Highmark Blue Cross Blue Shield West VirginiaJoyce Landers,Director Provider Relations

Autism Spectrum Disorder

www.highmarkbcbswv.com

As announced in the October 2011 issue of Provider News, the West Virginia Legislature passed a bill mandating coverage for diagnosis and treatment of Autism Spectrum Disorder (ASD) in children. Highmark Blue Cross Blue Shield West Virginia insured group policies issued or renewed on or after Jan. 1, 2012, will include coverage for diagnosis and treatment of ASD in children ages 0 months to 18 years. Coverage will include medically necessary treatments ordered or prescribed by a certified behavior analyst for any child diagnosed with ASD. In accordance with the legislation, Highmark West Virginia may require documentation of a treatment plan developed by a certified behavior analyst that incorporatescomprehensive evaluations or re-evaluations of the child that can be reviewed upon request by Highmark West Virginia every six months, along with semi-annual progress reports.

Highmark Blue Cross Blue Shield West Virginia Announces

A Limited Extension For Acceptance Of Version 004010Electronic Transactions

The HIPAA mandate to use Version 005010 for all electronic claim, inquiry and related transactions becomes effective Jan. 1, 2012. Many providers and trading partners have successfully made the transition to the 005010 format and have assured themselves of no interruptions in claims processing and payment due to the use of non-compliant transactions. These business partners can now turn their attention to the complex implementation of ICD-10 for claims coding, as well as to other health care reform initiatives. However, there are a number of other providers andtrading partners who have not been as successful in their 005010 migration efforts. As announced in a Special eBulletin posted online Dec. 2, 2011, for these business partners, Highmark West Virginia, in alignment with CMS’ direction, will continue to accept Version 004010 transactions for 90 days past the Version 005010 compliance date of Jan. 1, 2012.

Radiation Therapy Authorization Program to Take Effect Jan. 1, 2012

As announced in the October 2011 issue of Provider News and in hospital and professional Special Bulletins dated Aug. 1, 2011, in an effort to help ensure that the radiationtherapy services provided to our members are consistent with nationally recognized clinical guidelines, Highmark West Virginia has contracted with CareCore National, LLC toprovide medical necessity review and authorization where applicable for select radiation therapy services, effective with dates of service of Jan. 1, 2012, and beyond. A follow-up Special Bulletin dated Dec. 1, 2011, recently sent to Highmark West Virginia network oncology and urology providers included additional information regarding the Radiation Therapy Authorization Program which takes effect Jan. 1, 2012.

The Special Bulletin included:

• A list of products included in the program

• Step-by-step instructions for submitting authorization requests via NaviNet • Information about registering treatment plans prior toJan. 1. 2012, for members who are currently in treatment

• A frequently asked questions and answers document

Watch for New Member ID Cards

As part of our official name change to Highmark Blue CrossBlue Shield West Virginia, all member ID cards are beingconverted to include the new name and logo. The revised IDcards were recently distributed to members. An example ofthe new ID card is shown at right. Providers are reminded toalways check the member’s ID card as well as the member’sbenefits via the Eligibility and Benefits function on NaviNetprior to performing services.

Attention Anesthesiologists:

Highmark Blue Cross Blue Shield West Virginia applies anesthesia base units to procedure codes to determine reimbursement. Currently, Highmark West Virginia obtains these base units from the American Society of Anesthesiologists (ASA). The Centers for Medicare & Medicaid Services (CMS) also publishes anesthesia base units on its website.

For the most part, CMS anesthesia base units are the same as the ASA’s; however, for certain anesthesia procedure codes, the CMS base unit’s value is different. Beginning April 2, 2012, Highmark West Virginia will begin to use CMS as the sole source for anesthesia base units rather than the ASA for all Highmark West Virginia business, including HHIC Medicare Advantage PPO.

Use Appropriate NAIC Codes on Electronic Claimsfor HHIC FreedomBlue PPO Members to Avoid Denials

Plan Alpha Prefix Plan Code NAIC Code

Highmark BCBS

HKS 363 54828

Highmark BS HKR 378 54828

HHIC FreedomBlue PPO

HKP, HQM 377 71768

Highmark BCBS Freedom PPO

FEM 363 71768

Highmark BS Freedom Blue PPO

FER 378 71768

* USE OF NAVINET AUTOMATED CARE MANAGEMENT REQUIRED FOR SUBMISSION OF

ALL SCHEDULED INPATIENT AUTHORIZATION REQUESTS, EFFECTIVE APRIL 1, 2012 *

Effective April 1, 2012, Highmark West Virginia and Highmark Health Insurance Company (HHIC) will require all acute-care hospitals and critical access hospitals to submit their authorization requests for all scheduled inpatient admissions, including acute-to-acute transfer requests, through the NaviNet Automated Care Management (ACM) process.

Electronic Funds Transfer Registration Process Enhanced through NaviNet

On Feb. 6, 2012, Highmark Blue Cross Blue Shield West Virginia made a change to the Electronic Funds Transfer (EFT) Registration process to make it more efficient for provider offices. This change impacts the functions of the NaviNet Security office and the EFT Responsible Party.

Every provider that is NaviNet-enabled with Highmark West Virginia designates someone in their office as their NaviNet Security Officer. The Security Officer creates NaviNet Users and resets passwords as well as controls access to specific transactions.

Prior to the enhancement to the process, Highmark West Virginia providers did not have self-service access to register their banking information.

Highmark West Virginia has streamlined this process to allow the EFT Attestation and Registration button to be enabled for the Highmark West Virginia NaviNet offices. The NaviNet Security Officer can now enable/disable the EFT transaction permission for the office. The EFT Responsible party will be able to attest, electronically via NaviNet, to their position as the Responsible Party within the office. Separate paperwork is not required to receive the button or change banking information. The EFT Responsible Party will select only those providers/facilities for which they are the Responsible Party.

IMPORTANT: There are no changes to your current banking information. You will only need to electronically attest when you need to make a change to an existing account or register a new provider.