bcbs mra Blue Cross NC Medicare Risk Adjustment Explained

Blue Cross NC Medicare Risk Adjustment (MRA) is a complex process, but I'm here to break it down for you. The MRA is a data-driven process that helps ensure Medicare Advantage plans are paid fairly for the care they provide to their members.

The MRA data is collected from various sources, including claims data, patient assessments, and lab results. This data is then used to calculate a risk score for each member.

A risk score is a numerical value that represents the member's health status and expected healthcare costs. The risk score is used to determine the amount of risk adjustment payment a plan receives from the Centers for Medicare and Medicaid Services (CMS).

Suggestion: Equitable Adjustment

Blue Cross NC is requesting medical records from January 1st, 2020 to December 31st, 2020 for Medicare Risk Adjustment.

They will begin collecting these records on May 11th, 2021, and you will need to respond to their request within five business days.

The goals of risk adjustment are to collect accurate diagnosis information for proper treatment and to submit accurate diagnosis data to CMS for appropriate payment.

Blue Cross NC will use this data to adjust Part C payments made to Medicare Advantage plans based on factors associated with member demographics and health.

If your doctor tells you that you need prior approval for certain medical services, be sure to have the approval before scheduling your appointment, as this is a requirement for some services.

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Blue Cross NC will begin requesting medical records with dates of service from January 1, 2020 to December 31, 2020, starting May 11th, 2021.

The purpose of this request is to collect accurate and complete diagnosis information to ensure proper treatment, care management, and care coordination services.

The Centers for Medicare & Medicaid Services (CMS) uses this information to adjust Part C payments made to Medicare Advantage plans, including Blue Cross NC.

The goals of risk adjustment include collecting accurate and complete diagnosis information and submitting accurate and complete diagnosis data to CMS.

This process helps ensure that Medicare Advantage plans and providers receive appropriate payment for a member's health care.

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For radiological services, it's essential to know the approval process. Arkansas Blue Cross and Blue Shield health plans have an active outpatient diagnostic imaging program since September 1, 2006.

This program applies to individual and group members, but there are some exceptions, including Medicare Supplement, Medicare Advantage, Access Only, AR Health, BlueCard, and the Federal Employee Program.

Physicians must secure prior authorization for specific outpatient procedures, including CT Scan, MRI/MRA, Nuclear Cardiology, and PET Scan.

Suggestion: SCAN Health Plan

Inform your doctor about any upcoming medical services that may require prior approval. This will help ensure that you have the necessary authorization before scheduling your appointment.

If your doctor tells you that you need prior approval for a service, they will contact Blue Cross NC to request the authorization. You should confirm with your doctor that they have obtained the approval before proceeding with the appointment.

To avoid any delays or complications, it's essential to have the approval in hand before scheduling your appointment. This will also help you plan your care and make informed decisions about your treatment.

Here are some services that typically require prior approval:

Keep in mind that the specific requirements for prior approval may vary depending on your individual plan and circumstances.

Prior authorization is required for certain outpatient procedures under Arkansas Blue Cross health plans.

Physicians must secure prior authorization for CT Scan, MRI/MRA, Nuclear Cardiology, and PET Scan procedures.

Carelon Medical Benefits Management, an independent company, provides prior authorization services for Arkansas Blue Cross health plans.

Arkansas Blue Cross health plans that are exempt from the outpatient diagnostic imaging program include Medicare Supplement, Medicare Advantage, Access Only, AR Health (where Medicare is primary), BlueCard, and the Federal Employee Program (FEP).

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