partners in health update - march 2014services provided by or advertised in these third-party sites....

updateSM

Introducing Highlighting HEDIS® page 21

Reminder: 90-day Grace Period now in effect page 8

Key changes to CMS-1500 claim form and updated toolkit now available page 6

March 2014

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2014. www.dreamstime.com. All rights reserved.Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.The Blue Cross and Blue Shield names and symbols, BlueCard, BlueExchange, and Baby BluePrints are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.The third-party websites mentioned in this publication are maintained by organizations over which IBC exercises no control, and accordingly, IBC disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.NaviNet® is a registered trademark of NaviNet, Inc., an independent company.FutureScripts® and FutureScripts® Secure are independent companies that provide pharmacy benefits management services.CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (IBC), created to provide valuable information to the IBC-participating provider community. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with IBC. This publication is the primary method for communicating such general changes. Suggestions are welcome.

Contact information:Provider CommunicationsIndependence Blue Cross1901 Market Street 27th FloorPhiladelphia, PA [email protected]

Keystone 65 HMO has an accreditation status of Excellent from the National Committee for Quality Assurance (NCQA).

Keystone Health Plan East, Personal Choice®, and Personal Choice 65SM PPO have an accreditation status of Commendable from NCQA.

Inside this editionAnnouncements

► LabCorp named IBC’s exclusive national outpatient laboratory provider

Business Transformation ● Stay informed during our transition to the new platform

Administrative ● Request your office supplies online ● Reminder: Contraceptive coverage update for religious

organizations

Billing ► Key changes to CMS-1500 claim form and updated toolkit now available

► Professional Injectable and Vaccine Fee Schedule updates effective April 1, 2014

● Reminder: 90-day grace period now in effect ● Reminder: Use a valid NPI for all claims

Medical ► Medical and claim payment policy activity posted from January 26 – February 25, 2014

► Documentation requirements for DME services

Pharmacy ► Select Drug Program® Formulary updates ► Prescription drug updates

● Generic drugs available for the treatment of osteoporosis

ICD-10 ● Dial in for What’s Up Wednesday

Quality Management ● Introducing Highlighting HEDIS®

● QIPS High-Performing Office Summit

Health and Wellness ● Helping providers identify patients likely to be hospitalized ● New health risk screening tool for Medicare Advantage HMO

and PPO members ● Encourage your patients to be active to stay healthy

► Articles designated with a blue arrow include notice of changes or clarifications to administrative policies and procedures.

For articles specific to your area of interest, look for the appropriate icon:

Professional Facility Ancillary

March 2014 | Partners in Health UpdateSM 3 www.ibx.com/providers

ANNOUNCEMENTS

LabCorp named IBC’s exclusive national outpatient laboratory providerIBC has selected Laboratory Corporation of America® Holdings (LabCorp) as our exclusive national outpatient laboratory provider effective July 1, 2014. The IBC network will also include other currently contracted laboratories that will remain in our network in addition to LabCorp.

Why we made this decisionHealth care is undergoing rapid, remarkable change, spurred by implementation of the health care reform law, an increasing focus on the individual consumer, and continuing cost pressures. After a lengthy evaluation process, we chose LabCorp as our exclusive national outpatient laboratory provider. This initiative will provide significant savings for the benefit of our customers without affecting quality. In addition, it will create an important strategic partnership with a leading national laboratory, which allows for enhanced clinical initiatives.

Laboratory providers in the IBC networkAs of July 1, 2014, LabCorp will be IBC’s exclusive national outpatient laboratory provider, and IBC’s contract with Quest Diagnostics® will end. LabCorp includes the following members of its specialty testing group: Dianon Pathology, Integrated Oncology, Integrated Genetics, Medtox Laboratories, Monogram, and Litholink. In addition to LabCorp, the IBC network will also continue to include other currently contracted laboratories (see list at right).

As part of LabCorp’s commitment to this new contract, they will be opening additional Patient Service Centers in our region prior to July 1, 2014, and significantly increasing their support staff for physician offices.

For more informationWe will provide you with more information as it becomes available, including the locations of LabCorp’s new Patient Service Centers. For additional information, we will have a dedicated site on our Provider News Center to house relevant information about this transition to LabCorp as our exclusive national outpatient laboratory provider. For more information about LabCorp, please visit their website at www.labcorp.com/wps/portal/provider.

Participating outpatient laboratory providers in addition to LabCorpAbington Memorial HospitalAculabs, Inc.Atlantic Diagnostic LaboratoriesCBL PathGenomic Health, Inc.Health Network LaboratoriesInstitute for Dermatopathology, PC and AmeriPath New York, LLC (limited to anatomic pathology services related to dermatopathology)

Mercy Fitzgerald HospitalMyriad Genetics Laboratories, Inc.NeoGenomic LaboratoriesPottstown Memorial HospitalSMA Medical Lab, Inc.Therapath, LLCThomas Jefferson University HospitalUniversity of Pennsylvania:

Penn Cutaneous LaboratoryPenn Cytogenetic LaboratoryPenn Medicine at RadnorUniversity of Pennsylvania Hospital



BUSINESS TRANSFORMATION

Stay informed during our transition to the new platformAs of November 2013 and continuing through mid-2015, IBC is in the process of transitioning its membership to a new operating platform, generally based on when the customer/member’s benefit contract renews.

During this transition, we will be working with you in a dual claims-processing environment until all of our membership is migrated to the new platform. In other words, as members are migrated, their claims will be processed on the new platform; however, we will continue to process claims on the current IBC platform for members who have not yet been migrated.

We are committed to working closely with our entire provider network as we complete this Business Transformation. During this interim state, we will continue to provide comprehensive communications

and tools to support our members and provider network, both during and after the transition to the new platform.

Be sure to frequently visit our dedicated Business Transformation site at www.ibx.com/pnc/businesstransformation. On this site you will find a communication archive as well as a Frequently Asked Questions (FAQ) document. If you still have questions after reviewing the FAQ, email us at [email protected].

Visit our dedicated Business Transformation site at www.ibx.com/ pnc/businesstransformation.

ADMINISTRATIVE

Request your office supplies onlineTo replenish office supplies, such as manuals or health and wellness materials, please submit a request using our online order form at www.ibx.com/providersupplyline.

In order to properly fulfill your request, you will need to provide some basic office information, including your National Provider Identifier (NPI), mailing address, and office phone number. Orders are usually shipped within 24 hours and should arrive to you within 3 – 5 business days.

While completing your request, you also have the option to sign up to receive provider email notifications from IBC. We encourage you to sign up for this option to receive the latest provider information from IBC, including when a new edition of Partners in Health Update is available and news alerts.

For providers without Internet access, call 1-800-858-4728 to place your order. Note: Calls to the Provider Supply Line should be related to supply requests only. Providers must use the NaviNet® web portal for information related to member eligibility or claims status. All other provider inquiries should be directed to Customer Service at 1-800-ASK-BLUE.

To replenish office supplies, such as manuals or health and wellness materials, submit a request at www.ibx.com/providersupplyline.

www.ibx.com/pnc/businesstransformation

www.ibx.com/pnc/businesstransformation


ADMINISTRATIVE

Reminder: Contraceptive coverage update for religious organizationsThe Patient Protection and Affordable Care Act, also known as Health Care Reform, requires non-grandfathered health plans to cover contraceptive services for women with no out-of-pocket costs (i.e., $0 cost-sharing). There are two exceptions to this requirement:

● Religious employer exemption. Religious employers can elect not to provide contraceptive coverage, and their employees are not eligible for contraceptive coverage.

● Non-profit religious organization. Non-profit religious organizations can elect not to cover contraceptives for religious reasons but are not exempt as a “religious employer.”

For these non-profit religious organizations, Health Care Reform requires IBC to pay the cost of certain contraceptive services for eligible employees and eligible dependents of non-profit religious organizations that elect not to cover contraceptives.

Eligible members within these organizations will receive a separate ID card that indicates “Contraceptive Coverage.” Using this ID card, contraceptive methods approved by the U.S. Food and Drug Administration will be covered at an in-network level with no cost-sharing under the medical benefit and covered with no cost-sharing for generic products and for those brand products for which we do not have a generic equivalent under the pharmacy benefit at retail and mail order pharmacies.*

For these members, it is important that only contraceptive services be billed using the ID number on the Contraceptive Coverage ID card.*

Contraceptive Coverage ID card samples

For a complete listing of medical contraceptive services, please refer to the current version of Medical Policy #00.06.02: Preventive Care Services at www.ibx.com/medpolicy.

Please contact your Network Coordinator if you have any questions about this coverage or billing.

*Contraceptive services are covered under the pharmacy benefit only if the member has an IBC prescription drug plan.

IBC Medical and Rx Contraceptive Coverage

IBC & KHPEWPHCS Sample ID Card

Medical with Rx

SAMPLEMEMBER

Rx BIN CONTRACEPTIVE COVERAGE600428Rx PCN 03820000

USI1234567800

Pharmacy Benefits Administrator

Visit www.ibxpress.com

Member: Use this card for eligible medical and/or prescription contraceptive services only.

Submit Paper Claims to: PPO ClaimsP.O. Box 69352 Harrisburg, PA 17106-9352

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Customer Service1-800-ASK-BLUE

Independence Blue Cross, QCC Insurance Company and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.

Pharmacy Benefits1-888-678-7012

Medical Contraceptive Coverage Only — No IBC Rx Coverage*

IBC & KHPEWPHCS Sample ID Card

Medical Only

SAMPLEMEMBER

Rx BIN CONTRACEPTIVE COVERAGE600428Rx PCN 03820000

USI1234567800

Visit www.ibxpress.com

Member: Use this card for eligible medical contraceptive services only.

Submit Paper Claims to: PPO ClaimsP.O. Box 69352 Harrisburg, PA 17106-9352

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Customer Service1-800-ASK-BLUE

Independence Blue Cross, QCC Insurance Company and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.


BILLING

Key changes to CMS-1500 claim form and updated toolkit now availableAs previously communicated, the National Uniform Claim Committee (NUCC) has approved an updated version of its 1500 Health Insurance Claim Form (CMS-1500 claim form). The new claim form (02/12), which went into effect January 6, 2014, accommodates reporting needs for ICD-10 and aligns with data captured on electronic 837 transactions.

Timeline for implementing new claim form (02/12)IBC will enforce the following NUCC-approved transition timeline for the CMS-1500 (02/12) claim form:

● January 6, 2014: IBC began receiving and processing paper claims submitted on the new CMS-1500 (02/12) claim form.

● January 6 – March 31, 2014: Dual-use period during which IBC will continue to receive and process paper claims submitted on the old CMS-1500 (08/05) claim form or on the revised CMS-1500 (02/12) claim form.

● April 1, 2014: IBC will receive and process paper claims submitted only on the new CMS-1500 (02/12) claim form.

Key changes to the CMS-1500 (02/12) claim formThere are some notable differences between the original version (08/05) and the new version (02/12) of the CMS-1500 claim form, including the following:

● Field 21: - The most significant change, which may require your office to make system changes, is that Field 21 now

accommodates up to 12 diagnosis codes. These codes must be entered beginning in field A and then horizontally across the fields through field L, as shown in the example below. CMS-1500 (02/12) claim forms submitted incorrectly may be rejected or returned to the provider.

401 251 8 579 4

Enter ICD-9 diagnosis codes in alpha order, starting with field A.

123456789

G2 12345670008888888888$50 00 1A9920501 11 14 01 11 14 21 6

Correct

Incorrect

continued on the next page


BILLING

● Field 21 (continued) - This field now includes an ICD diagnosis code indicator. As shown in the example below, use a “9”

for ICD-9 codes. Once ICD-10 codes go into effect on October 1, 2014, use a “0” in this field.

● Field 24E: The Diagnosis Code Pointer on the new version (02/12) is now alphabetic and no longer numeric. ● Fields 24l, 32b, and 33b: The provider’s two-character qualifier has been changed to G2.

401 251 8 579 4

123456789

G2 12345670008888888888$50 00 1A

9

9920501 11 14 01 11 14 21 6

Enter “9” as the ICD-9 Diagnosis Code Indicator

Updated CMS-1500 toolkit and other resourcesTo assist you in submitting claims using the new CMS-1500 (02/12) claim form, we have revised our CMS-1500 toolkit to accommodate the updated version of the form. Download the toolkit, titled Claims submission toolkit for proper electronic and paper claims submissions, from www.ibx.com/providers/claims_and_billing/claim_requirements. This toolkit contains the latest information on electronic and paper claims submissions, a sample CMS-1500 (02/12) claim form, key fields, loop and data elements, and resources for finding additional information.

In addition, the NUCC has published an updated 1500 Health Insurance Claim Form Reference Instruction Manual, which is available under the 1500 Claim Form tab on their website at www.nucc.org.

CMS-1500 (02/12) claim forms can be purchased through office supply stores, local printing companies, or by calling the U.S. Government Printing Office at 1-866-512-1800.

For claims submission addresses by product, please refer to our payer ID grids, which are available at www.ibx.com/edi.

If you have any questions, please contact your Network Coordinator.

Professional Injectable and Vaccine Fee Schedule updates effective April 1, 2014Effective April 1, 2014, we will implement a quarterly update to our Professional Injectable and Vaccine Fee Schedule for all contracted providers. These updates reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables.

If you have any questions about the updates or where to view them, please contact your Network Coordinator.

continued from the previous page


BILLING

Reminder: 90-day grace period now in effectAs previously communicated, the Patient Protection and Affordable Care Act, also known as Health Care Reform, mandates a three-month grace period for individual members who receive a premium subsidy from the government and are delinquent in paying their portion of the premiums.

Under this mandate, insurers are required to pay medical claims received during the first 30 days of the grace period, but may pend medical claims for services rendered to those members and their eligible dependents during the second and third months of the grace period. Insurers are also required to notify affected providers when one of these members enters the grace period. If payment is not received by the end of the grace period, the pended claims will be denied and the member’s policy will be terminated.

To comply with the mandate, IBC will notify affected providers by mail upon receipt of a claim for services rendered for a member who is within the second or third month of the grace period. In addition, a new field called APTC (Advanced Premium Tax Credit) is available within the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal to show providers when a member is in the grace period and provide a status of the member’s claims. The APTC field will only display when a member is in a delinquency status. When the member enters the grace period, the APTC field will be populated on the Eligibility and Benefits Details screen (as shown below) with the word “Yes.” There will be a corresponding message that indicates the month of delinquency the member is in and the status of his or her claims. If payment is not received before the grace period expires, the member’s policy will be terminated.

If you have any questions about this mandate, please call Customer Service at 1-800-ASK-BLUE (1-800-275-2583). If you have questions regarding NaviNet transactions, please call the eBusiness Hotline at 215-640-7410.


BILLING

Reminder: Use a valid NPI for all claimsAs previously communicated, when submitting claims for IBC members, please be sure to continue using a valid National Provider Identifier (NPI) for billing, rendering, and referring providers, as applicable. This requirement applies to all claims — including those that are processed on our current and new operating platforms as we continue our transition of membership to the new claims processing system.

It is critical that you submit claims with a valid NPI, as the claims processing system reviews each claim for this data. Providers should work with their clearinghouse/trading partner to ensure accurate claims submission.

Using an invalid NPI could delay processing and payment.

The most common reasons that an NPI would be considered invalid are:

● The NPI is terminated. ● The NPI is entered incorrectly. ● The number is invalid.

Resources For additional information about NPI regulations, implementations, reports, and resources, go to www.ibx.com/npi. For more information about our Business Transformation, please visit our dedicated site at www.ibx.com/pnc/businesstransformation.

Using an invalid NPI could delay processing and payment.


MEDICAL


Medical and claim payment policy activity posted from January 26 – February 25, 2014 Below is a listing of the policy activity that we have posted to our website from January 26 – February 25, 2014.

New policiesThe following policies have been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with IBC.

Policy # Title Notification date Effective date

00.01.56 National Correct Coding Initiative (NCCI) Modifier Indicator 0 (Zero) Procedure Code Pairs February 12, 2014 May 13, 2014

08.01.10 Octreotide acetate (Sandostatin® LAR Depot) December 4, 2013 March 4, 2014

Updated policies The following policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with IBC.

Policy # Title Type of policy change Notification date Effective date

00.01.25t

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

Medical Codes n/a February 1, 2014

00.03.07g

Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products

Medical Codes n/a February 1, 2014

05.00.04c

Food and Drug Administration (FDA) Approval of Medical Devices

General Description, Guidelines, or Informational Update n/a February 12, 2014

05.00.09g

Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System

Medical Necessity Criteria; Medical Codes; General Description, Guidelines, or Informational Update

February 14, 2014 March 14, 2014

05.00.21m Durable Medical Equipment (DME)

Coverage and/or Reimbursement Position; Medical Codes; General Description, Guidelines, or Informational Update

n/a February 5, 2014

05.00.35c Foot Orthotics and Other Podiatric Appliances

Coverage and/or Reimbursement Position; Medical Codes

February 13, 2014 March 12, 2014

05.00.42e Patient Lifts Medical Necessity Criteria; Medical Coding November 6, 2013 February 5, 2014


MEDICALcontinued from the previous page


06.02.39a

Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab

Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

January 3, 2014 February 3, 2014

07.00.02g Intravenous Chelation Therapy

Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

November 7, 2013 February 5, 2014

07.02.03g Implantable Cardiac Loop Monitor

Coverage and/or Reimbursement Position; Medical Necessity Criteria

November 20, 2013 February 18, 2014

07.10.05b

Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System

Coverage and/or Reimbursement Position November 21, 2013

January 1, 2014 (Policy published on February 19, 2014)

08.00.73e Bortezomib (Velcade®) Medical Necessity Criteria; Medical Coding January 2, 2014 April 2, 2014

08.00.74g

Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®])

Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

January 2, 2014 April 2, 2014

08.00.81c Bendamustine Hydrochloride (Treanda®) Medical Necessity Criteria February 12, 2014 May 13, 2014

09.00.10p Brachytherapy


December 19, 2013 March 19, 2014

09.00.17j Intensity Modulated Radiation Therapy (IMRT)


January 3, 2014 April 2, 2014

09.00.46l High-Technology Radiology Services


January 31, 2014 (Revised: February 12, 2014)

May 1, 2014

09.00.49e Proton Beam Radiation Therapy

Medical Necessity Criteria; Medical Coding January 2, 2014 April 2, 2014

11.02.12e

Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery

Medical Necessity Criteria; Medical Coding

November 20, 2013 (Revised: January 23, 2014)

February 19, 2014

11.03.02n Bariatric SurgeryCoverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Codes

n/aJanuary 1, 2014 (Published on February 4, 2014)



MEDICAL


11.08.02f Reduction Mammoplasty Coverage and/or Reimbursement Position; Medical Coding

November 6, 2013 (Revised: December 2, 2013)

February 4, 2014

11.08.06g Abdominoplasty and/or Panniculectomy

Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

January 3, 2014 February 3, 2014

11.08.10f Excision of Redundant Skin

Medical Necessity Criteria; Medical Coding January 3, 2014 February 3, 2014

11.08.25j Scar Revision Coverage and/or Reimbursement Position; Medical Coding January 2, 2014 April 2, 2014

11.11.01fEvaluation and Treatment of Erectile Dysfunction (ED)

Medical Coding November 21, 2013 February 19, 2014

11.14.10k

Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty

Medical Coding November 6, 2013 February 5, 2014

11.16.01g Septoplasty, Rhinoplasty, and Septorhinoplasty

Medical Necessity Criteria; General Description, Guidelines, or Informational Update

December 19, 2013 March 19, 2014

12.01.01v Experimental/Investigational Services


n/aJanuary 1, 2014 (Published on February 7, 2014)

Reissued policiesThe following policies have been reviewed, and no substantive changes were made.

Policy # TitleReissue effective date

00.01.18c Reimbursement for Associated Services Performed in Conjunction with Dental Care February 19, 2014

05.00.12e Manual Wheelchairs February 19, 2014

05.00.25f Cranial Remolding Orthoses (Helmets) February 19, 2014

05.00.72b Upper Limb Prostheses February 19, 2014

07.00.14d Cold Laser Therapy February 19, 2014

07.08.01e Non-Surgical Spinal Decompression Therapy February 19, 2014

07.10.04b Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor February 19, 2014

11.06.04h Uterine Artery Embolization February 19, 2014

11.06.05b Endometrial Ablation February 19, 2014

11.06.07b Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome February 19, 2014

11.08.12g Surgery for Gynecomastia February 19, 2014

11.14.11e Arthroscopic Electrothermal Joint Repair February 19, 2014




MEDICAL

Archived policiesThe following are policies that IBC has determined are no longer necessary to remain active.

Policy # Title Notification dateArchive effective date

07.03.16b Electrosleep Therapy using a Cranial Electrical Stimulation Device January 16, 2014 February 17, 2014

Coding updatesThe following policies have been reviewed and updated to add new and revised medical codes (e.g., ICD-9 and ICD-10 diagnosis codes; CPT® and HCPCS codes; revenue codes) and/or remove terminated medical codes.

Policy # Title Effective date

00.01.49a Reporting Requirements for Drugs and BiologicalsJanuary 1, 2014 (Published on February 7, 2014)

00.03.02p Diagnostic Radiology Services Included in CapitationJanuary 1, 2014 (Published on February 7, 2014)

00.10.20j Add-on CodesJanuary 1, 2014 (Published on February 21, 2014)

00.10.36k Radiologic Guidance of a ProcedureJanuary 1, 2014 (Published on February 7, 2014)

03.00.06j Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the same Physician on the Day of a Procedure or Other Service

January 1, 2014 (Published on February 7, 2014)

03.00.15j Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period

January 1, 2014 (Published on February 7, 2014)

03.00.16j Modifier 57: Decision for SurgeryJanuary 1, 2014 (Published on February 7, 2014)

07.10.05c Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine SystemJanuary 2, 2014 (Published on February 20, 2014)

09.00.32k Diagnostic and Therapeutic Radiopharmaceutical AgentsJanuary 1, 2014 (Published on February 7, 2014)

09.00.45f Magnetic Resonance Imaging (MRI) Contrast AgentsJanuary 1, 2014 (Published on February 7, 2014)

11.15.16i Vagus Nerve Stimulation (VNS)January 1, 2014 (Published on February 7, 2014)

To view policy activity, go to www.ibx.com/medpolicy and select Accept and Go to Medical Policy Online. You can also view policy activity using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Be sure to check back often, as the site is updated frequently.



MEDICAL

Documentation requirements for DME servicesMany durable medical equipment (DME) suppliers and professional providers are aware of and currently comply with policy documentation requirements; however, we sometimes receive questions about what documentation is required and must be kept on file for orders of DME, prosthetics, orthotics, and supplies (e.g., ostomy supplies, splint supplies provided in the office setting, urinary drainage bag supplies, supplies for the treatment of diabetes).

This article summarizes some of our long-standing documentation requirements. Our requirements are consistent with the Centers for Medicare & Medicaid Services documentation requirements, which underscore the importance of securing and retaining documentation. If required documentation is not available on file to support a claim at the time of an audit or record request, IBC may seek repayment from the DME supplier for claims not properly documented.

Prescription (order) requirementsBefore submitting a claim to IBC, the supplier must have on file a timely, appropriate, and complete order for each billed item that is signed and dated by the member’s servicing provider.

Note: This requirement cannot be satisfied by having a provider sign a retrospective order at the time of an audit, or after an audit, for submission as an original order, reorder, or updated order.

Proof of deliveryMedical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. If delivered by a commercial carrier, the medical record documentation must include a copy of delivery confirmation. If delivered by the DME supplier/provider, the medical record documentation must include a copy of delivery confirmation that is signed by the member or caregiver. All documentation must be prepared at the same time as delivery and be available to IBC upon request.

Consumable suppliesThe DME supplier must monitor the quantity of accessories and supplies that a member is actually using. To do so, the DME supplier should contact the member regarding replenishment of supplies no sooner than approximately seven days prior to the delivery/shipping date. Dated documentation of this member contact is required in his or her medical record. Delivery of the supplies should be done no sooner than approximately five days before the member would exhaust his or her on-hand supply.

More information about our documentation requirements for DME services is available within the applicable medical policies. Visit www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, and type a keyword or medical code in the Search box. If you have any questions, please contact your Network Coordinator.

If required documentation is not available on file to support a claim at the time of an audit or record request, IBC may seek repayment from the DME supplier for claims not properly documented.

www.ibx.com/medpolicy


PHARMACY

Select Drug Program® Formulary updatesThe Select Drug Program Formulary is a list of medications approved by the U.S. Food and Drug Administration that were chosen for formulary coverage based on their medical effectiveness, safety, and value. The list changes periodically as the Pharmacy and Therapeutics Committee reviews the formulary to ensure its continued effectiveness. The most recent changes are listed below.

Generic additionsThese generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the appropriate generic formulary level of cost-sharing:

Generic drug Brand drug Formulary chapter Effective dateacamprosate calcium Campral® 3. Pain, Nervous System, & Psych August 16, 2013

adefovir dipivoxil Hepsera® 1. Antibiotics & Other Drugs Used for Infection August 16, 2013

ceftibuten Cedax® 1. Antibiotics & Other Drugs Used for Infection August 23, 2013

clonidine HCl ER* Kapvay™ 3. Pain, Nervous System, & Psych September 6, 2013

gatifloxacin Zymaxid™ 11. Eye Medications September 20, 2013

hydrocortisone butyrate/emoll Locoid Lipocream® 5. Skin Medications September 20, 2013

lidocaine Lidoderm® 3. Pain, Nervous System, & Psych September 27, 2013

lomustine n/a 2. Cancer & Organ Transplant Drugs July 25, 2013

niacin ER Niaspan® 4. Heart, Blood Pressure, & Cholesterol September 27, 2013

paricalcitol Zemplar® 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones September 27, 2013

sulfacetamide sodium Ovace® Plus 5. Skin Medications October 4, 2013

sulfacetamide sodium/sulfur AVAR-e™ LS cream 5. Skin Medications October 4, 2013

temozolomide* Temodar® 2. Cancer & Organ Transplant Drugs October 11, 2013

voriconazole susp Vfend® susp 1. Antibiotics & Other Drugs Used for Infection October 18, 2013

*Generic requires prior authorization

Brand additionsEffective February 1, 2014, these brand drugs were added to the formulary and are covered at the appropriate brand formulary level of cost-sharing:

Brand drug Formulary chapterAcanya® 5. Skin Medications

Beyaz® 10. Female, Hormone Replacement, & Birth Control

Celebrex® 9. Bone, Joint, & Muscle

Differin® 0.3% topical gel 5. Skin Medications



PHARMACY

Brand drug Formulary chapterFirst®-Progesterone VGS 25, VGS 400 10. Female, Hormone Replacement, & Birth Control

Generess® FE 10. Female, Hormone Replacement, & Birth Control

Lo Loestrin™ FE 10. Female, Hormone Replacement, & Birth Control

Minastrin® 24 FE 10. Female, Hormone Replacement, & Birth Control

Natazia® 10. Female, Hormone Replacement, & Birth Control

Ortho Tri-Cyclen® Lo 10. Female, Hormone Replacement, & Birth Control

Tazorac® 5. Skin Medications

Zovirax® cream 5. Skin Medications

Brand deletionsEffective April 1, 2014, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Generic drug Formulary chapterCampral® acamprosate calcium 3. Pain, Nervous System, & Psych

Depo-Provera® 150 mg medroxyprogesterone acetate 10. Female, Hormone Replacement, & Birth Control

Hepsera® adefovir dipivoxil 1. Antibiotics & Other Drugs Used for Infection

Niaspan® niacin ER 4. Heart, Blood Pressure, & Cholesterol

Temodar® temozolomide 2. Cancer & Organ Transplant Drugs

Vfend® susp voriconazole susp 1. Antibiotics & Other Drugs Used for Infection

The generic drugs for the above brand drugs are available at the generic formulary level of cost-sharing.

Brand deletionsEffective April 1, 2014, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternatives Formulary chapter

Depo-Provera® 104 mg medroxyprogesterone acetate 10. Female, Hormone Replacement, & Birth Control

Emend® granisetron, ondansetron 8. Gastroenterology

Estring® Premarin® Vaginal Cream 10. Female, Hormone Replacement, & Birth Control

Repronex® Menopur®, chorionic gonadotropin 15. Diagnostics & Miscellaneous Agents

There are no generic equivalents for the above brand drugs; however, there are formulary therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate formulary level of cost-sharing.



PHARMACY

Prescription drug updatesFor members enrolled in an IBC prescription drug program, prior authorization and quantity limit requirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medically necessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medication based upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for a particular drug. The most recent updates are reflected below.

Drugs requiring prior authorizationThe prior authorization requirement for the following non-formulary drugs was effective at the time the drugs became available in the marketplace:

Brand Generic drug Drug category Effective dateActemra® SC Not available Bone, Joint, & Muscle November 1, 2013

Adempas® Not available Heart, Blood Pressure, & Cholesterol October 11, 2013

Breo™ Ellipta™ Not available Allergy, Cough & Cold, Lung Meds July 12, 2013

Brintellix® Not available Pain, Nervous System, & Psych October 11, 2013

Gilotrif™ Not available Cancer & Organ Transplant Drugs August 23, 2013

Opsumit® Not available Heart, Blood Pressure, & Cholesterol October 25, 2013

The following drugs have been added to the list of drugs requiring prior authorization. Members taking these drugs prior to the effective date are not affected.

Brand drug Generic drug Drug category Effective dateAdvate® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Alphanate® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Alphanine® SD Not available Diagnostics & Miscellaneous Agents April 1, 2014

Androgel® Not available Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones April 1, 2014

Bebulin® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Belviq® Not available Pain, Nervous System, & Psych April 1, 2014

BeneFIX® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Feiba® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Helixate® FS Not available Diagnostics & Miscellaneous Agents April 1, 2014

Hemofil® M Not available Diagnostics & Miscellaneous Agents April 1, 2014

Humate-P® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Koate®-DVI Not available Diagnostics & Miscellaneous Agents April 1, 2014

Kogenate® FS Not available Diagnostics & Miscellaneous Agents April 1, 2014

Letairis® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014

Monoclate-P® Not available Diagnostics & Miscellaneous Agents April 1, 2014



PHARMACY

Brand drug Generic drug Drug category Effective dateMononine® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Novoseven® RT Not available Diagnostics & Miscellaneous Agents April 1, 2014

Profilnine® SD Not available Diagnostics & Miscellaneous Agents April 1, 2014

Recombinate™ Not available Diagnostics & Miscellaneous Agents April 1, 2014

Rixubis™ Not available Diagnostics & Miscellaneous Agents April 1, 2014

Tracleer® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014

Tyvaso® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014

Valchlor™ Not available Cancer & Organ Transplant Drugs April 1, 2014

Ventavis® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014

Wilate® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Xyntha® Not available Diagnostics & Miscellaneous Agents April 1, 2014

Zohydro™ ER Not available Pain, Nervous System, & Psych When drug becomes available

Drug no longer requiring prior authorizationEffective February 1, 2014, prior authorization was removed for the following drug:

Brand drug Generic drug Drug categoryRozerem® ramelteon Pain, Nervous System, & Psych

Drugs with quantity limitsEffective April 1, 2014, quantity limits will be added for the following drugs:

Brand drug Generic drug Quantity limitActemra® SC Not available 3.6 ml per 30 days

Depo-Provera® 104 mg, 150 mg

medroxyprogesterone acetate 1 vial/syringe per 90 days (applies to both brand and generic)

Esomeprazole Strontium Not available 30 caps per 30 days

Nuvaring® Not available 1 ring per 30 days

Ortho Evra® Patch Not available 3 patches per 30 days

Zohydro™ ER Not available 6 per 30 days (when drug becomes available)



PHARMACY

Generic drugs available for the treatment of osteoporosisOur research shows that some of our members are not taking their prescribed brand drugs for the treatment of osteoporosis because they are too costly. For this reason, we’d like to remind you that the following generic alternatives are available for the treatment of osteoporosis:

● alendronate ● ibandronate ● etidronate ● zoledronic acid

In addition to the above-mentioned drugs, the zoledronic acid injection is also available. Please keep in mind that for our Medicare Advantage HMO and PPO members, injectable drugs generally are covered under the pharmacy benefit (i.e., Part D) when given in the home or in a long-term care setting.

We encourage you to prescribe these generic drugs for the treatment of osteoporosis, when appropriate. These lower-cost alternatives may help improve member adherence to prescribed medications.


ICD-10

Dial in for What’s Up WednesdayWhat’s Up Wednesday is a monthly teleconference hosted by Pennsylvania’s Blue Plans to help prepare health care professionals for the ICD-10 transition on October 1, 2014. 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. All providers, clearinghouses, information trading partners, and information networks are encouraged to participate.

Next call: Wednesday, March 19 2 – 3 p.m. ET

How do you participate? ● Prior to the call, visit www.ibx.com/icd10 and select the What’s Up Wednesday link to access the presentation materials.

● Then dial 1-800-882-3610 and enter pass code 5411307 when prompted. Be sure to dial in five minutes early and have a copy of any presentation materials with you for reference.

Questions can be emailed prior to or during the teleconference to [email protected].

Reminder: Please be sure to secure a copy of the presentation prior to the teleconference. Presentations will not be provided once the teleconference has begun.

• Participation is free.• No registration.• Simply call toll-free.• Participation is free.

• No registration.• Simply call toll-free.

What’s Up Wednesday

Are you ready for ICD-10?

If you aren’t ready for ICD-10 by October 1, 2014, your

payments may be affected. Visit our dedicated site at

www.ibx.com/icd10 today for resources and more information.

QUALITY MANAGEMENT


We are pleased to introduce a new article series in Partners in Health Update: Highlighting HEDIS®. This series is designed to provide you with education and strategies to help you improve your HEDIS® performance.

What is HEDIS®?The Healthcare Effectiveness Data and Information Set (HEDIS®) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Altogether, HEDIS® consists of 75 measures across eight domains of care. Because so many plans collect HEDIS® data, and because the measures are so specifically defined, HEDIS® makes it possible to compare the performance of health plans on an "apples-to-apples" basis.1

Why is HEDIS® important to physicians?HEDIS® measures track a health plan’s and physician’s ability to manage health outcomes. Generally, strong HEDIS® performance reflects enhanced quality of care. With proactive population management, physicians can monitor care — improving quality while reducing costs.

Additionally, if you participate in the Quality Incentive Payment System (QIPS) program, improving your HEDIS® performance increases your practice’s earning potential.

Send us your feedback If you have comments about the information you read in Highlighting HEDIS® or you have topics you’d like to see included, email us at [email protected]. 1National Committee for Quality Assurance (NCQA)

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

Numerous HEDIS® measures overlap with measures for the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating Program. In each monthly article, we will identify those measures of critical importance to both HEDIS® and Stars with a yellow star indicator ( ). Similarly, HEDIS® measures used in the QIPS program will be identified with a blue star indicator ( ).

Highlighting HEDIS® articlesEach month, Highlighting HEDIS® may include the following:

● HEDIS® data: A visual display of data from a chosen measure of focus. Selected data will highlight key components or weaknesses for the measure.

● Measure definitions and data ● Quick tips for quick wins: Simple and easy pointers and strategies that can improve HEDIS® performance

● Coding 101: Instructions for coding ● Patient education documents: Links to educational documents available online

Introducing

High-Performing Office Summit

Become a high-performing office! Learn how to improve your ability to provide cost-effective care, reduce unnecessary hospitalization, and improve coding accuracy while increasing earning potential at one of three informational sessions:

Session 1Monday, March 24, 20145:30 to 8 p.m.G. Fred DiBona Building1901 Market StreetPhiladelphia, PA 19101

Session 2Wednesday, April 2, 20145:30 to 8 p.m.Villanova Conference Center601 County Line RoadRadnor, PA 19087

Session 3Tuesday, April 8, 20145:30 to 8 p.m.Sheraton Bucks County Hotel400 Oxford Valley RoadLanghorne, PA 19047

Participating physicians who attend any of the QIPS High-Performing Office Summit sessions will be provided a one-time training payment of $150, if eligible*.

Register:

Please send an email to [email protected] by Wednesday, March 19, 2014, with the following information:

● Preferred Session - Session 1: March 24 - Session 2: April 2 - Session 3: April 8

● Practice name ● Name and email address of each physician attending

● If eligible to receive the training payment, the name the check should be made payable to and the appropriate Tax ID.

Questions:

If you have any questions, please call Dayna Bersh at 215-241-2079.

About the QIPS program:The Quality Incentive Payment System (QIPS) program offers incentives for high-quality, accessible, and cost-effective care.

The QIPS program includes the following incentive components:

● Quality Performance Measure (QPM) Score Program

● Patient-Centered Medical Home (PCMH) Incentive Program

● Medical Cost Management Incentive Program - Generic Drug prescribing - Professional & Outpatient Cost Management


*For employed physicians, please check with your parent organization to see if you are eligible to receive a training payment. If you are eligible, please advise us if the payment should be sent to you or your employer.


HEALTH AND WELLNESS

Helping providers identify patients likely to be hospitalizedIBC is pleased to announce a new initiative to help physicians target care for their patients, our members. With a new and more accurate predictive model, we are able to assess our members’ likelihood of acute hospitalization within the next six months, based on conditions such as congestive heart failure and chronic obstructic pulmonary disease.

Starting in February, we began mailing providers lists of their at-risk patients, based on this predictive modeling. This information can assist providers with the following:

● prioritizing patient visits based on time spent with him or her;

● determining their frequency of visits to your office; ● educating patients; ● providing condition management; ● recommending available alternative care options to prevent hospitalization.

Additional resourcesHealth Coaches are available to help providers coordinate and facilitate care for these patients. If you have any questions or want to speak to a Health Coach, call 1-800-313-8628.

New health risk screening tool for Medicare Advantage HMO and PPO membersIn February, IBC introduced a new health risk assessment, the PraPlus™ Health Risk Screening Tool for Seniors for Medicare Advantage HMO and PPO members. This assessment enables IBC to identify the specific health care needs of our members who may benefit from our case management programs. Members are encouraged to complete the assessment and return it to IBC.

Primary care physicians of members who return the assessment will receive a letter, which includes an overall summary and individual scores for the members risk of repeat hospital admissions, frailty, and geriatric depression. We encourage physicians to use this information to address their patient’s medical conditions and needs and consider placing the Health Profile and Care Summary in the patient’s medical record to discuss at their next visit.


HEALTH AND WELLNESS

Encourage your patients to be active to stay healthyAre your IBC Medicare Advantage patients getting enough physical activity to stay healthy and fit? According to the Centers for Disease Control and Prevention, older adults should get at least two hours and 30 minutes of activity, such as brisk walking, every week as well as activity that works the muscles in the legs, hips, back, abdomen, chest, shoulders and arms two or more days per week.1

Your patients may not be that active, and they may have questions about their ability to exercise, including the following:

● How do I start to increase my activity? ● How often should I work out? ● What can I expect at a gym or fitness center? ● Are there any restrictions on what exercises I can do?

Encourage them to talk with you at their annual exam. Your answers to their questions can help them decide how to improve their fitness level.

SilverSneakers® can helpAn excellent way for your IBC Medicare Advantage patients to get the activity they need is to use the fitness benefit provided by their health plan – Healthways SilverSneakers® Fitness Program. With nearly 20 years of performance-based programming experience, SilverSneakers delivers innovative physical activity and social interventions to attract older adults and keep them engaged in improving their health. The program provides a basic fitness membership that allows participants to:

● access more than 11,000 fitness locations nationwide, including women-only sites;

● use exercise equipment and other amenities, such as pools and walking tracks;

● participate in signature SilverSneakers group fitness classes, designed specifically for active older adults and led by certified instructors;

● learn about relevant health topics; ● join fun social activities and events; ● receive guidance and assistance from a SilverSneakers Program AdvisorSM, a dedicated staff member at the fitness location.

SilverSneakers makes it easy for members to enroll and start using the program. Each IBC Medicare Advantage member receives a mailing from SilverSneakers that includes their personal SilverSneakers ID card and a list of the four fitness locations closest to their home. They simply take the ID card to the location of their choice and present it at the front desk. Members who haven’t received a card or who have misplaced theirs can call 1-888-423-4632 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m., ET. Using this number, members can request an ID card to be mailed and get their SilverSneakers ID number, which can be used temporarily until their card arrives in the mail.

Recommend the SilverSneakers Fitness program to your IBC Medicare Advantage patients. Follow up with them during their next exam to see if they are getting enough physical activity and to discuss strategies to overcome obstacles they mention.

Note: SilverSneakers is offered to Keystone 65 Select HMO, Keystone 65 Preferred HMO, and Personal Choice 65SM PPO members at no cost. For more information on the program, members can visit www.silversneakers.com or call 1-888-423-4632 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m., ET.

1cdc.gov/physicalactivity/everyone/guidelines/olderadults.html

SilverSneakers® is a registered mark of Healthways, Inc., an independent company.

Recommend the SilverSneakers Fitness Program to your IBC Medicare Advantage patients. More information on the program is available at www.silversneakers.com.

www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html

I m p o r t a n t R e s o u r c e s

V i s i t o u r w e b s i t e : w w w . i b x . c o m / p n c

Anti-Fraud and Corporate Compliance

Hotline 1-866-282-2707www.ibx.com/antifraud

Care Management and CoordinationBaby BluePrints® 215-241-2198 / 1-800-598-BABY (2229)*

Case Management 1-800-ASK-BLUE

Condition Management Program 1-800-ASK-BLUE

Credentialing

Credentialing Violation Hotline 215-988-1413www.ibx.com/credentials

Customer Service/Provider ServicesProvider Automated System† (eligibility/claims status/precertification) 1-800-ASK-BLUE

Provider Services user guide www.ibx.com/providerautomatedsystem

eBusinessHelp Desk 215-241-2305

FutureScripts® (commercial pharmacy benefits)Prescription drug prior authorization 1-888-678-7012

Fax 1-888-671-5285

Blood Glucose Meter Hotline 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.ibx.com/rx

FutureScripts® Secure (Medicare Part D pharmacy benefits)FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.ibxmedicare.com

Prescription drug prior authorization toll-free fax 1-888-671-5285

Other frequently used phone numbers and websitesIBC Direct Ship Injectables Program (medical benefits) www.ibx.com/directship

Medical Policy www.ibx.com/medpolicy

NaviNet® portal registration www.navinet.net

Provider Supply Line 1-800-858-4728www.ibx.com/providersupplyline

*Outside 215 area code

†The Provider Automated System will be phased out as members are migrated to the new operating platform. For more information go to www.ibx.com/pnc/businesstransformation.

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