January Provider Bulletin - Blue Cross of Northeastern Pennsylvania

Volume 16 • Issue 1 • January 2014
The Individual Grace Period: What You Need to Know
At Blue Cross of Northeastern
Pennsylvania (BCNEPA), we are
committed to keeping you informed
about Health Care Reform changes that
may affect you and your patients. That’s
why we want to let you know about
the individual grace period, which is
effective January 1, 2014.
How can I determine if a patient purchased their plan
through the Federally Facilitated Marketplace?
What is the Individual
Grace Period?
What does the Individual Grace Period mean to me?
The Department of Health and Human
Services published final regulations
that require health insurance plans
to provide a 3-month individual
grace period for premium payment.
This requirement only applies to
individuals who buy and enroll in
health insurance plans through the
Exchange—or Federally Facilitated
Marketplace (FFM)—AND receive a
premium tax credit.
Keep in mind, this longer grace period
does not apply to individuals who buy
and enroll in health insurance plans on
BlueCrossNEPAStore.com or plans
obtained on the Federally Facilitated
Marketplace without a premium tax
credit. These plans will have the same
standard 30-day grace period as our
current individual health plans.
To determine if your patient bought their health insurance plan on the
Federally Facilitated Marketplace, check their member ID number. Member ID
numbers that end with “FE” indicate a plan that was purchased on the Federally
Facilitated Marketplace.
According to Health Care Reform law, during the 3-month grace period,
you can expect the following:
• BCNEPA is obligated to pay claims during the first month of the grace period.
• BCNEPA may pend claims during the second and third months of the grace
period. If you provide care for the member or covered dependent(s) during
this period, we will notify you by mail.
• If the individual pays all outstanding premiums by the end of the grace
period, we will pay the claims, as appropriate.
• If not, the claims for the second and third months will be denied, in accordance
with the Centers for Medicare and Medicaid Services (CMS) final rule.
Can I check to see if a patient has paid their premiums?
Yes, you can now use NaviNet® to check your patients’ payment status. When
you submit a Member Eligibility and Benefits Inquiry, click on “Eligibility and
Benefits Detail” and the “Paid to Date” will display under “Product/Eligibility
Information.” The Paid to Date will show the day, month and year through
which the policy has been paid.
Continued on page 3
Table of Contents
2 Contraceptive Coverage
Provided through
Separate Policy
4Utilization Management
Updates
6Administrative Practice
Guidelines
10Electronic Provider Access
Capabilities for Providers
14Medical Policy Updates
Contraceptive Coverage Provided through Separate Policy
The federal Health Care Reform law, known as the Affordable Care Act (ACA), requires many changes to health insurance plans.
Effective January 1, 2014, the ACA requires insurers to provide contraceptive coverage, with no copays, to female employees
and their female dependents in eligible employer groups. Employers that certify as eligible nonprofit religious organizations
will receive this coverage through a separate “contraceptive coverage only” policy.
Only a small portion of our membership will qualify as eligible nonprofit religious organizations. We, therefore, anticipate a
very small portion of our members—your patients—will be required to have the separate contraceptive coverage only, which
will be provided as a supplement to the health insurance plan they already have.
What does this coverage include?
This required coverage includes both medical and pharmacy expenses related to contraceptive services. Medical services
provided with this coverage include voluntary sterilization procedures and insertion or removal of implantable
contraceptives. Covered codes are as follows:
Services
Procedure Codes
Diagnosis Codes
Contraceptive Methods
(Not Inpatient)
11976 –removal, capsules
11981 –insertion, non-biodegradable implant
57170 –diaphragm or cervical cap fitting
with instructions
58300 –insertion of IUD
58301 –removal of IUD
A4261 –cervical cap for contraceptive use
A4264 –permanent implantable intratubla
occulsion device
A4266 –diaphragm for contraceptive use
A4268 –contraceptive supply, female, each
A4269 –contraceptive supply, spermicide, each
J1055 –injection medroxyprogesterone
J7300 –copper IUD
J7302 –levonorgestrel releasing IUD
J7303 –hormone containing vaginal ring
J7304 –hormone containing patch
J7306 –levonorgestrel implant system
J7307 –etonogestrel implant system
S4981 –insertion of levonorgestrel releasing system
S4989 –PROGESTACERT IUD
S4993 –contraceptive pills
96372 –injection (admin code for the depo provera)
Contraceptive Management Diagnoses
V25.01, V25.02, V25.03, V25.04,
V25.09, V25.11, V25.13, V25.40,
V25.41, V25.42, V25.43, V25.49,
V25.5, V25.8, V25.9
Contraceptive services supplied for
a medical reason would be eligible,
however they will not pay at the
preventive level.
Contraceptive Management Diagnoses
V25.01, V25.02, V25.03, V25.09,
V25.11, V25.12, V25.13, V25.40,
V25.41, V25.42, V25.43, V25.49,
V25.5, V25.9
Hysterosalpingography (HSG)
HSG done within 180 days insertion
of the essure contraception
74740
(Surgical) Permanent Methods
of Sterilization (Not Inpatient)
Sterilization will be paid at
preventive level when done on
an outpatient basis.
58565, 58600, 58605, 58611, 58615, 58670,
58671, A4264
Contraceptive Counseling
No coding. The expectation
is discussions surrounding
contraceptives would be
performed during well visits.
The covered contraceptive drugs include only those that are on our drug list of contraceptives covered at “no cost share.”
This listing, which includes both preferred prescription drugs and specific OTC contraceptive products, can be found on
our website, bcnepa.com. Click on “Rx Drug Benefits,” then “Women’s Preventive” under “Related Resources.”
2
Continued from page 1
The Individual Grace Period:
What You Need to Know
Continued from page 2
Contraceptive Coverage
Provided through
Separate Policy
Where can I go for more information on Health
Care Reform?
Find out more about Health Care Reform from any
of these resources:
• Visit our Health Care Reform resource center by visiting our
Provider website on bcnepa.com. Click on “Provider Resources &
Tools,” and then select “Health Care Reform.” You’ll find a timeline
of provisions, frequently asked questions and Health Care
Reform articles featured in recent issues of the Provider Bulletin.
• Call your provider service rep with any questions.
• More information on the Federally Facilitated Marketplace
(FFM) and how to enroll are available on HealthCare.gov.
How do members access these services?
Females who are employees or dependents of an
employee of an eligible nonprofit religious organization
will receive a Contraceptive Coverage Agreement and
separate contraceptive coverage ID card in the mail
closer to the January 1, 2014, effective date. They will
be informed to use this new ID card only for medical
services related to contraception and prescription
contraceptives, starting January 1, 2014.
The new card will state that it is for contraceptive
coverage only:
Where can I send my patients for information
on Health Care Reform?
For patients who need more information about the Federally
Facilitated Marketplace, we offer several resources:
• You can send them to our Health Care Reform website
at bcnepa.com/reform where they can find up-to-date
information, tools, resources and videos.
• You can provide them with one of the Health Care Reform
brochures that Blue Cross of Northeastern Pennsylvania
distributed to your office. Keep in mind, if you need more
brochures, call your provider service rep and we will be happy
to send more. Or you can download and print brochures from
our Provider website at bcnepa.com.
• Check out our affordable new plans for 2014 on the Blue Cross
Store by visiting BlueCrossNEPAStore.com, if they need to
change health insurance plans or are shopping for a new one.
• Call a BCNEPA sales rep at 1.855.WANT.BLUE
(1.855.926.8258), weekdays, between 8 a.m. and 8 p.m.,
to enroll by phone or have their questions answered.
• You can encourage them to visit one of our retail stores,
weekdays, between 8 a.m. and 5 p.m., or during our extended
night and weekend hours at one of these locations:
JANE DOE
QFG123456789001
Plan Code
Rx ID
Rx Group
Rx PCN
Rx BIN
274
123456789001
BLPA01
A4
003658
Plan
CONTRACEPTIVE
COVERAGE ONLY
PPO
®
Eligible females will also be informed that their current
medical plan ID card for all other services will not
change. They will continue to use that as they do now
for all other covered medical services and prescription
drugs. Members scheduling procedures for voluntary
sterilization and insertion or removal of implantable
contraceptives will need to use the contraceptive
coverage only ID card.
We are notifying you of this change in order to help
prevent any member confusion. As mentioned above,
this new, separate ID card applies to a very small part
of our member population. Not every Blue Cross of
Northeastern Pennsylvania member will have 2 ID
cards. Please note this distinction.
Bartonsville Plaza
292 Frantz Road, Suite 109, Bartonsville, PA 18360
Park Center
1019 Commerce Boulevard, Dickson City, PA 18519
If you have any questions, please contact your Provider
Relations Consultant. Keep in mind, guidance on
Health Care Reform is continuing to be issued. As
Health Care Reform evolves, so does our website—
check bcnepa.com/reform frequently for updated
information, tools, resources and videos. You can
also visit our Provider Health Care Reform website for
information specific to your patients and your practice
at bcnepa.com/Providers.
Corporate Headquarters
19 North Main Street, Wilkes-Barre, PA 18711
• Visit the Federally Facilitated Marketplace (FFM) at
HealthCare.gov where they can see if they qualify to get
help from the government to pay for their health insurance.
(Policy Update 1601002)
(Policy Update 1601001)
3
updates
continued on page 5
Utilization Management Updates
New Prior Authorization Requirements
During the second quarter of 2014, the following services
will require prior authorization:
Services
Codes
Spinal fusion
20936, 20937, 20938, 22532,
22533, 22534, 22558, 22585,
22586, 22590, 22595, 22600,
22610, 22612, 22614, 22630,
22632, 22633, 22634, 81.00,
81.01, 81.02, 81.03, 81.04,
81.05, 81.06, 81.07, 81.08,
81.62, 81.63, 81.64
Knee replacement
27447, 81.54
Hip replacement
27130, 81.51
The prior authorization requirements will apply to
all First Priority Health® (FPH) and First Priority Life
Insurance Company® (FPLIC) products.
Additional surgical procedures are being analyzed for
inclusion in the precertification/prior authorization
requirements. Please check future editions of the
Provider Bulletin for more details regarding new prior
authorization requirements.
Regionalization of Utilization
Management Staff
Prior Authorization
Requirements for
CPAP Therapy
We continually analyze opportunities to enhance and improve
services to our members and providers. In an effort to provide
optimal service, the Utilization Management (UM) department
will be adopting a regional model, in which teams of staff
members will be assigned to the various regions that
BCNEPA services. This will allow for our staff to better serve the
specific needs of each region and assist in delivering the best
possible care to our members.
As notified in previous Provider Bulletin issues, CPAP
therapy requires precertification/prior authorization as
of January 1, 2014. Please note that if a member already
By early 2014, the UM staff will be divided into
3 unique regions:
has a CPAP rental in progress, they will not be subject
• The Eastern Region—Responsible for Luzerne,
Carbon, Monroe, Pike and Wayne counties
(as well as Lehigh Valley Hospital)
apply to new rentals after January 1. We will require
• The Western Region—Responsible for
Lackawanna, Bradford, Clinton, Lycoming, Sullivan,
Susquehanna, Tioga and Wyoming counties
(including Geisinger Medical Center in Danville)
delivered after January 1.
to this requirement for prior authorization; this will only
prior authorization of all CPAP machines ordered or
Additionally, please note that this will require initial
authorization of the machine as well as a check for
• The Out-of-Area/BlueCard® Region—Will handle
all requests from out-of-area providers
member compliance after 90 days. Upon receipt of
the initial authorization, we suggest the submission
All requests will be assigned by the region in which the service
is rendered. When calling the UM department, please listen
carefully to the prompts, as they have recently changed in
order to direct you to the appropriate region. Additionally,
please be aware that the UM department fax numbers will
soon be changing in order to align with these new regions.
Please check future editions of the Provider Bulletin for more
information regarding this initiative.
of the secondary request and proof of member
utilization before the initial 90 days is up in order for
efficient review processes.
4
updates
continued from page 4
Utilization Management Updates
Important Update:
Important Reminder:
Transition of Care Program
DRG Audit Process
As mentioned in previous versions of the Provider
Bulletin, the Utilization Management department is
partnering with our Case Management, Behavioral
Health and Pharmacy Management departments to
implement a member outreach program designed to
help select members with transition of care.
The DRG (diagnosis related group) Audit Review
department performs retrospective audits on
inpatient paid claims for contracted, DRG reimbursed
acute care providers.
After the audit is complete, the DRG nurse auditors
will generate a DRG Validation Report, which is a
compilation of the proposed audit changes. This report
is mailed to the provider, requesting a written response
about the proposed changes within 45 calendar days.
The UM Transition of Care program is designed to ensure
a safe and successful discharge plan and appropriate
follow-up care for our members. By closely following
our members’ progress after discharge, we will be able
to help identify gaps of care, connect members with
medication issues to BCNEPA pharmacists and educate
members and their families and/or caregivers about
their condition. This will also allow us to collaborate with
you to improve overall patient outcomes while helping
to reduce the number of patient readmissions.
When responding, please note that both coding and
utilization responses should be sent in one report. For
proper processing, please send the report response to
the following address:
In order to achieve these goals, the UM department
will take an active role in managing the discharge
planning process. They will help transition our members’
care and send referrals to our on-site pharmacists or
Medical/Behavioral Health Case Management/Disease
Management departments, as needed.
Blue Cross of Northeastern Pennsylvania
DRG department
C/O (Name of Nurse Auditor)
19 North Main Street
Wilkes-Barre, PA 18711-0302
To best support our members through transitions in
care, we would like to remind you of the importance
of sending a copy of the members’ discharge orders/
summary at the time of discharge, according to our
Policy. In order for you to best assist our members
and reduce readmissions/complications, we require
complete discharge information, including:
•
•
•
•
•
When you respond within 45 calendar days, the DRG
nurse auditors will review all written disagreements
and send you a Final Validation Report. The final
determination in each case will be based on any
additional valid documentation from you. Please note
that after the Final Validation Report is complete, no
further appeal of the cases will be considered.
A copy of member discharge orders
Discharge medications
Orders for durable medical equipment or home health
Need for follow-up appointments
Other directives for the discharged patient
Please also note that if we don’t receive a response
within 45 calendar days, we will consider the DRG
Validation Report findings as final and will adjust the
claim accordingly. In these cases, no further appeal will
be considered.
The program will be initiated with select hospitals
this month. Please contact your Provider Relations
Consultant if you have any questions. If you
should prefer, we would be happy to provide a
teleconference call to review this new program
with you. Please contact Andrea Martinez,
UM TOC Coordinator at 570.200.3790 to schedule.
For more information about the DRG audit process,
please review your specific contract or the Facility Policy
and Procedure Manual.
Thank you for your continued cooperation with our
efforts to provide high quality care to our members.
(Policy Update 1601003)
5
Revised:
Update:
Administrative Practice
Guidelines
Lead Screening Encouraged
for Children
The following Administrative Practice Guidelines have
BCNEPA continues to collaborate with the Children’s
Health Insurance Program (CHIP) to promote awareness
about childhood lead poisoning and the importance
of screening and detection. This allows for monitoring
of negative effects associated with elevated blood lead
levels, such as low IQs and behavioral problems, as
well as effects on cardiovascular, immunological and
endocrine systems.
been revised as of November 19, 2013, and approved by
the Credentialing Committee. Facility & Environment:
Primary Care Physicians (PCP) and Specialist
Physicians including Psychiatrists
• If the physician performs cardiac stress tests
(CST): Please refer to FPH/FPLIC credentialing/
recredentialing for cardiac stress testing (CST) and/
or holter monitoring as special billable procedures
administrative practice guidelines.
Although lead paint was banned in 1978, many homes
still contain layers of lead-based paint.
Pennsylvania ranks third in the nation for having the
most housing units built before 1950, when lead paint
was most prevalent. Pennsylvania ranks fourth in the
nation for having housing units that were built
before 1978.
Medical Record Documentation:
Primary Care Physicians (PCP) and Specialist
Physicians excluding Psychiatrists
According to the Pennsylvania Childhood Lead
Surveillance Program 2012 Annual Report
(health.state.pa.us), 149,689 children under age
7 were screened for lead in 2012. This accounts for
approximately 25% of the state’s population in this age
category, leaving a large percentage untested. Of these
children tested in Pennsylvania, 1,817 or 1.21% were
reported to have confirmed elevated lead levels
at ≥10µ/dL, a level considered unsafe.
• Tool(s): chart forms may be found on our website
at bcnepa.com.
• Add documentation of social history to
medical record.
• Added medical records must be easily located.
Administrative Practice Guidelines can be found
on our website at bcnepa.com. Just click on the
“Provider Homepage” tab; then, select the “Quality
However, Pennsylvania’s overall blood lead levels have
clearly been dropping. In 2004, the geometric mean
blood lead level on reported maximum blood levels
was approximately 3.5 µ/dL. In 2012, however, data
reflected a geometric mean blood lead level of 2.4 µ/dL.
This represents a 31.43% decrease since 2004.
Management” link. Click on the “Practice Guidelines”
link on the right side.
For questions or to request a copy of the guidelines,
please contact Gina Klepadlo, Nurse Analyst, at
570.200.4388, weekdays, between 8 a.m. and 5 p.m.
We are committed to encouraging lead screenings
so that at-risk children are identified early and
intervention can begin. We want to ensure that all
CHIP members are tested. Additional communication
will take place during the year to continue this
collaboration between BCNEPA and CHIP.
(Policy Update 1601004)
(Policy Update 1601005)
6
Prepare for ICD-10 with “What’s Up Wednesday”
Who should participate?
An ICD-10 preparedness teleconference series from
Pennsylvania’s Blue Plans (Blue Cross of Northeastern
Pennsylvania, Capital BlueCross, Highmark Blue Shield
and Independence Blue Cross).
All providers, clearing-houses, trade associations and
information networks are encouraged to participate.
How do I participate?
“What’s Up Wednesday” is a monthly teleconference for
Pennsylvania’s health care professionals about the transition
to ICD-10. “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.
When is the next call?
Before the call, visit the BCNEPA ICD-10 website at
bcnepa.com. On the Provider Homepage select the
“Resources and Tools” tab; then choose the “Privacy”
link and click on “ICD-10” to access the presentation.
Then dial 1.800.882.3610 and enter pass code 5411307
when prompted. Be sure to dial in a few minutes early.
January 15, 2014: 2–3 p.m. Going forward, calls will take
place on the third Wednesday of each month.
Questions can be emailed before or during the
teleconference to ICD10Inquiries@bcnepa.com.
(Policy Update 1601006)
Dual Delivery of Electronic &
Paper Remittance Advice
Upon mutual agreement between the provider and the
health plan, the timeframe for delivery of the paper RA may
be extended by an agreed-to timeframe, at which time
the health plan will discontinue delivery of the proprietary
paper claim RA.
The Department of Health and Human Services (HHS) adopts
operating rules for the health care electronic funds transfer
(EFT) and electronic remittance advice (ERA) transactions
under the Health Insurance Portability and Accountability
Act (HIPAA). The Council for Affordable Quality Healthcare’s
committee on Operating Rules for Information Exchange
(CAQH CORE) has established the standard data elements
for EFT and ERA enrollment effective January 1, 2014.
If you can’t implement and process the health plan’s
electronic 835 following the end of the initial dual delivery
timeframe and/or after an agreed-to extension, both you
and the health plan may mutually agree to continue delivery
of the paper claim RA.
The new Electronic Remittance Advice Request Form
(ERA/835) is now available on our website at
bcnepa.com/Era835/. The ERA/835 form allows you
to receive auto-posting capability electronically.
A health plan that currently issues paper claim remittance
advices (RA) is required to continue to offer such paper RA
to each provider during that provider’s initial implementation
testing of the v5010 X12 835 for a minimum of 31
calendar days from the initiation implementation. If the
31-calendar day period does not include a minimum of
3 payments to you by the health plan, the plan is required
to offer proprietary paper claim remittance advices for a
minimum of 3 payments.
Select the type of request you are submitting:
• New—initial request to receive ERA
• Cancel—request to discontinue receipt of ERA
• Change—request to change method of receipt
(clearinghouse) of ERA
At the end of this time period, delivery of the paper claim
RA will be discontinued.
Important Notes:
• When selecting the “Change” option, the only information
you can elect to change is the clearinghouse and any
associated location.
• If you need to change any other aspect of your
remittance, you will need to submit a “Cancel” Request
Form to stop your current remittance and then submit a
“New” Request Form with your new information. Example:
If you currently receive an ERA and are changing your Tax
ID or NPI number, you will need to complete a “Cancel”
and enter a “New” request.
At the provider’s discretion, the provider
may elect to:
• Not receive the paper RA
• Choose a shorter time period
• Discontinue receiving paper RA’s before the end of the
specified timeframe by notifying the health plan of
this decision
(Policy Update 1601007)
7
New HEDIS Measures
Available Online
Diabetes—Eye Screening for Diabetic
Retinal Disease
The following HEDIS measures will be
added in January to the HEDIS Homepage:
An eye screening for diabetic retinal disease as identified by
administrative data, including a retinal or dilated eye exam by
an eye care professional (optometrist or ophthalmologist) in
the measurement year or a negative retinal or dilated eye exam
(negative for retinopathy) by an eye care professional in the year
prior to the measurement year.
Diabetes A1C Testing and Control
Measure Description:
The percentage of members 18–75 years of
age with diabetes (Type 1 and Type 2) who
had Hemoglobin A1c (HbA1c) testing, coded
as follows:
• HbA1c control (<7.0%): CPT G3044F
• HbA1c control (<8.0%): CPT G3045F
• HbA1c poor control (>9.0%): CPT G3046F
Diabetes—LDL Screening
Measure Description:
The percentage of members 18–75 years of
age with diabetes (Type 1 and Type 2) who had
the following:
• LDL—C Screening
• LDL—C Control (<100 mg/dL)
Measure Description:
Diabetes—Medical Attention for Nephropathy
Measure Description:
The percentage of members 18–75 years of age with diabetes
(Type 1 and Type 2) who had medical attention for nephropathy.
There must be documentation of a nephropathy screening
test during the measurement year or evidence of nephropathy
during the measurement year, as documented through
administrative data or medical record review.
Visit the HEDIS Homepage for these and other measures with
documentation tips, best practice and information about the
importance of these measures to your practice on our website
at bcnepa.com.
Just click on the “Providers” tab; select “Quality Management,”
and then click on the link to the HEDIS Homepage.
(Policy Update 1601008)
DME/O&P/HOSPITAL Criteria for Initial and
Continuing Participation Changes:
The following changes were made to the FPH/ FPLIC criteria for initial and continuing participation of
Durable Medical Equipment (DME), Orthotic and Prosthetic (O&P) and hospital providers:
• DME—added American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) as
acceptable accreditation.
• O&P—added National Association of Boards of Pharmacy (NABP) as acceptable accreditation.
• Hospital—added Det Norske Veritas Healthcare (DNVHC) and Center for Improvement in
Healthcare Quality (CIHQ) as acceptable accreditation.
As a reminder, please note that all facility types should notify the Credentialing department at 570.200.4384
of any changes with respect to licensure, accreditation, insurance coverage, Medicare/Medicaid sanctions,
sentinel events, etc.
These criteria changes are effective December 1, 2013. The full FPH/FPLIC criteria for initial and
continuing participation of DME, O&P and hospital providers are available upon request from your
Provider Relations Consultant.
(Policy Update 1601009)
8
2013 Results:
Medical Record Documentation
As part of FPH’s Quality Management department’s (QM) initiative for
continuous quality improvement, we evaluated primary care offices in 2013
for medical record documentation (MRD). This evaluation was part of the
recredentialing process and /or random selection.
For the 2013 audit year, the Credentialing Committee approved the continued
monitoring of the same indicators since the 2003 audit. The compliance
threshold also remains the same at 84%.
The breakdown of the results for 2013 is as follows:
In collaboration with Healthcare
Effectiveness Data and Information Set
(HEDIS) data, we added documentation
of BMI, documentation of pediatric/
adolescent nutrition education and
documentation of pediatric/adolescent
activity as focus studies also.
We will be reviewing for documentation
of BMI value for adults and children.
• Total number of offices reviewed: 100
• Network standard score: 84%
• Percentage of offices above standard: 100%
Table 1: Medical record documentation (MRD) chart audit
Documentation of pediatric/
adolescent nutrition education
and counseling for physical activity
includes a note indicating the date,
and at least 1 of the following,
discussion of current nutrition and
current physical activity behaviors:
INDICATOR
Percent Compliant
2012
2013
Medical/surgical problem list
Medication/allergy list
Social history
Immunizations listed
Past medical history
Follow-up
PCP signs labs/imaging studies
Consultant reports present
Preventative service by age
Legible
Advising smokers to quit (focus study)
99.77%
100%
97.52%
85.71%
99.78%
92.84%
97.93%
99.42%
91.11%
99.33%
87.30%
100%
100%
98.48%
97.83%
100%
91.99%
99.54%
98.99%
95.68%
100%
66.67%
• Checklist indicating nutrition and
physical activity were addressed,
counseling or referral for nutrition
education and physical activity
Documentation of BMI ped/adult
combined (focus study)
N/A
89.17%
Documentation of ped/adol nutrition
(focus study)
N/A
72.14%
Documentation of ped/adol physical
activity (focus study)
N/A
72.22%
The MRD chart audit is performed
annually. Efforts are made
to coordinate office visits for
recredentialing and/or annual HEDIS
record reviews with the MRD audit.
If you would like copies of the MRD
practice guidelines or chart forms,
please visit our website at bcnepa.com
and click on the “Provider Homepage.”
Select “Quality Management” and click
on “Practice Guidelines.” You can also
access them via Navinet.
Using the 84% threshold, Table 1 illustrates the scored indicators. Of note, there
was a significant increase in the scores from 2012 for immunizations listed,
signing of labs and imaging studies and documentation of preventative service
by age. There were no significant decreases for any of the indicator scores.
Advising smokers to quit, which is not a scored indicator, but a focus study,
decreased significantly from last year. This indicator has been up and down
over the last 3 years. Therefore, this focus study continues to offer an opportunity
for improvement.
• Member received educational
materials on nutrition and
physical activity
• Anticipatory guidance for nutrition
and physical activity
These focus studies do not impact the
overall MRD audit score.
(Policy Update 1601010)
9
Electronic Provider Access Capabilities for Providers continued on page 11
The Blue Cross® and Blue Shield® Plans are launching a new tool on January 1, 2014, that will give you the
ability to access out-of-area member’s Blue Plan (Home Plan) provider portals to conduct electronic pre-service
review. The term pre-service review is used to refer to pre-notification, precertification, pre-authorization and
prior approval, amongst other pre-claim processes. Electronic Provider Access (EPA) will enable providers to
use their local Blue Plan provider portal to gain access to an out-of-area member’s Home Plan provider portal,
through a secure routing mechanism. Once in the Home Plan provider portal, the out-of-area provider will have
the same access to electronic pre-service review capabilities as the Home Plan’s local providers.
The availability of EPA on January 1, 2014, will vary depending on the capabilities of each Home Plan. Some Home
Plans will be fully implemented and have electronic pre-service review for many services, while others will not yet
have implemented electronic pre-service review capabilities. The following describes how to use EPA and what to
expect when attempting to contact Home Plans at different stages of implementation.
How to Use the EPA Tool
The first step for providers is to go
to BCNEPA NaviNet and login as
you do today. Then, you will select
the menu option:
“Pre-Service Review for
Out-of-Area Members”
(includes pre-notification,
precertification,
pre-authorization and
prior approval).
Next, you will be asked to enter the
alpha prefix from the member’s ID
card. The alpha prefix is the first three
alpha characters that precede the
member ID.
Note: You can first check whether
precertification is required by the
Home Plan by either:
1.Sending a service-specific request
through BlueExchange
2.Accessing the Home Plan’s
precertification requirements
pages by using the medical
policy router bcnepa.com/
Providers/OutOfAreaMember/
PlanInformation.aspx
10
Electronic Provider Access Capabilities for Providers continued from page 10
Entering the member’s alpha prefix from the ID card will automatically route you to the Home Plan EPA landing
page. This page will welcome you to the Home Plan portal and indicate that you have left BCNEPA NaviNet. The
landing page will allow you to connect to the available electronic pre-service review processes. Because the screens
and functionality of Home Plan pre-service review processes vary widely, Home Plans may include instructional
documents or e-learning tools on the Home Plan landing page to provide instruction on how to conduct an
electronic pre-service review. The page will also include instructions for conducting pre-service review for services
where the electronic function is not available.
The Home Plan landing page will look
similar across Home Plans, but will be
customized to the particular
Home Plan based on the electronic
pre-service review services they offer.
Given that Home Plans are in various
states of implementation, not all
routes will result in a completed
pre-service review. You can expect
the following, depending on the
implementation status of the Home
Plan to which you have been routed.
Scenario 1:
Scenario 2:
Scenario 3:
Real-time electronic pre-service
review is available for the service
you are seeking.
The Home Plan landing page will list
the services for which electronic
pre-service review is available.
From this page you will connect
to the Home Plan’s (or its vendor’s)
pre-service review processes. You
will enter the necessary information
and the Home Plan will approve or
deny the pre-service review request
in real-time.
Electronic pre-service review is
available for the service you are
seeking, but not in real-time.
The Home Plan landing page will list the
services for which electronic pre-service
review is available. From this page you
will connect to the Home Plan’s (or its
vendor’s) pre-service review processes. You
will enter the necessary information and
the Home Plan will provide an automated
response that the pre-service review has
been pended. You will be informed as to
how the results of the final review will be
communicated to you. In most cases, the
Home Plan will email, phone or fax you
with the final determination.
Electronic pre-service review is
available, but not for the particular
service for which you are seeking
pre-service review.
The Home Plan landing page will
list the services for which electronic
pre-service review is available. For
other services, the Home Plan will
include instructions for how to
conduct pre-service review. Home
Plans will most likely list a direct
phone number or provide a form
that you can download and fax for
pre-service review.
Keep in mind that not all Home Plans
provide pre-service review 24 hours a
day. The hours of operation will be posted
on the Home Plan landing pages.
continued on page 12
11
Electronic Provider Access Capabilities for Providers continued from page 11
Frequently Asked Questions
What happens if I am not routed to the Home Plan?
In some instances, you will receive an error message when you enter the alpha prefix. This error message may alert
you that you have not entered the appropriate number of alpha prefix characters, that the alpha prefix is inactive
or that you have entered an alpha prefix for an FEP member. (FEP alpha prefixes, which start with the letter “R,” are
not supported by EPA.)
Some Home Plans do not currently have electronic pre-service review capabilities. You will receive an alert message
with a direct phone number for conducting pre-service review for these Home Plans. For example:
Blue Cross and Blue Shield of Geography does not currently conduct electronic pre-service reviews.
Please call xxx.xxx.xxxx for pre-service review.
Some Home Plans only allow providers who are under contract with the local Blue Plan to access their Home Plan
provider portal. In this event, a non-Blue provider may see the following alert when attempting to enter an alpha
prefix for a member from a Home Plan with such a restriction:
Blue Cross and Blue Shield of Geography only allows Blue contracted providers to conduct
electronic pre-service review. Please call xxx.xxx.xxxx for pre-service review.
What should I do if I enter the member alpha prefix and nothing happens?
We hope these situations are rare as we work through early implementation issues. However, if this should happen,
you should call 1.800.676.BLUE to be routed to a Home Plan for phone pre-service review.
When will all Home Plans have EPA capabilities?
We will keep you updated about Home Plan EPA implementation status.
Who do I contact if I have additional questions?
If you have any questions on how to use the EPA tool or general questions, please call your Provider Relations
Consultant at 1.800.451.4447.
(Policy Update 1601011)
12
Take Action on HEDIS:
Spirometry Testing and
Diagnosis of COPD
Focus on Quality: Working
Together to Improve Care,
Health and Cost
Use of Spirometry Testing in the Assessment and Diagnosis of
COPD is included in the HEDIS (Health Plan Effectiveness Data
and Information Set) 2014 measure. This measure reflects the
percentage of men and women 40 years of age and older with a
new diagnosis or newly active COPD, who received appropriate
spirometry testing to confirm the diagnosis. The Global Initiative
for Chronic Obstructive Lung Disease (GOLD) guidelines
recommend that clinicians should consider COPD and
perform spirometry if any of these indicators are present in
an individual over age 40:
With the introduction of Health Care Reform this past year, there
has been much focus on the U.S. health care delivery system
and the different ways to improve care. Now more than ever, it
is important to understand the challenges we face and place
emphasis on the quality and value of care that we provide.
That’s why we are working with you to ensure high quality
and cost-effective care to our members and your patients.
In order to help accomplish our goal, we refer to the
Institute of Healthcare Improvement (IHI) Triple Aim strategy.
This was developed as an approach to optimize health
system performance.
• Chronic cough: may be intermittent and may be unproductive
The Triple Aim strategy consists of:
• Dyspnea that is: progressive (worsens over time),
characteristically worse with exercise, persistent
• Improving the patient experience of care
(including quality and satisfaction)
• Chronic sputum production: any pattern of chronic sputum
production may indicate COPD
• Improving the health of populations
• Reducing the per capita cost of health care
• A history of exposure to risk factors: Tobacco smoke,
smoke from home cooking and heating fuels, occupational
dusts and chemicals
As you may know, we have already taken steps to ensure
quality care through our Quality Incentive Program (QIP).
This program rewards eligible providers for delivering high
quality, cost-effective care to our members. The QIP assesses
performance through various metrics with an emphasis on
quality and categorized into the measurement areas of quality,
administrative and cost.
• Family history of COPD
COPD is usually a progressive disease, the result of cumulative
exposures over decades. Symptoms and lung function should
be monitored to guide treatment and monitor for complications.
Spirometry, performed at least once a year, can be used to
monitor COPD progression, according to GOLD guidelines.
We are implementing this strategy by focusing on the
Patient-Centered Medical Home (PCMH) model. This is an
approach to deliver comprehensive care coordinated by
a physician or a physician-led team. Through this model,
partnerships are formed between individual patients, their
physicians, and when appropriate, the patient’s family.
This model proposes to improve care by strengthening the
patient-doctor relationship through a more comprehensive
approach to patient care and more active patient involvement.
Spirometry codes found on the PCP billable listing are
as follows:
94010
Spirometry w/Record-TOT &
Timed VC-Expir Flo Rate
$40.42
94060
Bronchodilat Respn Pre&Post
Bronchodilat Admin
$68.16
To help you and your patients meet their treatment plan, we
offer Blue Health Solution’s COPD Management and Tobacco
Cessation Programs. A care coordinator can work with your
patients in providing resources, education and support.
Eligibility requirements and referral forms are available online at
bcnepa.com. Click on the “Provider Homepage” tab and select
“Health and Wellness.” After completing the referral form, fax it to
the Health Management department at 570.200.8010. Or call
1.866.262.4764 for more information.
By incorporating the Triple Aim strategy through our quality
incentive programs and the PCMH model, we will have healthier
populations and better coordination of care. By reducing the
per capita cost of care, we can ensure the best outcomes at
the lowest cost for our members. For more information on IHI’s
Triple Aim, visit their website at ihi.org/offerings/Initiatives/
TripleAIM/Pages/default.aspx.
Please continue to check future editions of the Provider Bulletin
for more information on our quality-focused initiatives.
Sources: The Global Initiative for Chronic Obstructive Lung Disease,
National Committee for Quality Assurance, Updated 2013
Sources: Institute for Healthcare Improvement,
American College of Physicians, NCQA
(Policy Update 1512012)
(Policy Update 1512013)
13
Medical Policy Updates
New Claims Review Vendor
We are changing vendors for the review of our claims
Effective
February 1st
2014
Transplant (MPO-490-0001)
payments in the area of high-cost drugs, biologics
7.03.08—Heart/Lung Transplant
and durable medical equipment/supplies. Effective
The following language has been added to Policy:
February 2014, we have engaged the professional
• Heart/lung retransplantation after a failed primary heart/lung
transplant may be considered medically necessary in patients
who meet criteria for heart/lung transplantation.
auditing services of Trover Solutions, Inc. They will
replace the services previously provided by SCIO Health
Analytics (formerly SCIOinspire).
• Heart/lung transplantation is considered investigational in all
other situations (i.e., when medically necessary criteria has not
been met).
Trover Solutions, Inc. will be reviewing claims data
7.03.08—Heart Transplant
and medical records to determine billing accuracy
The Policy language has been updated as follows:
• Heart retransplantation after a failed primary heart transplant
may be considered medically necessary in patients who meet
criteria for heart transplantation.
and contractual compliance. Also they will determine
if and to what extent BCNEPA may have overpaid for
• Heart transplantation is considered investigational in all other
situations (i.e., when medically necessary criteria has not
been met).
services related to drugs, biologics and durable medical
equipment/supplies. As part of the review, Trover
continued on page 15
Solutions, Inc. may request records and other information
related to the provision of these services from your office
or facility. Our processes are streamlined so that this
Reminder:
review will require minimal time from you and your staff.
Therefore, we ask that you cooperate with any requests
Eye Screening for Diabetic
Retinal Disease
for records you may receive.
We have entered into a business associate agreement
A retinal or dilated eye exam is an important quality
measure monitored through the Health Effectiveness
Data Information Set (HEDIS). Both the American
Diabetes Association and the American Academy of
Ophthalmology recommend annual eye exams for all
your patients with diabetes. This test can be carried out
by either an ophthalmologist or an optometrist.
with Trover Solutions, Inc., according to the Health
Insurance Portability and Accountability Act of 1996
(“HIPAA”). This also complies with the requirements of the
Health Information Technology for Economic and Clinical
It is vital that you document this exam in the patient’s
record at his/her primary care provider’s office.
In addition, the exam should be properly coded as a
retinal or dilated eye exam.
Health Act, as incorporated in the American Recovery and
Reinvestment Act of 2009 (the “HITECH Act”).
Please make sure that you send a letter to the primary
care provider’s office verifying the exam and results as
soon as it is completed. This will ensure that the patient
is getting best practice care along with capturing this
data for HEDIS reporting.
If you have any questions or need more information,
please feel free to call your Provider Relations Consultant
at 1.800.451.4447.
(Policy Update 1601014)
(Policy Update 1601015)
14
Medical Policy Updates Effective
February 1st
2014
continued from page 14
Genetic Testing (MPO-490-0083)
2.04.109—Genetic Testing for Epilepsy
2.04.103—Genetic Testing for Macular Degeneration
The following new language has been added to Policy:
The following new language has been added to Policy:
• BCNEPA will not provide coverage for genetic testing for
epilepsy as this is considered investigational.
• BCNEPA will not provide coverage for genetic testing for
macular degeneration as this is considered investigational.
2.04.110—Genecept Assay
2.04.107—Carrier Testing for Genetic Diseases
The following new language has been added to Policy:
New Policy language has been added as follows:
• BCNEPA will not provide coverage for the Genecept™ panel
assay as it is considered investigational for all indications.
• BCNEPA will provide coverage for carrier testing when
medically necessary.
2.04.111—Microarray-based Gene Expression Analysis for
Prostate Cancer Management
Carrier testing for genetic diseases is considered medically
necessary when 1 of the following criteria is met:
The following new language has been added to Policy:
• BCNEPA will not provide coverage for microarray-based gene
expression analysis to guide management of prostate cancer
as this is considered investigational in all situations.
– The individuals have a previously affected child with the
genetic disease
– One or both individuals have a first- or second-degree
relative who is affected
2.04.08—Genetic Testing for Lynch Syndrome and Other
Inherited Colon Cancer Syndromes
– One or both individuals have a first-degree relative with an
affected offspring
Policy language has been updated to include the
following statements:
– One individual is known to be a carrier
• Genetic testing for BRAF V600E or MLH1 promoter methylation
may be considered medically necessary to exclude a diagnosis
of Lynch syndrome when MLH1 protein is not expressed in a
colorectal cancer on immunohistochemical (IHC) analysis.
– One or both individuals are members of a population known
to have a carrier rate that exceeds a threshold considered
appropriate for testing for a particular condition
AND all of the following criteria are met:
• Genetic testing for all other gene mutations for Lynch
syndrome or colorectal cancer (i.e., when medically necessary
criteria has not been met) is considered investigational.
– The natural history of the disease is well understood
and there is a reasonable likelihood that the disease is 1
with high morbidity in the homozygous or compound
heterozygous state.
Experimental/Investigative Services Pathology/
Laboratory(MPO-490-0134)
– Alternative biochemical or other clinical tests to definitively
diagnose carrier status are not available, or, if available,
provide an indeterminate result or are individually less
efficacious than genetic testing.
2.04.100—Cardiovascular Risk Panels
The following language has been added to Policy:
• BCNEPA will not provide coverage for cardiovascular risk
panels, consisting of multiple individual biomarkers intended
to assess cardiac risk (other than simple lipid panels, i.e.,
total cholesterol, LDL cholesterol, HDL cholesterol, and
triglycerides), as they are considered investigational.
– The genetic test has adequate sensitivity and specificity
to guide clinical decision making and residual risk is
understood. An association of the marker with the disorder
has been established.
• Expanded carrier screening panels are considered to be not
medically necessary.
Experimental/Investigative Services Surgery
(MPO-490-0139)
2.04.108—Fetal RHD Genotyping Using Maternal Plasma
New Policy language has been added as follows:
7.01.134—Implantable Sinus Stents for Postoperative Use
Following Endoscopic Sinus Surgery
• BCNEPA will not provide coverage for fetal RHD genotyping
using maternal plasma as this is considered investigational.
The following language has been added to Policy:
• BCNEPA will not provide coverage for the use of implantable
sinus stents/spacers for postoperative treatment following
endoscopic sinus surgery as this is considered investigational.
(Policy Update 1601016)
15
presorted
standard
u.s. postage
paid
wilkes-barre, pa
permit no. 84
19 North Main Street
Wilkes-Barre, PA 18711-0302
bcnepa.com
Address Service Requested
Editors:
Jennifer Sensky
Ann Poepperling
Blue Cross of Northeastern Pennsylvania administers health plans
for Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield,
First Priority Health® and First Priority Life Insurance Company.®
Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan
issuer in the Federally Facilitated Marketplace.
Independent Licensee of the Blue Cross and Blue Shield Association.
®Registered Mark of the Blue Cross and Blue Shield Association.
Provider Relations Department:
1.800.451.4447
How You Can Reach Us
For questions about benefits,
eligibility or claims, please call,
weekdays, between 8 a.m. and 5 p.m.:
• BlueCare® HMO/HMO Plus—1.800.822.8752
• BlueCare PPO—1.866.262.5635
Important Fax Numbers:
BC Claims....................................... 570.200.6790
(For claims adjustments, BlueCare Senior, FEP)
BC Precertification........................ 570.200.6788
• BlueCare Traditional—1.888.827.7117
BlueCard® ITS Claims.................. 570.200.6790
• BlueCare EPO—1.888.345.2353
FPH Claims..................................... 570.200.6790
(For Maternity Precertification Forms, adjustments, Claims Research Request Forms, etc.)
Valuable Health Resources:
Refer your BlueCare patients to the following Blue
Health Solutions health and wellness resources:
SM
Provider Relations........................ 570.200.6880
• Personalized health management and
wellness programs, care management resources
and much more—1.866.262.4764
Provider Customer Service......... 570.200.6868
• 24/7 Nurse Now health care information—
1.866.442.BLUE and available online at
bcnepa.com. Login to Self-Service; click on
the “Health & Wellness” tab and then
select “24/7 Nurse Now.”
FPH Non-par Referral Requests.... 570.200.6840
FPH Complaint/Grievance.......... 570.200.6770
FPH Pharmacy................................ 570.200.6870
FPH Precertification...................... 570.200.6799
Other Party Liability (OPL)......... 570.200.6790
Report Fraud:
Call our Fraud Hotline at 1.800.352.9100, or email our
Special Investigations Unit at siu@bcnepa.com.
BCNEPA Provider
Relations Consultants
Odette Ashby • 570.200.4658
Odette.Ashby@bcnepa.com
Cheryl Hashagen • 570.200.4670
Cheryl.Hashagen@bcnepa.com
Louise LoPresto • 570.200.4674
Louise.LoPresto@bcnepa.com
Jean Wiernusz • 570.200.4682
Jean.Wiernusz@bcnepa.com
Tracie Wyandt • 570.200.4647
Tracie.Wyandt@bcnepa.com
Senior Manager,
Provider Relations
Dave Levenoskie • 570.200.4673
Dave.Levenoskie@bcnepa.com
Senior Manager,
Provider Services
Kevin Quaglia • 570.200.4676
Kevin.Quaglia@bcnepa.com
QUESTIONS?
CALL PROVIDER RELATIONS AT
1.800.451.4447
© Blue Cross of Northeastern Pennsylvania. 2014.