HM-Behind the Shield OCT-4DAVE

APRIL 2005
A Newsletter for Highmark
Blue Shield and HealthGuard
Providers in Central Pennsylvania
and the Lehigh Valley
Highmark Providers:
Mark Your
Calendar for
20O5
Spring Meetings
Plan to Join Us at Blue ConnectionsSM 2005 Spring Meetings
Highmark Blue Shield wants you to “think
spring” — that is, this year’s spring meetings
for Highmark providers and their office staff.
April
Please mark your calendar now to attend
one of the Blue Connections 2005 spring
meetings, which will be held across the
region this April and May (see list of meeting
dates, times and locations at right). Invitations
were mailed to providers in March.
¨ Thursday, April 14, 9 to 11 a.m., Nittany
Medical Center, Conference Rooms 1, 2, 3,
State College
Attending a Blue Connections meeting gives
you the chance to speak with Highmark
Provider Relations representatives, ask questions and gain valuable information for your
practice. Handouts featuring useful tips and
reminders will be available, along with a
wealth of information on other important
topics.
¨ Wednesday, April 27, 9 to 11 a.m., Heart
of Lancaster, Community Room, Lititz
Key topics to be discussed at this year’s
spring meetings include an update on
Highmark’s application to the Centers for
Medicare and Medicaid Services (CMS) to
offer FreedomBlueSM, a Medicare Advantage
PPO, in selected counties in central
Pennsylvania, the Lehigh Valley and northeast Pennsylvania in 2005. (See story on
Page 2.) Discussions also will focus on
enhancing efficiencies — specifically how
Highmark and its network providers can
work together to share information as accurately, quickly and effectively as possible in
order to avoid delays.
¨ Wednesday, May 4, 9 to 11 a.m.,
Lewistown Hospital, Classroom 4,
Lewistown
Meeting dates, times and locations are as
follows:
¨ Tuesday, April 12, 8 to 10 a.m., Gettysburg
Hospital, Classroom A, Gettysburg
¨ Tuesday, April 19, 9 to 11 a.m., Highmark
Building, Auditorium, Camp Hill
¨ Wednesday, April 20, 9 to 11 a.m., Holiday
Inn, East/West Room, Carlisle
¨ Thursday, April 28, 9 to 11 a.m., St. Luke’s
Hospital, Laros Auditorium, Bethlehem
May
¨ Tuesday, May 3, 9 to 11 a.m., Lehigh
Valley Hospital, Auditorium, Allentown
¨ Tuesday, May 10, 9 to 11 a.m.,
Susquehanna Valley Mall, Community
Room, Selinsgrove
¨ Wednesday, May 11, 9 to 11 a.m.,
Holiday Inn, Somerset Room, York
¨ Thursday, May 12, 9 to 11 a.m.,
Hampton Inn, (Room TBD), Bloomsburg
¨ Tuesday, May 17, 9 to 11 a.m.,
Reading Hospital, (Room TBD), Reading
¨ Wednesday, May 18, 9 to 11 a.m.,
Hanover Community Health and
Education Center, Classroom 1, Hanover
Register Today!
If you haven’t yet registered to attend one of
the meetings, please do so by completing and
returning the reply card included with
your invitation. Or, you may register
online by sending an e-mail to
omregister@highmark.com. (Please include
your provider/practice name, Highmark ID
number, telephone number, date and
location of the meeting you will attend
and the number of people attending from
your office, along with their names.)
I
N
S
I
D
E
Highmark Files with CMS to Offer
FreedomBlueSM in 2005...............................2
Donald R. Fischer, MD, Named Highmark
Chief Medical Officer ..................................2
Radiology Management Program
Updates........................................................3
Updates for Electronic Filers......................4
Quality Pay-for-Performance Program ......5
Notifications for Providers..........................6
Highmark to Integrate Behavioral Health
Medical Management Services .................7
Notification System for Medication
Requests ......................................................8
Highmark Striving to Meet
Patients’ Language Needs ..........................9
HealthGuard News....................................10
b
Questions?
Providers with Internet access will find helpful information online
at www.highmarkblueshield.com and www.hguard.com.
NaviNetSM users should use NaviNet for all routine inquiries.
But if you need to contact us, below are the telephone numbers
exclusively for providers.
HIGHMARK
1-866-731-2045
Option 1 – Claim status, benefits and enrollment
Option 2 – Customer Service
Option 3 – Forms orders
Option 4 – Provider Relations representatives
1-866-731-8080 – HMS pre-certification/authorization
requests (including behavioral health authorizations)
1-866-634-6468 – Requests for HMS peer-to-peer
conversations
1-800-992-0246 – EDI Operations (electronic billing)
1-866-488-0548 – Questions concerning Medicare Part B
HEALTHGUARD
1-800-513-0980 – Customer Service (claim status, coverage/
benefits, policy/procedures and enrollment/eligibility;
fax: 717-581-4580)
1-800-269-4606 – Utilization Management voice mail
pre-certifications for inpatient admissions and
ambulatory surgeries (digital pager: 717-951-6041,
after-hours/weekend requests)
1-800-513-1914 – Fax line for referral and pre-certification
forms
1-866-731-2045, Option 4 – Provider Relations
representatives
✍
Margaret LeMasters, Managing Editor
Adam Burau, Senior Editor
Matthew Clark, Contributing Editor
Highmark Files with CMS to
Offer FreedomBlueSM in 2005*
Highmark filed an application with the Centers for Medicare and Medicaid Services
(CMS) in March to offer FreedomBlue, a Medicare Advantage PPO product, in
selected counties in central Pennsylvania, the Lehigh Valley and northeast
Pennsylvania in 2005.
Over the last several months, Highmark has been preparing for this filing by
enrolling PremierBlueSM Shield providers to participate in the Medicare Advantage
network. So far, more than 2,000 physicians in 10 central Pennsylvania counties
have signed agreements to become Medicare Advantage PPO providers.
Additionally, as of early March, the following hospitals have signed
Medicare Advantage PPO contracts:
¨ Ephrata Community Hospital, Lancaster County
¨ Hanover Hospital, York County
¨ Holy Spirit Hospital of the Sisters of Christian Charity, Cumberland County
¨ Memorial Hospital, York County
¨ Pinnacle Health System, Dauphin County
¨ Reading Hospital and Medical Center, Berks County
¨ Sacred Heart Hospital, Lehigh County
¨ St. Luke's Hospital, Northampton County
¨ St. Luke's Hospital-Allentown Campus, Lehigh County
¨ The Milton S. Hershey Medical Center, Dauphin County
¨ WellSpan Health, Adams and York counties
“Pending CMS approval, Highmark could begin enrolling area seniors in the
FreedomBlue product as early as this spring,” says Edward Wargo, director,
Physician Recruitment and Relations. “FreedomBlue is designed to give qualified
older adults more choice, flexibility and value in their health care coverage, so we
anticipate a great response to the plan from seniors. That should come as good
news to our network providers.”
Providers who join the Medicare Advantage PPO network will enjoy a dependable
revenue stream with timely and accurate fee-for-service payments, payment based
on the Medicare allowance (after co-pay) and exceptional provider support from a
dedicated Provider Relations staff backed by online medical policy and medical
management through NaviNetSM.
Contracts and recruitment packets were sent last spring and fall to providers
throughout the region. If you didn’t receive a packet and would like to join the
Medicare Advantage PPO network, or if you have questions about FreedomBlue,
please contact your Provider Relations representative.
*pending approval from CMS
Comments/Suggestions Welcome
We want Behind the Shield to meet your needs for timely,
effective communication. If you have any suggestions,
comments or ideas for articles in future issues, please call your
Provider Relations representative, toll-free, at 1-866-731-2045,
Option 4, or write to the senior editor at:
Behind the Shield
Highmark Blue Shield
Fax: 412-544-5234
adam.burau@highmark.com
For More Information
For NaviNet users, this icon following an
article means that the material/information is
conveniently accessible from Plan Central.
Just click on Resource Center.
For providers who don’t yet have NaviNet
access, this icon means that the material/
information is available on Highmark’s Web
site at www.highmarkblueshield.com.
Just click on Provider Resource Center in the
lower, right corner.
All contents ©2005 Highmark Blue Shield
Donald R. Fischer, MD,
Named Highmark Chief
Medical Officer
Donald R. Fischer, MD, has been named senior vice
president and chief medical officer for Highmark Inc.
He will oversee the company’s new Integrated Clinical
Services unit, which comprises medical management
for central and western Pennsylvania, medical policy, quality management,
preventive health services, health management services and pharmacy affairs.
Dr. Fischer, who joined Highmark in 2001, recently served as the company’s
medical director for strategic physician relations. His focus has been working
with primary care physicians and specialists to reduce unwarranted variation in
practice patterns. In addition, he is actively involved in Highmark’s initiative to
create a regional strategy to address childhood obesity.
2
Radiology Management
Program Updates
Diagnostic imaging is one of the fastest growing expenses in American health
care. Highmark’s payments for diagnostic imaging services have been increasing
by more than 20 percent annually. Much of the recent growth in diagnostic
imaging is a result of technological advances that allow physicians and other
health care professionals to more accurately identify a patient’s condition.
There is growing concern, however, about the appropriateness and quality of
imaging services, leading to questions about the clinical benefits of these
services to patients.
For the sake of our group customers and members, Highmark is implementing a
program designed to help ensure quality and proper use of diagnostic imaging
consistent with clinical guidelines.
Prior Notification Phase Effective
March 1, 2005
Highmark has launched the first phase of
its Radiology Management Program, an
initiative intended to promote quality and
patient safety of imaging services for our
group customers and members.
The initiative’s Prior Notification phase took
effect March 1, 2005, and to prepare
ordering physicians for this step, Highmark
mailed the Prior Notification Phase
Reference Guide for Ordering Physicians
to providers in early January.
This valuable guide features detailed information about notifying National Imaging
Associates Inc. (NIA) when physicians want
to order the selected outpatient, nonemergency advanced imaging services that
are included in the Radiology Management
Program. NIA is the imaging management
firm that is administering the program.
“The Prior Notification period will enable
Highmark to collect data on the NIA
process, allowing us to assess the appropriateness of the studies that we’ve chosen
to review,” says Martin Fenster, MD,
Highmark’s Utilization Management
medical director. “This step also will provide
opportunities to learn how to make the
administrative responsibility on providers
minimal and to begin profiling ordering
patterns of physicians to help streamline
the process for providers whose requests
are nearly always consistent with clinical
guidelines.”
Participating in the Prior Notification phase
is important for providers because in late
2005 or early 2006, network physicians
will need to request a prior authorization
when ordering select CT scans, select MRI
and MRA scans and all PET scans, he says.
During the Prior Authorization phase
(which takes effect in late 2005 or early
2006), authorization numbers will be
issued and will be required to ensure
appropriate reimbursement. However,
during the Prior Notification period (which
took effect March 1, 2005), authorization
numbers won’t be issued or required when
submitting claims.
In addition to mailing the guide to physicians, Highmark has made it available via
our online Provider Resource Center at
www.highmarkblueshield.com. The
book is available under the Highmark
Radiology Management Program link.
The Prior Notification Phase Reference
Guide for Ordering Physicians outlines
the Highmark products included in the
3
initiative, features a complete list of CPT
codes and descriptions for the selected
imaging procedures, provides the toll-free
contact number and call center hours and
offers other valuable information about the
program. Before ordering a PET scan or any
of the selected CT, MRI or MRA scans, call
1-866-731-2045 and select Option 5, which
will automatically transfer you to NIA.
Privileging Phase Begins
Effective July 1, 2005
Another vital component of the program will
be privileging Highmark’s imaging network,
with the goal of making sure that all network
providers who perform imaging services meet
stringent quality and patient safety guidelines.
Privileging applications, along with the complete guidelines for participation, were mailed
in January. You may obtain an application and
review the privileging guidelines on our online
Provider Resource Center under the Highmark
Radiology Management Program link. If you
are interested in continuing to perform any
imaging services on Highmark patients effective July 1, 2005, be sure to complete and
return your application as soon as possible.
Highmark is now carefully reviewing
applications against the privileging guidelines.
Letters will be mailed over the next several
months to communicate to all applicants their
acceptance, provisional acceptance or denial.
Letters will also include information on the
appeal process. And, if providers decide to
address any deficiency that may have
prevented them from meeting the privileging
guidelines, they are encouraged to provide
written notification to NIA.
If you have any questions regarding your
privileging application, please contact your
Provider Relations representative or call NIA
at 1-888-972-9642.
Watch Behind the Shield for updates on
Highmark’s Radiology Management Program.
(See the December 2004 issue of Behind the
Shield for background on the program.)
Updates for Electronic Filers
EDI Operations Reports Most Common Rejection Codes
Providing Complete, Accurate Information Essential for Electronic Filers
Highmark’s Electronic Data Interchange (EDI) Operations department periodically receives inquiries from physicians and other
practitioners who file claims electronically to interpret why some
claims are rejected.
Following is a table that outlines the most common rejection codes
generated on the 277 Claim Acknowledgment Report; included are
descriptions of each code, along with insights to help you avoid
such rejections in the future. Submitting claims with correct and
complete information is one of the best ways to avoid claim rejections.
The 277 claim acknowledgement provides “accepted” or “not accepted”
status for each individual claim and is usually available for your review
within 24 hours of the claim submission. Please consult with your software vendor if you aren't currently retrieving this report, as the retrieval
method varies per Trading Partner and vendor system.
Rejection Code:
Description of Rejection:
What to Look for Within the Claim:
24/41
no affiliation between billing
provider number and the Trading
Partner
• Verify that the billing provider number being reported is correct.
• No leading zeros or alpha characters should be reported.
• If the number being submitted is correct, please contact EDI Operations
at 1-800-992-0246.
116
claim being sent to incorrect payer
• This usually occurs when a Personal Choice claim is sent under the Highmark
payer code 54771.
• If the patient’s identification number has a prefix of QCB, QCM or QCA, the
claim should be sent under the payer code 54704 for Personal Choice.
130/77
facility ID invalid or missing
• A facility number is required for all services rendered in a facility (Ex.: inpatient,
outpatient, emergency room, nursing home).
• The number reported must be the six-digit Blue Shield facility ID or tax ID number.
• No leading zeros or alpha characters should be reported.
130/82
rendering provider number
missing or invalid
• The number reported must be the individual provider number of the physician
who saw the patient.
• No leading zeros or alpha characters should be reported.
130/85
billing provider number
missing or invalid
• The number reported must be the group number or, if the provider isn’t part of
a group, the individual provider number.
• No leading zeros or alpha characters should be reported.
247
line information
• This status code is used to help identify that there is a rejection within the claim
at the service level. The actual rejection code will be reported on the service line
that caused the rejection (Ex.: 130/77, 255, 116).
255
invalid diagnosis code
• Verify that the diagnosis being reported is valid for the date of service.
• As of Oct. 1, 2004, due to HIPAA guidelines, the most specific diagnosis code
must be reported; if the diagnosis code has a fifth digit, it must be reported.
The rejection codes are found in the STC segment of the claim acknowledgement report. If you have questions on where to find the rejection
codes, please contact your vendor. If you need further explanation on these rejection codes, please call EDI Operations at 1-800-992-0246
between 8 a.m. and 5 p.m., Monday through Friday.
Attention Electronic Claims Filers:
Highmark Announces Standardized Password Requirements
To continuously ensure information security,
Highmark routinely monitors its information
technology systems and makes enhancements
whenever necessary.
As a result of a recent check, Highmark has
standardized password requirements for all
electronic data interchange (EDI) system users,
including providers and/or their billing vendors.
We ask that you please adhere to the following regulations when setting or changing your
passwords for Highmark’s EDI system:
¨ All initial passwords must be randomly
generated by Highmark.
¨ Change your password immediately upon
initial access to the system (first-time
users only) and every 60 days thereafter.
¨ All passwords must be at least eight
characters, alphanumeric (a combination
of both letters and numbers) and lower
case.
¨ Passwords may not be reused more often
than every sixth password change.
If you use a billing service, clearinghouse or
software vendor, please notify that third
party regarding Highmark’s standardized
password requirements for all EDI system
users.
44
Coming in April 2006 for PCPs
Highmark to Introduce
Highmark Blue Shield will introduce a quality
pay-for-performance program in April 2006 to
reward physicians who provide accessible, efficient,
high-quality health care.
This new program, to be named QualityBLUESM, will offer PCPs
(family practice, general practice, internal medicine and pediatric
providers) an opportunity to earn additional reimbursement as
an “add-on” to the fee schedule for select evaluation and
management (E&M) services. Performance goals will directly
relate to quality and efficiency measures that enhance the health
care services received by our members.
Measurement Methodology
QualityBLUE is comprised of measures in the following
six categories:
Measure:
Based on:
Eligibility Requirements
Clinical Quality
Providers who participate in the PremierBlueSM Shield network
are eligible once they execute the Physician Pay-for-Performance
Program Agreement and meet the following eligibility
requirements:
Specialty specific clinical quality
categories and corresponding
quality measures
Generic/Brand
Prescribing Patterns
The percent of prescriptions
A Hospital
written for generic
drugs
NaviNet Usage
¨ participate in the PremierBlue Shield network and the
FreedomBlueSM Medicare Advantage PPO network*
Authorizations and claims
investigations and inquiries
Member Access
Average office hours and
non-traditional office hours
¨ are NaviNetSM enabled
Best Practice
Clinical quality improvement activity
¨ achieve a 12-month claims volume of > $40,000 for
Highmark-paid E&M services, based on allowed fees
Electronic Health
Records
Implementation of electronic
health records
¨ achieve an electronic claims submission rate of ≥ 75 percent
*On March 1, 2005, Highmark filed an application with the Centers for
Medicare and Medicaid Services (CMS) to offer FreedomBlue in selected counties
in central Pennsylvania, the Lehigh Valley and northeast Pennsylvania.
Pay-for-Performance Program
The largest category is based on indicators directly related to
clinical quality of care guidelines that are based on nationally
accepted standards of preventive and disease-oriented basic
clinical care. The majority of these quality guidelines mirror
HEDIS®. Practice results will be re-evaluated quarterly.
Over the next several months, practices that meet the claims
volume requirement will be receiving more detailed information.
Also, watch for ongoing articles in Behind the Shield and in our
new clinical journal for physicians, Clinical Views, coming soon.
5
Notifications for
Providers
Several times annually, Highmark and HealthGuard notify providers of important policies
and guidelines. The following notifications are for your information and reference.
Highmark’s Notice of Privacy Practices Available Online
Highmark has established policies and procedures to protect the
privacy of its members’ protected health information (PHI) from
unauthorized or improper use. We encourage our provider network
to be familiar with our privacy practices. You can view this
information online at www.highmarkblueshield.com. In the
home page footer, click on Privacy and Security, and when a box
opens, click on View Notice of Privacy Practices. There, you’ll find
specific information on the uses and disclosures of PHI. If you have
specific questions about Highmark’s privacy practices, or if you wish
to obtain a paper copy of these guidelines, you can send an e-mail
to privacy@highmark.com, call our Highmark Privacy Department,
toll-free, at 1-866-228-9424 or send an inquiry to:
Highmark Privacy Department
1800 Center Street
Camp Hill, PA 17089
Highmark and HealthGuard Require 24/7 Coverage
for Members
Please be aware of the Highmark and HealthGuard credentialing
requirement that all network practitioners must provide coverage for
members 24 hours a day, seven days a week either directly or
through an on-call arrangement with another participating network
practitioner. This allows a member or another practitioner the ability
to access a practitioner (or his/her designee) directly in urgent or
emergent situations. The 24/7 coverage can be accomplished
through an answering service, pager or via direct telephone access
whereby the practitioner (or his/her designee) can be directly
accessed if needed. A referral to a crisis line or the nearest
emergency room isn’t acceptable coverage unless there is an
arrangement made between the practitioner and the crisis line or ER
whereby the practitioner (or his/her designee) can be contacted
directly if needed. It isn’t acceptable for any non-PCP practitioner to
refer patients to their PCP after normal business hours.
Appropriate Utilization Decision Making
Highmark and HealthGuard make utilization review decisions
based only on appropriateness of care and service and the
existence of coverage. In addition, Highmark and HealthGuard do
not specifically reward practitioners, providers, Highmark and
HealthGuard employees or other individuals conducting utilization
review for issuing denials of coverage or service, nor do they
provide any financial incentives to utilization management decision
makers to encourage denials of coverage.
The following specialties are exempt from this requirement:
¨ audiology
¨ speech therapy
¨ speech language pathology
¨ physical therapy
¨ preventive medicine
¨ dermatopathology
¨ pathology (only if working
outside of the acute care setting)
Request for Criteria
Highmark and HealthGuard use nationally recognized medical policy and Medicare guidelines in determining whether a requested
procedure, therapy, medication or equipment meets the requirements of medical necessity. This is done to ensure the delivery of
consistent and medically appropriate health care for our members.
If a PCP or specialist requests a service that a nurse in Healthcare
Management Services (HMS) Care Management is unable to
approve based on criteria/guidelines, the nurse will refer the
request to a Highmark/HealthGuard Physician Advisor or Medical
Director. A Highmark/HealthGuard Medical Director or Physician
Advisor may contact the PCP or specialist to discuss the request or
to obtain additional clinical information. A decision is made after
all of the clinical information has been reviewed.
At any time, the PCP or specialist may request a copy of the criteria/guidelines used in making the decision by calling Highmark at
1-800-421-4744 or HealthGuard at 1-800-513-0980.
6
Reminder:
Integrate
Highmark to
Use Correct Relationship Code On Claims
Highmark began issuing unique member
identifier (UMI) numbers to members in January
2004. Effective March 2004, Highmark began
issuing separate identification (ID) cards to individual members, rather than just to subscribers.
The new ID cards display the subscriber’s UMI
and the name of the individual member; they
do not feature a code documenting the
patient’s relationship (self, spouse, child or
other) to the subscriber. Please note that the
individual whose name is on the card is not
necessarily the subscriber in whose name the
coverage under this UMI has been established.
Providers should be aware that members are
identified in Highmark’s membership system by
a combination of data elements, including the
UMI/agreement number, as well as the member’s name, date of birth and relationship to the
subscriber. If a paper or direct-data entry claim
is submitted with an incorrect relationship code,
it could be rejected or suspended for manual
correction.
Highmark is currently changing its claims
processing logic to address this issue. Until
that time, however, providers are advised that
the best way to avoid delays in the current
processes is to ask the patient at the time of
services what his/her relationship is to the subscriber whose UMI is on the ID card and record
this information correctly on the claim prior to
submission. Relationship information also is
available through NaviNetSM via Patient Eligibility
and Benefits Inquiry.
Behavioral Health Medical
Management Services*
Company to assume responsibilities from Magellan
July 1, 2005
Highmark’s contract with Magellan Health Services for behavioral
health utilization and case management services expires on June 30,
2005, and Highmark has made a decision not to renew the contract
beyond that date.
Continuation of multi-year strategy of integrating medical,
behavioral health services
“In keeping with our multi-year strategy of integrating medical and behavioral
health utilization and case management activities, Highmark has decided to
assume all internal responsibility for administering behavioral health services,”
says Donald R. Fischer, MD, senior vice president and chief medical officer.
Highmark currently administers many important portions of the behavioral health
program, including contracting directly with behavioral health providers for our
western and central Pennsylvania networks. We also:
¨
¨
¨
¨
¨
¨
¨
pay claims
handle member appeals
handle member grievances
review provider appeals
develop and implement quality improvement programs
develop and implement medical policy
develop payment schedules
“This integration will afford Highmark the opportunity to work with providers
to coordinate services for members with both medical and behavioral health
conditions and to help them tailor treatment programs based on members’
needs,” Dr. Fischer says.
Attention:
Oral Surgeons and Billing Staff:
Reminder on Proper Use of
Modifier 47
When a surgeon performs anesthesia
services, Modifier 47 is added to the basic
services code to report regional or general
anesthesia provided by the surgeon. Modifier
47 should not be reported in conjunction
with dental anesthesia procedure codes
(D9220, D9221, D9241, D9242 and D9248),
as these codes, by their definition, are
anesthesia-only codes.
Highmark will work closely with Magellan to ensure a smooth transition for all
members who now receive case management support services from Magellan.
We also will assume responsibility for all open authorizations for both inpatient
and outpatient behavioral health services as of July 1, 2005.
With this change, Highmark anticipates an enhanced working relationship with
health care providers by coordinating medical and behavioral health care needs
for Highmark members, especially those who suffer from chronic medical conditions complicated by conditions such as anxiety or depression.
In addition, physicians and members will be offered more opportunities to access
Highmark support programs and services, including those focused on condition
management and preventive health services.
*This change does not apply to HealthGuard behavioral health services, which are provided
by ValueOptions.
Instead, providers should report the corresponding performance verification modifier
(e.g., AA, QK, QX, etc.) for anesthesia codes.
Please make note of this reminder and be
sure to share it with your billing staff. If
Modifier 47 is erroneously reported in
conjunction with anesthesia services, the
claim will be pended and/or denied.
Behavioral Health Provider Meetings Coming
In preparation for the transition of medical management services from
Magellan to Highmark on July 1, 2005, Highmark is planning to hold a
series of informational sessions for providers this spring. Watch your mail
as well as Behind the Shield and NaviNet’s Plan Central page for dates,
times and locations.
7
Changes to Special Program
for Obtaining Certain
Injectable Medications
Notification System
for Medication
New Drugs Being Added, Effective
April 1, 2005
Requests
Highmark recently began using a new system that allows us to notify physicians more quickly regarding decisions on medication requests for our clinical
management programs (non-formulary, prior authorization, etc.) that require
authorizations through a Highmark patient’s prescription drug benefit.
The new system, which debuted in January 2005, automatically notifies a
physician via fax once a decision has been made regarding a medication
request. In addition, a decision letter is still mailed to the patient and to
his/her requesting physician’s office. In order for you to receive a Fax
Status Letter notification and written notification, Highmark will
need to ask that you always provide your correct mailing address
and fax number.
Number to Call for Status of Medication Requests
If you have made a medication request and haven’t received a fax
notification of a decision, you can verify that the Pharmacy Service
Department is processing your request by calling 1-800-600-2227.
Pharmacy Care Management representatives are available Monday
through Friday from 8:30 a.m. to 4:30 p.m., Eastern Standard Time.
Decisions on medication requests are usually made the day after Highmark
receives your completed request form, and a decision letter and a Fax Status
Letter are generated immediately upon a decision.
NOTE: You can obtain a blank Medication Request form by calling
1-800-600-2227 and following the prompts to have this form
electronically sent to you via fax.
Effective April 1, 2005, several new medications
are being added to a special Highmark program
through which PremierBlueSM Shield providers may
order certain injectable drugs for their PPOBlueSM,
DirectBlue®, SelectBlue®, Access Care II and
Federal Employee Health Benefits Program (FEP)
patients. In addition, PremierBlue Shield providers
may use the program when ordering the applicable drugs for their National (BlueCard®) patients.
Through a unique arrangement with Medmark,
the sole preferred specialty pharmacy provider
for the program, Highmark is able to purchase
certain injectable drugs at discounted rates and
pass that savings on to our members. We will
reimburse Medmark directly for these drugs, so
you won’t have to submit a drug claim. And
because the program also eliminates the need for
you to purchase and store these drugs, you won’t
experience any out-of-pocket expenses. You’ll
continue to receive reimbursement for any related
office visit and drug administration services.
For a complete list of the medications being
added to this program effective April 1, see
the Special Bulletin dated February 2004.
What the Program Includes Now
The program already includes Hyalgan, Supartz,
Synvisc, Synagis, Amevive, antihemophilic factor
products, Botox, Myobloc, Immune globulin
intravenous products (IVIG), Thyrogen and Xolair.
For more information about these drugs, see
the Special Bulletin dated July 2003 and the
December 2003 issue of Behind the Shield.
There are no changes to policy or procedure.
Medications that currently require precertification
will continue to require precertification in 2005.
You can place your orders for these drugs for
your PPOBlue, DirectBlue, SelectBlue, Access
Care II, FEP and BlueCard patients quickly and
easily by telephone from Medmark, toll-free,
at 1-888-347-3416.
Medmark offers your patients disease education
and support and express delivery and has registered nurses and clinical pharmacists available
toll-free 24 hours a day, seven days a week to
answer your patients’ questions.
PremierBlue Shield physicians who have
earmarked supplies of the above drugs for their
PPOBlue, DirectBlue, SelectBlue, Access Care II,
FEP and BlueCard patients may want to reduce
their inventories in preparation of the drugs
being added to this program. However, physicians
may also choose to continue to purchase and bill
Highmark directly for any of these drugs for their
PPOBlue, DirectBlue, SelectBlue, Access Care II,
FEP and BlueCard patients.
8
Highmark Striving to Meet
Patients’ Language Needs*
Highmark’s quality improvement efforts are designed to ensure superior care and member satisfaction. To achieve this goal, we continually
review the aspects of our plan that affect member care and satisfaction
and look for ways to improve them. For example, by sharing information with network practitioners about the languages frequently spoken
in their geographic area and the availability of interpreting services, we
can assist both physicians and members in communicating effectively
and efficiently.
If you currently see non-English-speaking members, an excerpt from
the article “Using Bilingual Staff Members as Interpreters” from
Family Practice Management, 11(7):34-36, 2004, © American
Academy of Family Physicians, offers the following eight points to
keep in mind:
1. Use the universal form of the language whenever possible
(free of regional words and dialects).
2. Refrain from assuming the role of interviewer or decision maker.
3. Let the patient lead the discussion.
4. Translate everything.
5. Be aware of culturally significant issues that affect patient care,
and translate in a way that conveys the cultural framework.
6. Meet the patient prior to the medical encounter.
7. Develop interpreter-physician work plans for each patient.
8. Seek continuing education.
Highmark annually assesses languages spoken by the population in
our service area and compares these findings to the data that
practitioners report on their credentialing applications (page 1:
List languages spoken, other than English). Our 2004 analysis
concluded that the following counties had more than 1,000
residents speaking the following primary languages:
Language:
Counties in Which Language
is Spoken:†
Spanish or Spanish Creole
Adams, Berks, Centre, Cumberland, Dauphin,
Franklin, Lancaster, Lebanon, Lehigh,
Northampton, Northumberland, Schuylkill,
Union, York
Arabic
Chinese
French (incl. Patois, Cajun)
German
Lehigh
Centre, Lancaster, Lehigh
Dauphin, Lancaster, York
Berks, Cumberland, Dauphin, Lancaster,
Lehigh, Northampton, York
Berks, Northampton
Lehigh
Berks, Centre, Lancaster, Lebanon, Lehigh,
Mifflin, Schuylkill, Snyder, Union
Lancaster
Berks, Dauphin, Lancaster, Lehigh
Italian
Other Slavic Languages
Other West Germanic
Languages
Russian
Vietnamese
Visit http://www.medscape.com/viewarticle/484539 to access
the complete article, which includes resources for interpretation
services. One service highlighted in the article is 1-800-TRANSLATE,
which offers 24-7 services on a fee-for-service basis.
In an effort to better serve the Highmark members in your respective
counties, along with potential future members, please review your
credentialing/recredentialing application. If you speak any of the
previously mentioned languages or any foreign language that
isn’t included in your profile, you can update your information by
contacting Tim Schreiber at 412-544-1894 or by sending an e-mail
to timothy.schreiber@highmark.com; please provide the following in
your e-mail: provider name, provider number and languages spoken.
Finally, we’d like to ask that when hiring future staff, please consider
individuals who speak languages relevant to your patient population
and geographic location.
*The results of this study are relevant for HealthGuard providers who practice in
any of the counties listed in the table above.
The above data is from the 2000 U.S. Census. This information is based on
county population and not Highmark membership population.
†
Report valid
medical code sets
on all claims
Remember to report medical code sets, that is,
diagnosis codes and procedure codes, that are
valid at the time a service is performed on all
electronic and paper claims. Highmark requires
that you report appropriate medical code sets
because of the administrative simplification
provision of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
Highmark follows the Centers for Medicare and
Medicaid Services’ effective date guidelines for
diagnosis and procedure codes. Highmark does
not allow 90-day grace periods.
Buenas Noticias!
Blues On CallSM Resource Now Available in Spanish
®
Blues On Call’s Healthwise Knowledgebase is now available in Spanish for your
Knowledgebase is a comprehensive,
Healthwise
The
patients.
aking
Spanish-spe
evidence-based resource of accurate, physician-approved information for medical
consumers. It supports decisions about when a problem can be treated at home,
when to see a doctor and what treatment option is best for the individual.
SM
Members can access the Healthwise Knowledgebase on their My Shield Online page
to
resource
this
use
can
patients
Highmark
Your
at www.highmarkblueshield.com.
find information on a wide variety of medical topics from A Beta-2 Microglobulin
Amyloidosis to Zyvox. Spanish patients can click the link titled Informacion de la salud
to access the Spanish version of the Healthwise Knowledgebase.
For more information about Blues On Call, call the Provider Hotline at
1-866-348-3504. Your Highmark patients can reach a Blues On Call health
coach by calling 1-888-258-3428 (1-888-BLUE-428).
9
Referrals Still Required
Summary of Results
HealthGuard’s goal is to meet or exceed the 75th
percentile threshold published in the 2003 NCQA Quality
Compass® Report.
HealthGuard providers are reminded that referrals are
still necessary for all products that have traditionally
required them.
The top scores (percentage of patients who reported they were
satisfied) for each of the six composite categories and four overall
rating questions are listed in the table below. Shaded cells show
where 2004 goals haven’t been met.
HealthGuard 2004 Member Satisfaction
Survey Results
HealthGuard annually gathers data on member satisfaction
using the Consumer Assessment of Health Plans Survey
(CAHPS®), a tool developed by the National Committee
for Quality Assurance (NCQA). The survey includes key
aspects of member satisfaction, such as the relationship
between the patient and physician and the service
provided by the health plan.
Top Scores*
The CAHPS® survey results are part of the Pennsylvania
Department of Health managed care regulations and
NCQA requirements. HealthGuard surveyed HMO and
point-of-service (POS) members in separate surveys in
spring 2004. With a sample of 1,100 members, the HMO
survey had a response rate of 43.8 percent, and the POS
survey had a response rate of 45.1 percent.
Composite/Rating
2004
HMO
2004
POS
2003
2004
HMO/POS HealthGuard
GOAL
Composite 1:
Getting Needed Care
85.7%
79.9%
82.0%
81.0%
Composite 2:
Getting Care Quickly
83.6%
84.6%
82.5%
81.6%
Composite 3:
How Well Doctors
Communicate
92.6%
93.0%
94.7%
92.9%
Composite 4:
Courteous and
Helpful Office Staff
93.9%
91.7%
95.6%
94.1%
Composite 5:
Customer Service
73.9%
73.4%
75.4%
73.6%
Composite 6:
Claims Processing
93.9%
90.6%
91.7%
90.3%
Rating of Personal
Doctor
83.4%
79.8%
79.0%
77.8%
Rating of Specialist
77.7%
79.4%
75.4%
79.0%
Rating of Health Care
79.5%
78.6%
82.0%
79.2%
Rating of Health Plan
73.5%
68.2%
70.7%
66.7%
*Analysis
The 2003 scores are provided for comparison purposes; however, the 2003
scores may not be a statistically valid comparison to the 2004 scores
because of a change in methodology. The 2003 survey included both HMO
and POS members while individual surveys were conducted for each line of
business in 2004.
10
We work hard to ensure that our members receive quality
care and that the health plan provides high-quality and
timely service. Your participation in this effort is greatly
appreciated!
Many components of the CAHPS® surveys show a high rate of
member satisfaction. The following areas scored in the Top 10
percent of the 262 plans nationally that conducted the survey:
HMO Survey
POS Survey
Composites/Ratings:
Rating of the Personal Doctor
Rating of Health Plan
Getting Care Quickly Composite
Getting Needed Care Composite
Composites/Ratings:
Getting Care Quickly Composite
----
Individual Questions:
Ability to get a provider you are
happy with
Individual Questions:
How often doctors explained things
in a way you could understand
Ability to see a specialist that you
needed to see
Ability to get the help or advice you
needed when you called during
regular office hours
Ability to get the care, test or
treatment you or a doctor believed
necessary
Ability to get care when you
needed it right away for an illness,
injury or condition
Ability to get the help or advice you
needed when you called during
regular office hours
--
Ability to obtain care as soon as
you wanted, when care was not
needed right away
--
Handling of claims in a timely
manner
--
Handling claims correctly
--
Do You Need to Discuss a UM Issue?
Providers who wish to discuss a Utilization Management
(UM) issue can contact HealthGuard Customer Service at
717-581-4600 or toll-free at 1-800-513-0980 between
8 a.m. and 4 p.m., Monday through Friday. A provider service
representative can assist you, or, if you wish to speak with
someone on our UM staff, the provider service representative
can transfer your call to an appropriate staff member between
8 a.m. and 4 p.m. weekdays.
The high scores in these areas are a reflection of the quality
of the practitioners in the managed care network and the
commitment of each practitioner to the care and service of
each individual patient. We appreciate the ongoing support
and service you provide to our members and thank you
for the many ways you and your staff contribute to our
member satisfaction ratings!
A provider service representative can
assist you, or, if you wish to speak
with someone on our UM staff, the
provider service representative can
transfer your call to an appropriate
staff member.
11
This newsletter is primarily geared toward medical practitioners and their office staff, with information about:
®
®
®
Camp Hill, Pennsylvania 17089
www.highmarkblueshield.com
www.hguard.com
ALERT:
Highmark HIPAA Contingency Plan For Claim Transactions To End
NOTE: This notification is a follow-up to announcements made in September 2003 and October 2004
regarding Highmark’s HIPAA contingency plan for transactions and code sets (TCS).
Highmark’s current plans are to discontinue the acceptance of non-HIPAA-compliant claim transactions effective
May 26, 2005. Non-compliant electronic claim transactions received by Highmark for all payers after this date will
be rejected.
Highmark will require all providers, their billing services and clearinghouses to use only HIPAA-compliant 4010A1
formats for submitting electronic claim transactions.
Please note: Highmark is currently determining the date for discontinuing the transmission of non-compliant
electronic remittance advices (ERAs).
If you have questions about how to submit your electronic claims, call EDI Operations at 1-800-992-0246.
Highmark Blue Shield and HealthGuard are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans. Highmark Blue Shield serves the 21 counties of central Pennsylvania and the Lehigh Valley as a full-service health plan. HealthGuard
is a health maintenance organization serving south-central Pennsylvania. Blue Shield and the Shield symbol, BlueCard, SelectBlue, DirectBlue and ClassicBlue
are registered marks and BlueExchange, BlueAccount, Blues On Call, MedigapBlue, PremierBlue, PPOBlue, FreedomBlue, QualityBLUE, My Shield Online
and Blue Connections are service marks of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc.
NaviNet is a registered service mark of NaviMedix Inc. Shared Decision-Making and the SMART Registry are registered marks of Health Dialog Services Corp.
Healthwise Knowledgebase is a registered trademark of Health Dialog Services Corp. CAHPS is a registered trademark of the Agency for Healthcare Research
and Quality. HEDIS is a registered trademark of the National Committee for Quality Assurance.
12