medicare or other insurance; and/or

Claim status information (charged amount, paid amount and remittance date).

When accessing the eligibility lines, enter the numerical portions of the Member ID and follow the voice prompts. When obtaining eligibility information for a specific date of service, the service date must be entered in the appropriate format (Example: January 3, 2004 = 010304).

Access problems with the eligibility lines should be directed to the appropriate BlueCare or TennCareSelect Provider Service Line listed above.

E. Electronic Data Interchange (EDI)

The Bureau of TennCare mandated that all TennCare managed care organizations (MCOs) electronically provide claims status and capitation payment information to its participating Providers.

BlueCare has exceeded the mandated requirements by also implementing several other Electronic Data Interchange (EDI) processes to provide additional information via BlueAccess, the secure section of BlueCross BlueShield of Tennessee’s Web site and through our E C Gateway Bulletin Board System.

BlueAccess

BlueAccess includes e-Health Services® (benefits, claims and authorization information), as well as access to Primary Care Practitioner Member rosters, Provider remittance advices and much more.

First time users must register to access these online services. Just click on the registration tab located in the BlueAccess login box on the Home Page of our company Web site, www.bcbst.com and follow the easy registration instructions.

E C Gateway Bulletin Board System (BBS)

The EC Gateway Bulletin Board System is a communications system for use by Providers, billing agents, vendors, and groups to submit and receive electronic transactions.

Specific user IDs and passwords are assigned to employees designated by the Provider/vendor for use in sending or retrieving files. Submitters can access the mailbox, at their convenience, and download such things as electronic remits, confirmation reports, responses to claims status requests and much more.

For more information on BlueAccess and the EC Gateway Bulletin Board System, please call BlueCross BlueShield of Tennessee eBusiness Solutions at 423-535-5717.

III. BlueCare Primary Care Member Assignment

A. Care Management Fee

In addition to routine service fees, Primary Care Providers (PCPs) are eligible to receive additional compensation (Care Management Fee) for services they provide to their assigned Members.

Details of the Care Management Fee Program include:

1. Compensation of PCPs for services rendered to improve BlueCare Member health status through preventive or other risk assessment efforts, to coordinate BlueCare Members’ care and for participation in BlueCare’s Quality Improvement Program.

2. Compensation paid to PCPs who reach and maintain assignment of 300 Members.

3. Compensation paid when a minimum of 300 Members are assigned, up to a maximum of 1,500 Members per Primary Care Provider (PCP Physician Extenders are limited to a maximum of 1,250 assigned Members and paid the care management fee accordingly).

4. Care Management Fee payment eligibility is reviewed quarterly; PCPs assigned less than 300 Members at the quarterly review will not receive the care management fee for the following quarter.

NOTE: Errors detected in the Care Management Fee reimbursement should be documented,

including PCP name, provider number and/or National Provider Identifier (NPI), phone number and provider office contact person. Mail or send by facsimile to:

BlueCross BlueShield of Tennessee Provider Management 3TC 801 Pine Street

Chattanooga, TN 37402 Fax (423) 535-5808

B. BlueCare Care Management Fee Payment Process

Eligibility List for Monthly Management Fee

PCPs eligible for the Care Management Fee (minimum 300 assigned Members) receive a monthly eligibility list with their check. The eligibility list documents all activity reflected in the accompanying check. The checks and reports are produced the 2nd or 3rd Friday of each month and mailed within 2-3 weeks. The Care Management Fee paid amount is calculated Member months* x $1.50 = paid amount. *Member months reflect current membership and any retroactivity. Providers having electronic capabilities may also access this report the second Friday of each month through BlueCross BlueShield of Tennessee’s Electronic Bulletin Board. The report is broken down into four components and reflects the following information:

1. Eligibility List for Monthly Capitation

Lists demographic and other information about each Member for which the Provider is eligible to receive the Care Management Fee.

2. Eligibility Adjustment List for Monthly Capitation (As determined by the Bureau of TennCare) Lists information about any adjustments made to the Provider’s Care Management Fee, e.g., if a Member is determined to be eligible retroactively, the Provider will receive the Care Management Fee for the months of retroactive eligibility. If a Member is terminated, the care management fee will be deducted for the months the Provider should not have received the Care Management Fee for the Member.

3. Provider Member Months by Actuarial Class

Separates Members into classes based on age and gender. The amount received is calculated based on member months, not the number of people in each classification.

4. Provider Fund Breakdown

Summarizes the total number of enrollees for whom the Care Management Fee was paid and reflects the total amount of payment due the Provider.

A sample eligibility listing and legend follows:

Eligibility List for Monthly Capitation

Payee #: This field contains the Provider’s BlueCare number. Directly below this number, the Provider’s address is listed.

Enrollee: This field contains the BlueCare identification number of each member assigned to the Provider.

Last name: This field contains the Member’s last name.

First name: This field contains the Member’s first name and middle initial. Age/Sex: This field lists the Member’s age and sex. If the Member is less

than 1 year of age, the Member’s age is listed in days rather than years.

Coverage Dates: This field contains the dates for which the care management

fee was calculated.

BP: This field is used in commercial insurance only and does not apply to TennCare population. All BlueCare Members have the

same benefits.

Physician (under ALLOCATION) This field contains the amount the Provider will be paid for

each eligible Member.

Phy W/H (under ALLOCATION) This field is not used by BlueCare. Trans W/H (under ALLOCATION) This field is not used by BlueCare. Alt Provider (under ALLOCATION) This field is not used by BlueCare Eligibility Adjustment List for Monthly Capitation

Adjustment: This field lists the reason an adjustment was made for each Member. The reason is coded. The codes are listed in the bottom left-hand corner of the report.

Provider Member Months by Actuarial Class

Class: This field separates Members into categories based on age and sex. Months: This field contains the number of months Members in a

particular category that have been assigned the Provider.

Count: This field lists the number of Members in each category assigned to the Provider.

Provider Fund Breakdown

Number of Enrollees: This field list the number of Members for whom a care management fee was paid.

Paid Funds: This fields lists the amount paid to the Provider. Total Funds: This field lists the amount paid to the Provider.

SAMPLE COPY ONLY

BLUE CROSS AND BLUE SHIELD OF TENNESSEE - TENNCARE PAGE#: 1 801 PINE STREET

CHATTANOOGA, TN 37402

Eligibility List for Monthly Capitation Run Date: 06/15/97 For Period 07/1997 Beginning JUL 01,1997 Ending JUL 31,1997

PAYEE#: 105362 PROVIDER BANK CODE: 04 DOE, JANE, MD

801 PINE STREET CHATTANOOGA, TN 37402

ALLOCATION

--- ENROLLEE LASTNAME FIRSTNAME AGE/SEX COVERAGE DATES BP PHYSICIAN PHY W/H TRANS W/H ALT PROV --- --- --- --- --- ---- --- 51077491501 ARNOLD MEGAN B 4/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 41978373401 ARNOLD ROBERT L 3/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 31479767601 BARNES ZACHARY D 1/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 35384176501 BROOKS DANIEL H 7/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 41971620601 BROOKS KIM A 6/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 40075235701 BUCKELS CINDY R 4/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 41253340401 COBB TYLER L 9/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 41153765901 COBB KRISTEN M 9/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 88842050101 COBBLE HUNTER A 176D/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 41279383701 CORBY ELIZABETH N 1/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 41081425801 DRAKE NATHAN A 204D/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 41041582901 DRINNON KATHY D 17/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 41975083201 EVANS CALEB D 3/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 41447971901 FEEZELL MELISSA M 13/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 55941285501 FILLERS BEVERLY A 14/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 40812048201 GENTRY MEGAN B 7/F 07/01/97-07/31/97 25 1.50 .00 .00 .00 44429820601 GENTRY JEREMY S 19/M 07/01/97-07/31/97 25 1.50 .00 .00 .00 43915553801 GILBERT CHRIS 17/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 45563107601 GREENE DUSTIN E 9/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 40929785401 GREGG BILLY C 19/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 46765434701 GREGG DOROTHY J 7/F 07/01/97-07/31/97 10 1.50 .00 .00 .00 47139481201 GRIFFIN TIMOTHY E 14/M 07/01/97-07/31/97 04 1.50 .00 .00 .00 41471102901 GUNTER AMBER N 5/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 45659376301 GUNTER ANGELA N 8/F 07/01/97-07/31/97 00 1.50 .00 .00 .00 51465009301 STALNAKER TIM M 7/M 07/01/97-07/31/97 00 1.50 .00 .00 .00 --- --- --- --- 37.50 .00 .00 .00 ========== ========== ========== ==========

SAMPLE COPY ONLY

BLUE CROSS AND BLUE SHIELD OF TENNESSEE - TENNCARE PAGE#: 2 801 PINE STREET

CHATTANOOGA, TN 37402

Eligibility Adjustment List for Monthly Capitation Run Date: 06/15/97 For Period 07/1997 Beginning JUL 01,1997 Ending JUL 31,1997

PAYEE#: 105362 PROVIDER BANK CODE: 04 DOE, JANE MD 801 PINE STREET CHATTANOOGA, TN 37402 ALLOCATION Adjustment--- ENROLLEE LASTNAME FIRSTNAME AGE/SEX COVERAGE DATES BP RY ER PHYSICIAN PHY W/H TRANS W/H ALT PROV --- --- --- --- --- -- --- --- 51077491501 ARNOLD MEGAN B 4/F 06/01/97-06/30/97 00 PC 1.50 .00 .00 .00 41978373401 ARNOLD ROBERT L 3/M 06/01/97-06/30/97 00 PC 1.50 .00 .00 .00 31479767601 BARNES ZACHARY D 1/M 06/01/97-06/30/97 00 PC 1.50 .00 .00 .00 35384176501 BROOKS DANIEL H 7/M 07/01/97-07/31/97 00 RT -1.50 .00 .00 .00 41971620601 BROOKS KIM A 6/F 07/01/97-07/31/97 00 RT -1.50 .00 .00 .00 40075235701 BUCKELS CINDY R 4/F 07/01/97-07/31/97 00 RT -1.50 .00 .00 .00 41253340401 COBB TYLER L 9/M 06/01/97-06/30/97 00 PC 1.50 .00 .00 .00 41153765901 COBB KRISTEN M 9/F 06/01/97-06/30/97 00 PC 1.50 .00 .00 .00 47139481201 GRIFFIN TIMOTHY E 14/M 07/01/97-07/31/97 04 MM 1.50 .00 .00 .00 41471102901 GUNTER AMBER N 5/F 07/01/97-07/31/97 00 RT -1.50 .00 .00 .00 45659376301 GUNTER ANGELA N 8/F 07/01/97-07/31/97 00 PC 1.50 .00 .00 .00 51465009301 STALNAKER TIM M 7/M 07/01/97-07/31/97 00 VD -1.50 .00 .00 .00 --- --- --- --- 3.00 .00 .00 .00 ========== ========== ========== ======= Code Adjustment Reason

---- --- RYPC DEFAULT PCP CHANGE RYRT NEW ID CARD GENERATED

RYMM MASS MOVES OF MEMBERS TO AN HMO GROUP AND DIVISION RYTM CONTRACT TERMINATED BY THE STATE

RYMA MEMBER MANUALLY LOADED RY?? Unidentified RY code

RY01 CHRONIC LONG-TERM DIAGNOSIS RY06 HIGH COST TECHNOLOGY PROCEDURE

RYPL PCM ASSIGNED THROUGH PROVIDER PATIENT LISTINGS RY04 IDENTIFIED POSSIBLE DRUG SEEKER

RYVD VOID