bluelink letter

Quick Summary

Quality Improvement Practitioner Satisfaction Survey 2008 2

Maryland Releases the Health Plan Performance Report 2

Appointment Access 3

Claims and Billing

FEP Benefit Changes for 2009 4-5

Reporting Venipuncture with Other Services 6

Field 24C on New CMS 1500 Claim Form 6

Reminders Regarding Inquiries 6

What’s Happening

Enhancements to CareFirst Direct 7

BlueCross and BlueShield Association Mandates ID Card Changes 7

Select CareFirst and CareFirst BlueChoice Members Get New ID Cards 7

Health Care Policy

New Technology Evaluated 8Medical Policy Updates 9-11

Provider Seminars 12-13

Provider Representatives Institutional Provider Representatives 14

Phone Numbers & Addresses 15-16

Pharmacy Updates 17

A News Publication Linking CareFirst and CareFirst BlueChoice with Participating Physicians, Providers and Institutions

BlueLink November/December 2008 • Vol. 10, Issue 6

CareEssentialsBlueLink is part of the Utilization

Management component of

CareEssentials, our care management

program that provides you with

essential tools for patient care.

The CareFirst Center for Provider Education & Training Wins Best of Blue

Note: All references to “CareFirst” in this publication refer to CareFirst BlueCross BlueShield. All references to “CareFirst BlueChoice” refer to CareFirst BlueChoice, Inc.

Did you know that CareFirst has an award winning provider training Web site? The CareFirst Center for Provider Education & Training won the 2008 Blue Cross and Blue Shield Association Focus on Provider Best of Blue award for its contribution to improved provider satisfaction.

The Web site includes links to stand-alone, content-rich training that allows providers and their staff to learn anytime and anywhere. Need to learn more about BlueCard, DRG, or CareFirst Direct? There are modules available to help. In addition, there are modules specific to various specialties, with more being added each month. As an added bonus, the site includes links to convenient, on-line, quality Continuing Medical Education courses.

Along with our stand-alone training modules, CareFirst offers 30 to 45 minute web-based seminars called “webinars.” Webinar topics include product specific webinars, such as Maryland Point of Service and topics targeted for many professional specialties and most ancillary providers. Webinars allow you to attend training, specific to what you need, on-line, with the benefit of an instructor. And, the feedback from our participants indicates they find the training very useful. Plus, there is the added convenience of no travel, a real bonus for everyone these days.

Of course, provider training at CareFirst would not be complete without our regular seminars held throughout the area. The Back to Basics seminars are a good opportunity for someone new to working with CareFirst to learn the basics, in one sitting. We also offer Update Me seminars which target the latest CareFirst happenings along with seminars designed for specific provider specialties, including ancillary providers.

You can complete training or register for webinars and seminars through the Center for Provider Education and Training at http://www.carefirst.com/providers/CenterForProviderEducation/index.html. And check back often as new classes are being added regularly. And please, when you finish your training, complete an evaluation – your feedback is important to us.

BestofBLUE

2 bluelink November/December Vol. 10, Issue 6 u Visit us at www.carefirst.com

Quality Improvement

Practitioner Satisfaction Survey 2008

BluePreferred physicians identified strengths in the following areas:

n Feedback from Specialists and hospitalsn Overall satisfaction with CareFirstn General availability of specialists

BluePreferred physicians rated CareFirst as being much or somewhat better than the competition in the following areas:

n Overall number of specialistsn Availability of specialistsn Overall satisfactionn Utilization management overalln Ease of submitting Utilization Management authorizationsn Willingness of the Case Managers to work with you

Both CareFirst BlueChoice and BluePreferred physicians identified the following opportunities for improvement:

n Availability of behavioral health specialists and dermatologists in select geographic areas

n Regularly receiving feedback from hospitals, behavioral health specialists and skilled nursing facilities

n Usefulness of the information from skilled nursing facilitiesn Waiting times to get an appointment with a behavioral health

specialist

What are we doing to improve?:

n CareFirst contracts with all available applicable practitioners.

n CareFirst has completed interventions with the skilled nursing facilities requesting them to send a copy of the discharge summary to the primary care physician or treating physician. Since satisfaction with feedback from hospitals is declining and practitioners find this information helpful, CareFirst is making an effort to identify strategies to improve physician satisfaction.

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. survey their primary care physicians each year to evaluate their satisfaction with the medical management of CareFirst’s health plans. Physicians are asked to rate CareFirst as a whole and compare CareFirst to its competitors. Physicians rate CareFirst in the following areas: overall satisfaction, utilization management, administrative support, referral process, case management, ancillary and specialist practitioners, communication, provider services staff, and plan contact.

In September 2008, the Maryland Health Care Commission (MHCC)

released its 2008/2009 Health Plan Performance Report. This

report has provided information on Maryland’s health maintenance

organizations (HMOs) since 1997. This year, for the first time,

the MHCC has included information for preferred provider

organizations (PPOs). The report compares CareFirst BlueChoice

and CareFirst results with other organizations in Maryland. You can

access this information at http://mhcc.maryland.gov/hmo/index.

html and selecting 2008/2009 Health Plan Performance Report.

Maryland Releases the Health Plan Performance Report

November/December Vol. 10, Issue 6 bluelink 3

CareFirst and CareFirst BlueChoice have established preferred times for practitioner office appointments. These times are based on the type of visit that the member needs:

You can locate the preferred appointment times on pages 3 and 4 of the Practitioner Office Standards by accessing www.carefirst.com > Provider & Physicians > Resources & Seminars. The Practitioner Office Standards is found in the Documentation and Office Standards section.

Each year, CareFirst and CareFirst BlueChoice evaluate members’ access to primary care against the preferred times standards for appointments and member complaints. The following graphs show the results for 2007 and 2008 for each product.

In 2007, CareFirst BlueChoice exceeded the CareFirst goals in two measures: getting an appointment in 30 days (95 percent) and getting an appointment in 14 days (85 percent). Although improvement occurred in one measure for both BlueChoice and BluePreferred in 2008, the results for all measures fell below the goals of 95 percent for getting an appointment in 30 days and 85 percent for the remaining measures.

The following are a number of factors that affect a member’s satisfaction with getting an appointment: the hours of operation of the office; member’s lack of choice of appointment times; need to leave one’s job in order to keep an appointment; and the member’s expectation and perception of the need for care.

Please consider the preferred appointment times and factors affecting members’ satisfaction when reviewing your office procedures for assigning appointments.

Quality Improvement

Appointment Access

Type of Appointment Preferred Time for an Appointment

Non-symptomatic (Preventive Care)

30 days

Urgent Care Visits 24 hours

Symptomatic Non-urgent (Routine Care)

14 days

After-hours Care Responds to caller within 30 minutes

BlueChoice Accessibility Assessment BluePreferred Accessibility Assessment

PercentPercent

% % % % %

Wai

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tim

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ap

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Wai

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ap

poin

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Claims and Billing

FEP Benefit Changes for 20092009 Benefit Changes Standard Option Only Basic Option Only

CatastrophicOut-of-Pocket Max

$5,000 – Preferred Providers(previously- $4,500 Max)$7,000 – combined Preferred andNon-Preferred Providers (previously– $6,500 Max)

What we pay: What we pay:

Preferred Provider Office Visit 100% of plan allowance after $20 co-pay per visit (previously– $15 per visit)

100% of plan allowance after $25 co-pay per visit for a primary care physician(previously– $20 per visit)

Non-Preferred Provider Office Visit 70% of plan allowance (previously– 75% of plan allowance)

No change in benefits

Preferred Provider Services 85% of plan allowance(previously– 90% of plan allowance)


Non-Preferred Provider Services 70% of plan allowance(previously– 75% of plan allowance)


Preferred Facility Care 100% of plan allowance after $200 inpatient co-pay per admission (previously– $100 per admission)

100% of plan allowance after $50 outpatient co-pay per day per facility (previously– $40 per visit);100% of plan allowance after $75 emergency room co-pay per visit (previously– $50 per visit)

Non-Preferred Radiologist, Pathologist, and Assistant Surgeon Services at a Preferred Facility

85% of plan allowance (previously– 90% of plan allowance)


Non-Participating Emergency Room 100% after member pays up to $350 co-pay per visit (previously– 75% of plan allowance)


Non-Participating Surgeon 100% after member pays up to $7,500 co-pay per surgeon per surgical procedure (previously– 75% of plan allowance)


Non-Participating Anesthesiologist or CRNA

100% after member pays up to $800 co-pay per anesthetist per day (previously– 75% of plan allowance)


Ambulance Transport 100% of plan allowance after $100 co-pay per day for ground transport and $150 co-pay per day for air or sea transport (previously– $50 co-pay for all transport)

100% of plan allowance after $100 co-pay per day for ground transport and $150 co-pay per day for air or sea transport (previously– $50 co-pay for all transport)

Prescription Drug – Preferred Retail Pharmacy

80% of plan allowance for generic drugs and 70% of plan allowance for brand-name drugs (previously– 75% for generic and brand-name drugs)

Level II drugs – 100% of plan allowance after $35 co-pay per prescription (previously– $30 co-pay per prescription);Level III drugs – member liable for minimum of $45 co-pay for 34-day supply or $135 co-pay for 90-day supply (previously– $35 co-pay for 34-day supply) or $105 co-pay for 90-day supply)

Prescription Drug – Mail Service Program $10 co-pay waived for 1st 4 generic drug prescriptions (previously– $10 co-pay for all prescriptions):$65 for 1st 30 brand-name prescriptions filled and/or refilled, $50 co-pay per prescription thereafter (previously– $35 co-pay for all brand-name prescriptions)



Claims and Billing

FEP Benefit Changes for 20092009 Benefit Changes Standard Option Only Basic Option Only

Outpatient Mental Health/Substance Abuse services

Prior approval now required before receiving any outpatient services (previously– prior approval was required prior to the 9th visit)

No change in Mental Health/Substance Abuse Benefits

Chiropractor/Doctor of Chiropractic (D.C.) now considered “other health care profes-sionals” (previously– listed as physicians)

No change in benefits for this type of provider

No change in benefits for this type of provider

Prior approval is required for outpatient sur-gery for morbid obesity, correction of con-genital anomalies, and to correct accidental injuries (see Definitions) to jaws, cheeks, lips, tongue, roof and floor of mouth. (previ-ously– prior approval was not required)

No change in Surgical Procedures Benefits No change in Surgical Procedures Benefits

Effective 1/1/09, we now cover: What we pay: What we pay:

Portable X-ray Equipment (previously– no benefits)

Preferred: 85% of plan allowanceParticipating: 70% of plan allowanceNon-participating: 70% of plan allowance, member will be responsible for any differ-ence between our allowance and the billed amountNote: If a preferred provider uses a non-preferred laboratory or radiologist, we will pay non-preferred benefits for any labora-tory and X-ray charges.

Preferred primary care provider, preferred specialist, and other health care profession-al: We consider benefits in fullNote: 70% of the plan allowance for drugs and supplies.Participating/Non-participating:Member is liable for all charges.Note: For services billed by Participating and Non-participating laboratories or radiolo-gists, the member is liable for any difference between our allowance and billed amount.

Screening and behavioral change interven-tions for tobacco use and alcohol/sub-stance abuse as part of the Adult Preven-tive Care Benefits (previously– no benefits)

No change in Adult Preventive Care Ben-efits

No change in Adult Preventive Care Ben-efits

Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 18. (previously– benefits provided through age 12)

No change in Vision Services Benefits No change in Vision Services Benefits

Hearing aids for adults age 22 and over, limited to $1,000 per ear per 36-month period (previously– benefits were limited to bone anchored hearing aids for adults)

No change in Orthopedic and Prosthetic Devices Benefits

No change in Orthopedic and Prosthetic Devices Benefits

Wigs (scalp hair prosthesis) due to hair loss due to chemotherapy for cancer treatment.Note: Benefits for wigs are paid at 100% of the billed amount, limited to $350 for one wig per lifetime. (previously– no benefits)

Up to $350 of Plan Allowance Up to $350 of Plan Allowance

Medical foods, as defined by U.S. Food and Drug Administration, administered orally and provide the sole source (100%) of nutrition, for children up to age 22, for up to one year following the date of initial prescription or physician order for the medical food (previously– no benefits)

No change in Medical Supplies Benefits No change in Medical Supplies Benefits

Influenza vaccine (one each flu season) provided by a Preferred retail pharmacy (previously– no benefits)

Preferred retail pharmacy: 100% of Plan AllowanceNon-preferred retail pharmacy: Member is liable for all charges

Preferred retail pharmacy: 100% of Plan AllowanceNon-preferred retail pharmacy: Member is liable for all charges


Claims and Billing

Field 24C on New CMS 1500 Claim FormPlease leave field 24C ‘EMG’ blank on the new CMS form unless you are indicating emergency

care. The old CMS form used this field to indicate the type of service. If you use the EMG

field to indicate the type of service, the claim will be processed as an emergency, which could

result in an incorrect payment or denial.

Reminders Regarding Inquiries...If a claim is returned to your office for additional information, please re-file the claim with the requested information as a new claim.

If a claim has been denied and you wish to dispute the denial, please submit your inquiry with a Provider Inquiry Resolution Form* that includes the following information:

n Patient’s membership numbern Patient’s Namen Date of Servicen Claim numbern Reason for Inquiry

Please do not arbitrarily resubmit a claim that has not been paid or rejected. Please use our Voice Response Unit (VRU) or CareFirst Direct to check the status of your claim before re-filing and follow the above procedures when necessary.

* This form can be found by accessing www.carefirst.com >Provider & Physicians > Forms


What’s Happening

Enhancements to CareFirst Direct

BlueCross and BlueShield Association Mandates ID Card ChangesThe Blue Cross and Blue Shield Association is requiring all national Blues Plans, including CareFirst and CareFirst BlueChoice, to redesign member ID cards.

Effective Jan. 1, 2009, all “Blue-branded” ID cards will have a consistent format for member information, benefit information and logo placement. This new format will make ID cards more user-friendly for CareFirst and CareFirst BlueChoice members and providers. Current information such as member name, group name, group number, co-pays, OPEN ACCESS and service numbers will still appear on the ID cards, but their placement will change.

CareFirst and CareFirst BlueChoice will begin to distribute new member ID cards for newly-issued and reissued cards on Jan. 1, 2009, and complete the new format issuance by Jan. 1, 2011.

Above is a sample of the newly-formatted member ID cards. Remember: the information on member ID cards may vary depending upon the member’s coverage.

CareFirst and CareFirst BlueChoice have improved the services on CareFirst Direct to make it easier for you to gather member information.

Updated Benefit Information:In CareFirst Direct you will be able to see information on the member’s Lifetime Maximum under the benefit details section on CareFirst Direct. December enhancements include the deductible remaining as well as the members remaining out of pocket for their medical policy. Also in December, you will see remaining

amounts related to visits, days and dollars per service for Maryland members only.

Request for Coordination of Benefit Information:A Coordination of Benefits questionnaire will be available on the eligibility summary screen in CareFirst Direct. Please help us in obtaining the most up to date information by printing out the questionnaire for the member to complete.

Select CareFirst and BlueChoice Members Migrate to NASCO Processing System and Receive New ID CardsDuring the next 18 months, CareFirst and BlueChoice will be migrating more than 100 accounts to a different processing platform upon account renewal. The new platform, NASCO, is actually an existing, successfully proven platform. Members will receive new ID cards prior to their effective date and are being advised to present their new card upon the effective date.

How will this change impact you?Always ask the member to present their ID card. Prefixes, group numbers, and subscriber numbers are all changing. Using an outdated card to check eligibility or claims, for instance, may result

in receiving incorrect information that the member has terminated coverage. After the member receives their new card, you must reference the new Subscriber ID number.

Because some members may fail to present their new ID card, we strongly recommend that you verify eligibility using CareFirst Direct or our Voice Response Unit (VRU).

Claims submission addresses may change. Check the back of the ID card to route appropriately.

Payment will be sent on NASCO payment vouchers.


Health Care Policy

New Technology EvaluatedOur Technology Assessment Unit evaluates new and existing technologies to apply to our local indemnity and managed care benefit plans. The unit relies on current scientific evidence published in peer-reviewed medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst and CareFirst BlueChoice criteria for coverage. Policies for non-local accounts like NASCO and FEP may differ from our local determinations. Please verify member eligibility and benefits prior to rendering services via BlueLine, FirstLine or CareFirst Direct. The Technology Assessment Unit recently made the following determinations:

*Note: Current Procedural Terminology (CPT®) codes and descriptions only are copyright of the 1966 American Medical Association. All rights reserved.

Technology DescripTion careFirsT anD careFirsT Blue choice DeTerminaTion

Balloon sinuplasty An inflatable balloon is used to enlarge the opening into one or more accessory sinuses in an endoscopic procedure.

Sinusotomy/antrostomy is an established procedure to treat sinus obstruction resulting from chronic sinus-itis. The balloon sinuplasty device is a device used to perform the procedure.CPT® reporting codes 31256, 31276, or 31287. HCPCS reporting code S2344

Scintimammo-graphy

Breast imaging using radiop-harmaceuticals with single-photon emission computed tomography (SPECT)

The procedure is considered experimental/investigational as a means to select patients for biopsy.HCPCS reporting code S8080

Islet cell transplantation

Transplantation of islet cells extracted from the pan-creas as a graft in the portal circulation for production of insulin

Autologous islet transplant is considered medically necessary as an adjunct to pancreatectomy for chronic pancreatitis. Allogeneic islet transplant is considered experimental/investiga-tional for Type 1 diabetes mellitus.CPT® reporting codes 48160 (autolo-gous) or 0141T-0143T (allogeneic)

Percutaneous lysis of epidural adhesions

Use of a special catheter possibly with hypertonic sa-line, for adhesiolysis of the lower back to relieve post surgical pain.

Considered experimental / investigational

CPT® reporting codes 62263, 62264, or 0027T

PathFinderTG® molecular genetic pathology test

A proprietary molecular genetic test being promoted as an adjunct to cytology or histology to improve diag-nosing of certain cancers

Considered experimental / investigational.

CPT® reporting code 84999

The following Category III CPT® codes are effective January 1, 2009:

0193T Experimental/investigational



+0196T Experimental/investigational

0197T No additional benefit. Included in benefit for the primary procedure



Medical Policy UpdatesOur Health Care Policy

department continually

reviews medical policies

and operating procedures

as new, evidence-based

information becomes

available regarding

advances in new or

emerging technologies,

as well as current

technologies, procedures

and services.

The table to the right

is a guide designed to

provide updates on

any changes to existing

or new local policies

and procedures during

our review process.

Each local policy or

procedure listed includes

a brief description of its

status, select reporting

instructions and effective

dates. Policies for non-

local accounts, such as

NASCO and FEP, may

differ from our local

determinations. Please

verify member eligibility

and benefits prior to

rendering services via

BlueLine, FirstLine or

CareFirst Direct.

MEdICAl POlICy ACTIOnS, COMMEnTS And POlICy STATuS And And/Or PrOCEdurE rEPOrTIng guIdElInES EffECTIvE dATE

1.01.005H-wave Electrical Stimulation Devices For Home Use

1.01.057AWalkers and Accessories

1.01.072ACanes and Accessories

1.02.024AOver-the-Counter Miscellaneous Supplies and Equipment

1.03.003 Orthotic Foot Inserts

2.01.011Electrocorticography

2.01.015Vision Therapy (Orthoptics/ Pleoptics)

2.01.017Allergy Immunotherapy

2.01.044Video Electroencephalographic (EEG) Monitoring

Periodic review and

update

Effective 10/24/08

New Operating Procedure

Effective 11/17/08

New Operating

Procedure

Effective 10/20/08

Periodic review and

update

Effective 11/17/08

Policy revision

Effective 10/20/08

Periodic review and

update

Effective 10/24/08

Periodic review and

update

Effective 10/20/08

Periodic review and

update.

Effective 11/17/08

Periodic review and

update

Effective 11/14/08

Under Policy Guidelines added an updated 2008 rationale

statement. H-wave electrical stimulation devices for home use

remain experimental/ investigational.

Benefits are not provided for walkers as they can be purchased

over-the-counter and therefore are not a covered benefit.

Benefits are not provided for canes as they can be purchased

over-the-counter and therefore are not a covered benefit. Report

with HCPCS A4636, A4637, E0100 or E0105.

Operating Procedure updated with additional over-the-counter

items. The list is not all inclusive.

Under Provider Guidelines revised note to read, “HCPCS code

L3000 is used for a removable foot insert of the University of

California at Berkeley (UCB) type that has been molded to a

model of the patient’s foot (i.e., created from plaster, fiberglass,

foam or electronic imaging). This type of Orthotic is a functional

device which has a molded heel cup with a minimum depth of

10mm that holds the heel in a neutral position with intrinsic or

extrinsic posting designed to control foot motion. This device

is made of a rigid or semi rigid material. HCPCS code L3000

includes additions such as postings, padded top covers, soft

tissue supplements, balance padding and lesion or structure

accommodations. Other additions may be required as well.”


statement. Medically necessary, experimental/ investigational

and not medically necessary indications remain the same.

Description revised to include “vision therapy may involve the use

of lenses, prisms, filters and computer programs and is typically

administered in office visits over several weeks with techniques

taught to the patient to be practiced at home.” Under Policy

statement, added a brief description to the medically necessary

conditions. Under experimental/ investigational statement added

conditions including learning disabilities and dyslexia. Under

Policy Guidelines added an updated 2008 rationale statement.


statement. Medically necessary and experimental/ investigational

indications remain the same.


statement. Medically necessary and not medically necessary

indications remain the same.

Health Care Policy


MEdICAl POlICy ACTIOnS, COMMEnTS And POlICy STATuS And/Or PrOCEdurE rEPOrTIng guIdElInES And EffECTIvE dATE

Health Care Policy

Medical Policy Updates

2.01.050AProfessional Nutritional Counseling

2.03.010Genetic Testing for Inherited Susceptibility to Colon Cancer

2.03.009Antineoplaston A Therapy

4.02.001 Assisted Reproductive Technology (ART) Procedures: In Vitro Fertilization (IVF) Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT)

6.01.031Computerized Ophthalmic Diagnostic Imaging

6.01.039Magnetic Resonance Neurography

7.01.010Fetal Mesencephalic Transplantation for the Treatment of Parkinson’s Disease

7.01.062Lung Volume Reduction Surgery for Palliation of Severe Emphysema

7.01.067Prolotherapy (Proliferative Therapy)

7.01.080Transpupillary Thermotherapy

7.01.084Spinal Manipulation Under Anesthesia

7.01.097Gastric Electrical Stimulation

8.01.009Recreational Activity as Physical Therapy (e.g., Golf, Hippotherapy)

Periodic review and

update

Effective 10/20/08

Periodic review and

update

Effective 11/14/08

Periodic review and update

Effective 10/24/08

Periodic review and

update.

Effective 11/14/08


Effective 10/24/08


Effective 11/14/08

Periodic review and

update

Effective 11/14/08

Periodic review and

update

Effective 11/14/08


Effective 10/24/08

Periodic review and

update

Effective 11/14/08

Periodic review and

update

Effective 10/24/08


Effective 10/24/08

Periodic review and

update.

Effective 10/24/08

Check the member’s contract for benefits. Review operating procedure for

details.

Under Policy Guidelines added an updated 2008 rationale statement. Medically

necessary and experimental/ investigational indications remain the same.

Under Policy Guidelines added an updated 2008 rationale statement.

Antineoplaston A therapy remains experimental/ investigational.


Experimental/ investigational indications remain the same. Check the member’s

contract for benefits.

Under Provider Guidelines clarified reporting guidelines for computerized

ophthalmic diagnostic imaging. See Policy for details.

Under Policy Guidelines added an updated 2008 rationale statement. Magnetic

resonance neurography remains experimental/ investigational.

Under Policy Guidelines added an updated 2008 rationale statement. Fetal

mesencephalic transplantation for the treatment of Parkinson’s disease remains

experimental/ investigational.




Prolotherapy remains experimental/ investigational.



Under Policy Guidelines added an updated 2008 rationale statement. The use

of spinal manipulation under general anesthesia, in the absence of vertebral

fracture, remains experimental/ investigational.

Under Policy Guidelines added an updated 2008 rationale statement. Gastric

electrical stimulation remains experimental/ investigational.

Under Policy Guidelines added an updated 2008 rationale statement. Not

medically necessary and experimental/ investigational indications remain the

same.


MEdICAl POlICy ACTIOnS, COMMEnTS And POlICy STATuS And/Or PrOCEdurE rEPOrTIng guIdElInES And EffECTIvE dATE Medical

Policy Updates

MEdICAl POlICy ACTIOnS, COMMEnTS And POlICy STATuS And/Or PrOCEdurE rEPOrTIng guIdElInES And EffECTIvE dATE

8.01.015Monochromatic Infrared Energy (MIRE) Therapy

11.01.033Cytochrome P450 Genotyping

11.01.040Topographic genotyping, quantitative mutational analysis, e.g. Pathfinder TG®

11.01.041KRAS mutation analysis in metastatic colorectal cancer


Effective 10/24/08


Effective 11/17/08

New Policy

Effective 11/17/08

New Policy

Effective 11/17/08

Under Policy Guidelines added an updated 2008 rationale statement. MIRE therapy remains experimental/ investigational.

Under Policy Guidelines added an updated 2008 rationale statement. Cytochrome P450 to predict an individual’s optimum dosage response or to predict possible adverse drug reactions remains experimental/ investigational.

Topographic genotyping as an adjunct to cytology or histology in diagnosing cancer is considered experimental/ investigational.

KRAS mutation analysis is considered medically necessary to predict nonresponse to anti-EGFR monoclonal antibodies in the treatment of metastatic colorectal cancer. Report with molecular diagnostic CPT® code range 83890 – 83912.

Health Care Policy

*Note: Current Procedural Terminology (CPT®) codes and descriptions only are copyright of the 1966

American Medical Association. All rights reserved.

1.01.016A Coverage for Hearing Aids (Maryland Mandate)

1.04.001 Prosthetics

4.02.006A Assisted Reproductive Technology (ART): Artificial Insemination (AI)/ Intrauterine Insemination (IUI)

6.01.021A Image-Guided Surgery

8.01.013A Vertebral Axial Decompression

9.01.004A Anesthesia Consultation

9.01.007A General Anesthesia for Dental Care (Maryland and Virginia Mandates)

10.01.002A Attendance at Delivery

10.01.007A Private Room

10.01.008A Surgical Assistants

POlICIES unCHAngEd frOM lAST rEvIEW


Provider Seminars

Hospital Quarterly – designed for hospital office staff to receiveupdated CareFirst information.

Hospital Seminars

Practitioner and Staff Seminars and Training SessionsCareFirst and CareFirst BlueChoice offer half-day seminars, Webinars and hands-on training sessions designed to familiarize professional and institutional providers and their office staff with CareFirst and CareFirst BlueChoice policy, provider-oriented procedures and tools. The types of seminars are listed below accompanied by a brief description and its identification code to assist in selecting the presentations that best meet your needs. Hands on Training sessions and Ancillary Seminars will begin in April. Look for the dates and locations in our next issue.

date and Time location room

Tuesday, March 24, 200910 a.m. to 1 p.m.Hospital Quarterly

CF Owings Mills10455 Mill Run CircleOwings Mills, Md. 21117

MPR LL03

Professional Seminarsdate and Time location room

Tuesday, Feb. 24, 200910 a.m. to 1 p.m.Basics & updates

Franklin Square Med. Ctr.9000 Franklin Square DriveBaltimore, Md. 21237

Conference Room E

Thursday, Feb, 26, 200910 a.m. to 1 p.m.Mental Health

CF Columbia Gateway6731 Columbia Gateway DrColumbia, Md. 21046

Redwood Room

Tuesday, March 10, 200910 a.m. to 1 p.m.Basics & updates

St. Agnes Hospital900 Caton Ave.Baltimore, Md. 21229

Community Room A

Thursday, March 26, 200910 a.m. to 1 p.m.Basics & updates

CF Columbia Gateway6731 Columbia Gateway DrColumbia, Md. 21046

Redwood Room

Basics & Updates – this seminar is CareFirst’s newest addition to its professional provider seminars. Basics & Updates was created to replace the Back to Basics and Update Me seminars and is designed to com-bine new provider office staff tool necessities and CareFirst updates in a fresh, new training approach. This seminar is also appropriate for a refresher for seasoned provider office staff.

Mental Health – CareFirst has added a new Professional Provider Mental Health seminar to it’s 2009 line up. This seminar is designed to educate and update mental health profes-sional providers.

nEW

nEW

nEW

nEW


Provider Seminars

Practitioner and Staff Seminars and Training Sessions (continued)

Webinar -- A Web-based training designed to present CareFirst and CareFirst BlueChoice policies and procedures to professional and institutional provid-ers. These Webinars will last 30 min-utes, but participants should allow for log on and instruction time. After enrolling, you will receive instructions prior to the presentation date via email. Webinars are CareFirst Quality Rewards qualified Web-based office staff training modules.

Webinarsdate Subject Time

Jan. 20, 2009 BlueChoice 10 a.m.

Jan. 22, 2009 MPOS 10 a.m.

Jan. 22, 2009 ASC 12:30 p.m.

Jan. 28, 2009 CFD 10 a.m.

Jan. 28, 2009 HIT 12:30 p.m.

Feb. 3, 2009 Dialysis 12:30 p.m.

Feb. 3, 2009 BlueChoice 2 p.m.

Feb. 10, 2009 SNF 12:30 p.m.

Feb. 10, 2009 Anesthesia 2 p.m.

Feb. 18, 2009 MPOS 2 p.m.

Feb. 18, 2009 Sub/Mtl Facility 12:30 p.m.

Feb. 25, 2009 DME 12:30 p.m.

Feb. 25, 2009 CFD 2 p.m.

March 3, 2009 PT/OT/ST/Chiro 10 a.m.

March 18, 2009 Hospice 12:30 p.m.

March 18, 2009 MPOS 2 p.m.

March 25, 2009 BlueChoice 10 a.m.

March 25, 2009 HomeHealth 12:30 p.m.

March 31, 2009 DRG Training 12:30 p.m.

To register for any of these seminars, Webinars or training sessions, visit the Providers & Physicians section of www.carefirst.com for a full list of 2009’s most recently updated seminars, Webinars and training sessions and select Register for a Seminar in the Solution Center. If you do not have Internet access, call the Provider Seminar Registration Line at 877-269-2219. Please note: Sign in for seminars 15 minutes prior to the scheduled start time.

Ancillary – Regional Ancillary Seminars – dialysis, skilled nursing facility (SNF), durable medical equipment (DME), home infusion therapy (HIT), ambulatory surgical center (ASC), hospice, home health (HH) and substance abuse and mental health (Sub/Mtl) -- will begin in April, 2009. Please take advantage of our selection of ancillary webinars listed below. Webinars offer you the option of viewing a seminar without leaving your office. We encourage you to sign up for one today.

Ancillary Seminars


Provider Representatives

Not sure who your Institutional provider representative is or what number to call to reach him or her? See the chart below to find out. This information, as well as professional provider information, can be found in the Providers & Physicians section of www.carefirst.com by clicking on Professional or Institutional under Find My Provider Representative.

Find Your Institutional Provider Representatives

Ancillary Provider Assignments

Hospital Assignments

Joanna Clark

Carol Kreigh

Mike rutkowski

dena Whitener

dottie Humes

Anne Arundel, Baltimore and Harford counties and Baltimore City Caroline, Cecil, Dorchester, Kent, Queen Anne’s, Somerset, Talbot, Wicomico and Worcester counties

Calvert, Charles, Montgomery, Prince George’s and St, Mary’s counties and Washington, D.C. and Virginia

Allegany, Carroll, Frederick, Garrett, Howard and Washington counties and Pennsylvania and West Virginia

Maryland, Washington, D.C. and Virginia

representative name Telephone geographic Area

410-872-3572

410-763-6353

410-872-3539

410-872-3816

410-872-3575

representative name Telephone Hospital name

donna Brohawn

Amy Meister

Carol Kreigh

Chris Hudnall

Shawnette dickens

410-872-3571

410-872-3573

410-763-6353

410-872-3536

410-872-3537

* AA Medical Center * Frederick Memorial * Harford Memorial Hospital * Johns Hopkins * Kennedy Krieger* Mercy Medical Center

* Mem Hosp, Cumberland* Garrett County Memorial * Howard County General* Hopkins Bayview Medical Center* St. Agnes Hospital

* Upper Chesapeake Medical* Washington County Hospital* WMHS Braddock Hospital* Veteran’s Affairs Med. Center

* Bon Secours Hospital * Civista Medical Center * Calvert Memorial Hospital * Carroll Hospital Center * Franklin Square Hospital* Good Samaritan Hospital

* Greater Baltimore Medical* Harbor Hospital Center * Kernan Hospital * Maryland General Hospital* Mt. Washington Pediatric * North Arundel Hospital

* Northwest Hospital* Sheppard Pratt* Sinai Hospital* St. Joseph Medical Center * Union Memorial * U of MD Medical Center

* Dorchester General Hospital * Chesapeake Rehab * Union Hosp. of Cecil Cty

* Atlantic General * Memorial Hospital at Easton * McCready Memorial

* Peninsula Regional Medical Center * Chester River Hospital

* Inova Alexandria Hospital * Loudoun Hospital Center * Virginia Hospital Center * Mary Washington * Children’s Hosptial * Inova Mt. Vernon * Dominion Hospital

* Potomac Hospital* Inova Fairfax Hospital * Prince William Hospital* Fair Oaks Hospital * Providence Hospital* Faquier Hospital * Psychiatric Institute of Washington

* Ft. Washington Medical Center * Reston Hospital Center* George Washington Hospital * Northern Virginia Community* Greater Southeast Community Hospital * Veteran’s Affairs

* Doctor’s Community Hospital * Sibley Memorial Hospital * Georgetown Hospital * Southern Maryland Hospital Center* Holy Cross Hospital * Suburban Hospital* Hospital for Sick Children

* Washington Adventist* Howard University Hospital * Washington Hospital Center* Laurel Regional Hospital * Walter Reed Hospital * Montgomery General Hospital * National Naval Medical * National Rehabilitation Center

* Malcolm Grow Medical * Potomac Ridge * DeWitt Army Hospital * Prince George’s Hospital Center * St. Elizabeth Hospital* Shady Grove Adventist Hospital


November 1, 2008 : Here is a list of the CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. service areas that handle Maryland and National Capital Area provider inquiries. Please copy or detach for future reference. Information that has been added or changed since this page last appeared (September/October2008) is printed in blue font.

PrOvIdEr SErvICES nASCO PrOvIdEr SErvICES

MD INDEMNITY – XW PREFIX AND BLUECARD® CLAIMS 410-581-3581 / 800-437-2332

Claims (including oral surgery): Mail Administrator, P.O. Box 14115, Lexington, Ky. 40512-4115

Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky. 40512-4114

Mental Health for Level III and Key Groups only 410-581-3581 / 800-437-2332

Claims: Mail Administrator, P.O. Box 14117, Lexington, Ky. 40512-4117

NCA INDEMNITY – XIA PREFIX AND BLUECARD® CLAIMS CAREFIRST BLUECHOICE – XIC PREFIX BLUEPREFERRED – XIP PREFIX BLUECHOICE ADVANTAGE – XIH PREFIX BLUE PRECISION – BLUE PRECISION LOGO ON ID CARD MHIP - MHIP LOGO ON ID CARD 202-479-6560 / 800-842-5975

Claims: Mail Administrator, P.O. Box 14116, Lexington, Ky. 40512-4116

Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky. 40512-4114

State of Maryland - POS and PPO 877-228-7268 PPO Claims & Correspondence: Mail Administrator, P.O. Box 14115, Lexington, Ky. 40512-4115 or P.O. Box 9885, Baltimore, Md. 21284-9885 POS Claims & Correspondence: Mail Administrator, P.O. Box 14115 Lexington, Ky. 40512-4115 or P.O. Box 9885, Baltimore, Md. 21284-9885 State of Maryland - HMO 877-228-7268 HMO Correspondence and Appeals: Mail Administrator, Mailstop RR 230, Owings Mills, Md. 21117-4208

HMO Correspondence and Appeals: Mail Administrator, Mailstop RR 230, Owings Mills, Md. 21117-4208 NASCO – NATIONAL ACCOUNTS SERVICE AND CLAIMS OPERATIONS Northrop Grumman - NRG Prefix 877-228-7268 for claims information 800-972-8088 for benefit information Northrop Grumman - ESS or NGC Prefix 800-516-1269 All Other NASCO Accounts, including Consumer Directed Health (CDH) Plans 877-228-7268 Claims: Mail Administrator, P.O. Box 14115, Lexington, Ky. 40512-4115 Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky. 40512-4114 FEP – FEDERAL EMPLOYEE PROGRAM – R PREFIX Professional and Institutional providers in Montgomery & Prince George’s counties, Washington, DC and Northern Virginia (east of Rt. 123*) 202-488-4900 Claims: Mail Administrator, P.O. Box 14113, Lexington, Ky. 40512-4113 Correspondence: Mail Admnistrator, P.O. Box 14112, Lexington, Ky. 40512-4112 *For providers west of Rt. 123, send all claims and correspondence to local plan.

ALL OTHER MD FEP PROVIDERS Professional 410-581-3568 / 800-854-5256 Institutional 410-581-3567 / 800-321-2580 Claims: Mail Administrator, P.O. Box 14113 , Lexington, Ky. 40512-4113 Correspondence: Mail Administrator, P.O. Box 14111, Lexington, Ky. 40512-4111

fEP PrOvIdEr SErvICES

STATE Of MArylAnd PrOvIdEr SErvICES

✃✃

Important Phone Numbers and Addresses


What’s Happening

PrOvIdEr COnTACTS

BLUECARD® 800-676-BLUE (2583) for eligibility

PROVIDER INFORMATION AND CREDENTIALING 410-872-3500 / 877-269-9593 Fax: 410-872-4107 / 866-452-2304

Correspondence: CareFirst BlueCross BlueShield, 10455 Mill Run Circle, P.O. Box 825, Mailstop CG-41, Owings Mills, Md. 21117-0825

PROVIDER RELATIONS & PROFESSIONAL CONTRACTING 410-872-3500 / 877-269-9593 Fax: 410-505-6900 / 866-452-2306


INSTITUTIONAL AND VENDOR CONTRACTING 410-872-3500 / 877-269-9593 Fax: 410-872-4106 / 866-452-2305


PROVIDER SEMINAR REGISTRATION Professional, hospital and ancillary seminar registration 877-269-2219

CARE MANAGEMENT Authorizations 866-PRE-AUTH (773-2884) Fax for authorization: 410-528-7027

Case Management 410-605-2413 / 888-264-8648

Correspondence: CareFirst BlueCross BlueShield, Care Management, 1501 S. Clinton St., Mailstop CT-0816, Baltimore, Md. 21224

AuTOMATEd vOICE rESPOnSE unITS

BLUELINE MD Region – Authorizations, eligibility and claim and benefit inquiry for PPO, MPOS, PPN and MD Indemnity 410-581-3535 / 800-248-8410

FIRSTLINE NCA Region – Eligibility, claim and benefit inquiry for CareFirst BlueChoice, BluePreferred and NCA Indemnity 202-479-6560 / 800-842-5975

FEP – Eligibility, claim and benefit inquiry 202-488-4900

MARYLAND POINT OF SERVICE (MPOS) REFERRAL FAX LINE MPOS Referrals Fax for referrals: 410-998-5741

vEndOr COnTACTS ARGUS Pharmacy benefits manager 800-314-2872 for prior authorization requests Fax: 800-315-4025

ICORE HEALTHCARE Supplier of injectable drugs 866-522-2470

LABORATORY CORPORATION OF AMERICA (LABCORP) Contracted vendor for CareFirst BlueChoice members 800-322-3629

MAGELLAN HEALTH SERVICES Inpatient & outpatient mental health and substance abuse services 800-245-7013

MCKESSON SPECIALTY Supplier of injectable drugs 888-456-7274

ELECTRONIC CLAIMS Emdeon 800-845-6592 GatewayEdi 804-323-0275 MedAvant (formerly ProxyMed) 800-792-5256, ext. 813 MTrans (Misys) 800-347-3473, ext.2188 Payerpath 877-623-5706, ext. 2 RelayHealth Institutional 800-693-6890 Professional 847-608-7000 ProtoMed 800-648-4836 RealMed 877-927-8000

DISEASE MANAGEMENT To refer patients to a program call: Asthma/COPD 800-323-4472 Diabetes and Heart Disease 800-783-4582 Oncology 888-264-8648

✃✃

Important Phone Numbers and Addresses

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association.

®’ Registered trademark of CareFirst of Maryland, Inc.


Prior Authorization

The following prescription drugs require prior authorization for new prescriptions covered under the CareFirst and CareFirst BlueChoice prescription drug plan: • Hycamtin® used for treatment of relapsed small cell lung

cancer.

Quantity LimitsThe following drugs now have quantity limits: • Aloxi® used for treatment of CINV: Limited to 1 capsule per

prescription • Desowen® Kit for treatment of dermatitis: Limited to 1 kit per

prescription • Sancuso® used for treatment of CINV: 1 patch per prescription

Removed from Preferred Drug ListThe following drugs have been moved to tier 3 or non-preferred drugs.

The following drugs now have generic equivalents. The generics are available as a tier 1 and the brand-name drugs remains on tier 3 or non-preferred.

For the most current preferred drug list, prior authorization forms and pharmaceutical management procedures, visit www.carefirst.com and click on Providers & Physicians then Prescription Drugs. For a paper copy of the formulary and pharmaceutical management procedures, call 877-800-3086.

Pharmacy Updates

Brand name generic name

Depakote® ER divalproex

Keppra® levetiracetam

Tegretol ®XR carbamazepine

Topamax® topiramate

Yaz® drospirenone, ethinyl estradiol

Zomig® zolmitriptan

Maxalt® Rizatriptan

Brand name generic

Inspra® eplerenone

Razadyne® galantamine


CHIEF MEDICAL OFFICER AND SR. VICE PRESIDENT OF MEDICAL AFFAIRS EDITOR Jon P. Shematek M.D. Robert Hilson [email protected]

BlueLink is published bimonthly by CareFirst BlueCross BlueShield’s Corporate Communications Department.

10455 Mill Run Circle Mailstop OM1-800Owings Mills, Maryland 21117

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

PASAT STDUS POSTAGE

P A I DMANCHESTER, MD

PERMIT No. 10

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