Updates to the Physician Recognition Program



Updates to the Physician Recognition Program
A Quarterly Newsletter from Provider Relations and Education, BlueCross BlueShield of South Carolina
Updates to the Physician Recognition Program
Pharmacy Updates………….3
For Your Information……….5
Did You Know?……………...7
Education Updates……........8
First Quarter 2011
BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan of South
Carolina are pleased to announce the continuation of the Physician
Recognition Program (PRP). We launched the PRP in May 2005. Since then,
we have recognized hundreds of physicians for their program achievements.
Your participation in any of the Physician Recognition Programs is voluntary.
You must be a member of BlueCross’ Preferred Blue® or BlueChoice
HealthPlan’s provider networks. Network physicians who are recognized by
the ADA/NCQA Diabetes Recognition Program, the AHA/ASA/NCQA
Heart/Stroke Recognition Program or the American Society for Hypertension
(ASH) Specialists Program may receive $2,000 from both BlueCross and
BlueChoice HealthPlan! Become certified or re-certified for any two programs
before September 30, 2011 and receive up to two $2,000 payments.
Please review the Physician Recognition Program page for details and
qualifications. If you have already met the qualifications, congratulations! To
receive your award, complete the “Physician Recognition Program Payment
Request Form.” Submit the form with the letter of recognition/certification and
the W-9.
We also introduced a new program. The Patient-Centered Medical Home
Program began October 1, 2010 and offers incentives from BlueCross
BlueShield of South Carolina and BlueChoice Health Plan up to $2000 for any
physician practice that achieves A-C Mal status. This award is limited to one
payment per practice.
The National Committee for Quality Assurance (NCQA) defines a patientcentered medical home as a “health care setting that facilitates partnerships
between individual patients and their personal physicians, and when
appropriate, the patient’s family. Care is facilitated by patient registries,
information technology, health information exchange and other means to
assure that patients get the indicated care when they need it and in a
culturally and linguistically appropriate manner.” The NCQA-PCMH program
reflects the input of the American College of Physicians (ACP), American
Academy of Family Physicians (AAFP), American Academy of Pediatrics
(AAP) and American Osteopathic Association (AOA). We encourage you to
learn more about this program. It is rapidly gaining momentum and attention
as an innovative approach to primary care. Visit
http://www.ncqa.org/tabid/631/Default.aspx for more information.
BlueCross and BlueChoice HealthPlan look forward to recognizing you for one
of these programs. If you have any questions, please contact:
BlueCross: [email protected] or 803-264-9082.
BlueChoice HealthPlan: [email protected] or 803-382-5265.
If you have any questions regarding the information in this newsletter, please email us at [email protected]
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan are independent licensees of the Blue Cross and Blue Shield Association
HIPAA 5010: National Provider Identifier (NPI) Clarification
The HIPAA 5010 mandate requires that the reporting of your NPI be consistent by January 1, 2012, which means
that your NPI structure needs to be the same for all health plans. Doing so will simplify administrative efforts as
well as eliminate any payment issues with crossover or secondary claims. This uniform NPI structure must be
used for all HIPAA electronic transactions, including:
270/271 – Eligibility Request and Response
276/277 – Claim Status Request and Response
278 – Referrals and Prior Authorization
835 – Payment and Remittance Advice
837 – Claim Submission
If you are not currently enumerated the same for all plans, you will need to make a business decision and
develop a new enumeration strategy. Once you have made a decision on your new NPI structure, contact us and
your clearinghouse/vendor as soon as possible to allow time for our systems to be updated to ensure a seamless
Please contact us via email at [email protected] if changes to your enumeration strategy are required
so that we can work with you to update our files accordingly.
The Voice Response Unit GPS!
Electronic Funds
Transfer: Let’s Go
Green Together!
Electronic Funds Transfer (EFT) is
now our corporate delivery method
for payment to providers. We are
working to transition the remaining
providers to this delivery method. If
you have not transitioned, it is
important that you do so
Need help navigating through
our Provider Services Voice
Response Unit? We offer a
Voice Response Unit Guide
in our Bulletins section of
Save it to your computer,
bookmark it or print it out today!
One of the benefits of being a
Palmetto Paperless Provider is
receiving payments three to four
days faster. As a paperless
provider you will access copies of
remittance advices via My
Insurance Manager or My Remit
Manager .
You can download the forms at
Fax completed forms to 803-8708065 to Attention: EFT
If you have questions about this
mandate, please call Provider
Education at 803-264-4730.
If you have any questions regarding the information in this newsletter, please email us at [email protected]
Pharmacy Management
On our behalf, a group of in-network doctors and pharmacists
choose the medications for our drug lists based on their
effectiveness, safety and value. Recently, these doctors and
pharmacists recommended a few changes. The changes apply
to prescriptions written on or after January 1, 2011. They are
summarized here:
Preferred Drug List Changes. See our website for
Over-the-Counter (OTC) Drug Coverage. With a valid
prescription, we will extend coverage for both OTC allergy
(Alavert, Claritin, Zyrtec and any store brands) and OTC
reflux (Prilosec OTC, Prevacid 24HR, Zegerid OTC and
any store brands) medications for most members. Please
consider OTC medications for your patients, when
appropriate. Members will pay the lowest copayment
under their plans for OTC medications.
Step Therapy Program. See our website for the drugs
included in the program.
Prior Authorization Changes. We are adding several
drugs to our prior authorization program. We will minimize
impact to anyone currently using most of these drugs. See
our website for details.
Quantity Management Changes. We have added several
drugs and changed some limits. See the changes and the
complete listing on our website.
Now there’s a one-stop shop for drug
news, formulary lists, FDA recalls and
prescription updates! Check out the
Prescription Drug Information page in
the Provider’s section of
We believe you are best qualified to balance quality and costof-care in choosing prescription drug therapies for your
patients. We are providing this information for your
consideration only. We know that your prescribing decisions
take into account a number of patient-specific variables that
are not available to us.
Although you can always find the most up-to-date drug list
information on our website, it’s now easier than ever to stay on
top of changes with an electronic prescribing tool. If you are
not currently prescribing electronically, now is a great time to
consider doing so. To learn more about ePrescribing, select
the Electronic Prescribing link on the Provider’s Prescription
Drug Information page on our website.
You should know that generic drugs are always available at
the lowest copayment under our plans. Whenever the FDA
approves a new generic, most of the time its brand-name
counterpart will become non-preferred. Please consider
allowing generic substitution on the prescriptions you write
when appropriate.
If you have any questions regarding the information in this newsletter, please email us at [email protected]
Member ID Numbers – Look Twice!
Be sure to file the correct alpha
prefix on your claims for
BlueCard members. The alpha
prefix is very important. We use
this information to route your
claims to the appropriate home
Approximately 1,500 claims
each month are rejected due to
having the incorrect alpha prefix
filed on them. To prevent any
delays in processing your
claims, be sure to file the
correct alpha prefix as it
appears on the member’s ID
A group with a recent alpha
prefix change is WalMart
When reviewing your remits, be certain to pay particular attention to the
member ID number section of the remittance:
If there is a plus (+) next to the ID number on the remittance, that is an
indication that the ID number you submitted was incorrect and that it has been
corrected. On the same line of the remittance, next to the claim number, you
will see the incorrect ID number that you submitted on the claim.
Also, be sure to file your patients’ claims according to what’s printed on their ID
cards. The name printed on the ID card is the name we have on our system.
Filing claims under the patient’s nickname, for example, may prolong claim
Balance Billing
We have had an increase in
balance billing for total charges
for services and procedures.
This is a concern of our
members. Our participating
providers can collect
appropriate copayments,
deductibles and coinsurance
from members at the point of
service. It is important,
however, to bill based on the
appropriate allowables for the
procedures, and not on total
Be sure to correct the ID number and/or patient name in your files so future
claims you submit for that particular patient will come in with the correct data.
Publix PPO Members Require Precertification of Outpatient Services
Effective January 1, 2011, all outpatient services, with the exception of
preventive services, labs, X-rays, emergency room and urgent care, will
require precertification for Publix members with a BlueCross BlueShield
PPO. This will also include all physical, occupational and speech therapy
services rendered in an outpatient or office setting.
New Codes Added
Check the NIA section of our website for new procedure codes that
require preauthorization through NIA. On behalf of BlueCross, NIA
handles preauthorization for certain imaging services. NIA is an
independent company.
If you have any questions regarding the information in this newsletter, please email us at [email protected]
CPAP Authorization Requirements
Here is the information Health Care Services needs to review and approve
CPAP machine authorizations:
First Time CPAP Machine Renters:
First time users of CPAP must be approved for a 10-month rental purchase
Minimal Information Required for a Clinical Review:
 Complete scored reports of diagnostic sleep study
 CPAP Titration study or Auto Titration Study with download
 Most current diagnostic/baseline sleep study (must have been conducted
within the previous two years or the review will be referred to the medical
 History and physical, to include sleep history
CPAP Machine Changes or Replacements:
We need a letter of medical necessity from the physician to upgrade or
change the patient’s CPAP machine. The letter should include justification of
medical necessity as well as the reason for the machine change. Fax letters
to 803-264-0258. In some cases we approve replacement CPAPs as a direct
purchase. Here is the review criteria for replacement machines:
CITIA Program
Free assistance in understanding Medicare
and Medicaid incentive payment programs
is available for most primary care providers
with prescription privileges who practice in
one of these specialties: adolescent
medicine, family practice, general practice,
geriatrics, gynecology, internal medicine,
OB-GYN or pediatrics. To apply for up to
one year of free assistance in EHR
adoption and/or achieving meaningful use,
go to www.citiasc.org and click on “Apply
Online.” Nearly three fourths of the
available 1000 slots have been committed
in the first six months with more than 100
applications coming in each month.
Interested eligible providers should sign up
Minimal Criteria Required for a Replacement Review:
 Clinical information to document history of obstructive sleep apnea
diagnosis (old sleep studies are acceptable)
 Current machine age and specific malfunction problem
Please note that the patient’s current CPAP machine should be at least two
years old, out of warranty and have a malfunction in order to be considered
for a replacement. You can also fax this information to 803-264-0258.
Getting Online Precertifications
My Insurance ManagerSM features an automated authorization, precertification and referral feature that allows you to
request authorizations for many patient services online.
Benefits of Web Precertification:
 This method provides a quick turnaround. Physicians get 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.
 Fast Track allows you to submit precertification requests on procedures that you perform regularly.
 If you don’t see your procedure listed, the unlisted option allows you to provide detailed notes on the
requested procedure. Submit thorough notes so our staff can make the most appropriate determination.
 Additionally, you can request specific procedures be listed as Fast Track items for future precertification
requests. Your feedback allows us to continuously improve and effectively serve you.
For complete instructions on getting an online precertification, visit:
If you have any questions regarding the information in this newsletter, please email us at [email protected]
Medicare Advantage and Prescription Drug Plans
The health care reform law enacted on March 23, 2010 makes some changes to Medicare, but it does not eliminate Medicare
Advantage plans. People with Medicare can still choose between original Medicare and Medicare Advantage plans.
New Medicare Benefits
The new law adds a yearly wellness visit benefit and free preventive services to Medicare in 2011. BlueCross already offers
the wellness benefit. We also offer many other preventive services such as colorectal cancer screening exams and
mammograms at no or low cost sharing. In 2011, BlueCross will offer all Medicare-covered preventive services for free (no
cost sharing to the member). We mailed our Annual Notice of Change (ANOC) to members in late October, which explained all
of our 2011 benefits, including the free preventive benefits.
Medicare Prescription Drug Plan Changes
Rebate checks for the coverage gap:
People with a Medicare prescription drug plan who don’t qualify for the low-income subsidy may have received a onetime, $250 rebate check in 2010. The check came in the mail, directly from Medicare approximately four to six months
after the beneficiary hit the coverage gap.
A word of caution: Once the member reaches the coverage gap, Medicare will automatically send him/her a rebate
check. Members should never give out their Medicare, Social Security or bank account information to anyone to get
their rebate checks. For more information about rebate checks, please call 1-800-MEDICARE.
Discounts on brand-name drugs and changes to cost sharing for generic drugs:
Starting in 2011 the “coverage gap” will get smaller each year until it completely closes by 2020. Once a beneficiary
hits the coverage gap each year, he or she can save money through reduced cost sharing on generic drugs and
manufacturer discounts on brand-name drugs.
Medicare-Related Claims: Present on Admission Indicator
On October 1, 2007, the Centers for Medicare & Medicaid Services (CMS) began requiring hospitals to use a Present on
Admission (POA) indicator for every diagnosis for all patients they discharged on or after that date. It is one of the
requirements of the Deficit Reduction Act of 2005 that the Secretary of Health and Human Services (HHS) identify a limited
number of high-cost and/or high-volume conditions that are reasonably preventable through application of evidence-based
guidelines, and pay at a lower rate when Medicare claims show these conditions as present only on discharge and not on
admission. Starting October 1, 2008, claims began to receive a lower-paying Diagnosis Related Group (DRG) when one of the
secondary diagnosis codes identified by CMS is present on discharge but not present on admission.
What is the Present on Admission Indicator (POA)?
Hospitals use the Present on Admission (POA) indicator to note a condition that is present at the time the order for inpatient
admission occurs. The hospitals use one of these five values that identify whether secondary diagnoses are present when the
patient is admitted to a facility:
• Y = Yes
• N = No
• U = No information in the record
• W = Clinically undetermined
• 1 = Used on 4010A1 and 5010 versions of the 837 to represent a space or a blank and means the Diagnosis Code is exempt
from reporting POA
• Blank = Designates on the UB-04 Unreported/Not Used/Exempt from POA reporting
If you have any questions regarding the information in this newsletter, please email us at [email protected]
Why & How Allergies Can Make You Tired
The ragweed is in bloom or you visited a friend with a cat, and now your allergies are leaving you so exhausted you're
dragging around all day. Is it the allergies themselves that turn you into a lethargic ghost of your former self? Could it be your
medication? Why and how can allergies make you tired? When you have an allergic reaction, your body releases proteins
called pro-inflammatory cytokines, which are designed to neutralize invading particles. This includes allergens like pollen, pet
dander and mold. Essentially, your body is creating a temporary state of inflammation to fight off the allergens. Researchers
believe that cytokines act on the central nervous system and prompt leukocytes (white blood cells) and other cells to secrete
IL-1 beta (also called interleukin-1-beta). IL-1 beta is a hormone-like substance that can make you feel lethargic and depress
your mood. Perhaps fatigue from the inflammatory process is your body's way of telling you to rest so it can fight whatever is
plaguing your system.
Decreased Quality of Sleep
Some research links daytime drowsiness and lethargy to poor nighttime sleep, a complaint from many who suffer from
allergies. A stuffy nose, post-nasal drip and coughing can surely ruin a night's sleep. After several weeks of bad sleep during a
typical allergy season you're in a state of chronic fatigue. This can lead to other health problems that worsen fatigue.
One study reported that 35 percent of those suffering with allergic rhinitis (inflammation of the upper respiratory system due to
an allergic reaction) struggle with insomnia. A good night's sleep is vital to feeling refreshed and helping the body heal.
Allergies may lead to a vicious cycle of poor sleep and fatigue, as your body is less able to combat allergens. Also, your
inflamed upper respiratory system could reduce the amount of oxygen your body gets during sleep. This can lead to a
condition similar to sleep apnea and additional fatigue because of fragmented sleep. If you have allergy-related asthma, you
are also getting less oxygen during sleep and may experience daytime fatigue.
Ironically, some allergy medications may also lead to poor sleep and the same vicious cycle of insomnia and daytime
drowsiness. Many antihistamines can leave you groggy throughout the day. Or, if you take them at night, you may sleep for
awhile but wake up when the medication wears off. Think switching to a decongestant will help? In one study, 15 to 25 percent
of decongestant users reported insomnia. Some doctors switch their patients to prescription nasal corticosteroids, which are
not as likely to cause fatigue. Can allergies make you tired? Yes. Can you do anything about it? Yes. Limit exposure to
allergens, evaluate your medications and talk to your doctor about treatment options.
Read more at http://www.brighthub.com/health/allergies-asthma/articles/85566.aspx. This links leads to a third party website.
Bright Hub is solely responsible for the contents and privacy policy on its site.
Curriculum Available
Visit the Workshop section of our website for the complete
Palmetto Provider University curriculum. We have scheduled
webinars through September 2011. Topics include
BlueCard®, Claims Filing, My Remit ManagerSM and My
Insurance ManagerSM. You can register for any of the classes
by visiting:
If you have any questions regarding the information in this newsletter, please email us at [email protected]
In the Field
Our external provider advocates are currently visiting
offices to educate providers on various topics. Here’s
what they’re talking about in the field:
1. Remember to file the rendering physician’s NPI
number on your claims.
2. All injections with J-codes must have an NDC
3. Avoid filing duplicate claims by checking claim
4. If you haven’t returned your EFT paperwork in
order to become a Palmetto Paperless Provider,
please do so immediately.
5. Make sure your practice has created a profile
administrator for My Insurance Manager and
make sure all office staff has been approved.
We are here to help our providers and encourage
proper claim filing. Our goal is to provide superior
service and to enhance our relationships with you.
Change is a Good Thing!
We’ve experienced some recent management
changes in Provider Services and Education.
Brian Butler has been promoted to senior director! He
has great knowledge and experience in the provider
Tiffany Singleton has become senior manager over
Provider Education and Relations. She has worked for
several years in our area in many different capacities
and brings very solid leadership to this role. Sandy
Sullivan is returning to the area as a liaison for
Hospital Relations.
Brenda Bethel is the new director of Provider Services
and also introduces a new management team.
Marcelette Pearson, Brandon Saxon (former hospital
manager) and Tammy Ross bring many years of
experience in claims and service.
These folks have worked with you for years and their
proven leadership should take our levels of service to
higher levels. We are excited to work with them in
their new roles.
Have a Question for
Provider Education?
Contact our Provider Education
department by phone at 800-288-2227
extension 44730, or by email at
[email protected] with
any questions you may have. While our
external provider advocates love hearing
from you, they’re on the road three days
a week visiting your offices and may not
be able to respond to you immediately.
Our internal provider advocates are
equipped to handle your inquiries, and
also notify the external advocates of your
requests for education visits.
If you have any questions regarding the information in this newsletter, please email us at [email protected]

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