Note: Contents are subject to change and are not a guarantee of payment. BlueCross BlueShield of South Carolina and BlueChoice HealthPlan of South Carolina are independent licensees of the Blue Cross and Blue Shield Association.
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Mission Statement
To serve as liaisons between BlueCross, BlueChoice HealthPlan and the health care community to promote positive relationships through continued education and problem resolution.
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Workshop Agenda • Welcome and Introductions • Patient Protection and Affordable Care Act (PPACA) • ICD-10 Updates • Helpful Tips from Electronic Data Interchange (EDI) • BlueCross and BlueChoice® Quality Initiatives • HEDIS® • Transparency • National Imaging Associates (NIA)* • Web Precertification • Pharmacy Management • BlueCard® • Medical Coding, Filing and Service Updates
• BlueChoice HealthPlan • BlueChoice HealthPlan Medicaid • Medicare Advantage Pharmacy Update • Medicare Advantage • Federal Employee Plan • State Health Plan • SCANA • Walmart and Tyson • New Groups • Questions
*NIA is an independent company that handles preauthorization for certain imaging services on behalf of BlueCross and BlueChoice.
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Provider Education and Relations Brian Butler Senior Director
Tamara Fravel Manager
Donese Pinckney Provider Advocate
Teosha Harrison Provider Advocate
Ashlie Graves Provider Advocate
Mary Ann Shipley Provider Advocate
Donna Thompson Provider Advocate
Jada Addison Provider Advocate
Sandy Sullivan Provider Advocate
Billy Quarles Provider Advocate
Elizabeth Duvall Provider Advocate
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Provider Territories Cherokee 42 Spartanburg 11
23 39 37 Oconee
Picken s
01 Abbeville
29 Lancaster
20 36
Fairfield
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Saluda 19 Edgefield
32 Lexington
Richland 09 Calhoun
02 Aiken
13 Chesterfield
28 Kershaw
Newberry 2 Greenwood 4
33 Georgia
Union
30 Laurens
Provider Advocates 12 Chester
44 04 Anderson
North Carolina
46 York
Dillon 17 Darlington 16 31 Marion Lee 21 34 Florence
43 Sumter
14 Clarendon
38 Orangeburg 06 05 Barnwell Bamberg Dorchester Allendale 03 25 Hampton
15 Colleton
45 Williamsburg
08 Berkeley
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Ashlie Graves 26 Horry
Billy- Quarles Mary Ann Shipley Donna Thompson
18 Charleston 10
27 Jasper
Jada Addison
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Sandy Sullivan
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Donese Pinckney
These representatives handle education inquiries for institutions, professional offices and ambulatory surgical centers.
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Provider Services Brian Butler Senior Director
Brenda Bethel Director
Mark Austin Manager, National Alliance and Support Staff
Tammy Ross Manager, Local
Marcelette Pearson Manager, Written and Web 6
Patient Protection Affordable Care Act presented by Tamara Fravel
Women’s Preventive Services • The Patient Protection and Affordable Care Act (PPACA) requires health plans to cover designated women’s preventive services without cost sharing for the member when the services are provided by a network provider. • Cost sharing includes deductibles, copayments and coinsurance. Some of these benefits and services are already included in the existing PPACA preventive services requirements. 8
Women’s Preventive Services • Applied to all new health plans and renewals for individual groups and self-funded plans that are NOT grandfathered effective August 1, 2012. • Grandfathered health plans may choose to be exempt from this provision.
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Women’s Preventive Services: Covered Services
• We will cover these benefits and services with no cost sharing: – – – – – – – –
Well-woman visits Gestational diabetes screening Human papillomavirus (HPV) testing Counseling for sexually transmitted diseases HIV testing and counseling Contraceptive methods and counseling Breast-feeding support, supplies and counseling Domestic violence screening and counseling (Laboratory services associated with the screening are covered at no cost sharing.) 10
Modifier 33 • According to the American Medical Association, file modifier 33 with all preventive procedure codes. Here’s why:
– When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, Preventive Service, to the service. – For separately reported services specifically identified as preventive, the modifier should not be used.
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Modifier 33 — When to Use It • CPT modifier 33 is applicable for the identification of preventive services without cost-sharing in these four categories: 1. Services rated “A” or “B” by the U.S. Preventive Services Task Force (USPSTF) (see Table 1) as posted annually on the Agency for Healthcare Research and Quality’s website: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm
2. Immunizations for routine use in children, adolescents and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention 12
When to Use It 3. Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics) as supported by the Health Resources and Services Administration 4. Preventive care and screenings provided for women (not included in the Task Force recommendations) in the comprehensive guidelines supported by the Health Resources and Services Administration
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When Not to Use It • For services you report separately that are specifically identified as preventive, do not use the modifier.
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For More Information • Visit the Health Care Reform section in the Providers areas of our websites. • We will continue to add or update information as we get new regulations or further guidance from the government. 15
ICD-10 Updates presented by Bart Strickland and Melissa Chavis
Implementation Deadline
• The Centers for Medicare & Medicaid Services (CMS) recently announced the extension of ICD-10 from Oct. 1, 2013 to Oct. 1, 2014.
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Why the Transition? • ICD-10 codes refine and improve operational capabilities and processing, including: – Detailed health reporting and analytics: cost, utilization and outcomes – Detailed information on condition, severity, comorbidities, complications and location – Expanded coding flexibility by increasing code length to seven characters – Improved operational processes across the health care industry by classifying detail within codes to accurately process payments and reimbursements 18
Who Is Impacted? • Major impact on anyone who uses health care information that contains a diagnosis and/or inpatient procedure code, including: – – – – – –
Hospitals Health care practitioners and institutions Health insurers and other third-party payers Electronic transaction clearinghouses Hardware and software manufacturers and vendors Billing and practice management service providers
*Making the move to ICD-10 is not optional.* 19
Provider Planning • Identify your current systems and work processes that use ICD-9 codes. • Talk with your practice management system vendor about accommodations for ICD-10 codes. • Discuss implementation plans with all your clearinghouses, billing services and payers to ensure a smooth transition. 20
Provider Planning • Talk with your payers about how ICD-10 implementation might affect your contracts. • Identify potential changes to workflow and business processes. • Assess staff training needs.
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Provider Planning • Budget for time and costs related to ICD-10 implementation, including expenses for system changes, resource materials and training. • Conduct test transactions using ICD-10 codes with your payers and clearinghouses.
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Phases to Implementation 1. 2. 3. 4. 5. 6.
Planning Communication and Awareness Assessment Operational Implementation Testing Transition
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Helpful Tips from EDI Services presented by Bart Strickland and Melissa Chavis
Institutional Filing Guidelines – Referring Provider Loop: 2310F — REFERRING PROVIDER NAME Loop Usage: SITUATIONAL Situational Rule: Required on an outpatient claim when the Referring Provider is different from the Attending Provider. If not required by this implementation guide, do not send. TR3 Note: The Referring Provider is the provider who sends the patient to another provider for services. Source: 5010 837I Technical Report Type 3 25
Professional Filing Guidelines – Referring Provider Loop: 2310A — REFERRING PROVIDER NAME Usage: SITUATIONAL Situational Rule: Required when this claim involves a referral. If not required by this implementation guide, do not send. TR3 Note: When reporting the provider who ordered services, such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. Source: 5010 837P Technical Report Type 3 26
Tips from EDI Services 1. You submit an incorrect member ID number on the claim. Edits: 251(Professional), EAA (Institutional), PS7 (Both) Correction: Verify insurance card or submit an eligibility request.
2. The rendering/attending physician is not credentialed with BlueCross when he or she begins working at the practice/hospital. Edit: HA9 (Professional), F36 (Institutional) Correction: Email
[email protected] for assistance
3. The group/practice is not credentialed with BlueCross when accepting patients. Edit: 560 (Professional) Correction: Email
[email protected] for assistance
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Tips from EDI Services 4. Do not submit the rendering physician affiliated with a group/practice as the billing provider.
Edit: N70 (Professional) Correction: Billing provider information should pertain to the group/practice.
5. When the diagnosis code you submit is within the range 800– 999, a date is required in the accident date field.
Edit: 566 (Professional) Correction: Submit the appropriate accident indicator – “AA” (auto accident) or “OA” (other accident). Submit the date the accident/injury occurred in the accident date field.
6. Be sure you do not use any symbols or spaces when the patient has a hyphened last name. Edit: 557 (Professional and Institutional) Correction: Remove all symbols and spaces in last name field.
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Tips from EDI Services 7. Have the appropriate payer code submitted per the insurance plan: – – – – – – –
BlueCross BlueShield of South Carolina – 401 State Health Plan – 400 Federal Employee Program – 402 BlueChoice HealthPlan – 922 BlueCross Medicare Advantage – C63 Planned Administrators Inc. – 886 Thomas Cooper – 315
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Web Changes • Web changes started January 1, 2013. • There may be some display defects in eligibility, but all functionality will still be available. • Please be patient with the changes.
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Quality Initiatives presented by Sandy Sullivan
What Is a Patient-Centered Medical Home (PCMH)?
• A team-based approach to health care led by a physician, nurse practitioner or physician assistant. • A PCMH practice provides comprehensive care to patients with an emphasis on: – Better patient access – Improved health outcomes – Increased patient satisfaction
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BlueCross’ PCMH Program • Current program includes adult patients with: – Diabetes – Hypertension – Congestive heart failure (CHF)
• 2013 – Pediatrics – Asthma
• Participating providers receive a care coordination fee for each eligible patient with the identified disease state.
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Examples of Care Coordination Services • Care planning and pre-visit preparations • Tracking referrals, imaging services and lab tests • Coordinating with specialists, hospitals and other providers involved in patient care
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Examples of Care Coordination Services • Proactive outreach and care reminders to patients • Follow-up with patients after important visits • Monitoring and improving the health outcomes for your patient population
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Requirements for Provider Participation • The National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home Recognition • 200 minimum patient volume
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Provider Expectations • Physicians and specialists share member test results • Facilitate information and coordinate exchange of information
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Physician Quality Measurement Program • The Physician Quality Measurement program measures physician quality scores based on Healthcare Effectiveness Data and Information Set (HEDIS®) standards. • We have partnered with the Outpatient Quality Improvement Network (OQUIN): – A group of physicians dedicated to improving patient health
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Physician Quality Measurement Program • For this initiative, BlueCross and BlueChoice HealthPlan have chosen to display physician quality data in the diabetes category. • NCQA establishes measurement parameters for each HEDIS® measure.
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Physician Quality Measurement Program • The diabetes set includes the percentage of members 18 to 75 years old with diabetes (type 1 and type 2) who had: – – – –
Hemoglobin A1c (HbA1c) testing Eye exam (retinal) performed LDL-C screening Medical attention for nephropathy
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Physician Quality Measurement Program • Physicians participating in the Physician Quality Measurement program are measured on their performance in these categories. • OQUIN’s database, coupled with NCQA standards, will determine a local comparison score for each measure and compare that to the actual physician score to determine star ratings. 41
Physician Quality Measurement Program • We will use a three-star display based on the performance level score for each HEDIS physician measured, compared to the local average of participating physicians: – Below — 1 star – Meets — 2 stars – Exceeds — 3 stars
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Physician Quality Measurement Program Local averages for the diabetic measures are:
OQUIN has adapted these standards from the NCQA diabetes recognition program.
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Physician Quality Measurement Program Here’s what it will look like on our website:
If you would like to be a part of this initiative through our efforts with OQUIN, please contact OQUIN at
[email protected].
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Blue Physician Recognition Program • Launched in July 2012 by the Blue Cross and Blue Shield Association. • Will be part of the redesigned Blue National Doctor and Hospital FinderSM at www.bcbs.com. – BlueCross BlueShield of South Carolina and BlueChoice participate in the program.
• Promotes and recognizes physicians and group practices that have demonstrated quality patient-centered care. • Currently includes: – – – –
NCQA Diabetes Physician Recognition Program NCQA Heart/Stroke Recognition Program The American Society for Hypertension (ASH) Specialists Program NCQA Patient-Centered Medical Home 45
Blue Physician Recognition Program • Any physician practice that achieves PCMH status may also receive $2,000 from both BlueCross and BlueChoice. – Award is for one payment per practice.
• A physician who becomes certified or recertified may receive payment for up to two of the programs. – Please submit your certifications to us for recognition if you have not already done so. 46
Blue Physician Recognition Program • For more information, please visit our Physician Recognition Program page. • We will continue to identify programs and resources to support additional quality improvement and recognition opportunities. • We welcome your questions about our Physician Recognition Program. – If you would like to join, or want more information, please contact your provider advocate. 47
Rewarding Excellence: Hospital Recognition Program presented by Sandy Sullivan
Rewarding Excellence • Initiative that rewards acute care hospitals with increased payments for the quality of care they provide. • Incorporates Hospital Quality Recognition Program into contract negotiations to reward hospitals based on outcomes in lieu of unitbased price increases. • The better a hospital does on its quality measures, the greater the reward. 49
2013 Rewarding Excellence • New Measures – – – –
Mortality Patient safety Outpatient measures Align with CMS value-based purchasing
• Bonuses – Top rank among bed size – Top rank for improvement among bed size
• New calculations/scoring methodology – Increase allocation to patient experience – Easy to reproduce by hospitals 50
Quality Payments • Increased reimbursement based on points awarded for a total score • Bonus: – Highest rank among bed size peers – Highest improvement among bed size peers, excluding CLABSI – Increase per measure for < 10 percent improvement
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HEDIS® presented by Sandy Sullivan
HEDIS® • Healthcare Effectiveness Data and Information Set – Used nationally by health plans to report quality indicators. – Evaluates medical records for selected patients’ compliance with various “quality of care” measures. – Analyzed January through May each year.
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Medical Record Request Process • New in 2013: Copies of medical records are required for certain measures (will vary by health plan). • New in 2013: Shortened time frame to collect records (deadline May 1, instead of June 1). • You should receive record requests, via fax, by February 1, 2013. • You can provide requested records back to BlueChoice by: – – – –
Fax Mail Access to Electronic Medical Record (EMR) Allowing us to copy records to an encrypted flash
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How Providers Can Help • Report all diagnosis codes on every claim that are appropriate for the patient’s condition for every encounter to reduce the number of medical records we may request. • Document in the patient’s health record. • Encourage members to actively participate in their health (medication adherence).
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Body Mass Index (BMI) • Capture BMI as the fifth vital sign during routine check in. • File BMI using appropriate codes. • Office visit code in conjunction with diagnosis V85.0-V85.5
• Activate BMI settings if using EMR/practice management system. • Include calculated BMI documentation in chart, not just height and weight. 56
Tips to Increase Immunization and Screening Rates
• Use every clinical encounter as an opportunity to vaccinate or complete the vaccine series. • Use appropriate CPT codes when submitting claims (i.e., immunizations and screenings). • Insert immunization/screening reminders in the EMR to complete during the patient’s visit.
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Transparency presented by Sandy Sullivan
Patient Review of Physicians • In July 2012, the Blue Cross and Blue Shield Association began allowing Blue members to view and post physician reviews based on their experiences as patients. • You can find this new online tool at the Blue National Doctor & Hospital Finder. • We will begin displaying reviews in our secure online tools beginning in 2013. 59
Patient Review of Physicians • Will implement during the first quarter of 2013. • Claim-based reviews. • Members will answer basic questions about their visits. • Providers can respond once to each patient encounter. • Reviews will be moderated before they’re posted. 60
Cost and Quality Tools Cost and quality tools are now available for members in the Members sections of both websites.
SouthCarolinaBlues.com
BlueChoiceSC.com 61
Doctor and Hospital Finder
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Treatment Cost Estimator
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National Imaging Associates (NIA) presented by Mary Ann Shipley
Outpatient Radiology • National Imaging Associates (NIA) is an independent company that handles precertification for certain imaging services on behalf of BlueCross and BlueChoice HealthPlan.
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NIA Clinical Expertise and Provider Engagement
• Our goal is to ensure patients receive the most appropriate test early in an episode of care. • NIA reviews more than 300,000 advanced imaging provider requests each month.
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NIA Clinical Expertise and Provider Engagement
• The BlueCross and NIA chief medical officers review and mutually approve algorithms and guidelines. • Clinical consultation is a hallmark of NIA: – Has 96 board-certified physicians representing radiology – Has a host of other specialties available for physician-tophysician discussions 67
Who Is Included in the Radiology Program?
• BlueChoice HealthPlan • BlueCross BlueShield of South Carolina Fully Insured Business • Medicare Advantage (Jan. 1, 2013) • SOME BlueCross BlueShield of South Carolina Administrative Services Only (ASO) business – (see group prefixes listing on website)
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NIA Precertification Process • The ordering physician is responsible for getting precertification. • The precertification process should be an integral part of the radiological exam scheduling process.
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NIA Precertification Process • If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed, immediately call NIA with the appropriate clinical information for an expedited review. • If an emergency clinical situation exists outside of a hospital emergency room, immediately call NIA with the appropriate clinical information for an expedited review. 70
NIA Precertification Process • Separate precertification numbers are not needed for: ‒ CT-guided biopsy ‒ CT-guided radiation therapy ‒ Some MR-guided procedures
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NIA Optical Character Recognition (OCR) Fax Cover Sheet
Submission of Clinical Information
• NIA does not accept faxes for initial precertification requests. • NIA uses OCR technology that allows us to automatically attach the clinical information providers send to an existing precertification request. • For the automatic attachment to occur, providers must use the NIA fax cover sheet as the first page of the fax. 72
Radiology Program Details
• • • •
BlueCross
BlueChoice
www.radmd.com
www.radmd.com
Computerized Axial Tomography (CAT) scans Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Positron Emission Tomography (PET) scans
Computerized Axial Tomography (CAT) scans Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Positron Emission Tomography (PET) scans Cardiac Computed Tomography Angiography (CCTA) • Nuclear Cardiology Exams • • • • •
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NIA Phone Numbers BlueCross Fully Insured
866-500-7664
State Health Plan
866-500-7664
Publix
888-642-4810
Medicare Advantage
866-247-9729
BlueChoice HealthPlan
888-642-9181 74
Who Is Included in the Radiology Program?
• New groups that require precertification through NIA effective Jan. 1, 2013: – Medicare Advantage (ZCT) – SCANA (FWY) – Savannah River Site (SRS) Feb. 1, 2013
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For More Information • Visit: – SouthCarolinaBlues.com – BlueChoiceSC.com
• These sites include: – A complete list of groups whose members require authorization through NIA – NIA reference guides – Answers to frequently asked questions 76
Web Precertification presented by Donese Pinckney
Web Precertification • Benefits: – Providers receive most authorizations within 24 hours of submission. • Provide complete information to avoid delays. • Our internal staff of precertification technicians and nurses works very closely together to review and authorize your patients’ procedures as quickly as possible.
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Improve Efficiency: Browsers • For predictable, reliable performance, use My Insurance ManagerSM with one of these browsers: – Firefox – Safari – Internet Explorer 8+
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Improve Efficiency: Compatibility Settings • Make sure your browser’s compatibility settings are turned off when you use My Insurance Manager.
For example, in Internet Explorer, click “Tools,” “Compatibility View Settings,” and uncheck all these boxes.
My Insurance Manager Precertification and Referrals
• Tips on Finding Your Provider
‒ To search for a provider’s NPI number, visit: ◦
https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRe gistryHome.do
‒ You can search by practice or the doctor’s name and state. ‒ Copy and paste your search results into the appropriate field in My Insurance Manager. ‒ Continue and complete the required fields to get your precertification or referral. ‒ Create a “cheat sheet” or list of the providers you refer to most often.
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BlueCross BlueShield of South Carolina Pharmacy Management presented by Deno Sebastian
Overview • Preferred Drug List Changes • Prior Authorization Program Changes • Step Therapy Program Changes • Educational Outreach
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Preferred Drug List Changes (BlueCross and BlueChoice HealthPlan)
• Effective January 1, 2013 for all members: – We will add these four drugs to preferred/tier 2: • Azopt • Victoza • Rozerem • Zymaxid
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Drugs Moving to Higher Tier and Their Formulary List Alternatives Androgel Detrol LA, Enablex Oxytrol, Sanctura XL
Androderm, Axiron, Fortesta Oxybutynin, Trospium, Gelnique, Vesicare
Lumigan
Latanoprost, Travatan Z, Zioptan
Veramyst
Fluticasone, Nasonex
Vytorin
Atorvastatin, Simvastatin 85
Prior Authorization List Changes • Effective March 1, 2013 for most members: • We are adding 63 drugs to current prior authorization list. • New and current users must request prior authorization to continue using them on or after March 1, 2013. • Exceptions: • We will grandfather indefinitely members currently taking Lumigan, Oleptro, Olux-E and Riomet. • We will grandfather members using FreeStyle test strips through December 31, 2013.
• Visit the Prescription Drug Information page on www.SouthCarolinaBlues.com for complete details. 86
New Prior Authorization Drugs (effective March 1, 2013)
Drugs With Prior Authorization Requirements Cholesterol Lowering Sleep Medications Testosterone Replacement
Advicor, Altoprev, Crestor, Lescol/XL, Lipitor, Livalo, Lovaza, Mevacor, Pravachol, Vytorin, Zocor Ambien, Ambien CR, Edluar, Intermezzo, Lunesta, Silenor, Sonata or Zolpimist Androgel, Testim
Hypertension
Atacand, Avapro, Avalide, Cozaar, Diovan, Edarbi, Hyzaar, Tekturna/HCT, Teveten/HCT
Nasal Steroids
Beconase AQ, Dymista, Flonase, Nasacort AQ, Omnaris, QNASL, Rhinocort AQ, Veramyst, Zetonna
Overactive Bladder
Detrol, LA, Ditropan XL, Myrbetriq, Oxytrol, Sanctura/XR, Toviaz
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New Prior Authorization Drugs (effective March 1, 2013)
Drugs With Prior Authorization Requirements Diabetes Supplies Diabetes Seizure Glaucoma Depression Dermatologic
Freestyle Test Strips Fortamet, Glumetza, Jentadueto, Riomet, Tradjenta Gralise Lumigan Oleptro Olux-E
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New Prior Authorization Drugs (effective March 1, 2013)
Drugs Requiring Prior Authorization
Preferred Alternatives
Cholesterol Lowering
Advicor, Altoprev, Crestor, Lescol/XL, Lipitor, Livalo, Lovaza, Mevacor, Pravachol, Vytorin, Zocor
atorvastatin, simvastatin, pravastatin, Niaspan
Sleep Medications
Ambien, Ambien CR, Edluar, Intermezzo, Lunesta, Silenor, Sonata or Zolpimist
Rozerm, zolpidem, zaleplon
Testosterone Replacement
Androgel, Testim
Androderm, Axiron, Fortesta
Hypertension
Atacand/HCT, Avapro, Avalide, Cozaar, Hyzaar, Diovan/HCT, Edarbi, Edarbyclor, Tekturna/HCT Teveten/HCT
generic ACEs or ARBs, Benicar/HCT, Micardis/HCT
Nasal Steroids
Beconase AQ, Dymista, Flonase, Nasacort AQ, Omnaris, Qnasl, Rhinocort AQ, Veramyst, Zetonna
fluticasone nasal, Nasonex
Overactive Bladder
Detrol/LA, Ditropan XL, Myrbetriq, Oyxtrol, Sanctura/ XR, Toviaz
oxybutynin, trospium, Gelnique, Vesicare
Diabetes Supplies
FreeStyle test strips
AccuChek, OneTouch
Diabetes (Biquanides)
Fortamet, Glumetza, Riomet, Tradjenta, Jentadueto
metformin/XR, glyburide, glipizide
Seizure
Gralise
pregabalin, gabapentin, topiramate
Glaucoma
Lumigan
lantanoprost, Travatan Z, Zioptan
Depression
Oleptro
trazodone, venlafaxine, bupropion, sertraline
Dermatologic
Olux-E
clobetasol
Some multisource brand drugs require prior authorization of the generic equivalent prior to coverage. Example: Brand name Lipitor requires members to try atorvastatin (generic Lipitor) prior to brand Lipitor coverage. If brand Lipitor is approved, members will pay their non-preferred copayment/coinsurance and the cost difference between the brand and generic formulation. 89
Step Therapy Additions • Effective March 1, 2013 for BlueCross members: • We will add Pristiq to the Step Therapy Program. • We will grandfather current Pristiq users. • This program affects all new Pristiq users as of March 1, 2013. • Members must have claim histories that show they have tried venlafaxine or venlafaxine XR in the past prior to coverage of Pristiq.
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BlueChoice HealthPlan 2013 Pharmacy Benefit Management Overview presented by Deno Sebastian
BlueChoice HealthPlan
2013 Pharmacy Benefit Management Overview
• Hypertension – Drugs Requiring Prior Authorization • • • •
Atacand Atacand HCT Edarbi Edarbyclor
• • •
Micardis Teveten Teveten HCT
– Preferred Alternatives • • • • •
Benicar Benicar Diovan Eprosartan losartan/hctz
• • • • •
irbesartan/hctz HCT Irbesartan hctz valsartan Losartan 92
BlueChoice HealthPlan
2013 Pharmacy Benefit Management Overview
• Diabetes – Drugs Requiring Prior Authorization: • • • • • •
Humalog Humalog Mix 50/50 Humalog Mix 75/25 Humulin 70/30 Humulin N Humulin R
– Preferred Alternatives • • • • •
Novolog Novolin 70/30 Novolin N Novolin R Novolog Mix 70/30
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Educational Outreach • We will conduct member-specific mailings in late January 2013: • Will target members impacted by Preferred Drug List, prior authorization and step therapy program changes. • Will post news to www.SouthCarolinaBlues.com in March 2013.
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BlueCard® presented by Billy Quarles
BlueCard Program Request
Eligibility and Benefits
BlueCross BlueShield of South Carolina
Member’s Home Plan
800-676-BLUE (2583)
Precertification
View ID card for precertification telephone number
Claim Submission
File ALL primary and secondary claims electronically to your local plan
Claim Status
www.SouthCarolinaBlues.com Local Provider Services
Medical Review Request
www.SouthCarolinaBlues.com
View ID card for preauthorization telephone number
http://www.southcarolinablues.com/UserFiles/scblues/ Documents/Providers/medical%20review%20form0331 11%20interactive.pdf 96
Verifying Eligibility and Claim Status • Call BlueCard Eligibility at 800-676-BLUE (2583) – Enter the patient’s alpha prefix – Call will route to appropriate Blue Plan
• Check BlueCard claim status with your local plan – www.SouthCarolinaBlues.com – Send Web inquiries through “Ask Provider Services” concerning claim issues – Voice Response Unit 97
BlueCard Claims Filing Reminders • File claims for members from Puerto Rico, Panama, Uruguay and the U.S. Virgin Islands to the local Plan. – Domestic providers rendering service to these members must follow the same filing guidelines as other BlueCard claims.
• A large number of BlueCard claims have been incorrectly mailed to La Cruz Azul (LCA) in Puerto Rico. – Independence Blue Cross, the former license holder for LCA, said it will close the LCA mailbox soon. • The U.S. Postal Service will return mail to the sender.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
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BlueCard Claims Filing Reminders • Incorrect claims filing will result in delaying payment to providers. – Submit all Blue member claims to the local Plan, not to the Plan that appears on the member’s ID card.
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BlueCard Precertification and Medical Policies
Use our BlueCard® Precertification tool to check medical policies and get general precertification requirements for out-ofarea Blue patients. You can also get the contact information you need to initiate precertifications. In 2013 you will be able to link to other plans’ websites to initiate precertifications with the appropriate plan!
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Claim Resolution/Escalation Process • Check your claim status via normal channels. – My Insurance ManagerSM – Provider Services/VRU
• Escalate through Provider Services Management • Contact your Provider Advocate –
[email protected] – 803-264-4730 101
Medical Coding, Filing and Service Updates presented by Billy Quarles
Medical Record Requests • We have an increasing amount of medical records that have been requested and not yet received from our South Carolina providers. Some of the requests are over 60 days old. • Please respond as quickly as possible to our first request for medical records, as your claim could possibly remain rejected until the Home Plan receives the records. • Fax records individually. 103
Ancillary Claims • Generally, as a health care provider you should file claims for your Blue Cross and Blue Shield patients to the local Blue Plan. • But there are unique circumstances when claims filing directions will differ based on the type of provider and service. • Ancillary providers are: – Independent clinical laboratory – Durable/Home medical equipment and supplies – Specialty pharmacy providers
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Ancillary Claims: Independent Laboratories Provider Type Independent Clinical Laboratory (any type of nonhospital-based laboratory) Types of Service include, but are not limited to: Blood, urine, samples, analysis, etc.
How to File: (required fields) Referring Provider: • - Field 17 on CMS 1500 Health Insurance Claim Form OR - Loop 2310A (claim level) on the 837 Professional Electronic
Where to File File the claim to the Plan in whose state the specimen was drawn* ‒ *Where the specimen was drawn will be determined by which state the referring provider is located.
Example Blood is drawn* in lab located in Alabama. Blood analysis is done in South Carolina. File to: BlueCross BlueShield of Alabama. *Claims for the analysis of a lab must be filed to the Plan in whose state the specimen was drawn.
Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association.
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Ancillary Claims: Durable/Home Medical Equipment and Supplies Provider Type
How to File: (required fields)
Durable/Home Medical Equipment and Supplies (D/HME) Types of Service include, but are not limited to: Hospital beds, oxygen tanks, crutches, etc.
Patient’s Address: - Field 5 on CMS 1500 Health Insurance Claim Form or - Loop 2010CA on the 837 Professional Electronic Submission Ordering Provider: - Field 17 on CMS 1500 Health Insurance Claim Form or - Loop 2420E (line level) on the 837 Professional Electronic Submission Place of Service: - Field 24B on the CMS 1500 Health Insurance Claim Form or - Loop 2300, CLM05-1 on the 837 Professional Electronic Submissions Service Facility Location Information: - Field 32 on CMS 1500 Health Insurance Form or - Loop 2310C (claim level) on the 837 Professional Electronic Submission
Where to File File the claim to the Plan in whose state the equipment was shipped to or purchased in a retail store.
Example A.
Wheelchair is purchased at a retail store in South Carolina. File to: BlueCross BlueShield of South Carolina. B. Wheelchair is purchased on the Internet from an online retail supplier in Ohio and shipped to South Carolina. File to: BlueCross BlueShield of South Carolina.
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Ancillary Claims: Specialty Pharmacy • File claims to the Plan in whose state the ordering physician is located.
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Ancillary Claims • To facilitate claim adjudication, please file these claims with the referring provider’s NPI number: – Independent lab – DME – Specialty pharmacy
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DME Rentals • If a subscriber group changes Plans in the middle of a rental, you should only rent for the remaining rent up to purchase episode and not consider it beginning a new rental period.
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Birth Outcomes Initiatives Modifiers • Effective for dates of service on or after January 1, 2013, append modifiers for all deliveries. • In some cases we will also need you to complete the American College of Gynecologists (ACOG) Patient Safety Checklist or a comparable patient safety justification form. 110
Birth Outcomes Initiatives Modifiers • Please keep copies of these documents in your files and in the hospital record, which are subject to SCDHHS Program Integrity review. • In the Providers section of our website, www.SouthCarolinaBlues.com, you can find copies of ACOG- and Birth Outcomes Initiative (BOI)-approved delivery guidelines. – These guidelines justify elective inductions and deliveries prior to 39 weeks gestation. – You can also find the ACOG Patient Safety Checklists on our website.
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Birth Outcomes Initiatives Modifiers • To facilitate claim adjudication, please append these modifiers to all CPT codes when you bill for vaginal deliveries and C-sections: – GB – 39 weeks gestation and or more
• For all deliveries at 39 weeks gestation or more regardless of method (induction, C-section or spontaneous labor).
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Birth Outcomes Initiatives Modifiers – CG – Less than 39 weeks gestation
• For deliveries resulting from patients presenting in labor, or at risk of labor, and subsequently delivering before 39 weeks. • For inductions or C-sections that meet the ACOG or approved BOI medically necessary guidelines, please complete the appropriate ACOG Patient Safety Checklist. – Keep the documents in the patient’s file.
• For inductions or C-sections that do not meet the ACOG or approved BOI guidelines, please complete the appropriate ACOG Patient Safety Checklist.
– Also, you must get approval from the regional perinatal center’s maternal fetal medicine physician. – Then keep these documents in the patient’s file. 113
Birth Outcomes Initiatives Modifiers – UA – Prolonged labor when a vaginal delivery fails to progress and converts to a cesarean section
• Bill using the CPT code 59514 with a UA modifier. • Document in the patient record the time of admission to the hospital and the start time of the cesarean section. • Prolonged labor is defined as at least six hours of documented labor. • Use as a secondary modifier in conjunction with GB or CG. 114
Birth Outcomes Initiatives Modifiers – No Modifier – Elective deliveries less than 39 weeks gestation
• For deliveries less than 39 weeks gestation that do not meet ACOG or approved BOI guidelines, or are not approved by the designated regional perinatal center’s maternal fetal medicine physician.
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Colonoscopy Procedure Update • Even when a routine screening results in detection of suspicious tissue or removal of a polyp, you should assign the screening diagnosis code as the primary diagnosis. – This is because the intent of the procedure was preventive.
• Then, list the diagnosis code related to any additional findings or procedures you perform during the colonoscopy as secondary diagnoses.
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Colonoscopy Procedure Update • If you schedule a colonoscopy as a diagnostic procedure in response to symptoms indicating disease or as surveillance for prior documented disease, you should document the procedure as such. • For a diagnostic colonoscopy, however, applicable copayment, coinsurance and deductibles will apply depending on the member’s plan of coverage.
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Colonoscopy Procedure Update • For members who have a preventive benefit plan, we cover a screening colonoscopy at 100 percent. – Please note that these claims must have the appropriate: • Screening primary diagnosis code (for example: V76.51) • CPT code with either modifier 33 or PT
– See the Current Procedural Terminology (CPT) Manual for details.
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Refund Process • Provider: – Identifies an overpayment on a member’s account. – Completes an overpayment form from either: • www.SouthCarolinaBlues.com • www.BlueChoiceSC.com
– Provides documentation supporting the refund to include a check for the appropriate amount. – Sends information to address on form.
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Subrogation: What You Should and Should Not Do Do: Allow the subrogation screening methods to work. This will ensure questionnaires are sent to members for appropriate claims and will ensure when the questionnaire is returned, we will have all information necessary to process the questionnaires. Don’t: Send in questionnaires for every patient. Do: Send in completed and accurate questionnaires that include the member’s ID number and or claim number. Don’t: Fax or mail in stacks of questionnaires on all your patients. 120
Searching for Remits in My Insurance Manager Follow these tips when performing remit searches within My Insurance ManagerSM: 1. Choose a single location. Using the All Locations option may cause you to experience a document limit threshold, prohibiting you from seeing all remits within your search criteria. 2. Narrow the date span for your search to avoid a document limit threshold, prohibiting you from seeing all remits within your search criteria. 121
Use the Web and VRU • Please use the Web and Voice Response Unit (VRU) and/or the HIPAA electronic transactions for: – Claim status – Eligibility/benefits – Precertification – Appeals – Medical policies review – Much, much more … 122
BlueChoice HealthPlan presented by Ashlie Graves
Access to BlueChoice HealthPlan • Website: – www.BlueChoiceSC.com – Available 24 hours a day.
• Voice Response Unit (VRU): 800-868-2528 • Member Services: 800-868-2528 or fax 803-714-6443 – – – – – –
General inquiries Verification of member eligibility Benefits Authorization status Claims status Service representatives are available for more complicated questions Monday through Friday from 8:30 a.m. until 8 p.m.
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Access to BlueChoice HealthPlan • Health Care Services: 800-950-5387 – Authorization for referrals and procedures – Can call this number 24 hours a day
• Companion Benefit Alternatives: 800-868-1032 – Mental health and substance abuse referrals and authorizations Companion Benefits Alternatives is an independent company that manages behavioral health and substance abuse benefits for most of our members and their dependents on behalf of BlueCross and BlueChoice.
• EDI Support Center: 800-868-2505 – EDI (Electronic Data Interchange) electronic claims issues
• EFT Coordinator:
[email protected] – EFT (Electronic Funds Transfer) issues
• Provider File Changes:
[email protected]
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HMO: Primary Choice • Alpha Prefix: ZCC • Requires all members to select a primary care physician and get referrals from them before seeking the services of a specialist. • Primary Choice members do not have out-ofnetwork benefits. • Individual coverage for ages six weeks to age 30. 126
HMO: Primary Choice
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Open Access • Alpha Prefix: ZCL • Members may self-refer directly to any specialist or primary care physician in the physician network without a referral. • Once a member self-refers to a physician, the physician should follow BlueChoice’s normal process for services that require precertification.
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ADVANTAGEplus and CarolinaADVANTAGE HDHP High Deductible Open Access Health Plan • Alpha Prefix: ZCL • Members have health savings accounts, lower premiums and higher deductibles. • Works the same as regular ADVANTAGEplus and CarolinaADVANTAGE except members must meet deductible before BlueChoice pays for services for “sick care.” • Preventive care services (filed with a V-code diagnosis) are covered at 100 percent after the member’s copayment. Deductibles do not apply to preventive care.
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Individual Plans: MyChoice • • • •
Alpha Prefix: ZCL Individual and family coverage issued to age 64.5 In- and out-of-network benefits Open access plans — member can self-refer to specialists
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Point of Service • As of January 1, 2013 the Point of Service product is no longer available. • All existing members have been converted to other plans. • Alpha prefix ZCC
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Health and Disease Management Programs
Great Expectations® for health • • • • • •
Alcohol Management Asthma Back Care Children’s Health Chronic Kidney Disease Chronic Obstructive Pulmonary Disease (COPD) • Depression • Diabetes • Get In Control (Hypertension and High Cholesterol)
• Healthy and Active Kids (Childhood Obesity)
• • • • • • • • •
Heart Disease Heart Failure Maternity Men’s Health Migraine Pre-Diabetes Quit Smoking Weight Management Women’s Health 132
Great Expectations® for health Programs Integrate disease management and preventive services to support the health of our members Members with identified risks receive: • New member/enrollment packet • Educational material such as newsletters and calendars • Written reminders for needed care such as screening tests, eye exams, physician follow-ups
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Great Expectations® for health Programs Members with identified risks receive: • Coaching phone calls with a health specialist • Case management for poorly controlled conditions • Letters about elevated lab values, followup with physician • Free tools for self management: blood sugar monitors, peak flow meters, etc.
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BlueChoice HealthPlan Medicaid presented by Donna O. Thompson
Contacting BlueChoice HealthPlan Medicaid Remember: all contact information for BlueChoice HealthPlan Medicaid is different from commercial BlueChoice HealthPlan.
Website: www.BlueChoiceSCMedicaid.com Customer Care Center (Verify eligibility, benefits, claims status, general questions, etc.) • Voice: 866-757-8286 Monday to Friday: 8 a.m. to 6 p.m. • Fax: 912-233-4010 or 912-235-3246 TTY: 866-773-9634 MedCall (24-hour nurse help line) • Voice: 866-577-9710
TTY: 800-368-4424
Utilization Management (Prior authorization and hospital/facility admission notification) • Voice: 866-902-1689 Monday to Friday: 8 a.m. to 5 p.m. • Fax: 800-823-5520 Case Management (Care coordination and Women, Infants, and Children [WIC] Information) • Voice: 877-833-5736 Monday to Friday: 8 a.m. to 5 p.m. • Fax: 866-406-2808 24 hours a day, 7 days a week • WIC: 800-868-0404 Express Scripts, Inc. (Pharmacy benefits) • Voice: 800-470-0933 • Fax: 866-807-6241
Monday to Friday: 8 a.m. to 9 p.m. Saturday to Sunday: 8 a.m. to 6 p.m.
Express Scripts, Inc. is an independent company that provides pharmacy benefits management services on behalf of BlueChoice HealthPlan Medicaid.
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Verifying Eligibility • Checking eligibility is critical for every visit:
– Since each member has 90 days to switch plans after assignment – Since a member can lose eligibility at any time of the year based on a change in his or her status
Member ID card Customer Care Center: 866-757-8286 www.BlueChoiceSCMedicaid.com South Carolina Point of Sale (POS) device South Carolina Medicaid Interactive Voice Response System (IVRS) • South Carolina Medicaid Web portal: https://portal.scmedicaid.com • • • • •
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ID Card Members are required to carry their Stateissued Healthy Connections ID cards.
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Website www.BlueChoiceSCMedicaid.com
This website is different from the commercial website www.BlueChoiceSC.com.
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Available Resources • Provider Directory • Provider Operations Manual (POM) • POM Lite • Services Requiring Authorization • Forms • Pharmacy Information • Health Education • Screening, Brief Intervention, Referral to Treatment (SBIRT) 140
Secure ProviderAccess • Similar to My Insurance Manager, visit ProviderAccess to get member-specific information.
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Secure ProviderAccess • You’ll now need to include the prefix with the member’s ID number and date of birth when getting information.
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Provider Directory • This searchable directory allows you to search for a specific physician or physician group, or pull a personalized directory of your county or the entire state.
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Covered Benefits •MCO Plans are required to offer the same benefits as Healthy Connections (FFS).
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Covered Benefits •On our website, you can find a complete description of core services in: – The Member Handbook (Evidence of Coverage)
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Covered Benefits • In the Provider Operations Manual, find descriptions of these services: • Audiology • Behavioral Health • Chiropractic Service • Developmental Evaluation • DME • Emergency Transport • EPSDT • Family Planning • Federally Qualified Health Clinic (FQHC)/Rural Health Clinic(RHC) • Home Health
• Hysterectomies and Abortions • Labs • Inpatient Hospital • SNF/Nursing Homes • Maternity • OPAC – aids clinic services • Outpatient Services • Physician Services • Prescription Drugs • Preventive and Rehab Services • Certain Transplant Services • X-rays 146
Benefits Covered by Healthy Connections (FFS)
• These benefits are carved out of BlueChoice HealthPlan Medicaid and covered by the state: • • • • •
Vision hardware for members under 21 Dental services for members under 21 Dental emergencies for adults Hospice services Non-emergency transportation
• Available for doctors’ appointments, dialysis, X-rays, lab work, drug store or other medical appointments
• Skilled Nursing Facility (SNF)
• BlueChoice HealthPlan Medicaid covers the first 90 days of a member’s stay in an SNF until the member can be moved into Healthy Connections. 147
Copayments Benefit
Copayment
Primary care visits, RHCs and FQHCs
$3.30
Specialists visits (including optometrists)
$3.30
Medical equipment
$3.40
Chiropractor
$1.15
Home health (limited to 50 visits)
$3.30
Prescription drugs (grand and generic)
$3.40
Outpatient hospital
$3.40
Inpatient hospital
$25.00 148
Copayment Exceptions • These beneficiaries are exempt from copayment requirements:
– Children under 19 years of age – Pregnant women – Institutionalized individuals – Individuals receiving emergency services in the ER – Individuals receiving Medicaid hospice services – Members of a Federally Recognized Indian Tribe • Exempt when services are rendered by the Catawba Service Unit in Rock Hill and when referred to a specialist by Catawba
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Copayment Exceptions • These services are not subject to copayments: – Medical equipment and supplies provided by DHEC – Family planning – End stage renal disease services – Infusion centers
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Early and Periodic Screening, Diagnosis and Treatment • The South Carolina Medicaid Program, in accordance with federal requirements, must develop and maintain an EPSDT program for Medicaid-eligible children.
– Early and Periodic Screening, Diagnosis and Treatment – Is the preventive, well-child screening program in South Carolina – Provides comprehensive and preventive health services to Medicaid-eligible children from birth to age 21 through periodic medical screenings
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Early and Periodic Screening, Diagnosis and Treatment • The screening package includes:
– A comprehensive health and developmental history – A comprehensive unclothed physical examination – Appropriate immunizations according to age and health history – Health education, including anticipatory guidance – Vision and hearing screening – Dental screening
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Appropriate EPSDT Codes 96110
Developmental Screening
99050 and 99051
After Hours
99381– 99385 and 99391– 99395
Well-Child Visits
99173– 99174
Vision Screening
92551– 92552
Hearing Screening
99401– 99404
Preventive Medicine and Individual Counseling
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Maternity:
Screening, Brief Intervention, Referral to Treatment (SBIRT)
• Collaborative effort among:
– South Carolina Department of Health & Human Services (SCDHHS) – South Carolina Department of Alcohol and Other Drug Abuse Services (DAODAS) – South Carolina Department of Mental Health – Managed Care Organizations (MCOs) – Medical Home Networks (MHNs)
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Maternity:
Screening, Brief Intervention, Referral to Treatment (SBIRT)
• Complete screening on all pregnant members to include 12 months post partum for: – Alcohol – Substance abuse – Tobacco use – Domestic violence
• Fax screening tool to the member’s plan or DHHS if applicable
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Maternity:
Screening, Brief Intervention, Referral to Treatment (SBIRT)
• Bill for the services
– Secondary dx should be V82.9 – H0002 U1 – behavioral health screening – billed once per fiscal year – H0004 U1 – behavioral health intervention – billed twice per fiscal year
• Note: For Rural Health Clinics and Federally Qualified Health Centers: – Reimbursement for SBIRT is included in the encounter code. – H codes should be billed for reporting purposes with a $0.00 charge for reporting purposes.
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Maternity: Notification • Routine delivery and newborn services (two days for vaginal birth and four days for caesarean section) do not require a precertification. • But notification for all deliveries is required. 157
Maternity: Notification • Hospitals can provide notification by contacting the Utilization Management department by fax or phone at the time of delivery. Fax: 800-823-5520 Phone: 866-902-1689 158
Maternity: Notification • Hospitals can use the “Newborn Delivery Notification” form on our website. – A new interactive form is now available.
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Maternity: Notification • Last Menstrual Period (LMP) is required on all delivery claims. • Birth weight in grams is required on all newborn claims.
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Maternity: Birth Outcomes Initiative (BOI) • Effective for dates of service on or after August 1, 2012, providers must include these modifiers on claims for a scheduled induction of labor or a planned cesarean section for deliveries less than 39 weeks gestation: – GB — 39 weeks gestation and or more – CG — less than 39 weeks gestation – UA — Prolonged labor when a vaginal delivery fails to progress and converts to a cesarean section • Use as a secondary modifier in conjunction with GB or CG
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Maternity: Birth Outcomes Initiative (BOI) – No Modifier — elective non-medically necessary deliveries less than 39 weeks gestation
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Precertifications • In-Network Precertification Process – Contact us: • Fax: 800-823-5520 • Phone: 866-902-1689
– List of services requiring prior authorization is available at www.BlueChoiceSCMedicaid.com. – We complete more than 85 percent of all requests within three business days (14-day standard). – We complete all urgent requests within 24 hours (72-hour standard). 163
Precertifications • Out-of-Network Referrals (866-902-1689) – We will accept out-of-network referrals when an innetwork specialist cannot be located. – Contact via fax or phone. – Please note: The list of services requiring authorization provided on the website is not all-inclusive. – Please contact Utilization Management if you have questions on a particular CPT code.
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Precertifications: Pharmacy • Four prescriptions are allowed in a calendar month. – For adults only – Children have no limit
• Point of Service (POS) Pharmacy Override
– Four prescription limit can be overridden at the discretion of the pharmacist
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Precertifications: Pharmacy • Precertification Process (800-470-0933) – Precertification seeks to promote the appropriate use of drugs
• Drugs that are part of a step therapy plan, which have a lower cost option, or tend to be misused or abused • A drug that tends to have severe side effects or is reserved for FDA indications
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Precertifications: Pharmacy • Precertification Process (800-470-0933) – Precertification criteria may include:
• Failure to respond to two preferred drugs • Failure to respond to generic option • Adverse reaction to formulary drug
– On our website, you can find a Prescription Drug List (PDL) including a list of drugs requiring precertification.
Note: Walgreens is now a participating pharmacy 167
Laboratory Services • We have an exclusive agreement with LabCorp for all labs. • Labs sent to LabCorp do not require precertification. • Anatomical pathology and cytology specimens may be sent to a local contracting pathology group or to LabCorp without precertification. • See our website for a complete list of labs that can be done in your office and billed to BlueChoice HealthPlan Medicaid. 168
Claim Submission • Claim Filing Limits ‒ All providers are allowed 365 days to submit claims.
• Electronic Data Interchange (Payer ID 00403) ‒ Preferred and fastest way to submit your claims. ‒ For setup and information, call 800-470-9630.
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Claim Submission • Hard Copy Claim Submission, Corrected Claims and Correspondence ‒ If you need to file a hard copy claim, submit a corrected claim, file an appeal or submit a correspondence, please mail to: BlueChoice HealthPlan Medicaid ATTN: Medicaid Claims PO Box 100124 Columbia, SC 29202-3124
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Timely Filing, Re-submissions and Appeals • Original Claims Please submit original claims within 365 days of the date of service. • Corrected Claims We must receive corrected claims within 90 days from the process date to be considered for payment. You must submit corrected claims with the Claim Follow Up Form. • Appeals We must receive appeals within 90 days from the process date to be considered for review. You must submit appeals with the Provider Dispute Resolution Request Form. 171
Reminders • Because of specific contract changes, we have been required to re-contract with our Medicaid providers. • If you have received an updated contract to be signed and returned, please do so as soon as possible.
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Behavioral Health • Effective April 1, 2012, our behavioral health services coverage will change. We will now cover outpatient behavioral health services that South Carolina Healthy Connections previously covered. Which Providers Will Be Affected? • This change applies to those providers who are licensed, independent practitioners providing services to our members either in the office or in a Federally Qualified Health Clinic or Rural Health Clinic. • For more information: – Visit our Behavioral Health Provider Information page.
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2013 Medicare Pharmacy Update presented by Ranarda Jones, Pharm D, MBA
Overview • • • • • •
Reaching for the Stars Major Formulary Changes in 2013 Medicare B or Medicare D Member Mailings Medication Therapy Management (MTM) Coverage Determinations and Appeals
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Star Measures • Quality and Performance Rating • Nine categories up to a total of 53 individual measures • Current year rating based on data from two years ago – i.e., 2013 star ratings based on 2011 data
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2013 Star Ratings
Ratings are on the Medicare website: www.medicare.gov
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Reaching for the Stars • Initiative started in July 2012 to increase awareness of star ratings • Internal team to discuss strategies to increase star ratings going forward • Vendor assistance from Inovalon and Caremark Inovalon is an independent company that handles clinical documentation services on behalf of BlueCross.
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How Providers Can Help • Document, document and document – If a screening, test, vaccine, procedure, lab, or treatment was done … DOCUMENT. – Not only taking height and weight but CALCULATE BMI and DOCUMENT.
• Encourage medication adherence and medication therapy management participation. • Be familiar with finding formulary alternatives or completing coverage determinations. 179
Drug Removal • We will remove these drugs from the formulary in 2013 for Medicare BlueSM and MedBlue RxSM formularies: – All Lilly insulin products excluding Humulin R-500
• Humulin R, Humulin N, Humalog, Humalog Mix • Novo Nordisk products will be preferred (Novolin, Novolog)
– High-risk medications as determined by the Pharmacy Quality Alliance
• Premarin, estropipate, Prempro, promethazine, cyproheptadine, hydroxyzine, cyclobenzaprine, methocarbamol, orphenadrine, dipyridamole
– Micardis, Micardis HCT, Teveten, Teveten HCT
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More Drug Removals • • • • • • •
Trilipix, Advicor, Vytorin Lansoprazole Venlafaxine ER tablets only Nuvigil Metadate CD Oxycontin We will NOT remove Crestor, Nexium, Symbicort, Seroquel XR as we previously communicated to members.
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Generic Pipeline • We will remove several branded medications from the formulary or move them to a higher tier because their generic formulation is due to launch 4th quarter 2012 or 1st quarter 2013. – Examples: • • • • • •
Diovan Diovan HCT Atacand Maxalt Tricor Propecia
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Medicare B or Medicare D • Prescription rejects at point of sale (POS) as B vs. D. • The pharmacist can use the information on the prescription to make the determination. • Examples: – Immunosuppressant drugs are covered under Part B for Medicare-approved transplants. – If the physician writes “Medicare covered transplant” on the prescription, the pharmacist would know to bill Part B. – If physician writes “not being used for organ rejection” or “member not eligible for Medicare at time of transplant,” the pharmacist would know to bill Part D.
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Oral Anti-Emetics • Examples: – Oral anti-emetic drugs are covered under Part B if being used up to 48 hours after chemotherapy in place of IV anti-emetic therapy. – If physician writes “full replacement for IV administration within 48 hours of cancer treatment,” then the pharmacist could make the determination to bill Part B. – If physician writes “for non-chemo related N/V,” the pharmacist could make the determination to bill Part D. 184
Nebulizer Solutions • Nebulizer solutions may reject at point of sale for B vs. D determination. • Inhalation solutions administered via nebulizer in the home are covered under Part B. • For residents in long-term care facilities, these medications will ALWAYS be billed under Part D.
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Oral Chemotherapy Agents • Covered under Part B if the oral medication has an infusible form and the patient has a diagnosis of cancer. • Including a diagnosis code on the prescription would help the pharmacist make the determination of B vs. D.
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Vaccines • Vaccines covered under Part B: – Flu and pneumonia – Incident to exposure • Tetanus shots if member stepped on a rusty nail
• Preventive vaccines are covered under Part D (see formulary)
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Member Mailings • Transition Fill Letters – Physician Office Action:
• Change therapy to a formulary medication or start the coverage determination process
• Negative Change Letters – Physician Office Action:
• Change therapy to a formulary medication, approve for generic to be dispensed, or start the coverage determination process
• Adherence to Drug Therapy Letters – Physician Office Action:
• Encourage member to take medications as prescribed, simplify therapy if possible 188
Medication Therapy Management (MTM) • MTM program offered at no cost to members who meet these criteria: – Take eight or more Medicare Part D covered maintenance drugs – Have three or more long-term health conditions, such as: • Diabetes • Asthma • High blood pressure
– Anticipate drug spend is greater than $3,144 a year 189
Medication Therapy Management (MTM) • Once member is targeted, he or she is autoenrolled into the program • Opt-out method only • Targeted members offered a comprehensive medication review
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Medication Therapy Management (MTM) • Physician offices receive targeted medication reviews • Physician office action: • Encourage member participation to receive comprehensive medication review • Respond to targeted medication review faxes
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Coverage Determinations and Appeals • • • •
Highly regulated and monitored by CMS Standard request 72-hour decision Expedited/Urgent request 24-hour decision Exception requests require a supporting statement from the physician
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How to Complete a Prior Authorization • To retrieve the most current forms: – Go to www.SouthCarolinaBlues.com > Providers > Forms > Prescription Drugs > Medicare Part D Plans
• Fax form to 855-633-7673 • Verbal requests to 800-294-5979 – Have the chart ready to complete the form over the phone 193
Request for Coverage Determination Form — Page 1 • Coverage Determination department contact information • Enrollee information • Drug information ‒ Name ‒ Strength ‒ Quantity per month prescribed
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Request for Coverage Determination Form — Page 2
195
Request for Coverage Determination Form — Page 3
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Exceptions • Quantity limit, step therapy, prior authorization don’t apply • Supporting statement must illustrate one of these: – Recommended formulary alternatives have been ineffective or, based on clinical evidence, would be ineffective for member’s condition – Recommended formulary alternatives have caused or, based on clinical evidence, would cause adverse reaction or harm to the member 197
Increase Response Rate • The physician’s office can increase response rate and decision making by: – Completing the prior authorization criteria correctly (e.g., if yes to question #3, skip to #5) – For exceptions, submitting a valid supporting statement – Including patient pharmacy ID information and diagnosis codes – Responding to the Request For more Information (RFI) faxes 198
Appeals • All denied coverage determinations can be appealed • Our pharmacy benefits managers handles redeterminations on our behalf • Standard redeterminations — 7 days • Expedited/Urgent redeterminations — 3 days • Denied redeterminations can be appealed to independent review entity – Currently Maximus 199
Medicare Advantage presented by Teosha Harrison
Medicare Advantage Standard Option: Medicare Blue
No Part D: Medicare Blue Saver
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Service Areas and Product Changes • Medicare Blue (PPO) Three service areas for 2013: – Upstate, Midlands, Rural – CMS requires us to dis-enroll members affected by this change. • Members will have to reapply to remain in the Plan, with the service area change noted.
• Medicare Blue Plus (PPO) – Will not be offered in 2013 – Members in this product will be dis-enrolled on December 31, 2012 and return to traditional Medicare, unless they enroll in a new Medicare Advantage plan. 202
Helpful Tips • Be as specific as possible in providing a diagnosis code for patients and all diagnosis codes must be documented in the patient’s health record. – This includes important information on: • • • •
Diagnosis BMI Blood pressure Other vitals
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Helpful Tips • Providers in our Medicare Advantage network should NOT balance bill patients. – As a contracted provider, you agree to accept BlueCross’ reimbursement in addition to the beneficiary’s cost sharing as payment in full.
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Helpful Tips • Effective January 1, 2013, certain advanced imaging services for Medicare Advantage beneficiaries will require precertification from National Imaging Associates (NIA) when performed and billed in an outpatient or office location. • Providers in our Medicare Advantage network are REQUIRED to file claims electronically to us unless they have an exemption from Medicare. 205
Discharge Coordination Services for Medicare Advantage Members
• We are introducing discharge coordination services for BlueCross BlueShield of South Carolina Medicare Advantage beneficiaries. These services: – Ensure members receive appropriate care and follow up when hospitalized. – Identify those beneficiaries who may need more case management upon discharge.
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Discharge Coordination Services for Medicare Advantage Members
• A team of registered nurses will implement the discharge coordination services. This team will: – Facilitate referrals to network providers, internal case managers and disease managers, as necessary. – Facilitate smooth transitions home. • The team will work with hospital case managers and discharge planners to ensure a plan of care is in place.
– Have an after-care conversation with members. • The team will address any gaps in care as soon as possible.
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Inovalon and BlueCross Medicare Advantage
• Inovalon: – Is an independent company that handles clinical documentation services on behalf of BlueCross. – Helps our Medicare Advantage members remember to get the care they need through outreach programs and in-home health assessments. – Assists us in documenting the patient condition information we report to CMS through chart and other reviews. 208
Inovalon Services • In-home patient visits to help close gaps in care • CMS-mandated medical chart reviews • Encounter facilitation letters and phone calls to beneficiaries encouraging them to make and keep doctor appointments • Subjective Objective Assessment Plan (SOAP) notes facilitation and collection via paper and electronic versions of beneficiary medical health topics 209
CMS Required Acceptable Signatures • From the 2008 Medicare Call Letter:
– “For purposes of risk adjustment data submission and validation, the MA organizations must ensure that the provider of service for face-to-face encounters is appropriately identified on medical records via their signature and physician specialty credentials.”
• “specialty credentials” — means degree or professional designation – e.g., MD, DO, NP, PA
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CMS Required Acceptable Signatures • All credentials must be:
– Legible – Pre-printed on the form or a part of a compliant electronic signature
• A compliant handwritten signature: – Is legible – Includes the clinician’s credentials
• For non-compliant handwritten signatures:
– Make it compliant by having the clinician’s name and credentials pre-printed on the form. • This may be in the letterhead, or in the form of a signature “block” on the form.
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Compliant Signatures
Although the signature is completely illegible, the name and credential of the treating physician is checked.
Although the signature is illegible, the physician’s name and credential are pre-printed on the progress note.
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Non-compliant Signature 1
In this case, there are two clinicians in the group, but no clinician’s name is checked, and the signature is illegible.
In this case, we don’t know Dr. Public’s credential. Without it, we don’t know if he’s an MD, DO or DPM, or has a doctorate in a non-medical field. 213
Electronic Signatures • An electronic signature can only be used to authenticate an electronic medical record (EMR). – It must contain language that clearly shows it’s a signature, not just the physician’s name.
• Like a physical signature, electronic signatures must contain the clinician’s credential.
214
Examples of Electronic Signatures • • • • • •
Electronically signed by John Smith, DO Digitally signed by Steven Smith, MD Authenticated by Randall Black, DPM Approved by Robert Johnson, Psy.D Finalized by Richard Jones, DPT Validated by Michael Richards, LCSW
215
Signature Facsimiles • A signature facsimile in an EMR is insufficient to authenticate the record. – The note must still indicate that it has been electronically signed.
216
Other Unacceptable Signatures • As of January 1, 2009, CMS no longer accepts signature stamps for any purpose. • You cannot use a progress note template that includes a signature incorporated into it. – The clinician must authenticate each progress note when the service is rendered.
217
How to Remedy an Unacceptable Signature
• In Medicare Advantage, only a CMSgenerated attestation in a Risk Adjustment Data Validation (RADV) can remedy an unacceptable signature.
218
Medicare Advantage Preventive Services
• Preventive Medicine Visits (physicals) are non-covered for traditional Medicare and for our Medicare Advantage plans. – CPT codes 99381–99397
• A one-time “Welcome to Medicare” physical is covered. – G codes G0402–G0405
• Annual wellness visits are covered • You can download CMS’s Quick Reference Information chart.
219
Federal Employee Program presented by Jada Addison
Federal Employee Program (FEP)
221
FEP Standard Option Changes SERVICE
2012 BENEFIT
Urgent Care Members paid 15 percent of plan allowance after deductible was met Members paid Continuous $200 copayment Home per episode Hospice Care
2013 BENEFIT
Members pay $40 copayment for services
Members pay $250 copayment per episode 222
FEP Basic Option Changes SERVICE
2012 BENEFIT
2013 BENEFIT
Physical, Members paid Members pay Occupational and $75 copayment $25 copayment Speech Therapy by a Preferred Hospital Outpatient Facility Members paid Members pay Services by a $75 copayment $100 copayment Preferred Hospital per day per day Cardiac, Cognitive Members paid Members pay and Rehabilitation $75 per day $25 per day per Services by a per facility facility 223 Preferred Hospital
FEP Basic Option Changes (continued) SERVICE
2012 BENEFIT
2013 BENEFIT
Diagnostic Test Members paid Members pay nothing $25, $75 or Related to an $100 Accidental copayment Injury Members paid Benefits paid in Drugs and 30 percent of full Supplies Administered plan allowance by Urgent Care 224
FEP Standard and Basic Option Changes SERVICE
2012 BENEFIT
2013 BENEFIT
Human Papillomavirus (HPV) Breastfeeding Pump Kit
Benefits were included in cervical cancer tests No benefits
Contraceptive Services and Sterilization for Preferred Providers
Benefits were subject to costshare
One screening per year for female members One kit per year through CVS Caremark for pregnant and/or nursing women Benefits provided in full for women 225
FEP Standard and Basic Option Changes (continued)
SERVICE
2012 BENEFIT
2013 BENEFIT
Over-the-Counter Contraceptives and Devices
Items were not covered
Full benefits provided for women when the contraceptives meet FDA standards and when purchased with a physician’s prescription at a Preferred retail pharmacy
226
FEP Standard and Basic Option Changes (continued)
SERVICE
2012 BENEFIT
2013 BENEFIT
Children’s Hearing Aids and Related Supplies
Limited to $1,250 per ear per calendar year
Up to $2,500 payable per calendar year
Adult Hearing Aids Limited to $1,250 and Related Supplies per ear per calendar year per 36-month period Bone Anchored Limited to $1,250 Hearing Aids per ear per calendar year
Up to $2,500 payable every three calendar years Up to $5,000 per calendar year for adults and children 227
FEP Standard and Basic Option Changes (continued)
SERVICE
2012 BENEFIT
2013 BENEFIT
Inpatient Hospice Care (Standard Option)
Benefits available up to seven consecutive days and subject to a $250 copayment per admission
Benefits provided in full when services rendered at a Preferred hospice facility up to 30 consecutive days
Inpatient Hospice Care (Basic Option)
Benefits provided in full Benefits available when services rendered at up to seven consecutive days a Preferred hospice facility and subject to $150 up to 30 consecutive days copayment per admission 228
FEP Benefits at a Glance 2013 Calendar Year Deductibles Standard Option $350 per person or $700 per family Basic Option
$0
229
State Health Plan presented by Jada Addison
State Health Plan Standard Plan
Savings Plan
231
Savings Plan: Covered Codes for Annual Physical Exams • The annual physical exam allowed under the Savings Plan includes: – A preventive comprehensive examination – A complete urinalysis – An electrocardiogram – A fecal occult blood test – A general health laboratory panel “blood work” – A lipid panel every five years – A Pap smear for women 232
Savings Plan: Covered Codes for Annual Physical Exams • Use these CPT codes for the comprehensive exam, which typically includes a simple “dipstick” urinalysis for a new patient:
– Initial preventive medicine evaluation and management of an individual including a comprehensive history – A comprehensive examination – Counseling/anticipatory guidance/risk factor reduction interventions – The ordering of appropriate laboratory/diagnostic procedures, new patient – 99384 age 12 through 17 years – 99385 age 18 through 39 years – 99386 age 40 through 64 years – 99387 age 65 and older 233
Savings Plan: Covered Codes for Annual Physical Exams • Periodic preventive medicine evaluation and management of an individual including:
– A comprehensive history – A comprehensive examination – Counseling/anticipatory guidance/risk factor reduction interventions – The ordering of appropriate laboratory/diagnostic procedures, established patient – 99394 age 12 through 17 years – 99395 age 18 through 39 years – 99396 age 40 through 64 years – 99397 age 65 and older 234
Savings Plan: Covered Codes for Annual Physical Exams • Use these CPT codes for a urinalysis: – 81000:
• Urinalysis by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity • Urobilinogen, any number of these constituents • Non-automated, with microscopy
– 81001:
• Urinalysis by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity • Urobilinogen, any number of these constituents • Automated, with microscopy 235
Savings Plan: Covered Codes for Annual Physical Exams • Use this CPT code for an EKG: – 93000:
• Electrocardiogram, routine ECG with at least 12 lead; with interpretation and report
• Use this CPT code for a fecal occult blood test: – 82270:
• Blood, occult by peroxidase activity (e.g., guaiac); feces, 1–3 simultaneous determinations
236
Savings Plan: Covered Codes for Annual Physical Exams • Use these CPT codes for health panels or any component contained within: – 36415:
• Collection of Venous Blood by Venipuncture
– 80050:
• General Health Panel
– 80061:
• Lipid Panel, payable once every five years
237
State Preventive Benefits: Mammography • Mammography benefits include:
– One baseline mammogram for women age 35 through 39 – One routine mammogram every year for women age 40 through 74
• Participating providers must perform routine mammograms.
238
State Preventive Benefits: Mammography • Standard Plan
– The office service special deductible, the plan deductible and coinsurance do not apply to this service.
• Savings Plan (HDHP)
– The plan deductible and coinsurance do not apply to this service.
239
State Preventive Benefits: Pap Tests • Standard Option
– Pap test benefits include: • One routine test each year for covered female patients age 18 through 65 – The related routine office visit will be covered at the level two exam rate for patients age 18 through 65. – Services are not subject to the calendar year deductible or coinsurance. – You can balance bill the patient for the remaining cost of the routine office visit. – This benefit does not include payment of any other routine lab service performed in conjunction with the routine Pap test. 240
State Preventive Benefits: Pap Tests • Savings Plan (HDHP)
– Pap test benefits include:
• One routine test each year for covered female patients age 18 through 65.
– One annual routine visit is allowed. – Office visits can be covered when done in conjunction with a routine physical or routine obstetric and gynecological visit, but not both. – Services are not subject to the calendar year deductible or coinsurance. – You can balance bill the patient for the remaining cost of the routine office visit. – This benefit does not include payment of any other routine lab service performed in conjunction with the 241 routine Pap test.
Flu Vaccinations Less than 6 months Not Covered
STANDARD OPTION
6 months through 18 years
Covered
Over 18
Not Covered
Less than 6 months Not Covered
SAVINGS OPTION
6 months through 18 years
Allowed
Over 18
Not Covered 242
SCANA (FWY) presented by Tamara Fravel
Precertification • Effective January 1, 2013, precertification is required for all outpatient surgeries (place of service = 22).
244
Walmart and Tyson presented by Tamara Fravel
AIM Specialty HealthSM • Beginning January 1, 2013, BlueAdvantage Administrators of Arkansas will begin working with AIM Specialty Health on a new Integrated Imaging Program for outpatient diagnostic imaging procedures for Walmart associates and Tyson team members and their covered dependents throughout the U.S. – AIM is an independent company that reviews advanced imaging services for clinical appropriateness on behalf of Blue Cross and Blue Shield of Arkansas. 246
AIM Specialty HealthSM • Walmart associates and Tyson team members residing in your area will be included in this national care management program.
Arkansas Blue Cross and Blue Shield and BlueAdvantage Administrators of Arkansas are Independent Licensees of the Blue Cross and Blue Shield Association. 247
Contact Information There are two ways you can interact with AIM: 1. Register at AIM’s website: • www.aimspecialtyhealth.com/goweb • Allows use of ProviderPortal – AIM’s interactive Internet application.
2. Call AIM’s Call Center: • Phone number is on the back of the member’s ID card. • 866-688-1449 248
New Groups presented by Tamara Fravel
BlueCross New Groups • • • • • • • • • • •
AFL Telecommunications Advanced Disposal Alent, Inc. Alstom Baptist Health Care BMW Associate Health Clinic Capella Healthcare CLECO Continental AG - Rx Danisco Renewal Darden Restaurants
• Fairway Outdoor Advertising • Holy Cross Hospital • Insurance Offices of America • Resolute Forest Products • SCANA • Schaeffler • Seaboard Corp. • UCI Medical Affiliates • Wegmans Renewal • W.R. Grace & Co 250
Thanks for Coming • Stay tuned for 2013 educational opportunities on: – Working successfully with BlueCross – Transparency initiatives – Dental – And more!
Provider Education and Relations
[email protected] 803-264-4730 251
