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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

Voice of the Physician, Office Manager studies completed Blue Cross and Blue Shield of Florida conducted research earlier this year to better understand physicians’ and their office/business managers’ expectations when doing business with us. The information is being used to identify what’s most and least important to you and to help us learn what we can do to improve our working relationship. In conducting the study we were particularly interested in:

The contracting decision process Your relationships with insurance carriers and their representatives How you view billing and claims and the effect on your practice of medicine The role of technology in providing better support in running your offices and caring for your patients

Findings Study findings indicate physicians and office managers want processes streamlined — from contracting and referrals/authorizations to claim payment — minimizing the time and resources needed to treat patients and resolve issues. Respondents also said they would like to quickly and correctly verify a patient's eligibility, coverage and financial responsibility.

Office managers are looking for improvements that will help their offices run smoothly and cost-effectively, and in turn allow physicians to deliver higher-quality patient care. They are seeking efficiency across all day-to-day administrative processes — less paperwork, more interactive technology. Automated phone and online transaction capabilities received high marks for making daily tasks easier. They also value high-quality customer service representatives capable of quickly resolving any issues that arise, as well as enhanced communications and support from insurance carriers. Reducing claim processing rejections and help to diagnose and fix claim problems are important.

Blue Cross and Blue Shield of Florida is pleased that physicians and office managers participating in the survey rated our company higher overall than our competitors. Many of the enhancements we have implemented speak to the issues important to you:

Contracting We have streamlined the contracting and credentialing processes. Communications Our website provides easy and timely access to process changes, manuals and billing guides, practice parameters and more. Our email update to physicians who sign up for the service alerts their office staff to process and/or product changes. Referrals/Authorizations We have continued to reduce the need for referrals and authorizations. Technology Through Availity®1, we provide easy access to verify eligibility and benefits and other transactions. We’ve made contacting us easier with one number to reach our Provider Contact Center, and voice recognition technology has enhanced phone service. Issues Resolution We have a team dedicated to resolving issues in a timely manner. Service Our knowledgeable physician/provider service representatives provide one-on-one support for physicians and their staffs.

We thank all the physicians and office and business managers who participated in the survey.

1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue cross and Blue Shield of Florida, Inc. has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving the patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website at www.availity.com.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

New BCBSF member IDs in place Beginning Jan. 1, 2006, Blue Cross and Blue Shield of Florida (BCBSF) will complete conversion to the new non-Social Security based member ID numbers. Only the new numbers will be included on most documents, including paper Explanations of Benefits, Remittance Advices, capitation rosters and correspondence.

BCBSF’s new member ID includes the 3-digit alpha prefix in the first three positions, then the letter H and 8 to 10 numbers; e.g., XJBH12345678 (PPO), XJGH1234567801 (HMO).

To avoid claim processing delays after Dec. 31, 2005, please ensure you have the current member ID. Ask members for their new ID cards at each visit. If a Social Security number-based ID is presented, check eligibility and benefits on Availity®1 for the new ID number. Please update member ID numbers on your billing system. In future, claims may deny due to invalid member ID if an old number is used.

Details about this change are available on our website at www.bcbsfl.com. Refer to Member ID Number Change – Further Protecting Member’s Privacy under Tools & Resources, BlueNews Seminars.

If you have questions about the new ID number change, call the Provider Contact Center at (800) 727-2227 or your physician/provider relations specialist.

1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue cross and Blue Shield of Florida, Inc. has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving the patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website at www.availity.com.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

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State introduces more plan options in 2006 The state of Florida has restructured its health care program to offer more choices and provide new tools and resources to help its employees find health care that fits their diverse needs. In addition to the standard State Employees’ PPO Plan, Blue Cross and Blue Shield of Florida (BCBSF) will administer the State’s new Health Investor PPO. Caremark® will administer prescription drug coverage.

Preferred Patient Care (PPC) is the participating network for both plans. However, members can receive services from non-participating physicians and providers at a higher cost. Physicians and providers who participate in the PPC and Traditional networks should not balance bill these members for the difference between their charge and BCBSF’s allowed amount.

Health Investor PPO Eligible members who enroll in the Health Investor PPO medical plan enjoy lower premiums in exchange for higher deductibles and out-of-pocket limits. They also pay a percentage of the cost of services (coinsurance) for a network office visit.

The Health Investor PPO plan covers the same medical services and supplies as the standard State Employees’ PPO plan. However, with the exception of some routine physical exams and health screenings such as Well Child Care and Adult Preventive Care, the deductible applies before any benefits are paid.

Eligibility and benefit information Obtain eligibility and benefit information electronically through Availity1. Physicians and providers may also call (800) 727-2227 or the number on the member’s ID card. Click the following links for a summary of Standard and Health Investor PPO benefits, including adult preventive benefits and a summary of adult preventive services and immunizations.

1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue cross and Blue Shield of Florida, Inc. has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving the patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website at www.availity.com.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

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FEP adds limited chiropractic benefits to Standard Option, decreases Basic Option maternity admission copay Federal Employee Program (FEP) benefit changes for 2006 include the addition of limited chiropractic benefits for the Standard Option plan and a reduction to a $100 per admission copay for inpatient maternity services for the Basic Option plan. For the 2006 summary of benefits, click here.

The FEP member ID number begins with an “R” followed by 8 numbers (i.e., R12345678). The two PPO plans administered by Blue Cross and Blue Shield of Florida include the Standard Option and Basic Option.

Provider networks The participating network for both the Standard and Basic options is Preferred Patient Care (PPC):

Standard Option Standard Option members who choose providers participating in PPC enjoy lower out-of pocket costs. If they choose participating providers from our Traditional (PPS/PHS) network, out-of-pocket costs are greater for the member, but members are not subject to balance billing. Basic Option Basic Option members must use preferred (PPC) providers or they will be responsible for all charges. The Traditional (PPS/PHS) network agreements do not apply to Basic Options in most cases.

Eligibility and benefits Obtain eligibility and benefit information electronically through Availity1. Physicians and providers may also call (800) 333-2227 to verify eligibility and coverage.

Claims filing and status We encourage you to send claims and check claims status electronically through the Availity Gateway. Provide the complete member ID number, including the “R,” when submitting claims. Physicians and providers may also call (800) 333-2227 to check claims status.

For paper claims, mail to:

Blue Cross and Blue Shield of Florida P.O. Box 1798 Jacksonville, FL 32231-0079

1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue cross and Blue Shield of Florida, Inc. has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving the patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website at www.availity.com.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

NIA medical directors available for consultations Medical directors with National Imaging Associates, Inc. (NIA) are a valuable resource for peer-to-peer consultation regarding radiology imaging procedures and specific cases regarding BlueCare, Medicare & More and ActivelyYou members. Blue Cross and Blue Shield of Florida’s HMO subsidiary, Health Options, contracts with NIA to provide pre-service review and authorization of select imaging services to support physicians participating in our Health Options network.

We encourage participating physicians to review NIA’s guidelines located on our website to call NIA’s medical directors directly at (888) 642-7649 for consultation. Of course, BCBSF/Health Options medical directors are also available to discuss radiology issues with participating physicians as needed.

NIA authorizations are required for MRIs, MRAs, CT scans, PET scans and cardiovascular system nuclear medicine procedures for our HMO members. For radiology authorizations, ordering physicians should call NIA at (866) 326-6302 with the supporting medical information for the diagnostic testing.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

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NetworkBlue Fast Tracker available online NetworkBlue is the participating network for all BlueOptions PPO point-of-service health plans. For your convenience, our website includes quick reference materials and bulletins to help physician and provider staff serve our members.

BlueOptions members can receive services in or out of NetworkBlue. Directing members to providers that participate in NetworkBlue helps members maximize their benefits and minimize their out-of-pocket costs. No authorizations or referrals are necessary, but notification is required by the end of the next business day after inpatient admission. For a current listing of providers in NetworkBlue, visit our online provider directory at www.bcbsfl.com.

Plan features Please keep in mind the following:

Traditional network Members who receive services from physicians and providers in the Traditional network pay out-of-network costs but are protected from balance billing. Laboratory services Quest Diagnostics is the participating clinical laboratory for NetworkBlue. Referring members to Quest Diagnostics lowers members’ costs. Only select lab services can be performed in the office. Hospital tiering Hospitals participating in NetworkBlue are categorized by options indicating members’ cost-sharing level for services, with Option 1 as the lowest and Option 3 as the highest. After-hours services NetworkBlue physicians are eligible for reimbursement for certain after-hours services to BlueOptions members.

For more information on NetworkBlue, refer to the NetworkBlue Fast Tracker on our website at www.bcbsfl.com, in the Physicians & Providers section under Tools & Resources, Fast Trackers. NetworkBlue information is also available in your applicable physician or provider manual.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

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Advanced Renal Options program participation ends Health Options’ participation in the Advanced Renal Options (ARO) program will end Dec. 31, 2005.

The Centers for Medicare & Medicaid Services demonstration program, which was initially designed as a three-year pilot, has been in place approximately eight years. Among other things, the program was designed to test whether integrated acute and chronic care services and case management for end-stage renal disease patients improve health outcomes; and whether additional benefits are cost-effective.

ARO nephrologists serving as primary care physicians and affected members have previously been notified of this change.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

Fill out forms online! We continue to look for ways to make working with us easier by using electronic capabilities. Our website provides a wealth of information about products and services, as well tools and resources you can use.

And now for your convenience, when you need to complete one of our forms, you can fill it out electronically online. Once completed, just print and fax or mail the form back to us.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

New tools help members make better health care decisions On Dec. 29, Blue Cross and Blue Shield of Florida is launching two interactive tools on its member website – Subimo’s Physician Selection Advisor and Healthcare Advisor. Educating members is increasingly important as more employers and individuals opt for consumer-driven health plans. Each of the new tools will interact with the current hospital quality program and will provide members with information that can help them make better, more informed decisions about their health and their health care needs.

Our goal is to provide members with clear, accurate information about their local providers alongside easy-to-understand guidance regarding treatment options. The information provided is culled from publicly reported information from more than 50 industry and government data sources, including the American Medical Association. Subimo’s data vendor standardizes, consolidates and validates the data.

Physician Selection Our Physician Selection tool enables members to view and compare attributes of physicians. Information includes physician name, specialty, office location, phone number, medical group affiliation, hospital affiliation(s), distance from zip code, board certified specialties, medical school, residency, years since graduation, gender and the date information was last updated. State of Florida sanctions data are also included.

The tool links the information to the hospitals where the physicians have admitting privileges. Identifying physician activity by hospital enables users to determine high-volume performers at hospitals convenient to them. Inpatient procedure volumes will be shown for the most recent year of Florida Agency for Health Care Administration (AHCA) information.

Health Care Decision Support Our Health Care Decision Support tool offers members personalized health care information to help them think through their health care decisions. It covers more than 150 conditions and procedures and contains information on managing a condition, preparing for a procedure, questions to ask a doctor and benefit plan, and links to other resources.

Healthcare Advisor links to Subimo’s Hospital Advisor, which we currently provide for members on our website. Hospital Advisor enables users to choose a hospital based on information that is important to them (e.g., outcomes, costs, teaching facility, etc.).

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Medicare Advantage plan benefits updated for 2006 Three Medicare Advantage plans are available from Blue Cross and Blue Shield of Florida and its HMO subsidiary, Health Options. They include:

BluePreferred® PPO available in Broward, Palm Beach, Hillsborough and Pinellas counties

Two HMO plans, Medicare & More® and ActivelyYouSM, available in Broward, Dade and Palm Beach counties

BluePreferred gives members the freedom to choose any physician, but members’ cost-sharing levels are lower when they choose physicians in NetworkBlue.

As HMO plans, Medicare & More and ActivelyYou require members to select a primary care physician; there are no out-of-network benefits except for emergency care.

Benefit changes Pharmacy benefits are included in all three plans at no extra cost. Current pharmacy benefits will be replaced in 2006 with BlueScript for Medicare Part D. (For pharmacy benefit details, see BlueLine PharmacyNews, Winter 2005-06, and BlueLine, September/October 2005.)

There are no changes to medical benefits for the BluePreferred or ActivelyYou plans for 2006.

Medicare & More changes include higher copayments for office visits, including primary, specialist, outpatient mental health, outpatient substance abuse and urgent care.

Click the following links for summaries highlighting 2006 benefits for Medicare Advantage HMO and PPO plans. Please note the summary is not intended to be all-inclusive. For complete information, refer to your applicable physician or provider manual/addendum located on our website at www.bcbsfl.com under Physicians & Providers, Tools & Resources, Manuals & Billing Guides.

2006 Medicare Advantage HMO Benefit Summary Medicare & More ActivelyYou

Monthly premium $0 $47

Physician Office

PCP $15 per visit $15 per visit

Specialist $30 per visit $30 per visit

Outpatient Mental Health/Substance Abuse $30 per visit $30 per visit

Other Services

Outpatient Surgery $250 per outpatient hospital facility visit $100 per ASC visit $0 for physician

$250 per outpatient hospital facility visit $100 per ASC visit $0 for physician

Outpatient Services(Excludes mammograms) $50 per outpatient hospital visit $0 per ASC visit

$50 per outpatient hospital visit $0 per ASC visit

Urgent Care $30 per visit Worldwide coverage

$30 per visit Worldwide coverage

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2006 Medicare Advantage PPO Benefit Summary

Outpatient Medical Services and Supplies

Diagnostic tests, X-rays, lab services and radiation therapy

$0 Office/facility copay may apply

$0 Office/facility copay may apply

Manual manipulation of the spine $15 per PCP visit $30 per specialist visit No referral needed for network providers

$15 per PCP visit $30 per specialist visit No referral needed for network providers

Medically Necessary Foot Care Routine Foot Care (1 visit per 61 days)

$15 per PCP visit $30 per specialist visit $15 per PCP visit $30 per specialist visit

$15 per PCP visit $30 per specialist visit $15 per PCP visit $30 per specialist visit

Outpatient rehabilitation (occupational, physical, speech and cardiac rehab)

$30 per visit $30 per visit

Preventive Services

Annual Screening - Mammograms (for women with Medicare age 40 and older)

$0 for Medicare-covered Screening Mammogram $0 for each additional screening – up to one exam per year No referral necessary for network providers

$0 for Medicare-covered Screening Mammogram $0 for each additional screening – up to one exam per year No referral necessary for network providers

Pap Smears and Pelvic Exams (for women with Medicare)

$0 per pap smear. $0 per pelvic exam. $0 for each additional screening – up to one exam per year No referral necessary for network providers Office visit copay applies

$0 per pap smear. $0 per pelvic exam. $0 for each additional screening – up to one exam per year No referral necessary for network providers Office visit copay applies

BluePreferred

Monthly premium $108

Deductibles/Coinsurance/Limits

Calendar Year Deductible (CYD) per person In-Network Out-of-Network

$0 $500

Coinsurance (amount member pays) In-Network Out-of-Network

N/A 40%

Out-of-Pocket Maximum per person (includes CYD, Coin-surance, Copays; excludes Rx)

In-Network Out-of-Network

$2,500 $25,000

Physician Services

Physician Office Services In-Network Family Physicians In-Network Specialists Out-of-Network Providers

$10 Copay $30 Copay CYD + 40% coinsurance

Urgent Care Centers In-Network Out-of-Network

$30 Copay $30 Copay

Physician Services at Hospital & ER In-Network Out-of-Network

$0 $0

Physician Services at Locations other than Office, Hospital & ER

In-Network Family Physicians In-Network Specialists Out-of-Network Providers

$0 $0 CYD + 40% coinsurance

Other Services

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

Ambulatory Surgical Center Facility In-Network Out-of-Network

$75 Copay CYD + 40% coinsurance

Independent Diagnostic Testing Facility In-Network Out-of-Network

$75 Copay CYD + 40% coinsurance

Independent Clinical Lab In-Network Out-of-Network

$0 CYD + 40% coinsurance

Preventive Services

Mammograms In- or Out-of-Network $0

Bone Density Tests In-Network Out-of-Network

Based on service location CYD + 40% coinsurance

Annual Exams (Pap, Pelvic, PSAs, routine physicals, etc.)

In-Network Family Physicians In-Network Specialists Out-of-Network Providers

$10 Copay $30 Copay CYD + 40% coinsurance

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

New BlueOptions plans offer richer benefits Blue Cross and Blue Shield of Florida has launched three new BlueOptions plans with effective dates of Jan. 1, 2006:

Two Small Group Network Advantage Plans One new Large Group Network Advantage Plan

These new plans offer maximum choice, freedom and flexibility, with open access to the largest provider network in Florida and most services at affordable copays. Two of the plans offer $0 deductible for in-network services. Even if a member selects a provider outside NetworkBlue, their payment is still a copayment in most cases. Coinsurance for all three plans is 20 percent for in-network services. Balance billing protection applies as long as members choose a BCBSF-contracted provider, including physicians in our Traditional network (PPS).

The plans are designed to appeal to consumers who want copay benefits in or out of network, as well as broad access to care.

Network Advantage Plan Copayments

Small Group Large Group

In-network Out-of-network In-network Out-of-network

Office Visit

Family physician $15 or $20* $30 or $40* $15 $30

Specialist $30 or $35* $45 or $55* $30 $45

Physician services at the hospital & ER

$0 CYD+ coinsurance

$0 CYD+ coinsurance

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

Use the overpayment refund form to speed the recovery process Blue Cross and Blue Shield of Florida diligently pursues timely recovery of overpayments to physicians and other providers as part of its effort to maintain stable premium rates. Information about the overpayment recovery process is available in our physician and provider manuals.

To expedite posting of refunds, we request physicians and providers include pertinent identifying information with their refund checks. Following the guidelines below ensures a timely and accurate refund process:

Enclose a copy of our refund request letter or the invoice/invoice number with your check. When sending unsolicited refunds to us, enclose a completed Claim Overpayment Refund Form. The form is available on our website, www.bcbsfl.com, under Physicians & Providers, Forms.

If you dispute a refund request, you must submit the reason in writing within 30 days of receiving our request.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

National accounts get new alpha prefixes and IDs Claim processing for national accounts with employees in Florida is being moved in phases to a common Blue Cross and Blue Shield of Florida system currently used for our regular HMO and PPO claims. This change is designed to streamline administration.

New alpha prefixes and member IDs will be issued to groups as their claims are entered onto the common system. Therefore, it is important to ask members for a copy of their ID card at each visit and to update your information and billing systems if there is a change.

New alpha prefixes and member IDs are effective Jan. 1, 2006, for employees who reside in Florida for the following national accounts:

Please use the new alpha prefix and member IDs for all claims and inquiries regarding services rendered on or after Jan. 1. However, use the old alpha prefix and member IDs in effect prior to Jan. 1 for claims and inquiries regarding services rendered in 2005.

Remittance advices will look like those you see today for our HMO and PPO plans for claims submitted for these groups.

There are no changes for submitting claims or contacting Blue Cross and Blue Shield of Florida. For questions, call the Provider Contact Center at (800) 727-2227. (Click here for an article on new BCBSF member IDs.)

New Old

The Crom Corporation (BlueOptions/BlueChoice) XJB CRO

Environmental Consulting (BlueOptions/BlueChoice) XJB ENM

A Duda & Sons AYD ADU

Holland & Knight HFK HAK

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

New process prices multiple modifiers Good news! Blue Cross and Blue Shield of Florida has implemented a processing change to accommodate professional claims submitted with multiple modifiers. Procedure code modifiers denote degree of difficulty, complexity and multiplicity, and affect physician claim payments.

The new process prices claims based on the first and second modifiers. It affects all professional claims except Medicare supplement and pharmacy. Implementation of this processing change will reduce your administrative time, decrease modifier-related reimbursement delays and improve the accuracy of claim payments involving multiple modifiers. It also will ensure patient liability is communicated more accurately and timely.

For more information, check the Addendum to Procedure Code Modifiers in the Insurance Manual for Physicians and the Health Options HMO Manual for Physicians or the Manual for Ancillary Providers on our website located under Physicians, Tools & Resources, Manuals & Billing Guides.

If you have any questions about claims processing, call the Blue Cross and Blue Shield of Florida Provider Contact Center at (800) 727-2227.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

Update Health Care Services Review requests through the Availity Gateway Physicians and providers can now update Health Care Services Review (i.e., authorization, certification, notification, referral, etc.) requests through the Availity1 Gateway. Select the “Health Care Service Inquiry” option to make changes to particular information on an existing request or to void (cancel) a request.

Changes can be made only when:

The current status is Approved or Held, The Admission or Service From Date is in the future, and No claims have been received for the authorization.

The select fields that can be updated are:

Service dates Procedure date(s) (Procedure codes can be added, but cannot be modified or deleted.) Referred to provider Referred to facility Additional referred to provider

(Note: General Practice is returned on all inquiry responses regardless of the actual specialty. Please disregard; this does not affect claim processing and will be corrected in a future update.)

How it works To update existing requests:

Select Health Care Services Inquiry under the Auths and Referrals menu. Complete the required fields to search. Select the appropriate request from the results list. Click the Update button and complete the changes. Click Submit.

To void (cancel) existing requests:

Select Health Care Services Inquiry under the Auths and Referrals menu. Complete the required fields to search. Select the appropriate request from the results list. Click the Void button to cancel the request.

The Update and Void buttons are only visible to providers who have access to change a specific request and when the request status is approved or held. For a matrix of fields that can be updated and who can update them, click here.

For more information on updating your existing Health Care Services Review requests, call (800) 955-5692.

1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue Cross and Blue Shield of Florida has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving the patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity's website at www.availity.com.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

Overpayment Recovery Program applied to BlueCard claims Blue Cross and Blue Shield of Florida’s (BCBSF) is moving all claims to a common claims processing system in phases, including BlueCard claims. As a result, our standard overpayment recovery procedures will apply to BlueCard claims. (See related article on the overpayment recovery process.)

Physicians and providers who receive payment from BCBSF in excess of the allowed amount can refund the overpayment to us, or BCBSF may deduct the overpayment from any future payments to you. For details about this change, please see the Important Changes to BlueCard Claims Processing bulletin on our website at www.bcbsfl.com, Physicians, Tools & Resources, Bulletins.

Please refer to the Overpayment Recovery chapter of your applicable physician or provider manual located on our website at www.bcbsfl.com for details about our overpayment recovery procedures. You may also contact your physician/provider relations specialist or call the Provider Contact Center at (800) 727-2227.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

bcbsfl.com

Mammography benefits increase with age The U.S. Preventive Services Task Force (USPSTF) has reviewed evidence regarding the effectiveness of mammography, clinical breast examination and breast self-examination in reducing breast cancer mortality. Following is an excerpt from the USPSTF's Summary of Recommendation issued in February 2002:

The USPSTF recommends screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older. The USPSTF found fair evidence that mammography screening every 12-33 months significantly reduces mortality from breast cancer. Evidence is strongest for women aged 50-69 ... For women aged 40-49, the evidence ... is weaker, and the absolute benefit of mammography is smaller* than it is for older women … [T]he evidence is also generalized to women aged 70 and older (who face a higher absolute risk of breast cancer) if their life expectancy is not compromised by co-morbid disease. The absolute probability of benefits of regular mammography increase along a continuum with age … …[E]vidence is insufficient to recommend for or against routine clinical breast examination (CBE) alone to screen for breast cancer. No screening trial has examined the benefits of CBE alone (without accompanying mammography) compared to no screening… …[E]vidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE).

Coverage Blue Cross and Blue Shield of Florida and its HMO subsidiary, Health Options, cover baseline mammograms for women aged 35-39, mammograms every two years for women 40-49, and annually for women 50 and older and those who are at risk for breast cancer because of personal or family history (based on a physician's recommendation).

Generally, covered mammograms (routine and with diagnosis) are reimbursed at 100 percent for most plans, group and individual. They are not subject to deductibles or copays for BlueChoice and BlueOptions members. However, coverage varies among some plans, such as the State Employees’ PPO Plan and the State’s new Health Investor PPO.

HMO and Medicare Advantage plans (BlueCare, Medicare & More, ActivelyYou, BluePreferred—no copayment. PPO, PPO point-of-service plans (BlueChoice, BlueOptions)—no deductible, copayment or coinsurance and does not apply toward the Adult Wellness benefit. State Employees’ PPO and Health Investor PPO—reimburses 80 percent; subject to calendar-year deductible.

When checking eligibility and benefits on the Availity Gateway®1, choose "Diagnostic X-ray" (specialty benefit options).

For more information Complete information on the USPSTF breast cancer screening study is available in the article, "Breast Cancer Screening with Mammography: Summary of the Evidence" and in the systematic Evidence Review on this topic, prepared by the Evidence-based Practice Center at Oregon Health and Science University, which is supported by the Agency for Healthcare Research and Quality (AHRQ). Physicians can access these documents at the USPSTF website, www.ahrq.gov/clinic/uspstfix.htm, through the National Guideline ClearinghouseTM, www.guideline.gov, or in print through the AHRQ Publications Clearinghouse, (800) 358-9295.

*The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause.

1Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue cross and Blue Shield of Florida, Inc. has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving the patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website at www.availity.com.

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Pre-op consult with GYN oncologist recommended for patients with endometrial cancer Endometrial cancer is the fourth most common cancer in women. It will be diagnosed in more than 40,800 women in the United States—2,500 Floridians—and will be responsible for 7,310 deaths this year.

The selection and sequencing of treatment are important. Preoperative consultation with a specialist in endometrial cancer management, such as a gynecologic oncologist, may be beneficial, especially in the following situations:

The ability to completely and adequately surgically stage the patient is not readily available at the time of the initial procedure. Preoperative histology (biopsy) suggests a high risk for extrauterine spread. The final pathology reveals an unexpected endometrial cancer following a hysterectomy performed for other indications. There is evidence of cervical or extrauterine disease. The pelvic washings are positive for malignant cells. Recurrent disease is diagnosed or suspected. Nonoperative therapy is contemplated.

For information about the care and treatment of patients with endometrial cancer and the benefits of consultation with a gynecologic oncologist, visit the Florida Society of Gynecologic Oncologists website at www.fsgo.org.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

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Screen for diabetic retinopathy Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 24-74 years.1 Since few visual symptoms are present and treatment is most effective at preventing vision loss, screening for retinopathy is extremely important.

The American Diabetic Association recommends the following:

Adults with type 1 should have an initial dilated and comprehensive eye exam within five years after the onset of diabetes. Patients with type 2 should have an initial dilated and comprehensive eye exam shortly after diagnosis. Subsequent exams for type 1 and type 2 should be repeated annually.

HMO coverage No referral is required for BlueCare and Medicare Advantage members to visit a participating ophthalmologist for an annual dilated retinopathy exam (DRE). Members in the Blueprint for Health® Diabetes Program who, according to our records have not had a DRE in the past 12 months, receive information on DRE and are encouraged to provide a copy of exam results to their primary care physicians.

If you have any questions about the Blueprint for Health Diabetes Program or would like to refer a member to the program, call (800) 937-9285, option 1, ext. 45891.

1 Diabetes Care, Volume 28, Supplement 1, January 2005

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

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Program makes inroads in educating members with CHF Blue Cross and Blue Shield of Florida offers a voluntary statewide Congestive Heart Failure (CHF) Program designed to help improve quality of life for members with CHF. The condition affects nearly 5 million Americans and is the third most common diagnosis cited for hospitalizations across all age groups. Our program’s goal is to empower members to take a more active role in their disease management so as to decrease emergency room visits and hospitalizations.

We identify eligible members from various referral sources. Using New York Heart Association guidelines, we stratify the severity of their condition into one of four classes, Class 4 being the most severe.

Members are educated about their disease process, co-morbidities and the importance of following their physicians’ treatment plans, which may include a low sodium diet, medications and daily weight monitoring. They also learn to identify the signs and symptoms that should prompt a call to their physician. In addition, CHF case managers work with the members’ physicians, respite care, Meals on Wheels and transportation providers to help members comply with their treatment. A medical director or pharmacist may be consulted as needed.

For more information about the program or CHF practice guidelines, visit our website at www.bcbsfl.com, or call (800) 955-7635, press 1, then ext. 17572, 17566 or 37749, to refer a member to the program.

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BlueLine is produced for Blue Cross and Blue Shield of Florida and Health Options contracted physicians and providers by Blue Cross and Blue Shield of Florida, P. O. Box 44269, Jacksonville, FL 32231-4269.

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Is an asthma specialist needed? The 2004 Health Options HEDIS® scores on use of appropriate medications for asthma indicate a continued effort is needed to raise performance above the national average.

Certain patients need special care. The National, Heart, Lung and Blood Institutes’ guidelines recommend referring a patient with asthma to an asthma specialist when the patient:

has had a life-threatening asthma exacerbation; is not meeting the goals of asthma therapy after three to six months of treatment; shows atypical signs and symptoms or there are problems in differential diagnosis; requires additional education and guidance on complications of therapy, problems with adherence or allergen avoidance; is being considered for immunotherapy; has severe persistent asthma; requires continuous oral corticosteroid therapy, high-dose ICS, or has required more than two bursts of oral corticosteroids in one year.*

The Health Options Asthma Care Committee recommends that members who have had an asthma-related admission follow up with their primary care physician or asthma specialist within one month of discharge.

For information about our Blueprint for Health® Asthma Program, call 800-937-9285, ext 45834 or 45836.

* Source: Expert Panel 2: Guidelines for the Diagnosis and Management of Asthma, 1997.