January Provider Bulletin - Blue Cross of Northeastern Pennsylvania
Transcription
January Provider Bulletin - Blue Cross of Northeastern Pennsylvania
Volume 16 • Issue 1 • January 2014 The Individual Grace Period: What You Need to Know At Blue Cross of Northeastern Pennsylvania (BCNEPA), we are committed to keeping you informed about Health Care Reform changes that may affect you and your patients. That’s why we want to let you know about the individual grace period, which is effective January 1, 2014. How can I determine if a patient purchased their plan through the Federally Facilitated Marketplace? What is the Individual Grace Period? What does the Individual Grace Period mean to me? The Department of Health and Human Services published final regulations that require health insurance plans to provide a 3-month individual grace period for premium payment. This requirement only applies to individuals who buy and enroll in health insurance plans through the Exchange—or Federally Facilitated Marketplace (FFM)—AND receive a premium tax credit. Keep in mind, this longer grace period does not apply to individuals who buy and enroll in health insurance plans on BlueCrossNEPAStore.com or plans obtained on the Federally Facilitated Marketplace without a premium tax credit. These plans will have the same standard 30-day grace period as our current individual health plans. To determine if your patient bought their health insurance plan on the Federally Facilitated Marketplace, check their member ID number. Member ID numbers that end with “FE” indicate a plan that was purchased on the Federally Facilitated Marketplace. According to Health Care Reform law, during the 3-month grace period, you can expect the following: • BCNEPA is obligated to pay claims during the first month of the grace period. • BCNEPA may pend claims during the second and third months of the grace period. If you provide care for the member or covered dependent(s) during this period, we will notify you by mail. • If the individual pays all outstanding premiums by the end of the grace period, we will pay the claims, as appropriate. • If not, the claims for the second and third months will be denied, in accordance with the Centers for Medicare and Medicaid Services (CMS) final rule. Can I check to see if a patient has paid their premiums? Yes, you can now use NaviNet® to check your patients’ payment status. When you submit a Member Eligibility and Benefits Inquiry, click on “Eligibility and Benefits Detail” and the “Paid to Date” will display under “Product/Eligibility Information.” The Paid to Date will show the day, month and year through which the policy has been paid. Continued on page 3 Table of Contents 2 Contraceptive Coverage Provided through Separate Policy 4Utilization Management Updates 6Administrative Practice Guidelines 10Electronic Provider Access Capabilities for Providers 14Medical Policy Updates Contraceptive Coverage Provided through Separate Policy The federal Health Care Reform law, known as the Affordable Care Act (ACA), requires many changes to health insurance plans. Effective January 1, 2014, the ACA requires insurers to provide contraceptive coverage, with no copays, to female employees and their female dependents in eligible employer groups. Employers that certify as eligible nonprofit religious organizations will receive this coverage through a separate “contraceptive coverage only” policy. Only a small portion of our membership will qualify as eligible nonprofit religious organizations. We, therefore, anticipate a very small portion of our members—your patients—will be required to have the separate contraceptive coverage only, which will be provided as a supplement to the health insurance plan they already have. What does this coverage include? This required coverage includes both medical and pharmacy expenses related to contraceptive services. Medical services provided with this coverage include voluntary sterilization procedures and insertion or removal of implantable contraceptives. Covered codes are as follows: Services Procedure Codes Diagnosis Codes Contraceptive Methods (Not Inpatient) 11976 –removal, capsules 11981 –insertion, non-biodegradable implant 57170 –diaphragm or cervical cap fitting with instructions 58300 –insertion of IUD 58301 –removal of IUD A4261 –cervical cap for contraceptive use A4264 –permanent implantable intratubla occulsion device A4266 –diaphragm for contraceptive use A4268 –contraceptive supply, female, each A4269 –contraceptive supply, spermicide, each J1055 –injection medroxyprogesterone J7300 –copper IUD J7302 –levonorgestrel releasing IUD J7303 –hormone containing vaginal ring J7304 –hormone containing patch J7306 –levonorgestrel implant system J7307 –etonogestrel implant system S4981 –insertion of levonorgestrel releasing system S4989 –PROGESTACERT IUD S4993 –contraceptive pills 96372 –injection (admin code for the depo provera) Contraceptive Management Diagnoses V25.01, V25.02, V25.03, V25.04, V25.09, V25.11, V25.13, V25.40, V25.41, V25.42, V25.43, V25.49, V25.5, V25.8, V25.9 Contraceptive services supplied for a medical reason would be eligible, however they will not pay at the preventive level. Contraceptive Management Diagnoses V25.01, V25.02, V25.03, V25.09, V25.11, V25.12, V25.13, V25.40, V25.41, V25.42, V25.43, V25.49, V25.5, V25.9 Hysterosalpingography (HSG) HSG done within 180 days insertion of the essure contraception 74740 (Surgical) Permanent Methods of Sterilization (Not Inpatient) Sterilization will be paid at preventive level when done on an outpatient basis. 58565, 58600, 58605, 58611, 58615, 58670, 58671, A4264 Contraceptive Counseling No coding. The expectation is discussions surrounding contraceptives would be performed during well visits. The covered contraceptive drugs include only those that are on our drug list of contraceptives covered at “no cost share.” This listing, which includes both preferred prescription drugs and specific OTC contraceptive products, can be found on our website, bcnepa.com. Click on “Rx Drug Benefits,” then “Women’s Preventive” under “Related Resources.” 2 Continued from page 1 The Individual Grace Period: What You Need to Know Continued from page 2 Contraceptive Coverage Provided through Separate Policy Where can I go for more information on Health Care Reform? Find out more about Health Care Reform from any of these resources: • Visit our Health Care Reform resource center by visiting our Provider website on bcnepa.com. Click on “Provider Resources & Tools,” and then select “Health Care Reform.” You’ll find a timeline of provisions, frequently asked questions and Health Care Reform articles featured in recent issues of the Provider Bulletin. • Call your provider service rep with any questions. • More information on the Federally Facilitated Marketplace (FFM) and how to enroll are available on HealthCare.gov. How do members access these services? Females who are employees or dependents of an employee of an eligible nonprofit religious organization will receive a Contraceptive Coverage Agreement and separate contraceptive coverage ID card in the mail closer to the January 1, 2014, effective date. They will be informed to use this new ID card only for medical services related to contraception and prescription contraceptives, starting January 1, 2014. The new card will state that it is for contraceptive coverage only: Where can I send my patients for information on Health Care Reform? For patients who need more information about the Federally Facilitated Marketplace, we offer several resources: • You can send them to our Health Care Reform website at bcnepa.com/reform where they can find up-to-date information, tools, resources and videos. • You can provide them with one of the Health Care Reform brochures that Blue Cross of Northeastern Pennsylvania distributed to your office. Keep in mind, if you need more brochures, call your provider service rep and we will be happy to send more. Or you can download and print brochures from our Provider website at bcnepa.com. • Check out our affordable new plans for 2014 on the Blue Cross Store by visiting BlueCrossNEPAStore.com, if they need to change health insurance plans or are shopping for a new one. • Call a BCNEPA sales rep at 1.855.WANT.BLUE (1.855.926.8258), weekdays, between 8 a.m. and 8 p.m., to enroll by phone or have their questions answered. • You can encourage them to visit one of our retail stores, weekdays, between 8 a.m. and 5 p.m., or during our extended night and weekend hours at one of these locations: JANE DOE QFG123456789001 Plan Code Rx ID Rx Group Rx PCN Rx BIN 274 123456789001 BLPA01 A4 003658 Plan CONTRACEPTIVE COVERAGE ONLY PPO ® Eligible females will also be informed that their current medical plan ID card for all other services will not change. They will continue to use that as they do now for all other covered medical services and prescription drugs. Members scheduling procedures for voluntary sterilization and insertion or removal of implantable contraceptives will need to use the contraceptive coverage only ID card. We are notifying you of this change in order to help prevent any member confusion. As mentioned above, this new, separate ID card applies to a very small part of our member population. Not every Blue Cross of Northeastern Pennsylvania member will have 2 ID cards. Please note this distinction. Bartonsville Plaza 292 Frantz Road, Suite 109, Bartonsville, PA 18360 Park Center 1019 Commerce Boulevard, Dickson City, PA 18519 If you have any questions, please contact your Provider Relations Consultant. Keep in mind, guidance on Health Care Reform is continuing to be issued. As Health Care Reform evolves, so does our website— check bcnepa.com/reform frequently for updated information, tools, resources and videos. You can also visit our Provider Health Care Reform website for information specific to your patients and your practice at bcnepa.com/Providers. Corporate Headquarters 19 North Main Street, Wilkes-Barre, PA 18711 • Visit the Federally Facilitated Marketplace (FFM) at HealthCare.gov where they can see if they qualify to get help from the government to pay for their health insurance. (Policy Update 1601002) (Policy Update 1601001) 3 updates continued on page 5 Utilization Management Updates New Prior Authorization Requirements During the second quarter of 2014, the following services will require prior authorization: Services Codes Spinal fusion 20936, 20937, 20938, 22532, 22533, 22534, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 81.00, 81.01, 81.02, 81.03, 81.04, 81.05, 81.06, 81.07, 81.08, 81.62, 81.63, 81.64 Knee replacement 27447, 81.54 Hip replacement 27130, 81.51 The prior authorization requirements will apply to all First Priority Health® (FPH) and First Priority Life Insurance Company® (FPLIC) products. Additional surgical procedures are being analyzed for inclusion in the precertification/prior authorization requirements. Please check future editions of the Provider Bulletin for more details regarding new prior authorization requirements. Regionalization of Utilization Management Staff Prior Authorization Requirements for CPAP Therapy We continually analyze opportunities to enhance and improve services to our members and providers. In an effort to provide optimal service, the Utilization Management (UM) department will be adopting a regional model, in which teams of staff members will be assigned to the various regions that BCNEPA services. This will allow for our staff to better serve the specific needs of each region and assist in delivering the best possible care to our members. As notified in previous Provider Bulletin issues, CPAP therapy requires precertification/prior authorization as of January 1, 2014. Please note that if a member already By early 2014, the UM staff will be divided into 3 unique regions: has a CPAP rental in progress, they will not be subject • The Eastern Region—Responsible for Luzerne, Carbon, Monroe, Pike and Wayne counties (as well as Lehigh Valley Hospital) apply to new rentals after January 1. We will require • The Western Region—Responsible for Lackawanna, Bradford, Clinton, Lycoming, Sullivan, Susquehanna, Tioga and Wyoming counties (including Geisinger Medical Center in Danville) delivered after January 1. to this requirement for prior authorization; this will only prior authorization of all CPAP machines ordered or Additionally, please note that this will require initial authorization of the machine as well as a check for • The Out-of-Area/BlueCard® Region—Will handle all requests from out-of-area providers member compliance after 90 days. Upon receipt of the initial authorization, we suggest the submission All requests will be assigned by the region in which the service is rendered. When calling the UM department, please listen carefully to the prompts, as they have recently changed in order to direct you to the appropriate region. Additionally, please be aware that the UM department fax numbers will soon be changing in order to align with these new regions. Please check future editions of the Provider Bulletin for more information regarding this initiative. of the secondary request and proof of member utilization before the initial 90 days is up in order for efficient review processes. 4 updates continued from page 4 Utilization Management Updates Important Update: Important Reminder: Transition of Care Program DRG Audit Process As mentioned in previous versions of the Provider Bulletin, the Utilization Management department is partnering with our Case Management, Behavioral Health and Pharmacy Management departments to implement a member outreach program designed to help select members with transition of care. The DRG (diagnosis related group) Audit Review department performs retrospective audits on inpatient paid claims for contracted, DRG reimbursed acute care providers. After the audit is complete, the DRG nurse auditors will generate a DRG Validation Report, which is a compilation of the proposed audit changes. This report is mailed to the provider, requesting a written response about the proposed changes within 45 calendar days. The UM Transition of Care program is designed to ensure a safe and successful discharge plan and appropriate follow-up care for our members. By closely following our members’ progress after discharge, we will be able to help identify gaps of care, connect members with medication issues to BCNEPA pharmacists and educate members and their families and/or caregivers about their condition. This will also allow us to collaborate with you to improve overall patient outcomes while helping to reduce the number of patient readmissions. When responding, please note that both coding and utilization responses should be sent in one report. For proper processing, please send the report response to the following address: In order to achieve these goals, the UM department will take an active role in managing the discharge planning process. They will help transition our members’ care and send referrals to our on-site pharmacists or Medical/Behavioral Health Case Management/Disease Management departments, as needed. Blue Cross of Northeastern Pennsylvania DRG department C/O (Name of Nurse Auditor) 19 North Main Street Wilkes-Barre, PA 18711-0302 To best support our members through transitions in care, we would like to remind you of the importance of sending a copy of the members’ discharge orders/ summary at the time of discharge, according to our Policy. In order for you to best assist our members and reduce readmissions/complications, we require complete discharge information, including: • • • • • When you respond within 45 calendar days, the DRG nurse auditors will review all written disagreements and send you a Final Validation Report. The final determination in each case will be based on any additional valid documentation from you. Please note that after the Final Validation Report is complete, no further appeal of the cases will be considered. A copy of member discharge orders Discharge medications Orders for durable medical equipment or home health Need for follow-up appointments Other directives for the discharged patient Please also note that if we don’t receive a response within 45 calendar days, we will consider the DRG Validation Report findings as final and will adjust the claim accordingly. In these cases, no further appeal will be considered. The program will be initiated with select hospitals this month. Please contact your Provider Relations Consultant if you have any questions. If you should prefer, we would be happy to provide a teleconference call to review this new program with you. Please contact Andrea Martinez, UM TOC Coordinator at 570.200.3790 to schedule. For more information about the DRG audit process, please review your specific contract or the Facility Policy and Procedure Manual. Thank you for your continued cooperation with our efforts to provide high quality care to our members. (Policy Update 1601003) 5 Revised: Update: Administrative Practice Guidelines Lead Screening Encouraged for Children The following Administrative Practice Guidelines have BCNEPA continues to collaborate with the Children’s Health Insurance Program (CHIP) to promote awareness about childhood lead poisoning and the importance of screening and detection. This allows for monitoring of negative effects associated with elevated blood lead levels, such as low IQs and behavioral problems, as well as effects on cardiovascular, immunological and endocrine systems. been revised as of November 19, 2013, and approved by the Credentialing Committee. Facility & Environment: Primary Care Physicians (PCP) and Specialist Physicians including Psychiatrists • If the physician performs cardiac stress tests (CST): Please refer to FPH/FPLIC credentialing/ recredentialing for cardiac stress testing (CST) and/ or holter monitoring as special billable procedures administrative practice guidelines. Although lead paint was banned in 1978, many homes still contain layers of lead-based paint. Pennsylvania ranks third in the nation for having the most housing units built before 1950, when lead paint was most prevalent. Pennsylvania ranks fourth in the nation for having housing units that were built before 1978. Medical Record Documentation: Primary Care Physicians (PCP) and Specialist Physicians excluding Psychiatrists According to the Pennsylvania Childhood Lead Surveillance Program 2012 Annual Report (health.state.pa.us), 149,689 children under age 7 were screened for lead in 2012. This accounts for approximately 25% of the state’s population in this age category, leaving a large percentage untested. Of these children tested in Pennsylvania, 1,817 or 1.21% were reported to have confirmed elevated lead levels at ≥10µ/dL, a level considered unsafe. • Tool(s): chart forms may be found on our website at bcnepa.com. • Add documentation of social history to medical record. • Added medical records must be easily located. Administrative Practice Guidelines can be found on our website at bcnepa.com. Just click on the “Provider Homepage” tab; then, select the “Quality However, Pennsylvania’s overall blood lead levels have clearly been dropping. In 2004, the geometric mean blood lead level on reported maximum blood levels was approximately 3.5 µ/dL. In 2012, however, data reflected a geometric mean blood lead level of 2.4 µ/dL. This represents a 31.43% decrease since 2004. Management” link. Click on the “Practice Guidelines” link on the right side. For questions or to request a copy of the guidelines, please contact Gina Klepadlo, Nurse Analyst, at 570.200.4388, weekdays, between 8 a.m. and 5 p.m. We are committed to encouraging lead screenings so that at-risk children are identified early and intervention can begin. We want to ensure that all CHIP members are tested. Additional communication will take place during the year to continue this collaboration between BCNEPA and CHIP. (Policy Update 1601004) (Policy Update 1601005) 6 Prepare for ICD-10 with “What’s Up Wednesday” Who should participate? An ICD-10 preparedness teleconference series from Pennsylvania’s Blue Plans (Blue Cross of Northeastern Pennsylvania, Capital BlueCross, Highmark Blue Shield and Independence Blue Cross). All providers, clearing-houses, trade associations and information networks are encouraged to participate. How do I participate? “What’s Up Wednesday” is a monthly teleconference for Pennsylvania’s health care professionals about the transition to ICD-10. “What’s Up Wednesday” will feature special guests and ICD-10 experts who will lead discussions to help you get ready for the October 1, 2014, compliance date. When is the next call? Before the call, visit the BCNEPA ICD-10 website at bcnepa.com. On the Provider Homepage select the “Resources and Tools” tab; then choose the “Privacy” link and click on “ICD-10” to access the presentation. Then dial 1.800.882.3610 and enter pass code 5411307 when prompted. Be sure to dial in a few minutes early. January 15, 2014: 2–3 p.m. Going forward, calls will take place on the third Wednesday of each month. Questions can be emailed before or during the teleconference to [email protected]. (Policy Update 1601006) Dual Delivery of Electronic & Paper Remittance Advice Upon mutual agreement between the provider and the health plan, the timeframe for delivery of the paper RA may be extended by an agreed-to timeframe, at which time the health plan will discontinue delivery of the proprietary paper claim RA. The Department of Health and Human Services (HHS) adopts operating rules for the health care electronic funds transfer (EFT) and electronic remittance advice (ERA) transactions under the Health Insurance Portability and Accountability Act (HIPAA). The Council for Affordable Quality Healthcare’s committee on Operating Rules for Information Exchange (CAQH CORE) has established the standard data elements for EFT and ERA enrollment effective January 1, 2014. If you can’t implement and process the health plan’s electronic 835 following the end of the initial dual delivery timeframe and/or after an agreed-to extension, both you and the health plan may mutually agree to continue delivery of the paper claim RA. The new Electronic Remittance Advice Request Form (ERA/835) is now available on our website at bcnepa.com/Era835/. The ERA/835 form allows you to receive auto-posting capability electronically. A health plan that currently issues paper claim remittance advices (RA) is required to continue to offer such paper RA to each provider during that provider’s initial implementation testing of the v5010 X12 835 for a minimum of 31 calendar days from the initiation implementation. If the 31-calendar day period does not include a minimum of 3 payments to you by the health plan, the plan is required to offer proprietary paper claim remittance advices for a minimum of 3 payments. Select the type of request you are submitting: • New—initial request to receive ERA • Cancel—request to discontinue receipt of ERA • Change—request to change method of receipt (clearinghouse) of ERA At the end of this time period, delivery of the paper claim RA will be discontinued. Important Notes: • When selecting the “Change” option, the only information you can elect to change is the clearinghouse and any associated location. • If you need to change any other aspect of your remittance, you will need to submit a “Cancel” Request Form to stop your current remittance and then submit a “New” Request Form with your new information. Example: If you currently receive an ERA and are changing your Tax ID or NPI number, you will need to complete a “Cancel” and enter a “New” request. At the provider’s discretion, the provider may elect to: • Not receive the paper RA • Choose a shorter time period • Discontinue receiving paper RA’s before the end of the specified timeframe by notifying the health plan of this decision (Policy Update 1601007) 7 New HEDIS Measures Available Online Diabetes—Eye Screening for Diabetic Retinal Disease The following HEDIS measures will be added in January to the HEDIS Homepage: An eye screening for diabetic retinal disease as identified by administrative data, including a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. Diabetes A1C Testing and Control Measure Description: The percentage of members 18–75 years of age with diabetes (Type 1 and Type 2) who had Hemoglobin A1c (HbA1c) testing, coded as follows: • HbA1c control (<7.0%): CPT G3044F • HbA1c control (<8.0%): CPT G3045F • HbA1c poor control (>9.0%): CPT G3046F Diabetes—LDL Screening Measure Description: The percentage of members 18–75 years of age with diabetes (Type 1 and Type 2) who had the following: • LDL—C Screening • LDL—C Control (<100 mg/dL) Measure Description: Diabetes—Medical Attention for Nephropathy Measure Description: The percentage of members 18–75 years of age with diabetes (Type 1 and Type 2) who had medical attention for nephropathy. There must be documentation of a nephropathy screening test during the measurement year or evidence of nephropathy during the measurement year, as documented through administrative data or medical record review. Visit the HEDIS Homepage for these and other measures with documentation tips, best practice and information about the importance of these measures to your practice on our website at bcnepa.com. Just click on the “Providers” tab; select “Quality Management,” and then click on the link to the HEDIS Homepage. (Policy Update 1601008) DME/O&P/HOSPITAL Criteria for Initial and Continuing Participation Changes: The following changes were made to the FPH/ FPLIC criteria for initial and continuing participation of Durable Medical Equipment (DME), Orthotic and Prosthetic (O&P) and hospital providers: • DME—added American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) as acceptable accreditation. • O&P—added National Association of Boards of Pharmacy (NABP) as acceptable accreditation. • Hospital—added Det Norske Veritas Healthcare (DNVHC) and Center for Improvement in Healthcare Quality (CIHQ) as acceptable accreditation. As a reminder, please note that all facility types should notify the Credentialing department at 570.200.4384 of any changes with respect to licensure, accreditation, insurance coverage, Medicare/Medicaid sanctions, sentinel events, etc. These criteria changes are effective December 1, 2013. The full FPH/FPLIC criteria for initial and continuing participation of DME, O&P and hospital providers are available upon request from your Provider Relations Consultant. (Policy Update 1601009) 8 2013 Results: Medical Record Documentation As part of FPH’s Quality Management department’s (QM) initiative for continuous quality improvement, we evaluated primary care offices in 2013 for medical record documentation (MRD). This evaluation was part of the recredentialing process and /or random selection. For the 2013 audit year, the Credentialing Committee approved the continued monitoring of the same indicators since the 2003 audit. The compliance threshold also remains the same at 84%. The breakdown of the results for 2013 is as follows: In collaboration with Healthcare Effectiveness Data and Information Set (HEDIS) data, we added documentation of BMI, documentation of pediatric/ adolescent nutrition education and documentation of pediatric/adolescent activity as focus studies also. We will be reviewing for documentation of BMI value for adults and children. • Total number of offices reviewed: 100 • Network standard score: 84% • Percentage of offices above standard: 100% Table 1: Medical record documentation (MRD) chart audit Documentation of pediatric/ adolescent nutrition education and counseling for physical activity includes a note indicating the date, and at least 1 of the following, discussion of current nutrition and current physical activity behaviors: INDICATOR Percent Compliant 2012 2013 Medical/surgical problem list Medication/allergy list Social history Immunizations listed Past medical history Follow-up PCP signs labs/imaging studies Consultant reports present Preventative service by age Legible Advising smokers to quit (focus study) 99.77% 100% 97.52% 85.71% 99.78% 92.84% 97.93% 99.42% 91.11% 99.33% 87.30% 100% 100% 98.48% 97.83% 100% 91.99% 99.54% 98.99% 95.68% 100% 66.67% • Checklist indicating nutrition and physical activity were addressed, counseling or referral for nutrition education and physical activity Documentation of BMI ped/adult combined (focus study) N/A 89.17% Documentation of ped/adol nutrition (focus study) N/A 72.14% Documentation of ped/adol physical activity (focus study) N/A 72.22% The MRD chart audit is performed annually. Efforts are made to coordinate office visits for recredentialing and/or annual HEDIS record reviews with the MRD audit. If you would like copies of the MRD practice guidelines or chart forms, please visit our website at bcnepa.com and click on the “Provider Homepage.” Select “Quality Management” and click on “Practice Guidelines.” You can also access them via Navinet. Using the 84% threshold, Table 1 illustrates the scored indicators. Of note, there was a significant increase in the scores from 2012 for immunizations listed, signing of labs and imaging studies and documentation of preventative service by age. There were no significant decreases for any of the indicator scores. Advising smokers to quit, which is not a scored indicator, but a focus study, decreased significantly from last year. This indicator has been up and down over the last 3 years. Therefore, this focus study continues to offer an opportunity for improvement. • Member received educational materials on nutrition and physical activity • Anticipatory guidance for nutrition and physical activity These focus studies do not impact the overall MRD audit score. (Policy Update 1601010) 9 Electronic Provider Access Capabilities for Providers continued on page 11 The Blue Cross® and Blue Shield® Plans are launching a new tool on January 1, 2014, that will give you the ability to access out-of-area member’s Blue Plan (Home Plan) provider portals to conduct electronic pre-service review. The term pre-service review is used to refer to pre-notification, precertification, pre-authorization and prior approval, amongst other pre-claim processes. Electronic Provider Access (EPA) will enable providers to use their local Blue Plan provider portal to gain access to an out-of-area member’s Home Plan provider portal, through a secure routing mechanism. Once in the Home Plan provider portal, the out-of-area provider will have the same access to electronic pre-service review capabilities as the Home Plan’s local providers. The availability of EPA on January 1, 2014, will vary depending on the capabilities of each Home Plan. Some Home Plans will be fully implemented and have electronic pre-service review for many services, while others will not yet have implemented electronic pre-service review capabilities. The following describes how to use EPA and what to expect when attempting to contact Home Plans at different stages of implementation. How to Use the EPA Tool The first step for providers is to go to BCNEPA NaviNet and login as you do today. Then, you will select the menu option: “Pre-Service Review for Out-of-Area Members” (includes pre-notification, precertification, pre-authorization and prior approval). Next, you will be asked to enter the alpha prefix from the member’s ID card. The alpha prefix is the first three alpha characters that precede the member ID. Note: You can first check whether precertification is required by the Home Plan by either: 1.Sending a service-specific request through BlueExchange 2.Accessing the Home Plan’s precertification requirements pages by using the medical policy router bcnepa.com/ Providers/OutOfAreaMember/ PlanInformation.aspx 10 Electronic Provider Access Capabilities for Providers continued from page 10 Entering the member’s alpha prefix from the ID card will automatically route you to the Home Plan EPA landing page. This page will welcome you to the Home Plan portal and indicate that you have left BCNEPA NaviNet. The landing page will allow you to connect to the available electronic pre-service review processes. Because the screens and functionality of Home Plan pre-service review processes vary widely, Home Plans may include instructional documents or e-learning tools on the Home Plan landing page to provide instruction on how to conduct an electronic pre-service review. The page will also include instructions for conducting pre-service review for services where the electronic function is not available. The Home Plan landing page will look similar across Home Plans, but will be customized to the particular Home Plan based on the electronic pre-service review services they offer. Given that Home Plans are in various states of implementation, not all routes will result in a completed pre-service review. You can expect the following, depending on the implementation status of the Home Plan to which you have been routed. Scenario 1: Scenario 2: Scenario 3: Real-time electronic pre-service review is available for the service you are seeking. The Home Plan landing page will list the services for which electronic pre-service review is available. From this page you will connect to the Home Plan’s (or its vendor’s) pre-service review processes. You will enter the necessary information and the Home Plan will approve or deny the pre-service review request in real-time. Electronic pre-service review is available for the service you are seeking, but not in real-time. The Home Plan landing page will list the services for which electronic pre-service review is available. From this page you will connect to the Home Plan’s (or its vendor’s) pre-service review processes. You will enter the necessary information and the Home Plan will provide an automated response that the pre-service review has been pended. You will be informed as to how the results of the final review will be communicated to you. In most cases, the Home Plan will email, phone or fax you with the final determination. Electronic pre-service review is available, but not for the particular service for which you are seeking pre-service review. The Home Plan landing page will list the services for which electronic pre-service review is available. For other services, the Home Plan will include instructions for how to conduct pre-service review. Home Plans will most likely list a direct phone number or provide a form that you can download and fax for pre-service review. Keep in mind that not all Home Plans provide pre-service review 24 hours a day. The hours of operation will be posted on the Home Plan landing pages. continued on page 12 11 Electronic Provider Access Capabilities for Providers continued from page 11 Frequently Asked Questions What happens if I am not routed to the Home Plan? In some instances, you will receive an error message when you enter the alpha prefix. This error message may alert you that you have not entered the appropriate number of alpha prefix characters, that the alpha prefix is inactive or that you have entered an alpha prefix for an FEP member. (FEP alpha prefixes, which start with the letter “R,” are not supported by EPA.) Some Home Plans do not currently have electronic pre-service review capabilities. You will receive an alert message with a direct phone number for conducting pre-service review for these Home Plans. For example: Blue Cross and Blue Shield of Geography does not currently conduct electronic pre-service reviews. Please call xxx.xxx.xxxx for pre-service review. Some Home Plans only allow providers who are under contract with the local Blue Plan to access their Home Plan provider portal. In this event, a non-Blue provider may see the following alert when attempting to enter an alpha prefix for a member from a Home Plan with such a restriction: Blue Cross and Blue Shield of Geography only allows Blue contracted providers to conduct electronic pre-service review. Please call xxx.xxx.xxxx for pre-service review. What should I do if I enter the member alpha prefix and nothing happens? We hope these situations are rare as we work through early implementation issues. However, if this should happen, you should call 1.800.676.BLUE to be routed to a Home Plan for phone pre-service review. When will all Home Plans have EPA capabilities? We will keep you updated about Home Plan EPA implementation status. Who do I contact if I have additional questions? If you have any questions on how to use the EPA tool or general questions, please call your Provider Relations Consultant at 1.800.451.4447. (Policy Update 1601011) 12 Take Action on HEDIS: Spirometry Testing and Diagnosis of COPD Focus on Quality: Working Together to Improve Care, Health and Cost Use of Spirometry Testing in the Assessment and Diagnosis of COPD is included in the HEDIS (Health Plan Effectiveness Data and Information Set) 2014 measure. This measure reflects the percentage of men and women 40 years of age and older with a new diagnosis or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend that clinicians should consider COPD and perform spirometry if any of these indicators are present in an individual over age 40: With the introduction of Health Care Reform this past year, there has been much focus on the U.S. health care delivery system and the different ways to improve care. Now more than ever, it is important to understand the challenges we face and place emphasis on the quality and value of care that we provide. That’s why we are working with you to ensure high quality and cost-effective care to our members and your patients. In order to help accomplish our goal, we refer to the Institute of Healthcare Improvement (IHI) Triple Aim strategy. This was developed as an approach to optimize health system performance. • Chronic cough: may be intermittent and may be unproductive The Triple Aim strategy consists of: • Dyspnea that is: progressive (worsens over time), characteristically worse with exercise, persistent • Improving the patient experience of care (including quality and satisfaction) • Chronic sputum production: any pattern of chronic sputum production may indicate COPD • Improving the health of populations • Reducing the per capita cost of health care • A history of exposure to risk factors: Tobacco smoke, smoke from home cooking and heating fuels, occupational dusts and chemicals As you may know, we have already taken steps to ensure quality care through our Quality Incentive Program (QIP). This program rewards eligible providers for delivering high quality, cost-effective care to our members. The QIP assesses performance through various metrics with an emphasis on quality and categorized into the measurement areas of quality, administrative and cost. • Family history of COPD COPD is usually a progressive disease, the result of cumulative exposures over decades. Symptoms and lung function should be monitored to guide treatment and monitor for complications. Spirometry, performed at least once a year, can be used to monitor COPD progression, according to GOLD guidelines. We are implementing this strategy by focusing on the Patient-Centered Medical Home (PCMH) model. This is an approach to deliver comprehensive care coordinated by a physician or a physician-led team. Through this model, partnerships are formed between individual patients, their physicians, and when appropriate, the patient’s family. This model proposes to improve care by strengthening the patient-doctor relationship through a more comprehensive approach to patient care and more active patient involvement. Spirometry codes found on the PCP billable listing are as follows: 94010 Spirometry w/Record-TOT & Timed VC-Expir Flo Rate $40.42 94060 Bronchodilat Respn Pre&Post Bronchodilat Admin $68.16 To help you and your patients meet their treatment plan, we offer Blue Health Solution’s COPD Management and Tobacco Cessation Programs. A care coordinator can work with your patients in providing resources, education and support. Eligibility requirements and referral forms are available online at bcnepa.com. Click on the “Provider Homepage” tab and select “Health and Wellness.” After completing the referral form, fax it to the Health Management department at 570.200.8010. Or call 1.866.262.4764 for more information. By incorporating the Triple Aim strategy through our quality incentive programs and the PCMH model, we will have healthier populations and better coordination of care. By reducing the per capita cost of care, we can ensure the best outcomes at the lowest cost for our members. For more information on IHI’s Triple Aim, visit their website at ihi.org/offerings/Initiatives/ TripleAIM/Pages/default.aspx. Please continue to check future editions of the Provider Bulletin for more information on our quality-focused initiatives. Sources: The Global Initiative for Chronic Obstructive Lung Disease, National Committee for Quality Assurance, Updated 2013 Sources: Institute for Healthcare Improvement, American College of Physicians, NCQA (Policy Update 1512012) (Policy Update 1512013) 13 Medical Policy Updates New Claims Review Vendor We are changing vendors for the review of our claims Effective February 1st 2014 Transplant (MPO-490-0001) payments in the area of high-cost drugs, biologics 7.03.08—Heart/Lung Transplant and durable medical equipment/supplies. Effective The following language has been added to Policy: February 2014, we have engaged the professional • Heart/lung retransplantation after a failed primary heart/lung transplant may be considered medically necessary in patients who meet criteria for heart/lung transplantation. auditing services of Trover Solutions, Inc. They will replace the services previously provided by SCIO Health Analytics (formerly SCIOinspire). • Heart/lung transplantation is considered investigational in all other situations (i.e., when medically necessary criteria has not been met). Trover Solutions, Inc. will be reviewing claims data 7.03.08—Heart Transplant and medical records to determine billing accuracy The Policy language has been updated as follows: • Heart retransplantation after a failed primary heart transplant may be considered medically necessary in patients who meet criteria for heart transplantation. and contractual compliance. Also they will determine if and to what extent BCNEPA may have overpaid for • Heart transplantation is considered investigational in all other situations (i.e., when medically necessary criteria has not been met). services related to drugs, biologics and durable medical equipment/supplies. As part of the review, Trover continued on page 15 Solutions, Inc. may request records and other information related to the provision of these services from your office or facility. Our processes are streamlined so that this Reminder: review will require minimal time from you and your staff. Therefore, we ask that you cooperate with any requests Eye Screening for Diabetic Retinal Disease for records you may receive. We have entered into a business associate agreement A retinal or dilated eye exam is an important quality measure monitored through the Health Effectiveness Data Information Set (HEDIS). Both the American Diabetes Association and the American Academy of Ophthalmology recommend annual eye exams for all your patients with diabetes. This test can be carried out by either an ophthalmologist or an optometrist. with Trover Solutions, Inc., according to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). This also complies with the requirements of the Health Information Technology for Economic and Clinical It is vital that you document this exam in the patient’s record at his/her primary care provider’s office. In addition, the exam should be properly coded as a retinal or dilated eye exam. Health Act, as incorporated in the American Recovery and Reinvestment Act of 2009 (the “HITECH Act”). Please make sure that you send a letter to the primary care provider’s office verifying the exam and results as soon as it is completed. This will ensure that the patient is getting best practice care along with capturing this data for HEDIS reporting. If you have any questions or need more information, please feel free to call your Provider Relations Consultant at 1.800.451.4447. (Policy Update 1601014) (Policy Update 1601015) 14 Medical Policy Updates Effective February 1st 2014 continued from page 14 Genetic Testing (MPO-490-0083) 2.04.109—Genetic Testing for Epilepsy 2.04.103—Genetic Testing for Macular Degeneration The following new language has been added to Policy: The following new language has been added to Policy: • BCNEPA will not provide coverage for genetic testing for epilepsy as this is considered investigational. • BCNEPA will not provide coverage for genetic testing for macular degeneration as this is considered investigational. 2.04.110—Genecept Assay 2.04.107—Carrier Testing for Genetic Diseases The following new language has been added to Policy: New Policy language has been added as follows: • BCNEPA will not provide coverage for the Genecept™ panel assay as it is considered investigational for all indications. • BCNEPA will provide coverage for carrier testing when medically necessary. 2.04.111—Microarray-based Gene Expression Analysis for Prostate Cancer Management Carrier testing for genetic diseases is considered medically necessary when 1 of the following criteria is met: The following new language has been added to Policy: • BCNEPA will not provide coverage for microarray-based gene expression analysis to guide management of prostate cancer as this is considered investigational in all situations. – The individuals have a previously affected child with the genetic disease – One or both individuals have a first- or second-degree relative who is affected 2.04.08—Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes – One or both individuals have a first-degree relative with an affected offspring Policy language has been updated to include the following statements: – One individual is known to be a carrier • Genetic testing for BRAF V600E or MLH1 promoter methylation may be considered medically necessary to exclude a diagnosis of Lynch syndrome when MLH1 protein is not expressed in a colorectal cancer on immunohistochemical (IHC) analysis. – One or both individuals are members of a population known to have a carrier rate that exceeds a threshold considered appropriate for testing for a particular condition AND all of the following criteria are met: • Genetic testing for all other gene mutations for Lynch syndrome or colorectal cancer (i.e., when medically necessary criteria has not been met) is considered investigational. – The natural history of the disease is well understood and there is a reasonable likelihood that the disease is 1 with high morbidity in the homozygous or compound heterozygous state. Experimental/Investigative Services Pathology/ Laboratory(MPO-490-0134) – Alternative biochemical or other clinical tests to definitively diagnose carrier status are not available, or, if available, provide an indeterminate result or are individually less efficacious than genetic testing. 2.04.100—Cardiovascular Risk Panels The following language has been added to Policy: • BCNEPA will not provide coverage for cardiovascular risk panels, consisting of multiple individual biomarkers intended to assess cardiac risk (other than simple lipid panels, i.e., total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides), as they are considered investigational. – The genetic test has adequate sensitivity and specificity to guide clinical decision making and residual risk is understood. An association of the marker with the disorder has been established. • Expanded carrier screening panels are considered to be not medically necessary. Experimental/Investigative Services Surgery (MPO-490-0139) 2.04.108—Fetal RHD Genotyping Using Maternal Plasma New Policy language has been added as follows: 7.01.134—Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery • BCNEPA will not provide coverage for fetal RHD genotyping using maternal plasma as this is considered investigational. The following language has been added to Policy: • BCNEPA will not provide coverage for the use of implantable sinus stents/spacers for postoperative treatment following endoscopic sinus surgery as this is considered investigational. (Policy Update 1601016) 15 presorted standard u.s. postage paid wilkes-barre, pa permit no. 84 19 North Main Street Wilkes-Barre, PA 18711-0302 bcnepa.com Address Service Requested Editors: Jennifer Sensky Ann Poepperling Blue Cross of Northeastern Pennsylvania administers health plans for Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First Priority Health® and First Priority Life Insurance Company.® Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan issuer in the Federally Facilitated Marketplace. Independent Licensee of the Blue Cross and Blue Shield Association. ®Registered Mark of the Blue Cross and Blue Shield Association. Provider Relations Department: 1.800.451.4447 How You Can Reach Us For questions about benefits, eligibility or claims, please call, weekdays, between 8 a.m. and 5 p.m.: • BlueCare® HMO/HMO Plus—1.800.822.8752 • BlueCare PPO—1.866.262.5635 Important Fax Numbers: BC Claims....................................... 570.200.6790 (For claims adjustments, BlueCare Senior, FEP) BC Precertification........................ 570.200.6788 • BlueCare Traditional—1.888.827.7117 BlueCard® ITS Claims.................. 570.200.6790 • BlueCare EPO—1.888.345.2353 FPH Claims..................................... 570.200.6790 (For Maternity Precertification Forms, adjustments, Claims Research Request Forms, etc.) Valuable Health Resources: Refer your BlueCare patients to the following Blue Health Solutions health and wellness resources: SM Provider Relations........................ 570.200.6880 • Personalized health management and wellness programs, care management resources and much more—1.866.262.4764 Provider Customer Service......... 570.200.6868 • 24/7 Nurse Now health care information— 1.866.442.BLUE and available online at bcnepa.com. Login to Self-Service; click on the “Health & Wellness” tab and then select “24/7 Nurse Now.” FPH Non-par Referral Requests.... 570.200.6840 FPH Complaint/Grievance.......... 570.200.6770 FPH Pharmacy................................ 570.200.6870 FPH Precertification...................... 570.200.6799 Other Party Liability (OPL)......... 570.200.6790 Report Fraud: Call our Fraud Hotline at 1.800.352.9100, or email our Special Investigations Unit at [email protected]. BCNEPA Provider Relations Consultants Odette Ashby • 570.200.4658 [email protected] Cheryl Hashagen • 570.200.4670 [email protected] Louise LoPresto • 570.200.4674 [email protected] Jean Wiernusz • 570.200.4682 [email protected] Tracie Wyandt • 570.200.4647 [email protected] Senior Manager, Provider Relations Dave Levenoskie • 570.200.4673 [email protected] Senior Manager, Provider Services Kevin Quaglia • 570.200.4676 [email protected] QUESTIONS? CALL PROVIDER RELATIONS AT 1.800.451.4447 © Blue Cross of Northeastern Pennsylvania. 2014.
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