PIH Update - August 2016 - Independence Blue Cross

update
SM
New functionality for
CAQH ProView™
page 4
New transactions on
NaviNet® and user
guides available
page 5
Behavioral health:
Promoting provider
communication and
collaboration: Part 2
page 14
August 2016
Inside this edition
Administrative
●● Required lead time when updating your provider information
►► Carenet outreach program continues
►► New functionality for CAQH ProView™
►► Notification for inpatient facility maternity claims
NaviNet®
►► New transactions on NaviNet® and user guides available
Announcements
Partners in Health UpdateSM is a publication
of Independence Blue Cross and its affiliates
(Independence), created to provide valuable
information to the Independence-participating provider
community. This publication may include notice of
changes or clarifications to administrative policies and
procedures that are related to the covered services
you provide in accordance with your participating
professional provider, hospital, or ancillary
provider/ancillary facility contract with Independence.
This publication is the primary method for
communicating such general changes.
Suggestions are welcome.
Contact information:
►► Introducing Independence LIVE!
Medical
►► C
overage requirements for applied behavioral analysis for the
treatment of autism spectrum disorders
►► New policies for Modifier 53: Discontinued Procedure
►► Updated policies for Always Bundled Procedure Codes
Provider Communications
Independence Blue Cross
1901 Market Street
27th Floor
Philadelphia, PA 19103
[email protected]
►► Upcoming changes to 2016 ePASS® incentive opportunity
●● R
eminder: Utilization management program for genetic/genomic
tests, certain molecular analyses, and cytogenetic tests now in
effect
►► Upcoming coverage position changes for certain laboratory tests
●● Vitamin D testing policies now in effect
●● View up-to-date policy activity on our Medical Policy Portal
Quality Management
►► Updated physician quality measure rankings
Health and Wellness
●● B
ehavioral health: Promoting provider communication and
collaboration: Part 2 – Behavioral health resources available for
assessment and treatment of opioid misuse and abuse
●● E
ncourage pregnant Independence members to enroll in
Baby BluePrints®
●● Help your patients get healthy this summer
Models are used for illustrative purposes only. Some illustrations
in this publication copyright 2016 www.dreamstime.com. All rights
reserved.
Independence Blue Cross offers products through its subsidiaries
Independence Hospital Indemnity Plan, Keystone Health Plan
East, and QCC Insurance Company, and with Highmark Blue
Shield — independent licensees of the Blue Cross and Blue Shield
Association.
This is not a statement of benefits. Benefits may vary based on state
requirements, Benefits Program (HMO, PPO, etc.), and/or employer
groups. Providers should call Provider Services for the member’s
applicable benefits information. Members should be instructed to call
the Customer Service telephone number on their ID card.
The third-party websites mentioned in this publication are maintained
by organizations over which Independence exercises no control,
and accordingly, Independence disclaims any responsibility for the
content, the accuracy of the information, and/or quality of products
or services provided by or advertised in these third-party sites. URLs
are presented for informational purposes only. Certain services/
treatments referred to in third-party sites may not be covered by all
benefits plans. Members should refer to their benefits contract for
complete details of the terms, limitations, and exclusions of their
coverage.
NaviNet is a registered trademark of NaviNet, Inc., an independent
company.
FutureScripts and FutureScripts Secure are independent companies
that provide pharmacy benefits management services.
CPT copyright 2015 American Medical Association. All rights
reserved. CPT is a registered trademark of the American Medical
Association.
For articles specific to your area of interest, look for the appropriate icon:
Professional
Facility
Ancillary
►► A
rticles designated with a blue arrow include notice of changes or
clarifications to administrative policies and procedures.
Keystone Health Plan East, Personal Choice®, Keystone 65
HMO, and Personal Choice 65SM PPO have an accreditation
status of Commendable from the National Committee for
Quality Assurance (NCQA).
ADMINISTRATIVE
Required lead time when updating your provider information
Independence would like to remind you that, per your Independence Professional Provider Agreement and/or
Hospital, Ancillary Facility, or Ancillary Provider Agreement (Agreement), you are required to notify Independence
whenever key provider demographic information changes. Submitting changes in a timely manner helps to ensure
prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our
provider directories.
Professional providers*
Independence requires at least 30 days advanced notice to process most updates as long as the information
submitted is accurate. For a complete outline of the advanced notice time frames that Independence requires
to process most updates, refer to the Administrative Procedures section of the Provider Manual for Participating
Professional Providers (Provider Manual). Most of the changes to basic practice information can be quickly submitted
using the Provider Change Form, available at www.ibx.com/providerforms.
Note: The Provider Change Form cannot be used if you are closing your practice or terminating from the network.
Refer to “Resignation/termination from the Independence network” in the Administrative Procedures section of the
Provider Manual for more information regarding policies and procedures for resigning or terminating from the network.
Facility and ancillary providers
As outlined in the Administrative Procedures section of the Hospital Manual for Participating Hospitals, Ancillary
Facilities, and Ancillary Providers, Independence requires at least 30 days advanced written notice to process
changes to your information as long as the information submitted is accurate.
Per your Agreement, all changes must be submitted in writing to our contracting and legal departments at the following
addresses:
Independence Blue Cross
Attn: Senior Vice President, Provider Networks and Value-Based Solutions
1901 Market Street, 27th Floor
Philadelphia, PA 19103
Independence Blue Cross
Attn: Deputy General Counsel, Managed Care
1901 Market Street, 43rd Floor
Philadelphia, PA 19103
Authorizing signature and W-9 Forms
Updates resulting in a change on your W-9 Form (e.g., changes to a provider’s name, tax ID number, billing vendor or
“pay to” address, or ownership) require the following signatures:
●● For professional providers: A signature from a legally authorized representative (e.g., head physician of the
practice, practice administrator) is required.
●● For facility and ancillary providers: Written notification on company letterhead is required. An updated copy
of your W-9 Form reflecting these changes must also be included to ensure that we provide you with a correct
1099 Form for your tax purposes. If you do not submit a copy of your new W-9 Form, your change will not be
processed.
Independence will not be responsible for changes not processed due to lack of proper notice. If you have any
questions about updating your provider information, please contact your Network Coordinator. 
*To ensure appropriate setup in Independence systems, the timelines outlined above also apply to behavioral health providers contracted with
Magellan Healthcare, Inc., an independent company, but they must submit any changes to their practice information to Magellan via their online
Provider Data Change form at www.MagellanHealth.com/provider by selecting the “Display/Edit Practice Info” link or by contacting their Network
Management Specialist at 1-800-866-4108 for assistance.
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ADMINISTRATIVE
Carenet outreach program continues
As part of an ongoing commitment to improve health outcomes for members, Independence is continuing our outreach
program to encourage our Medicare Advantage HMO and PPO members with gaps in care to visit their doctors. As a
participating network provider, you may receive a call from Carenet Healthcare Services (Carenet), an independent
company. Calls from Carenet are intended to help our members schedule needed appointments with their primary
care physician (PCP) or specialist. A Carenet representative will contact our member to see if they would like to set up
an appointment. If the member accepts, Carenet will conference in the member’s PCP or specialist’s office to facilitate
scheduling the appointment.
If you have any questions, please contact your network medical director. 
New functionality for CAQH ProView™*
CAQH recently enhanced CAQH ProView with new functionality so participating organizations receive complete
CAQH ProView data profiles from providers, reducing the need for follow-up with providers after attestation. In
addition, certain fields are now required.
New improvements include:
●● Employment information screen: It will be easier for providers to enter their employment history. Participating
organizations use this information for verification purposes during the credentialing process.
●● Required fields: Certain fields that were previously optional are now required. Participating organizations need
this information for credentialing and to update provider directories. During re-attestation, CAQH ProView will
prompt providers to update their profiles based on these new field requirements. The following sections contain
fields that are now required:
−− Professional IDs section
−− Education section
−− Professional Training section
−− Specialties section
−− Practice Location section
These changes to CAQH ProView will not affect a provider’s status in CAQH ProView or the ability for authorized
participating organizations to view their data.
If you have questions about the recent changes to CAQH ProView, please email them at
[email protected]. 
*This does not apply to providers contracted with Magellan Healthcare, Inc.
Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members.
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ADMINISTRATIVE
Notification for inpatient facility maternity claims
As previously communicated, with the transition to our new operating platform, there could be some differences in
claims processing and outcomes.
Please be advised that a notification is needed to assure proper claims payment for maternity admissions that exceed
the following lengths of stay:
●● vaginal deliveries of 5 days or greater
●● cesarean deliveries of 7 days or greater
If you have an admission that exceeds these parameters, please contact Clinical Services at 1-800-ASK-BLUE to
provide notification.
For any questions regarding this requirement, please contact your Network Coordinator. 
NAVINET®
New transactions on NaviNet® and user guides available
In recent months, we have communicated information about several new transactions being introduced to
Independence providers on the NaviNet web portal, including Eligibility and Benefits Inquiry, Claims Dashboard, and
Document Exchange. New user guides are now available for these transactions, and we strongly encourage you to
review them to become more familiar with the updates.
Eligibility and Benefits Inquiry
In July, we introduced our new Eligibility and Benefits Inquiry transaction to a select number of provider offices.
Starting on August 3, 2016, all remaining NaviNet-enabled participating providers will be given access to this new
transaction.
The member search criteria will be modified, and the presentation of the eligibility and benefits information will
change. The updated transaction will continue to provide you with access to real-time, detailed eligibility and benefits
information for Independence members. You will be able to view information about a member’s demographics,
insurance, and cost-sharing (e.g., copayment, deductible, and coinsurance). In addition, the Eligibility and Benefits
Details screen will offer a list of benefit categories to view and will continue to include links to the member’s capitated
site information (where applicable), ID card, and product-wide provisions associated with the member’s benefit plan.
Please note the following about the new Eligibility and Benefits Inquiry transaction:
●● FEP members. The new transaction will not return information for Federal Employee Program (FEP) members.
You will need to obtain eligibility and benefits information for FEP members through the Eligibility and Benefits
Inquiry transaction in the BlueExchange® Out of Area Workflows menu option.
●● Dates of service. The new transaction will eventually allow you to search for a member’s eligibility and benefits
record up to two years in the past from the current date. However, when the new transaction is first released,
you will only be able to search retroactively for dates of service on or after July 1, 2015. Eligibility and benefits
information will not be available through NaviNet for dates of service prior to July 1, 2015.
continued on the next page
August 2016 | Partners in Health UpdateSM
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NAVINET®
continued from the previous page
Claims Dashboard
We recently introduced the new Claims Dashboard transaction, which allows you to view your Accounts Receivable
in a more comprehensive manner. Claims Dashboard provides you with access to view both pended and finalized
claims.
Note: The data presented within the transaction is provided for general informational purposes. In addition, there is a
lag time between finalized and pended claims data updates.
Document Exchange
Later this month, Document Exchange will be introduced to Independence providers. This new feature will allow us to
share more information electronically with our provider network.
When Document Exchange is first released, your designated NaviNet Security Officer will control which end users,
including himself or herself, associated with your NaviNet office will be given access to the following five unique
Practice Document Categories:
●● Billing/Financial Report
●● Patient Roster Report
●● Patient Transition Report
●● Pharmacy Report
●● Program Enrollment Report
Once an end user is granted permission to access a specific Practice Document Category, that individual will be
able to view and download any documents associated with that category. For example, if a NaviNet Security Officer
grants permission to an associate to access the Billing/Financial Reports category, all reports made available by
Independence under that category will be available to the associate to view or download.
It is important that your designated NaviNet Security Officer manages permissions appropriately for each document
category to ensure reports are accessed in a manner that is compliant with role-based access requirements of the
Health Insurance Portability and Accountability Act (HIPAA).
Note: Third-party vendors that have access to NaviNet will not have the ability to access Document Exchange.
Initial report
The first report that will be made available under Document Exchange will be the High Risk Hospitalization Predictor
report from August 2016 (not February 2016, which was previously communicated). This report will be made available
to targeted primary care physician practices and, based on a predictive model, identifies members treated who are at
high risk of acute hospitalization in the next six months and who have one or more of the following chronic conditions:
●● chronic obstructive pulmonary disease (COPD)
●● congestive heart failure (CHF)
●● coronary artery disease (CAD)
●● diabetes
If you have questions or suggestions that relate to the High Risk Hospitalization Predictor report, please contact your
network medical director.
For more information
You can download the recently published user guides for these new transactions in the NaviNet Resources section
of our Provider News Center at www.ibx.com/pnc/navinet. If you have any questions about any NaviNet transactions,
please call the eBusiness Hotline at 215-640-7410. 
August 2016 | Partners in Health UpdateSM
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ANNOUNCEMENTS
Attention! An update has been made to the content of this article.
Introducing Independence LIVE!
Now open to the public, Independence is pleased to announce Independence LIVE, a new, state-of-the-art, customer
experience center featuring licensed agents, health and wellness programs, a tech arcade, and live cooking
demonstrations.
Located on the 2nd floor of 1919 Market Street in Philadelphia, the center is home to our Customer Service
Department, and is staffed with full-service, licensed agents who can accept premium payments, answer benefits and
claims questions, and enroll or renew Independence members.
Also available for our members are daytime and evening health and wellness events including classes and programs
on nutrition, fitness, stress management, and family and financial health. Members can also attend demonstrations
on healthy cooking in our full kitchen! Registration for these events can be made by visiting http://events.ibx.com or
calling 215-241-3502.
Providers participating in our network may take advantage of Independence LIVE’s Community meetingtspaces,
which include multiple semi-private and private meeting rooms, reception space for up to 100 guests, a board
room for up to 12 guests, and much more. Reserve a room by emailing the Independence LIVE inbox at
[email protected].
Please share this information with your Independence patients, and join us at Independence LIVE for any or all of the
events and services offered. We look forward to sharing this center with our member and provider community. 
August 2016 | Partners in Health UpdateSM7
www.ibx.com/providers
MEDICAL
Coverage requirements for applied behavioral analysis for
the treatment of autism spectrum disorders
Independence’s policy on the evaluation and
management of autism spectrum disorders (ASD) is
being updated to communicate our continuing position
of medically necessary criteria for outpatient applied
behavioral analysis (ABA) services for ASD for members
enrolled in Independence commercial products.
As a reminder, providers must obtain prior authorization
for evaluation and management services for ASD
to ensure consistent benefit adjudication, as well as
appropriate utilization in accordance with state mandate
requirements.
About ABA services
Methodologies to promote learning are believed to
enhance verbal and non-verbal communication, improve
developmentally appropriate self-care, teach social
skills, and reduce maladaptive behaviors (e.g., harm
to self or others). These methodologies are based on
several model programs, including behavioral, structured
teaching, and/or developmental programs.
Of the many treatment modalities available for the
management of ASD, ABA is arguably the most studied.
The ABA modality applies human behavior principles
in various settings (i.e., clinics, schools, homes, and
communities) to diminish substantial deficits in a
recipient’s adaptive functioning or significant behavior
problems due to ASD. ABA is the process of applying
interventions that are based on the principles of
learning derived from experimental psychology research
to systematically change behavior (e.g., positive
reinforcement). It can also be used to teach new skills
and to demonstrate that the interventions used are
responsible for the observable improvements in behavior.
The goal of ABA methods is to replace maladaptive,
interfering behaviors with more desirable, adaptive
behaviors and to narrow the conditions under which
maladaptive, interfering behaviors occur.
August 2016 | Partners in Health UpdateSM
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As set forth in the medical policy for evaluation and
management of ASD, coverage of ABA services is
contingent on the following:
●● A current (within 24 months), documented diagnosis
of ASD consistent with the DSM-5 criteria, using
validated assessment tools, has been made by a
qualified licensed treating professional provider
including a physician, physician assistant,
psychologist, or certified registered nurse practitioner
as is consistent with state licensing requirements.
●● The qualified licensed treating professional provider is
other than the behavior analyst practitioner performing
services related to ABA services.
●● An individualized, documented treatment plan has
been developed by a licensed professional provider
(e.g., MD/DO, licensed psychologist).
●● ABA services must be provided by or under the
supervision of the following professionals: a Board
Certified Behavior Analyst-Doctoral (BCBA-D) or
Board Certified Behavior Analyst (BCBA)-graduatelevel certification in behavior analysis.
For more information and a complete list of medically
necessary criteria for ABA services, review Medical Policy
#07.03.07o: Evaluation and Management of Autism
Spectrum Disorders (ASD), which is currently posted as a
Notification and will become effective on August 19, 2016.
To view the Notification for this policy, visit our Medical
Policy Portal at www.ibx.com/medpolicy. Select Accept
and Go to Medical Policy Online, then select Commercial
under Active Notifications.
If you have any questions, please contact your Network
Coordinator. 
www.ibx.com/providers
MEDICAL
New policies for Modifier 53: Discontinued Procedure
Effective October 1, 2016, Modifier 53: Discontinued Procedure can be reported when a professional provider
or other qualified health care professional terminates a procedure (e.g., surgical or diagnostic) due to extenuating
circumstances that may threaten the health of a patient. When Modifier 53 is appended to a procedure, the service(s)
is eligible for reimbursement at 50 percent of the provider’s applicable contracted rate.
Independence created the following policies, which were posted as Notifications on July 1, 2016, to address the use
of Modifier 53:
●● Commercial: #03.00.33: Modifier 53: Discontinued Procedure
●● Medicare Advantage: #MA03.018: Modifier 53: Discontinued Procedure
Note: These policies apply to professional providers who bill on a CMS-1500 claim form or the electronic equivalent,
837P, for all Independence members.
To view the Notifications for these policies, visit our Medical Policy Portal at www.ibx.com/medpolicy and select Accept
and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications.
If you have any questions, please contact your Network Coordinator. 
Updated policies for Always Bundled Procedure Codes
Always Bundled Procedure Codes are not eligible for separate reimbursement whether billed alone or in conjunction
with other services. Effective October 1, 2016, the following anesthesia CPT® codes will be added to the list of
Always Bundled Procedure Codes: 99100, 99116, 99135, and 99140.
Updates to the following policies were posted as Notifications on July 1, 2016:
●● Commercial: #00.01.52d: Always Bundled Procedure Codes
●● Medicare Advantage: #MA00.026b: Always Bundled Procedure Codes
Note: These policies apply to professional providers billing on a CMS-1500 claim form or the electronic equivalent,
837P, for all Independence members.
To view the Notifications for these policies, visit our Medical Policy Portal at www.ibx.com/medpolicy and select Accept
and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications.
If you have any questions, please contact your Network Coordinator. 
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August 2016 | Partners in Health UpdateSM
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MEDICAL
Reminder: Utilization management program for genetic/
genomic tests, certain molecular analyses, and cytogenetic
tests now in effect
Independence recently introduced a new utilization
management program for genetic/genomic tests,
certain molecular analyses, and cytogenetic tests for all
commercial Independence members. We are working
with CareCore National, LLC d/b/a eviCore healthcare
(eviCore), an independent specialty benefit management
company, to manage precertification and/or prepayment
reviews.
Please note that the ordering provider is responsible for
the prior authorization to ensure the member’s care is
not interrupted.
Precertification requirements
Ordering health care providers must contact eviCore to
obtain precertification for certain genetic/genomic tests,
including, but not limited to, the following:*
●● BRCA gene testing
●● genetic panels and cancer gene expression tests
●● genome-wide tests
●● pharmacogenomic tests
You can find the complete list of procedure codes
requiring precertification at www.evicore.com/
Online%20Forms/Independence%20Lab%20Prior%20
Authorization%20Codes.pdf.
Submitting requests to eviCore
You can request precertification for genetic/genomic
tests by calling eviCore directly at 1-866-686-2649 or
submitting requests via the NaviNet® web portal. To
submit a request on NaviNet, select CareCore from the
Authorizations option in the Workflows menu, and a
new window will open that sends providers directly to
eviCore’s provider portal to initiate the precertification
process. Once on eviCore’s portal, you will be required
to create a login and password, which will be used every
time you request precertification through eviCore. If you
have already established credentials for eviCore’s portal,
please use your current login information.
Important information for laboratories
When a request for genetic/genomic testing is
received, laboratories must ensure a precertification
is on file before rendering services. If precertification
is not on file for the member, it is the laboratory’s
responsibility to submit a request to eviCore.
Prepayment review
All genetic/genomic tests, along with certain molecular
analyses and cytogenetic tests are reviewed by eviCore.
Examples of molecular analyses and cytogenetic tests
include, but are not limited to, the following:*
●● comparative genomic hybridization (CGH)
●● flow cytometry
●● fluorescent in situ hybridization (FISH)
●● immunohistochemistry (IHC)
●● morphometric analyses
Lab management policy and guidelines
Review Medical Policy #06.02.52: eviCore Lab
Management Program for more information about the
utilization management program. The policy includes
a link to the Lab Management Program Clinical
Guidelines that eviCore uses during the precertification
and prepayment review processes, as well as a listing
of procedure codes requiring precertification and/or
prepayment review.
To view this policy, visit our Medical Policy Portal at
www.ibx.com/medpolicy. Select Accept and Go to
Medical Policy Online, then select the Commercial tab
from the top of the page and type the policy name or
number in the Search field.
More information
If you have questions about any of these requirements,
you can contact your Network Coordinator or call
Customer Service at 1-800-ASK-BLUE. 
*This list of services is subject to change.
August 2016 | Partners in Health UpdateSM10
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MEDICAL
Upcoming coverage position changes for certain laboratory
tests
Effective October 1, 2016, our coverage position on the laboratory tests outlined below will be considered
experimental/investigational.
Fecal calprotectin
Effective October 1, 2016, procedure code 83993: Fecal calprotectin will be considered experimental/investigational
for all commercial and Medicare Advantage members.
Fecal calprotectin is a calcium- and zinc-binding protein that is a potential marker of intestinal inflammation. Fecal
calprotectin testing is proposed as a noninvasive test to diagnose inflammatory bowel disease (IBD). Other proposed
uses are to evaluate response to treatment for patients with IBD and as a marker of relapse. Peer-reviewed evidence
does not unequivocally support the clinical usefulness of this testing for management of any patient populations.
Nontraditional lipid biomarkers
Effective October 1, 2016, the following procedure codes will be considered experimental/investigational for all
commercial members:
●● procedure code 83695: Lipoprotein (a);
●● procedure code 83700: Lipoprotein, blood; electrophoretic separation and quantitation;
●● procedure code 83701: Lipoprotein, blood; high-resolution fractionation and quantitation of lipoproteins including
lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation).
Low-density lipoproteins (LDLs) have been identified as the major atherogenic lipoproteins and have long been
identified by the National Cholesterol Education Project (NCEP) as the primary target of cholesterol-lowering
therapy. Numerous nontraditional lipid and non-lipid biomarkers have been proposed as potential risk markers for
cardiovascular disease. There is a lack of consensus among professional guidelines, and the quality of peer-reviewed
evidence is insufficient to determine the effects of these nontraditional lipid and non-lipid biomarkers on relevant
health outcomes, including any clinically important information beyond that of traditional lipid measures, in the
intended patient populations.
Policy updates
The change in coverage position for these procedure codes is also communicated in the following policy Notifications,
which were posted on July 1, 2016, and will become effective on October 1, 2016:
●● Commercial: #12.01.01ah: Experimental/Investigational Services
●● Medicare Advantage: #MA00.005g: Experimental/Investigational Services
To view the Notifications for these policies, visit our Medical Policy Portal at www.ibx.com/medpolicy and select Accept
and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications.
If you have any questions about these changes, please contact your Network Coordinator. 
August 2016 | Partners in Health UpdateSM11
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MEDICAL
Vitamin D testing policies now in effect
Vitamin D, also known as calciferol, is a fat-soluble vitamin that has a variety of physiologic effects, most prominently
in calcium homeostasis and bone metabolism. Providers are reminded there should be a direct medical need or
indication for testing of vitamin D serum levels. Therefore, routine testing for vitamin D deficiency in healthy adults and
children is not indicated according to evidence-based reviews or clinical practice guidelines from organizations that
include, but are not limited to, the U.S. Preventive Services Task Force.
Vitamin D testing
The following policies, effective as of August 1, 2016, were developed by Independence to communicate the
medically necessary uses for vitamin D testing:
●● Commercial: #06.02.51: Testing Serum Vitamin D Levels
●● Medicare Advantage: #MA06.031: Vitamin D Assay Testing
To view these policies, visit our Medical Policy Portal at www.ibx.com/medpolicy. Select Accept and Go to Medical
Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the
version of the policy you would like to view. Then type the policy name or number in the Search field.
When clinically appropriate, Independence-participating laboratories are capable of performing vitamin D testing. If
you have any questions about participating laboratories, please contact your Network Coordinator. 
View up-to-date policy activity on our Medical Policy Portal
Changes to Independence medical and claim payment policies for
our commercial and Medicare Advantage Benefit Programs occur
frequently in response to industry, medical, and regulatory changes.
We encourage you to view the Site Activity section of our Medical
Policy Portal in order to keep up to date with changes to our policies.
The Site Activity section is updated in real time as changes are made
to the medical and claim payment policies. Topics include:
●● Notifications
●● Reissued Policies
●● New Policies
●● Coding Updates
●● Updated Policies
●● Archived Policies
For your convenience, the information provided in Site Activity can
be printed to keep a copy on hand as a reference.
News & Announcements
In addition to the information posted
in our Site Activity section, articles
related to our website and medical
and claim payment policies are
periodically posted within the News &
Announcements section. Simply select
the appropriate link (Commercial,
Medicare Advantage, or MAPPO Host)
under the News & Announcements
header on the Medical Policy Portal
homepage to stay informed of the
latest information.
To access the Site Activity section, go to our Medical Policy Portal at www.ibx.com/medpolicy and select Accept
and Go to Medical Policy Online. From here you can select Commercial or Medicare Advantage under Site Activity
to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage tab
from the top of the page. To access medical policies from Independence NaviNet® Plan Central, select Medical Policy
Portal under Provider Tools in the right hand column. 
August 2016 | Partners in Health UpdateSM12
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QUALITY MANAGEMENT
Updated physician quality measure rankings
During the third quarter of 2016, Independence will submit updated physician ratings to the Blue Cross and Blue
Shield Association (BCBSA), an association of independent Blue Cross and Blue Shield plans, to be displayed within
their National Doctor and Hospital Finder at http://provider.bcbs.com. These ratings are also currently available on our
local Find a Doctor/Hospital tool at www.ibx.com within the Accreditation & Quality tab.
The following physician quality measures are rated:
●● Cancer Screening
−− Breast Cancer Screening
−− Cervical Cancer Screening
●● Diabetes
−− Blood Sugar (Glucose) Testing
−− LDL-C (Bad Cholesterol) Screening – Patients
with Diabetes
−− Kidney Disease (Nephropathy) Screening and
Treatment
●● Heart Disease
−− Beta-Blocker (PBH) Treatment after a Heart
Attack
−− LDL-C (Bad Cholesterol) Screening for Heart
Patients Conditions
●● Immunizations
−− Chicken Pox (VZV)
−− Measles, Mumps, Rubella (MMR)
●● Medication monitoring
−− Monitoring for Patients (Adults) on Persistent
Medications
●● Respiratory infections
−− Bronchitis – Avoidance of Antibiotic Treatment in
Adults
−− Strep Test for Sore Throat – Appropriate Use of
Antibiotics
−− Common Colds (Treatment) – Avoidance of
Antibiotics
●● Women’s health
−− Breast Cancer Screening (same measure under
Cancer Screening)
−− Cervical Cancer Screening (same measure
under Cancer Screening)
If you wish to review your scores in advance of our submission, you can do so from August 8 through September 30.
For more information on how to review your scores, please contact your Network Coordinator. 
August 2016 | Partners in Health UpdateSM13
www.ibx.com/providers
HEALTH AND WELLNESS
Behavioral health: Promoting provider communication and
collaboration
We are pleased to continue our short series of articles in Partners in Health Update that is designed
to explore potential barriers and opportunities to facilitate communication and collaboration between
primary care physicians and behavioral health providers and to achieve optimal outcomes for your
patients.
Part 2 – Behavioral health resources available for assessment and treatment of
opioid misuse and abuse*
Pain management is a complex issue for many primary care physicians (PCP). Generally, PCPs are able to identify
opioid abuse, but opioid misuse is more difficult to pinpoint – especially in those patients with chronic pain.1
Independence and Magellan Healthcare, Inc. (Magellan), an independent company, are aware that opioid
management is a current and relevant problem for PCPs. As such, we are collaborating to provide resources for the
assessment and management of opioid misuse and abuse. The Chabal 5-Point Prescription Opiate Abuse Checklist,
available at https://infamedic.wordpress.com/2015/06/19/chabal-5-point-prescription-opiate-abuse-checklist/, includes
questions you may have already incorporated into your daily practice. This checklist is a reliable and valid tool. Three
positive responses alert you to possible abuse of prescription opiates.2
The National Institute on Drug Abuse3 (NIDA), a subdivision of the National Institutes of Health (NIH), provides
resource tools for screening patients for opiate misuse and abuse. Two such aids include:
●● NIDA Drug Use Screening Tool. This online screening tool assists providers in identifying risk of substance abuse
and resources in patient care and support.
●● CAGE-AID assessment tool. The CAGE-AID assessment tool is similar to the CAGE assessment tool for
alcoholism, but adapted to assess for other substance use.
You also can check an opioid database (state-based databases with information on patients with opioid prescriptions
that provide patient-specific data on frequency, dose, and name of medication as well as a list of prescribing
practitioners) for patterns in member prescriptions and opioid use.
Additionally, the NIDA has a variety of assessment tools and questionnaires that patients can complete before they
see their PCP. This is especially helpful if completed by new patients or patients requiring pain management for the
first time. These self-reported questionnaires provide valuable information about patient history and behaviors that
can contribute to opioid abuse. During the course of treatment, the PCP can re-evaluate the patient and implement
strategies to more effectively manage these behaviors while providing pain management. You can access screening
tools and other resources via the NIDA website at www.drugabuse.gov/nidamed-medical-health-professionals.
Magellan can assist with getting your patient the right services
The relationship the PCP has with his or her patient with chronic pain is valuable; this relationship creates a strong
base to facilitate an open discussion as well as help solve issues. As concerns arise, you may want to start a
discussion with your patient about your observations and alternatives for pain management. This may be a difficult
conversation to initiate because of the social stigma of abuse and addiction attached to prescription pain medication
as well as the patient’s own perceptions of pain and medication use.
continued on the next page
August 2016 | Partners in Health UpdateSM14
www.ibx.com/providers
HEALTH AND WELLNESS
continued from the previous page
Fortunately, there are behavioral health providers available who can assist with your concerns about your patients’
behaviors. Magellan is available to assist in matching the patient with the right behavioral health provider.
If you identify possible opioid abuse or misuse, you can:
●● Encourage the patient to call the number on the back of their medical ID card to arrange a referral to a
behavioral health provider. A Plan staff member will work with the member to determine the most appropriate
resource based on patient need and preference, provider specialty, and provider location, as well as other
specific patient requests or considerations.
●● Contact Magellan directly (with patient permission) to request assistance with connecting the patient to the
appropriate behavioral health provider.
Magellan’s Behavioral Health Disorders Toolkit
Magellan also offers access to a variety of collaborative behavioral health materials, including substance use
resources, through Magellan’s Behavioral Health Disorders Toolkit. Organized by category, the materials are
designed to give medical practitioners the information and screening tools needed to assist in making behavioral
health referrals. You can access Magellan’s Behavioral Health Disorders Toolkit, including information on CAGE
and CAGE-AID screening, via our Providers webpage at www.ibx.com/providers/resources/worksheets/ or on the
NaviNet® web portal in the Administrative Tools & Resources section under Health and Wellness.
Working together
We are committed to promoting integration of medical and behavioral health services toward the goal of better
overall outcomes for patients and encourage you to access these resources.
Remember, you don’t have to do this alone. Collaboration with a behavioral health provider can enhance the
treatment regimen that you and your patient are developing to manage pain. 
*These guidelines are not intended to replace a practitioner’s clinical judgment. They are designed to provide information and to assist
practitioners with decisions regarding care. The guidelines are not intended to define a standard of care or exclusive course of treatment.
Health care practitioners using these guidelines are responsible for considering their patients’ particular situation in evaluating the
appropriateness of these guidelines. This information is not a statement of benefits. Benefits may vary and individual coverage must be
verified.
1
artrick, C, Gatchel, R & Conroy, S. (2012). “Identification and management of pain medication abuse and misuse: current state and future
H
directions,” Expert Review of Neurotherapeutics, 12:5, 601-610, DOI: 10.1586/ern 12_34.
2
habal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. (1997) “Prescription opiate abuse in chronic pain patients: clinical criteria,
C
incidence, and predictors,” Clinical Journal of Pain, Jun: 13(2): 150-155.
3
National Institute on Drug Abuse: www.drugabuse.gov/publications
Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.
August 2016 | Partners in Health UpdateSM15
www.ibx.com/providers
HEALTH AND WELLNESS
Encourage pregnant Independence members to enroll in
Baby BluePrints®
The Baby BluePrints program supports expectant
mothers and promotes a healthy pregnancy
throughout each trimester. We ask that you inform
pregnant Independence members about the Baby
BluePrints program at their first prenatal visit and
encourage them to self-enroll by calling our toll-free
number, 1-800-598-BABY. Upon calling, a Health
Coach will explain the program to the member
and ask her a series of questions to complete the
enrollment process.
Once enrolled in the program, members will receive
a welcome letter that includes information on how
to access educational materials on our secure
member website, www.ibxpress.com, and the
1-800-598-BABY phone number for questions and
support during pregnancy. In addition, high-risk
members eligible for condition management will be given the name and contact information for a Health Coach.
Resources available
Upon request, a flyer is available to place in the member’s chart and distribute at the first prenatal visit to encourage
her to enroll in Baby BluePrints. To order flyers, please submit an online request at www.ibx.com/providersupplyline
or call the Provider Supply Line at 1-800-858-4728. If you have any questions, please call Customer Service at
1-800-ASK-BLUE. 
Postpartum office visits
As a reminder, postpartum visits should be scheduled 21 to 56 days after delivery. Adhering to this time
frame provides the best opportunity to assess the physical healing for new mothers and to prescribe
contraception, if necessary. These visits should be scheduled before members are discharged from
the hospital.
August 2016 | Partners in Health UpdateSM16
www.ibx.com/providers
HEALTH AND WELLNESS
Help your patients get healthy this summer
Summer is in full swing and with warm, sunny weather comes longer days, summer trips, and visits from friends and
family. For your older patients, keeping up with this increased activity can be a challenge — SilverSneakers® Fitness
can help them conquer it.
SilverSneakers is a benefit that is available at no additional cost to Keystone 65 Select HMO, Keystone 65 Preferred
HMO, Keystone 65 Focus Rx HMO, and Personal Choice 65SM PPO members. Some of these members may be
eligible but not yet taking advantage of this benefit.
SilverSneakers
benefits
include:
SilverSneakers
benefits
includes:
a fitness
membership
a local
fitness
location
— plus
access
to 13,000+
locations
nationwide
— with
●● ●a● fitness
membership
at a at
local
fitness
location
— plus
access
to 13,000+
locations
nationwide
— with
access to
access
to
exercise
equipment,
swimming
pools,
saunas,
and
other
amenities;*
exercise equipment, swimming pools, saunas, and other amenities (varies by location);
● signature
SilverSneakers
classes
designed
specifically
for older
and taught
by certified
instructors;
●● ●signature
SilverSneakers
classes
designed
specifically
for older
adultsadults
and taught
by certified
instructors;
● yoga
and
classes,
walking
groups,
and
other
activities
held
outdoors
and
various
neighborhood
●● ●yoga
and
taitai
chichi
classes,
walking
groups,
and
other
activities
held
outdoors
and
at at
various
neighborhood
locations;*
locations;*
●● fun social events, a supportive online community, and helpful resources.
●● fun social events, a supportive online community, and helpful resources.
SilverSneakers helps millions of members gain strength, improve balance, and lead healthier lives. In fact, 62 percent
of members in 2015 reported their health as “excellent” or “very good”1 — compared to only 30 percent of older adults
nationally.
The program works because it’s easy and fun. SilverSneakers members aren’t just exercising — they’re getting out,
making friends, and improving their quality of life.
Encourage your Independence Medicare Advantage patients to visit www.silversneakers.com or call 1-888-423-4632
(TTY: 711), Monday through Friday, 8 a.m. – 8 p.m. ET, and start taking advantage of this incredible health benefit. 
*Amenities vary by location.
1
Healthways SilverSneakers Annual Member Survey, 2015 (based on SF-12 scores)
SilverSneakers® is a registered trademark of Healthways, Inc. and/or its subsidaries, independent companies. ©2016 Healthways, Inc. All rights
reserved.
August 2016 | Partners in Health UpdateSM17
www.ibx.com/providers
Important Resources
Anti-Fraud and Corporate Compliance
Hotline
1-866-282-2707 or www.ibx.com/antifraud
Clinical Services
Baby BluePrints®
215-241-2198 / 1-800-598-BABY (2229)*
Case and Condition Management
1-800-313-8628
Credentialing
Credentialing Violation Hotline
215-988-1413 or www.ibx.com/credentials
Customer Service
Provider Services (prompt 1)
1-800-ASK-BLUE (1-800-275-2583)
Provider Automated System User Guide
www.ibx.com/providerautomatedsystem
Electronic Data Interchange (EDI)
Highmark EDI Operations
1-800-992-0246
FutureScripts® (commercial pharmacy benefits)
Prescription drug prior authorization
1-888-678-7012
Pharmacy website (formulary updates, prior authorization)
www.ibx.com/rx
FutureScripts® Secure (Medicare Part D pharmacy benefits)
FutureScripts Secure Customer Service
Formulary updates
1-888-678-7015
www.ibxmedicare.com
Mental Health/Substance Abuse Precertification
Independence1-800-688-1911
Independence Administrators
1-800-634-5334
CHIP1-800-294-0800
NaviNet® web portal
Independence eBusiness Hotline
Registration
215-640-7410
www.navinet.net
Other frequently used phone numbers and websites
Independence Direct Ship Drug Program (medical benefits)
www.ibx.com/directship
Medical Policy
www.ibx.com/medpolicy
Provider Supply Line
1-800-858-4728 or www.ibx.com/providersupplyline
*Outside 215 area code
Visit our Provider News Center:
www.ibx.com/pnc