Minnesota Health Care Programs (MHCP) Provider Toolkit

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 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.

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.

The format of MHCP 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)

MHCP claims, including original claims, replacement claims (frequency code 7) and void claims (frequency 8) 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 is unable 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 processed via Bridgeview, i.e., Elderly Waiver claims, should be submitted using Payer ID FS802.

BlueRide Non-Emergency Transportation (NEMT) Claims should 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 Payer ID code 00726 when submitting a 276/277 Electronic Data Interchange (EDI) transaction.

Weekly Remittance EDI file are 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: (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.

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 appeals on Availity Essentials (for additional information, see appeals training video available in Availity Learning Center). This is the preferred and most efficient method.
• Submit the AUC Claims Appeal Request form with appropriate documentation via fax: (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

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

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

Blue Cross requires prior authorization (PA) for some admissions, continued stays, services, procedures, drugs, and medical devices before they can be covered. Prior authorization is a review and approval before a service happens to determine whether it’s medically necessary and appropriate.

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, Blue Cross recommends utilizing 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.

Availity Essentials Authorization Submission Guides

• Inpatient Authorization Submission Guide for MHCP Members
• Outpatient Authorization Submission Guide for MHCP Members

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.

Inpatient Admission, Concurrent, and Discharge Submission Requirements

Sub-acute/Post-acute care facilities, as referenced in the tables below, 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 will I know if there are changes to prior authorization requirements?

Upcoming changes to prior authorizations will be documented in a Provider Bulletin, 60 days prior to the effective date. All Provider Bulletins are published on the first business day of each month.

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. Claims should be submitted under Payer ID BLRDE for processing.

Visit the BlueRide Transportation page for more information.