Migration of Minnesota Health Care Programs (MHCP)

Appeals

Date identified: January 5, 2024

Date resolved: N/A

Appeals are being faxed to incorrect fax lines. Please submit appeals to the following fax numbers:

• To appeal the outcome of a processed claim, fax the appeal to (651) 662-6288
• To appeal the determination of a prior authorization, fax the appeal to (651) 662-6287

Availity Essentials Chat / Messaging

Date identified: February 14, 2024

Date resolved: TBD

Blue Cross strives to respond to e-messages submitted on Availity Essentials within 5 business days; however, due to higher receipts than expected, that turnaround time isn’t currently being met. Some staff has been temporarily reassigned to respond to MHCP e-messaging and additional staff has been hired. Blue Cross continues to work toward meeting a five business day turnaround time.

Please remember that any follow-up message submitted, such as requesting a status on your inquiry, resets your message submission date and will further delay a response. Also, any message sent, including a “Thank you” response, must be responded to and adds to the delay in responding to messages.

Blue Cross is providing frequent updates below regarding the submission date currently being worked to provide turnaround time expectations. 

As of 5/8/2024, Blue Cross is working on e-messages received on 5/3/2024.

Availity Essentials Remittance Viewer

Date identified: February 16, 2024

Date resolved: NA

If a provider is unable to view remits on Availity Essentials Remittance Viewer for MHCP claims, you can click here to manage access and add access to Blue Plus MHCP payer ID 00726. It is recommended that a provider be logged in to Availity Essentials prior to clicking this link.

Claims

Date identified: January 2, 2024

Date resolved: In-progress

Claims will be rejected if the member’s name does not match the name on the member ID card. An incorrect date of birth will also cause a claim to reject. Submit a new claim with the member’s name matching the name on the member ID card or a corrected date of birth. The member’s name can also be obtained by performing an eligibility and benefits inquiry on Availity essentials if a member card is not provided. 

Date identified: January 10, 2024

Date resolved: In-progress

Providers that are assigned an UMPI number and submit claims directly into Availity may find that their UMPI does not show up in the Payer Assigned Provider ID field on the Claim Entry screen form. These providers will need to go to “Manage My Organization” and verify that the new Payer name “BCBSMN BLUE PLUS MEDICAID” with payer ID 00726 is associated with the Payer Assigned Provider ID identifier and their UMPI number. If the Payer Assigned Provider ID is not listed, enter the provider’s UMPI.

Date identified: March 29, 2024

Date resolved: N/A

Blue Cross is receiving claims with more than one place of service submitted on the claim. The claim system is aligned with CMS processing rules and cannot process a claim submitted with more than one place of service. Claims submitted with multiple places of service will be denied. New claims must be submitted with a single place of service per claim.

Date identified: March 29, 2024

Date resolved: N/A

Units for a service or item provided on a single date of service should be submitted on a single claim line with multiple units. Claims submitted with units for a single date of service that are billed on multiple lines will be denied as duplicates. This logic does not apply if different modifiers are appended to the procedure code on each claim line. If a duplicate denial is received, a replacement claim may be submitted to combine the units on one claim line.

Date identified: March 29, 2024

Date resolved: TBD

An issue has been identified with acupuncture claims billed with diagnoses that should be allowed denying CO204 on the remittance which states, “This service/equipment/drug is not covered under the patient’s current benefit plan.” As of 4/22/24, the update to configuration is now complete. Claims requiring adjustments have been identified and are in queue for reprocessing.

Date identified: April 23, 2024

Date resolved: TBD

Blue Cross identified Outpatient Substance Use Disorder facility claims denying due to the use of Claim Frequency Code 1 and Patient Status Code 30. The claim edit that was causing this processing error has been corrected. Affected Claims have been identified and are in queue to be reprocessed. 

Date identified: April 23, 2024

Date resolved: N/A

Claims submitted with a social security number along with an SY qualifier were rejecting in error with a rejection reason of A8:562:85 / A8:128:85. The system has been corrected and providers may resubmit any impacted claims.

Claims Status

Date identified: January 3, 2024

Date resolved: In-progress

Please use Availity essentials to inquire about a claim’s status before contacting Blue Cross’s Provider Services. Claims processed by Amerigroup (AGP) can be viewed in Availity essentials under the payer “BCBSMN BLUE PLUS MEDICAID (00726).”
 

Eligibility and Benefits

Date identified: January 12, 2024

Date resolved: In-progress

The plan type (example: Families and Children, MNCare, MSHO) is not currently returned when an Eligibility and Benefits Inquiry is submitted on Availity essentials. Blue Cross is working toward that information being returned but no estimate for when it will be available can be provided at this time.

The plan type can be obtained by viewing the member’s card, contacting Provider Services, submitting a question via messaging within the Eligibility and Benefits Inquiry application on Availity essentials, or verifying on MN-ITS.

Prior Authorizations

Date identified: March 18, 2024

Date resolved: NA

Blue Cross is aware of discrepancies between MHCP member benefit booklets and the prior authorization lists regarding the services requiring prior authorization. Please use the published prior authorization lists and/or look-up tools to determine whether services require a prior authorization as the lists may change throughout the year. The benefit booklets will be updated for 2025. If you receive member inquiries or concerns, please direct them to contact Blue Cross member services at the phone number on the back of their ID card.

At this time, service types impacted include: acupuncture, chiropractic, circumcision, oral surgery/orthodontics and hospice.

Replacement Claims and Adjustment Requests

Date identified: April 10, 2024

Date resolved: N/A

Blue Cross has begun processing and remitting adjustments and replacement claims to validate the process. Providers will see larger volumes of adjustments starting with the remittances April 12th and continuing to process the pending adjustments over the following weeks. Work has been completed to ensure that these adjustments could be correctly processed and remitted. 

Provider bulletins and QuickPoints: To review Provider Bulletins and QuickPoints go to the Provider Forms and Publications page.

Webinar Slide Deck

• MHCP Migration Webinar Slide Deck

FAQs

• MHCP Migration Webinar FAQ
• MHCP Authorization and Availity Submissions

For all questions including eligibility and benefits, utilization management, or claims, contact Provider Services at (651) 662-9962 or toll free at 1-866-518-8448.

Availity Essentials Messaging may be sent after receiving a valid Eligibility & Benefits or Claim Status response on Availity Essentials.

Within Availity Essentials, select ‘BCBSMN BLUE PLUS MEDICAID (00726)’ from the Payer dropdown list. Use the new Payer ID code 00726 when submitting a 270/271 Electronic Data Interchange (EDI) transaction. If an Eligibility & Benefits EDI transaction is not submitted with the new Payer Name or ID code, a non-covered response may be received. Providers will need to correct the Payer Name or ID and resubmit the transaction.

New subscriber IDs were assigned for MHCP members effective January 1, 2024. All members received new ID cards.

The format of the subscriber IDs is the “product prefix” + “8” + MHCP’s Patient Master Index (PMI) number. 

• “MQG” is the prefix for Families and Children, MinnesotaCare, and Minnesota Senior Care Plus (MSC+) 
• “MQS” is the prefix for Minnesota Senior Health Options (MSHO)

Blue Cross previously advised that providers should submit claims using the subscriber ID effective on the date of service; however, using the subscriber ID effective for dates of service prior to 2024 is causing claims to reject as “Subscriber not found.” Providers should use the subscriber ID effective 1/1/2024, regardless of the date of service on the claim. If checking Eligibility and Benefits, the new subscriber ID will show dates of coverage prior to 2024, if applicable.

Sample ID cards are shown below. Please note that providers may see a slight variation after final testing and approvals are complete.

Blue Advantage (No Copay and with Copay)

MinnesotaCare (No Copay and with Copay)

MSHO

Claims, including original claims, replacement claims (frequency code 7) and void claims (frequency 8), submitted on or after January 1, 2024, regardless of date of service, must be submitted to Blue Cross using payer ID 00726. Claims submitted with an incorrect payer ID will be rejected and the claims will need to be resubmitted with the correct payer ID.

For Subscribers that have a primary commercial Blue Cross plan and secondary MHCP plan, Blue Cross will not have the ability to automatically crossover the claim to coordinate benefits. A secondary claim must be submitted with the appropriate secondary subscriber ID and payer code, along with the primary payment information.

Claims currently processed via Bridgeview, i.e., Elderly Waiver claims, will continue to be processed by Bridgeview. The Payer ID for Bridgeview claims remains the same: FS802.

BlueRide Non-Emergency Transportation (NEMT) Claims should continue to be submitted under Payer ID BLRDE.

Claim attachments must be submitted via fax using the MN AUC Claims Attachment Cover Sheet or by mail:

Fax to 1-800-793-6928

Mail to:

Blue Cross and Blue Shield of Minnesota and Blue Plus 
Attention: Claims Processing  
PO Box 982816
El Paso, TX 79998-2816

When checking Claim Status on Availity Essentials, select ‘BCBSMN BLUE PLUS MEDICAID (00726)’ from the Payer dropdown list. Use the new Payer ID code 00726 when submitting a 276/277 Electronic Data Interchange (EDI) transaction.

If a Claim Status EDI transaction is not submitted with the new Payer Name or ID code, a claim not found response may be received. Providers will need to correct the Payer Name or ID and resubmit the transaction. 

Weekly Remittance EDI file will be delivered and viewable on the Remittance Viewer application within Availity Essentials by the end of the day on Thursdays.

Pre-Service Appeals:

• Submit appeal with appropriate documentation via fax to (651) 662-6287
• Submit the appeal with appropriate documentation via USPS:

      Blue Cross and Blue Shield of Minnesota and Blue Plus
      Attention: Appeals & Grievances
      PO Box 982816
      El Paso, TX 79998-2816

Post-Service Appeals:

Post-Service claims appeals submitted beginning on January 1, 2024, will be reviewed by Blue Cross regardless of the original payer. Upon migration to Blue Cross, providers will not have the capability to submit appeals through the Availity Essentials platform. Blue Cross anticipates this capability will be available soon and will communicate this information when applicable.

Post-service claim appeals must be submitted within 90 days of the remittance date.

If a claim is denied due to a required Prior Authorization not being obtained, an appeal for medical necessity will not be accepted. An administrative appeal may be submitted for limited situations. These exceptions are listed below, and must be supported by submitted documentation:

• Blue Cross is the subscriber’s secondary coverage and PA is not required (e.g., Medicare is primary). 
• Another insurance company is identified as the payer and a claim was submitted to the other payer within the timely filing guidelines with Blue Cross subsequently identified as the patient’s primary coverage.
• The patient is identified as the payer and is billed for the service, but later the patient reports Blue Cross coverage for the date of service. Appeals for this exception must include notes about accounts receivable actions. For example, include notes documenting calls with the Blue Cross Service Center or notes that the subscriber was sent to collections within 120 days after date of service.
• The subscriber was enrolled in the plan retrospectively, after the service was provided.
• A previously prior-authorized service unexpectedly changed for medically necessary reasons, or it was determined that an unforeseen additional service was necessary.
• Extenuating circumstances beyond the control of the rendering provider or facility that make it impractical to obtain or validate the existence of a precertification of coverage prior to rendering the service (e.g., natural disaster or Availity outage). 
• Emergency and urgent care services that are performed in the emergency room do not require prior authorization and will be considered at the in-network benefit level.

Provider Appeals must be submitted using one of the following processes: 

• Submit the AUC Claims Appeal Request form with appropriate documentation via fax to (651) 662-6288
• Submit the AUC Claims Appeal Request form with appropriate documentation via USPS:

      Blue Cross and Blue Shield of Minnesota and Blue Plus
      Attention: Provider Appeals 
      PO Box 982816
      El Paso, TX 79998-2816
 

Effective January 1, 2024, Blue Cross implemented new medical policies that will apply to services provided under the medical benefit.

Federal and State Guidelines, including Minnesota Health Care Program (MHCP) policies, may supersede the Medical Policies.

Visit the Medical and Behavioral Health Policies page to review medical policies and find additional information.

Prior Authorization Lists

To review the list of services requiring a prior authorization, visit the Prior Authorization page or use the Prior Authorization Look-Up Tool, which is also available on Availity Essentials. 

Prior Authorization Look-Up Tool

Providers can quickly determine if a service or item requires prior authorization from the health plan before care is provided by entering the member group number, date of service and procedure code. The PA Look Up tool response also includes details related to the medical policy or evidence-based criteria that may apply and any special instructions related to the prior authorization process.

There are two options for providers to use: 

• The Prior Authorization Lookup tool on the Blue Cross website
• On Availity Essentials, follow the Authorization Request process. The first step in this process allows the provider to determine if a PA is required using the “Is Authorization Required” tool. If an authorization is required, the provider can simply proceed to the next step to complete the process.

If an authorization is required, it is highly recommended for the provider to utilize the online process through Availity Essentials. 

If providers are unable to verify prior authorization requirements through Availity Essentials or the Blue Cross website, providers may call Provider Services for assistance at 866-518-8448.

If providers are unable to complete the prior authorization process through Availity Essentials or the Blue Cross website, providers may fax the Prior Authorization (PA) Request form, and include the Availity error, to fax (651) 662-6284.

How to Submit an Outpatient Authorization on Availity Essentials

The following guide provides step-by-step instructions for submitting outpatient authorizations on Availity Essentials for MHCP members.

• Outpatient Authorization Submission Guide for MHCP Members

Acute Admissions, Concurrent Review, and Discharge Submission Requirements 

Blue Cross will be requiring notification at the time of acute inpatient admission. 

Blue Cross has partnered with vendor Audacious Inquiry (AI) for Admission, Discharge, Transfer (ADT) data for implementation on January 1, 2024, for Minnesota Health Care Programs (MHCP).

Admission and discharge notification requirements have become automated for acute inpatient admissions at facilities located in Minnesota or a bordering county that are participating in the MN EAS service for admission dates beginning January 1, 2024.

Providers participating with MN EAS no longer need to submit admission and discharge notification information.

Complete information on the use of MN EAS can be found in Provider Bulletin, “Blue Cross and Blue Shield of Minnesota to Automate Receipt of Acute Admission, Discharge and Transfer Data for MHCP Members” (P74-23).

+ A future communication will be published when discharge submission is available in Availity Essentials.

Newborn Admissions

Effective January 1, 2024, providers are not required to notify Blue Cross when an enrolled subscriber gives birth. Eligible newborns of mothers enrolled in Blue Advantage Families and Children (F&C) or Blue Plus MinnesotaCare are automatically enrolled in Blue Cross for the calendar month of the birth only if they meet MHCP eligibility criteria.

It is important that the mother notify her local agency of the birth of her child as soon as possible following the birth for the enrollment process to begin.

Providers are encouraged to develop a process to assist MHCP subscribers in enrolling eligible newborns.

Sub-Acute/Post-Acute Admissions Submission Requirements

Sub-acute/Post-acute care facilities include the following: Acute Rehabilitation, Long Term Acute Care (LTAC), Skilled Nursing Facility, Eating Disorder Residential Services, Mental Health Residential Services, and Substance Use Disorders Residential Care.

* A future communication will be published when concurrent review submission is available in Availity Essentials.

+ A future communication will be published when discharge submission is available in Availity Essentials.

How to Submit an Inpatient Authorization on Availity Essentials

The following guide provides step-by-step instructions for submitting inpatient authorizations on Availity Essentials for MHCP members.

• Inpatient Authorization Submission Guide for MHCP Members

Milliman Care Guidelines (MCG)

MCG care guidelines, 27th edition, will be used to guide utilization management decisions. The five (5) products licensed include the following:

• Inpatient & Surgical Care (ISC): Manage, review, and assess people facing hospitalization or surgery proactively with nearly 400 condition-specific guidelines, goals, optimal care pathways, and other decision support tools.
• General Recovery Care (GRG): Effectively manage complex cases where a single Inpatient & Surgical Care guideline or set of guidelines is insufficient, including the treatment of people with diagnostic uncertainty or multiple diagnoses. 
• Home Care (HC): Provides evidence-based comprehensive guidelines to enable case managers and others to maintain quality and efficiency in the patient's home environment. 
• Behavioral Health Care (BHC): Provides evidence-based guidelines to help healthcare professionals guide the effective treatment of patients with psychiatric disorders.

Visit the Reimbursement Policies page to view policies.

Please note that reimbursement for many services follows MHCP guidelines and therefore no Reimbursement Policy will be published for those services.

The Restricted Recipient Program (RRP) is a State Mandated program that Blue Plus is required to implement and manage per contractual requirements from the MN Department of Human Services (DHS). RRP is a program for Medicaid recipients who meet certain criteria. 

Potential Program Recipients:

• Frequent Emergency Department (ED) Utilizers
• Subscribers who struggle with substance abuse (multiple prescriptions for controlled RX, duplication of prescribers/pharmacies, receiving controlled RX while enrolled in Medication Assisted Therapy)
• Subscribers or claims that indicate potential Fraud, Waste and Abuse (of clinics/ED/transportation services)
• High dollar claims

Providers will submit Restricted Recipient referrals through the current Blue Cross processes. No change in the submission process for Government Program member requests is required. The Managed Care Referral Form and Minnesota Restricted Recipient Program Member Referral Request Form can be found on the Blue Cross website under the “forms – clinical operations” category. 

• Managed Care Referral Form
• Minnesota Restricted Recipient Program Member Referral Request Form

Restricted Recipient information will not be returned on the 271 eligibility and benefits transaction or found on an Availity Essentials Eligibility and Benefits inquiry response. Blue Cross anticipates this capability will be available soon and will communicate this information when available. Providers should verify Restricted Recipient status using MN-ITS.

Questions can be directed to the RRP Team at (651) 662-5062 (telephone) or (651) 662-6286 (fax).
 

BlueRide handles Common Carrier and Special Transportation requests for rides to and from medical and dental appointments with in-network providers if the subscriber has no other means of transportation.

Subscribers who need to schedule a ride to a medical or dental appointment should be directed to call BlueRide at 1-866-340-8648 or (651)-662- 8648. No changes are being made to the scheduling of rides or the claim submission process for NEMT providers. Claims should continue to be submitted under Payer ID BLRDE for processing.

For more information regarding BlueRide, go to: bluecrossmn.com/members/shop-plans/minnesota-health-care-programs/blueride-transportation