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Looking for help? Check out these FAQs from providers like you.

CHIP Provider Enrollment

Why do I need to enroll?

Enrollment in Provider Reimbursement and Operations Management Information System (PROMISe™) is a federal requirement. Per the Patient Protection and Affordable Care Act (PPACA), if you render, order, refer, prescribe, or bill for items or services for CHIP members, you must enroll.

I am already enrolled in the Pennsylvania Medical Assistance (MA) program, do I need to enroll again?

No. If you have already enrolled in the MA program, you do not need to enroll again. However, if you see CHIP patients from multiple locations, you must enroll each location. If you are enrolled for another state’s Medicaid, CHIP, or Medicare program, you must enroll with the Pennsylvania Department of Health Services (DHS). If you are seeing CHIP patients and billing various Managed Care Organizations (MCOs), you are only required to enroll once. You do not need to enroll for each MCO.

Will enrolling require me to accept MA?

No. If you have already enrolled in the MA program, you do not need to enroll again. However, if you see CHIP patients from multiple locations, you must enroll each location. If you are enrolled for another state’s Medicaid, CHIP, or Medicare program, you must enroll with the Pennsylvania Department of Health Services (DHS). If you are seeing CHIP patients and billing various Managed Care Organizations (MCOs), you are only required to enroll once. You do not need to enroll for each MCO.

How do I enroll?

Enroll here. Select a provider type based on your current scope of practice and follow on-screen prompts.

Does it cost anything to enroll?

PPACA requires DHS to charge each provider a $560 application fee. Examples of provider types subject to the fee are rehabilitation facilities, home health agencies, hospices, FQHC/RHC/IMSC clinics, pharmacies, DME/medical supplies, transportation (i.e., ambulance or life support), laboratories, residential treatment facilities, inpatient facilities, ambulatory surgical centers, and extended care facilities. If you already paid a fee to Medicare or another state’s CHIP or MA program, you will not be charged again.

Do I need to enroll each location/address where I practice?

Yes. Each location/address at which you practice must be separately enrolled.

What will happen if I do not enroll?

If enrollment has not been completed prior to March 1, 2018, claims received from your practice may be denied. In addition, your practice may be terminated from our CHIP provider network.

How will claims submission change to include this information?

Effective January 1, 2018, when submitting claims, the Master Provider Identifier (MPI) number registered with DHS should be submitted in the “Remarks” field of all claims. This 13-digit MPI number is comprised of the following information:

  • 9-digit PROMISe ID + 4-digit Service Location Identifier

No hyphens or spaces should be used.

Example: 1234567891234
In addition, you are required to include the National Provider Identifier (NPI) on the claim for any ordering, referring, or prescribing providers associated with the claim. Claims submitted without this information will be denied.

What will happen to claims submitted while my application is pending approval from DHS?

Claims for service on or after March 1, 2018 will pend for 60 days from the date of service.

If a PROMISe ID is not obtained within the 60-day window, claims will be denied. If a claim is denied while pending approval of a PROMISe ID, Capital Blue Cross requests that the claim be corrected via an adjustment to the denied claim. A new claim should not be submitted in this instance.

Where can additional questions on the enrollment process be directed?

Please contact DHS’ Provider Enrollment department at 800.537.8862.

CHIP coverage is issued by Keystone Health Plan® Central through a contract with the Commonwealth of Pennsylvania. Capital Blue Cross Dental and Blue Cross Vision are issued by Capital Advantage Assurance Company®. Keystone Health Plan Central and Capital Advantage Assurance Company are subsidiaries of Capital Blue Cross. All are independent licensees of the Blue Cross Blue Shield Association. Communication issued by Capital Blue Cross in its capacity as administrator of programs and provider relations.

Notice of Medicare Non-Coverage (NOMNC) Questions

What is an NOMNC?

A Notice of Medicare Non-Coverage (NOMNC) is approved by the Office of Management and Budget (OMB) to inform Medicare members in writing that their Medicare health plan and/or provider are terminating their covered Skilled Nursing Facility (SNF), Home Health (HH), or Comprehensive Rehab Facility (CORF) care. All Medicare enrollees receiving covered SNF, HH, or CORF services must receive an NOMNC before services end—even if they agreed that services should end. This is a Centers for Medicare & Medicaid Services (CMS) requirement.

When should an NOMMNC be delivered?

Healthcare providers are required to deliver the NOMNC no later than two calendar days before the enrollee’s covered services end. It covers critical information about his or her right to an independent review of the termination and fulfills CMS requirement 42 CFR 422.624 (b)(2). 

Where can an NOMNC form be obtained?

Find NOMNC forms and instructions to use them here.

When is an NOMNC not required?

NOMNCs are not required in the following instances:

  • The Medicare enrollee never received Medicare-covered services from as SNF, HH, or CORF.
  • The Medicare services are being reduced.
    • Example: An HH was providing physical therapy and occupational therapy, and the occupational therapy is discontinued.
  • The Medicare enrollee is moving to a higher level of care.
    • Example: Enrollee is moving from HH to SNF care.
  • The Medicare enrollee has exhausted his or her benefits.
    • Example: Enrollee has reached 100 days in an SNF.
  • The Medicare enrollee ends the care on his or her initiative.
    • Example: Enrollee decides that he or she no longer needs HH care.
  • The Medicare enrollee transfers to another provider at the same level of care.
    • Example: Enrollee decides to receive HH care from a different agency/provider.
  • The Medicare enrollee discontinues care for business reasons.
    • Example: HH agency refuses to go to enrollee’s home due to hazardous living conditions.

Who is responsible for obtaining signoff on an NOMNC?

Effective April 3, 2018, if the Medicare healthcare provider makes the decision to terminate SNF, HH, or CORF services, they are responsible for NOMNC delivery and enrollee signature.

If Capital Blue Cross makes the decision that an enrollee’s services are no longer medically necessary, we will issue the NOMNC to the provider at least two calendar days before coverage ends. The provider is then responsible for the enrollee’s signature.

Are there specific requirements when filling out an NOMNC form?

Yes.

Do:

  • Complete NOMNC forms using a font size equivalent to Times New Roman, 12 pt.
  • Ensure the CMS form number and OMB control number are displayed on the notice.
  • Include accurate dates of service and provider demographic information (i.e. provider name, address, and telephone number of provider delivering the form).
  • Include enrollee’s medical record number or identification number. Health Insurance Claim Numbers (HICN) should not be used.
  • Document the type of services ending (i.e., SNF, HH, CORF services).
  • Document the exact date services will end.
  • Document the correct Quality Improvement Organization (QIO) information.
  • Document the plan contact information.

Don’t:

  • Modify the NOMNC form in any way, including the font. 
  • Delete any form language, including the CMS form number or OMB control number. These must appear on every NOMNC form.
  • Use the enrollee’s HICN where the enrollee’s ID is requested.
  • Provide an NOMNC when it is not required.

Where should signed NOMNC forms be retained?

Original copies of the signed/dated NOMNC forms should be retained in the enrollee’s file.

What if a enrollee or enrollee’s representative refuses to sign?

If an enrollee or his or her representative refuses to sign and date the NOMNC, a note stating “the enrollee refused to sign the notice” should be made in the enrollee’s file.

According to CMS guidance , Medicare Advantage (MA) plans and providers are required to develop procedures to use when the enrollee is incompetent or incapable of receiving the notice, and the provider cannot obtain the signature of the enrollee’s representative through direct personal contact.

What Quality Improvement Organization (QIO) phone number should be utilized when services are provided outside the state of Pennsylvania?

When providing SNF, HHC, or CORF services outside of the state of Pennsylvania, providers should utilize the QIO phone number provided for the state where services are being provided.

Medical Policy 3.016 - Drug Infusion Site of Service

What is the purpose of this policy?

The purpose of the medical policy is to ensure the infused medications (medications usually administered intravenously) included in the policy will be administered in the most appropriate site of care. This allows Capital Blue Cross to ensure our members are getting appropriate levels of care at an affordable cost. Medication included in the medical policy will no longer be authorized for administration in a hospital setting unless medically necessary.

What medications are impacted by this policy?

The following medications are the only ones impacted at this time:

  • Infliximab Products (Remicade & Inflectra)
  • Natalizumab (Tysabri)

What is considered a less intensive site of care?

Capital Blue Cross considers the most appropriate site of care to be an outpatient infusion center, physician’s office, or a home infusion service. Unless medically necessary, Capital Blue Cross will no longer be authorizing administration of these medications in a hospital setting.

What is a hospital setting (hospital outpatient or hospital affiliated infusion suite)?

A hospital outpatient setting or a hospital-affiliated infusion suite is expected to have immediate access to specific services of a medical center/hospital setting, including having emergency resuscitation equipment and personnel (ACLS protocol), emergency services, and inpatient admission or intensive care, if necessary.

When is it medically necessary to have these medications administered in a hospital setting?

Capital Blue Cross may authorize administration in a hospital setting when:

  • All non-hospital outpatient settings are greater than 10 miles further from the Member’s home than the hospital outpatient setting AND
  • There are no home infusion services near a Member’s home

OR

  • There is clinical documentation that home infusion would present an unnecessary health risk, including:
    • Clinical documentation of a severe or potentially life-threatening adverse event during or following infusion of the prescribed drug, and the adverse event cannot be managed through pre-medication in the home or office setting.
    • There is clinical documentation of a significant comorbidity (e.g., cardiopulmonary disorder) or concerns regarding fluid overload status that precludes treatment at an alternative less intensive site of care.
    • Clinical documentation of unstable vascular access.
    • A new prescription is begin initiated.
    • Therapy is being reinitiated after the member has been off therapy for at least six (6) months.

Does the existing preauthorization criteria still need to be met in order to obtain either of the medications on the policy?

Yes, Capital Blue Cross will still maintain a medical policy for these medications. Criteria within those policies must still be met in order to obtain a pre-authorization for the medication. Criteria for the medications can be located in the following medical policies: Medical Policy 2.133 Infliximab Products Medical Policy 2.127 Natalizumab (Tysabri)

When does this policy become effective?

This policy will be effective for services provided on or after November 1, 2017.

Will Capital Blue Cross honor all authorizations provided before the implementation of this medical policy?

Yes, Capital Blue Cross will honor all authorizations given prior to the implementation of the medical policy. All authorizations or authorization renewals requested by your physician on or after November 1, 2017 will be subject to the criteria within the new medical policy.

To which lines of business will this policy not apply?

This policy does not apply to Federal Employee Program (FEP), Medicare Advantage HMO, or Medicare Advantage PPO.

What does year-round medical record data collection for quality reporting mean?

Capital Blue Cross collects medical record data for Healthcare Effectiveness Data and Information Sets (HEDIS®) using specifications by the National Committee for Quality Assurance (NCQA) and Risk Adjustment using specifications by the Centers for Medicare & Medicaid Services (CMS). HEDIS® is the most widely used and nationally accepted effectiveness of care measurement available, while Risk compares the wellness among members of a population and can predict future healthcare costs. In addition to helping us meet CMS requirements, HEDIS® and Risk medical record collection plays an important role in supporting the care you provide to your patients. Medical record collection allows visualization of current care status and the ability to engage your patients and increase compliance across the mandated requirements.

To meet HEDIS requirements and decrease the burden on health care providers during the annual hybrid medical record retrieval each spring, Capital Blue Cross will be requesting HEDIS medical records. Q4 retrieval will focus on a limited number of measures, including measures not included in annual HEDIS requests (known as administrative measures). The Q4 retrieval project does not replace current opportunities to submit medical records.

Who is Reveleer?

Reveleer, our contracted HEDIS vendor, offers a variety of medical record retrieval options for health plans. A representative from Reveleer, will contact practice’s office or facilities beginning in the fourth quarter of 2022 to request medical records. Reveleer, as a contracted business associate of Capital Blue Cross, will comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and compliance does not require signed consent for release of records for quality-related health care operations.

Since Reveller is the the authorized collection agent for Capital Blue Cross, we ask that you contact us directly with your questions by calling: Reveleer Provider Relations at 855.454.6182.

What is the difference between prospective collection vs. retrospective collection?

Prospective collection looks for documentation to closes gaps in care during the measurement year, retrospective HEDIS collection takes place in the spring collecting records for services completed in the previous year or earlier.

Can providers request reimbursement for records?

Providers are not to invoice Capital Blue Cross for medical records requested by us or our Members. Refer to Unit 2 (Medical Records Documentation Requirements) of the Provider Manual.

Participating providers agree to make available, at no charge, the medical records to us, the Commonwealth of Pennsylvania, CMS, or any other agency with accreditation, regulatory, or enforcement jurisdiction over us. Providers are not to invoice Capital Blue Cross for medical records requested by us or our Members.

Can providers request different avenues of retrieval?

Capital Blue Cross and the vendor will work with the provider to the method of retrieval that is least intrusive to the provider. Direct questions to Reveleer Provider Relations at 855.454.6182.

Fax the requested Medical Records to: 818.630.9374.

Mail the requested Medical Records hardcopy to this specific address:

Reveleer 
9450 SW Gemini Dr #78243 
Beaverton, Oregon 97008-7105

Mail Digital Media (e.g., CD's, thumb drives, etc.) to:

Reveleer 
6525 W. Campus Oval 
Suite 110 
New Albany, OH 43054

For additional information, please contact your Provider Engagement Consultant or visit our Provider engagement consultant look up tool and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.

Kidney Care Strive Health

Kidney Care – Strive Health Provider Brochure

Provider Brochure (CBC-04)

Who is Strive Health?

Strive is working with Capital Blue Cross to offer wrap-around services to your patients.

Which of my patients qualify for Strive?

Strive supports Capital Blue Cross members who have chronic kidney disease stages 3, 4, 5, and End-Stage Renal Disease.

What services does Strive provide for my patients?

Strive has a multi-disciplinary team of nurse practitioners, Registered Nurse care managers, dietitians, social workers and care coordinators.

Strive can offer your patients

  • Close coordination between Strive and patients’ other healthcare providers.
  • 24/7 access to a kind and dedicated team of clinicians.
  • Support with achieving their health care goals eligible for such as transportation and meal programs.
  • A personalized nutrition plan and coaching.
  • Education about their kidneys and their condition.
  • Appointment and care coordination.

How do our patients enroll in Strive?

Patients receive a call from Strive’s enrollment team to learn about the Strive program.

The ability to reference the patient’s provider is key to engaging patients.

Patients, providers and staff can also call us directly to enroll at 717.345.9117

I know a patient who would benefit from Strive. Can I refer them?

Absolutely! We will send a list of eligible patients to a contact at your practice. If any of these patients would especially benefit from our services, feel free to give them our number or reach out to us with these patients’ names and let them know to expect a call

How do we make sure that Strive’s interactions with our patients support our existing care plan?

Strive is designed to support your care plan. ractices will often grant read-only electronic health record access so that the Strive team can see the latest care plan whenever they interact with a patient.

If that is not possible, we will request medical records before our initial visits.

If you have any further questions, please contact:
Allea Donaldson
Sr. Manager Provider Integration adonaldson@strivehealth.com
828.674.1889

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