Frequently Asked Questions


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BCBSRI will take actions to recover payments made as the result of fraudulent activity, put systems in place to stop the fraudulent behavior, and may also work with law enforcement when appropriate. As the result of fraud detection efforts, BCBSRI has realized over $10 million in savings over the past three years.

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You can protect yourself from fraud by safeguarding your member ID card and Social Security number, being wary of “free” services, and making sure you’ve received the medical services listed in your BCBSRI account.

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Blue Cross prevents and identifies fraud by analyzing data and collaborating with outside organizations.

In addition to fraud reported by members or doctors, Blue Cross also prevents and identifies fraud by:

  • Analyzing data – We are implementing new, highly sophisticated fraud detection software to further analyze claims data and identify unusual billing patterns of medical procedures, and any patterns of potentially fraudulent behavior.
  • Collaborating with outside organizations – When appropriate, we work with the National Health Care Anti-Fraud Association, the Blue Cross and Blue Shield Association, law enforcement agencies, and public and private organizations to stop fraudulent activities.
     

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Historically, funding amounts have ranged from $8,000 per year to $30,000 per year.

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We do not ordinarily meet with applicants during the letter of inquiry stage. Please email any questions about the BlueAngel Community Health Grants program to blueangel_news@bcbsri.org.

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It takes some time for us to process and review the letters of intent. We will notify you as to whether or not your organization will advance to the full proposal stage within approximately 10 business days from the date your submission was received. At that time, we will email you the proposal guidelines, application materials, and the proposal due date.

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Proposals are only accepted by invitation after the letter of intent review process. The proposal must include a coherent and valid discussion of how you intend to evaluate and measure the program's success. We cannot consider proposals that do not include evaluation information. A clear plan for communicating the partnership with Blue Cross also must be included. 

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Yes, as they relate to a specific program. For instance, we would be unlikely to fund ABC nonprofit’s executive director position, but more likely to fund personnel costs associated with a program (such as a counselor to provide nutrition classes).

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Blue Cross does not have an open application process. We accept letters of inquiry only at designated times during the year. Key dates are noted in the letter of inquiry form. However, applicants are welcome to contact us with ideas to be considered during our grant cycles.

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First log in to the secure site, then click on Pharmacy from your member page. (If you don’t already have a login account, click on “Create a New Account”.) You will have access to a variety of pharmacy tools and information.

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You may use any of the 60,000 participating pharmacies in our network. To change your prescription to a new pharmacy, you can:

1. Bring your prescription bottle(s) to the new participating pharmacy. The pharmacist will contact your previous pharmacy and arrange for your prescriptions to be transferred.
-OR-
2. Request a new written prescription from your doctor, and bring it to the new pharmacy to be filled.

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Several reputable agencies and organizations have posted helpful information about HIPAA Security on their Web sites:

  • The Centers for Medicare and Medicaid Services (CMS), the enforcement agency for HIPAA Security, has a section devoted to security education materials.
  • The U. S. Government Printing Office Web site has a link to the Federal Register (February 20, 2003) containing the final Security Rule.
  • The Workgroup for Electronic Data Interchange (WEDI), has information and links to other HIPAA resources.

We hope this information will assist you in your efforts to comply with the HIPAA Security Rule. If you would like to discuss how this new law will affect the way you communicate with BCBSRI, please contact your account executive.

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Blue Cross & Blue Shield of Rhode Island (BCBSRI) insures that our business practices comply with the security regulations. Some of the activities completed include:

  • Appointment of an information security official and privacy official
  • Routine risk assessments
  • Creating and/or modifying existing security and privacy policies/procedures
  • Entering into business associate contracts with key vendors
  • Executing a security and privacy awareness training program for our workforce
     
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Any covered entity (healthcare provider, healthcare plan and healthcare clearinghouse) that files claims or receives remittance advices electronically must comply with the HIPAA Security Regulation. Please consult your legal counsel to determine your obligations. 

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The HIPAA Security Regulation defines specific standards and controls that must be in place to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI). ePHI is information transmitted over the Internet and/or stored on a computer, CD, disk, magnetic tape, or other related means. This includes ePHI that is created, received, maintained, or transmitted. You can find the final Security Rule in the Federal Register of February 20, 2003.
 

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Type 1 NPIs are healthcare providers, such as physicians and dentists. Type 2 NPIs are organizations such as facilities, hospitals, home health agencies, labs, and DME suppliers.

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Yes, for those providers who are not enrolled in Direct Deposit, the current paper remittance advice will be produced.

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Yes. You will need to change the first position of the Submitter ID from “T” (Test) to “P” (Production). You will also need to change the ISA15 from “T” (Test) to “P” (Production).

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You should always expect a 999 Acknowledgement and Plain Language 999 for each 837 file you submit. If a reasonable time has elapsed since file submission and you have yet to receive the appropriate 999, please contact Blue Cross Service Desk at 401-751-1673 or 1-855-721-4211 for assistance.

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The Provider Control Reports identify claims that were not accepted for claims adjudication. This reject report will list any claim that is rejected from our front-end edit process and the reason the claim rejected. These claims must be corrected by you and resubmitted for processing.

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We accept the HIPAA limits—50 lines for Professional claims and 98 lines for Institutional claims. If a professional claim has more than 50 lines, it is rejected up front and will appear on your Provider Control Report. If we receive an institutional claim with more than 98 lines, the claim is split manually.

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In situations where there is no clear national code set equivalent, the closest valid national code set will be selected and used to process applicable claims.

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Blue Cross EDI Gateway must accept any ANSI-compliant home infusion claim submitted on either 837I or 837P. However, Blue Cross will reject any 837P home infusion claim during the internal business editing process as “not a contracted service for this form type.” A home infusion provider would have to use the 837I format in order to receive payment under the terms of their contract.

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You can obtain copies of our Companion Guides on the HIPAA Transactions Documents page.

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Blue Cross has developed a Partner Testing approach to ensure Trading Partner transactions are ANSWER HIPAA compliant and meet Blue Cross business rules. The extensive testing required during the  Partner Testing phase should result in a smooth transition to production. In general, the major components are:

  • Complete the Trading Partner Agreement and Trading Partner Registration form.
  • Successfully test files using the Foresight Online Validator tool.
  • Successfully test files through the Blue Cross end-to-end test environment (Phase 2).

For additional information on HIPAA Partner Testing contact the Blue Cross Service Desk at (401) 751-1673 or 1-855-721-4211or hipaa.edi.support@bcbsri.org. An EDI analyst will work with you during each phase of partner testing.

 

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No. Regardless of practice size, all providers transmitting designated transactions electronically are subject to the HIPAA Administrative Simplification requirements. Effective October 16, 2003, small practices are exempt from the Administrative Simplification Certificate Act (ASCA) provision that excludes paper claims from Medicare coverage. Small practices will be able to continue to submit paper claims. ASCA defines a small practice or supplier as:

  1. A provider of services with fewer than 25 full-time equivalent employees or
  2. A physician, practitioner, facility or supplier (other than provider of services) with fewer than 10 full-time equivalent employees.

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Typically, your renewal is on the anniversary date of your plan's initial effective date. For example, if your plan became effective on January 1, 2009, your renewal would be January 1, 2010.

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Blue Cross provides funding for existing, new, and expanding programs. 

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Yes. However, we prefer to be a funding partner along with other sources of revenue. We believe an application is strengthened by seeking multiple sources of support (as this is a key indicator of sustainability).

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Blue Cross will fund acquisition of equipment as it relates to a specific program, but is unlikely to fund equipment alone. Please note that we typically do not fund construction (e.g., bricks and mortar).

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While Blue Cross does not have a strict policy against indirect costs, we do not look favorably upon applications that request excessive costs in this area. Projects requesting funding for direct service or program-related costs (e.g., supplies, education materials, salaries) are viewed more favorably.

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No, but we fund agencies that can help individuals. 

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Yes, you may reapply. 

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Final decisions will be communicated in December.

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Yes, as long as the proposed effort is not for religious purposes.

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Blue Cross does not have an open application process. We accept letters of inquiry only at designated times during the year. Key dates are noted in the letter of inquiry form. However, applicants are welcome to contact us with ideas to be considered during our grant cycles. 

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Blue Cross is not currently making multiyear grant awards. However, applicants who receive funding may apply for second-year transitional funding.

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An organization may not apply for more than one BlueAngel Community Health grant during the year. Applicants who receive a grant may not submit another letter of intent or proposal for funding the same program within the same year. Applicants who are not approved for funding are welcome to reapply in the next grant cycle.

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Blue Cross will not fund projects or programs of fraternal or religious organizations where the primary beneficiaries are members of these organizations. We also do not contribute to organizations seeking contributions for advertising space, tickets, or sponsorship of dinners, fundraising events, or promotional materials. Additionally, the BACHG program does not fund requests from hospitals.

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You can always speak with a member of the Blue Cross Community Relations Department staff if you have questions about the eligibility requirements and funding priority. Please contact us at blueangel_news@bcbsri.org.

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Organizations are eligible for grants from Blue Cross if they have qualified for exemption under Section 501(c)(3) of the IRS Code or are public instrumentalities (e.g., a government entity). Grants are not awarded to individuals. Private foundations [as defined by Section 509(a) of the Code] are not eligible for funding.

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