HealthPro News

HealthPro News
A monthly publication for participating HMSA health care providers, facilities, and their staff.
November 2014
ADMINISTRATION & NEWS
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On July 31, 2014, the U.S. Department of Health and Human Services
issued a rule that finalized October 1, 2015, as the ICD-10 transition date.
This deadline allows providers, insurance companies, and others in the
health care industry time to ramp up their operations to ensure their
systems and business processes are ready to go on October 1, 2015.
Coding & Claims
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Pharmacy
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The CMS website, cms.gov, has been updated with several new topics
that might be of interest to you and helpful in your practice. CMS has
created “Road to 10” to help small practices restart their transition to
ICD-10. The Quick References section also provides resources for clinical
documentation, coding, and implementation guides. You can also view
special documentation webcasts.
Plans
5
Policy News
6
HMSA has continued its efforts to convert to ICD-10 during the delay. We’re
now developing a revised implementation schedule based on the October 1,
2015, date. We’ll share details with you as they’re finalized.
Calendar
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Medicare
Hawai‘i Medical
Service Association
Outpatient Surgical PRG List
Effective February 1, 2015, all mandatory office procedures that have
grouper assignments will be removed from the Outpatient Surgical
Procedure-Related Group (PRG) list posted in the Provider Resource
Center. If you think an office procedure should be done in a higher setting,
please contact HMSA to precertify the service. To review the list, visit
hmsa.com/portal/provider/zav_pel.fh.out.600.htm.
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Commercial QUEST
ICD-10 News
818 Keeaumoku St.
(808) 948-6330
An Independent Licensee of the Blue Cross and Blue Shield Association
P.O. Box 860
Honolulu, HI 96808-0860
hmsa.com
hhin.hmsa.com
Provider Resource Center
hmsa.com/portal/provider
1100-1074
What’s
Inside
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HealthPro News - Health Care Providers, Facilities, and Staff
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November 2014
Use Social Media
Are you on social media? Did you know …
Ninety percent of respondents 18-24 years of age say they would trust medical information shared by others
on their social media networks?
Why does this matter? A millennial’s social media network is a group of people that’s well-trusted online, which
presents an opportunity for health care professionals to connect with this group in a new and authentic way.
Sixty percent of social media users are more likely to trust social media posts and activity by doctors over
any other group.
Why does this matter? Doctors are highly revered for their opinions when shared on social media. This is even
more reason to boost your reach as a health care professional and use social media to discuss the industry.
Follow us on social media and we’ll follow you! Let’s work together, connect online, and share what we know to
advance the health of Hawaii.
Facebook: myhmsa
Twitter: @AskHMSA
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Instagram: @AskHMSA
Pinterest: @MyHMSA
Vine: @AskHMSA
LinkedIn: HMSA
YouTube: HMSANow
Using the KX Modifier Appropriately
By using the KX modifier, a DME supplier indicates that coverage criteria have been met and medical necessity has
been established as defined in the Medicare National Coverage Determinations, Noridian Medicare DME LCDs/
Articles, and/or HMSA Medical Policies. It also indicates the required documentation (including appropriate medical
record documentation) is on file at the supplier’s location and available if requested by HMSA. DME suppliers should
review the specific documentation requirements in the Medicare National Coverage Determinations, Local Coverage
Determinations (LCDs) and Policy Articles, and HMSA Medical Policies to ensure that documentation requirements
have been met.
Simply adding the KX modifier without understanding what it represents is improper billing. HMSA monitors the
use of the KX modifier and may request records for retrospective reviews to validate that the KX modifier is used
appropriately.
HMSA Akamai Advantage plans follow Medicare rules. The KX modifier is not accepted on claims under certain
HMSA medical policies for DME, prosthetics, and orthotics that require precertification. For commercial lines of
business, HMSA accepts the KX modifier for the following items:
• AFO/KAFO.
• Cervical traction units.
• Commodes.
• Continuous positive airway pressure devices (CPAP).
• External infusion pumps (except insulin pumps
and CGMS).
• Hospital beds.
• Manual wheelchair bases (except K0004,
K0005, K0009).
• Nebulizers.
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Commercial QUEST
Medicare
• Orthopedic footwear.
• Patient lifts.
• Prefabricated knee orthoses.
• Pressure-reducing support surfaces.
• Speech generating devices.
• Therapeutic shoes for people with diabetes.
• Walkers.
• Wheelchair options/accessories (except for E1399
and K0108).
• Wheelchair seating (except for E1399 and K0108).
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HealthPro News - Health Care Providers, Facilities, and Staff
November 2014
CODING & CLAIMS
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Chlamydia Screening
Chlamydia trachomatis is one of the most common sexually transmitted infections in the U.S. This infection is most
prevalent among sexually active adolescent and young adult women. This often can be a sensitive subject for these
women. Confidentiality is very important for your patient. You should know that:
• A chlamydia screening will display as “Diagnostic Lab” on a claims report.
• The Report to Member (RTM) will also indicate “Diagnostic Lab” for a chlamydia screening.
Based on the eligibility of the member, you may qualify for reimbursement. As a note, screenings submitted directly
to the Hawaii Department of Health are not eligible for HMSA reimbursement.
For sexually active female patients ages 16-24, please use the CPT codes listed below to file claims that identify
chlamydia screenings. Using these codes:
• Eliminates the need for you to manually log the screenings in Cozeva; the data is automatically applied to your
pay-for-quality measures (to those that are eligible).
• Reduces the need for supplemental audit of your data.
• Provides HMSA with valuable data to track trends.
CPT Code
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Description
87110
Culture, chlamydia, any source
87270
Chlamydia trachomatis, immunoflorescent
87320
Chlamydia trachomatis, EIA, qualitative or semi- qualitative
87490
Chlamydia trachomatis, direct probe technique
87491
Chlamydia trachomatis, amplified probe technique
87492
Chlamydia trachomatis, quantification
87810
Chlamydia trachomatis, direct optical observation
Revised CMS-1500 Form
Beginning October 1, 2014, paper claims must be submitted using the revised CMS-1500 form (version 02-12).
We are no longer accepting the previous version.
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Updates to Bright Futures Recommendations
The American Academy of Pediatrics/Bright Futures released the 2014 Recommendations for Preventive Pediatric
Health Care (Periodicity Schedule) and a new resource titled Achieving Bright Futures, which provides guidance on
the service categories recommended at each Bright Futures preventive care visit. HMSA refers to these documents
to stay in compliance with Affordable Care Act requirements on preventive care. We encourage providers to
familiarize themselves with these documents, which can be found via the American Academy of Pediatrics website:
2014 Recommendations for Preventive Pediatric Health Care:
aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf
Achieving Bright Futures:
aap.org/en-us/professional-resources/practice-support/Pages/achieving-bright.aspx
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Commercial QUEST
Medicare
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November 2014
PHARMACY
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Hydrocodone Scheduling Change: Hydrocodone Combination Products (HCPs)
Beginning October 6, 2014, the U.S. Drug Enforcement Administration (DEA) changed all hydrocodone combination
products (HCPs) from Schedule III to Schedule II of the Controlled Substance Act (CSA).
Why? The CSA places substances with accepted medical use into one of four schedules. Substances that have the
highest potential for harm and abuse are in Schedule II and substances with progressively less potential for harm and
abuse are in Schedules III through V.
What does this mean for my patients? Active hydrocodone prescriptions are void and patients will need new hard
copy prescriptions to get future HCPs after October 6, 2014. Prescriptions written for HCPs after October 6, 2014,
cannot be written to allow refills.
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New FDA-Approved Drug for Treatment of Hepatitis C
On October 10, 2014, the FDA approved Harvoni (ledipasvir/sofosbuvir), the first all-oral, interferon-free regimen to
treat chronic hepatitis C genotype 1 infection in adults. Precertification is required for this drug and can be obtained
through CVS/Caremark. As Harvoni’s primary component is sofosbuvir (Sovaldi), the criteria in the Sovaldi policy are
applicable, as appropriate, until a medical policy specific to Harvoni can be developed.
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Specialty - Commercial Medical Plans
Relevant Changes to Specialty Drugs Processing through the Medical Benefit
Generic Name
sodium hyaluronate
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Brand Name
Drug Class
Monovisc, Orthovisc, Gel-One, Hyalgan,
Supartz, Euflexxa, Synvisc, Synvisc One
Osteoarthritis
(Hyaluronic acid
derivatives)
Current
Tier
Tier
effective
2/1/15
Specialty
Specialty
Utilization Management
Description
Prior authorization and step
therapy will be applied
New Large Print Prescription Label Available at Mail Order
CVS/Caremark, HMSA’s mail-order pharmacy vendor, is now offering an easier-to-read prescription label for your
patients with vision difficulties. Request this benefit for your patients by putting “Large Font” on their mail-order
prescription. To provide clarity for the prescription entry technicians, please separate these words from the drug
name and dosing instructions. Once a member has opted in for large-print labels, all future labels will be large print.
Remember that mail order saves trips to the pharmacy, improves adherence, and can save money for your Akamai
Advantage members. Please encourage use of 90-day fills by mail for maintenance medications.
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Commercial QUEST
Medicare
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HealthPro News - Health Care Providers, Facilities, and Staff
November 2014
PLANS
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QUEST Referral Policy
As a reminder, PCPs no longer need to register patient referrals to most HMSA participating specialists. If the
specialist participates with HMSA QUEST and practices on the patient’s island of residence, then the PCP doesn’t
have to register the referral with HMSA QUEST.
Specialists should document the referral in their patients’ medical records. If a referral isn’t in your medical records,
please contact the PCP to confirm if specialty care is recommended.
PCPs still need to register referrals for the following types of services to ensure the specialists’ claims are paid:
• All off-island specialty care involving patient travel.
• Plastic surgery.
• Rehabilitation services.
• Dermatology services.
Principles of the referral policy
• PCPs will continue to manage and coordinate their patients’ care and to be the source of referral for
specialty care.
• We discourage patients from self-referring to specialists. We emphasize the importance of communication and
collaboration between PCPs and specialists. In the interest of continuity of care, PCPs should document in
their medical records that they have referred the patient to a specialist. Specialists, in turn, should document
in their medical records that the patient was referred by the PCP and communicate the findings of the
consultation or the results of the procedure.
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QUEST Provider Handbook Updates – HMSA QUEST 24-Hour Nurse Advice Line
There have been changes to sections of the QUEST Provider Handbook. The changes include information on the
HMSA QUEST 24-Hour Nurse Advice Line that our QUEST members can call free of charge to speak with a nurse 24
hours a day. The nurse can answer medical questions and advise whether members should apply home care, make
an appointment to see their PCP, or go to the emergency room for immediate care.
Let your HMSA QUEST patients know about the availability of the HMSA QUEST 24-Hour Nurse Advice Line and
encourage them to call when they need to speak with a medical professional at any time. The number is 948-6486
on Oahu or 1 (800) 440-0640 toll-free on the Neighbor Islands.
QUEST – Enabling Services: j.mp/hmsa-prc0080
QUEST – Emergent/Urgent Care: j.mp/hmsa-prc0081
QUEST – Responsibilities of the PCP: hmsa.com/prc0049
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Commercial QUEST
Medicare
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HealthPro News - Health Care Providers, Facilities, and Staff
November 2014
POLICY NEWS
Medical policies are at hmsa.com/prc0004. For copies, call Provider Services at 948-6330 on Oahu or
1 (800) 790-4672 toll-free on the Neighbor Islands.
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Magnetic Resonance Spectroscopy (MRS) – Precertification Required
Effective December 1, 2014, MRS will be covered for the following:
• To differentiate post-treatment tumor recurrence from post-treatment scarring/abnormalities.
• When there is evidence or suspicion of neonatal hypoxic ischemic encephalopathy.
Precertification will be required for MRS. This requirement applies to all providers whether or not the provider is
waived from the precertification requirements for advanced imaging services. The MRS Clinical Practice Guidelines
can be found on RadMD.com. Precertification can be obtained from NIA by logging on to RadMD.com or by calling
1 (866) 306-9729 toll-free.
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New Policy Drafts Online for Review
Drafts of new medical policies are posted online for your review. Please visit hmsa.com/prc0005 in the Provider
E-Library for drafts of policies that may affect your practice.
Please comment by the due date indicated online. You can send email to medical_policy@hmsa.com or fax
944-5611 on Oahu. For questions, call Provider Services at 948-6330 on Oahu or 1 (800) 790-4672 toll-free
on the Neighbor Islands.
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Annual Review of Medical Policies
The following policies have undergone review and have been updated in the Provider E-Library at hmsa.com/
prc0006; printed copies are available on request.
• Apnea Monitors for Infants.
• Bariatric Surgery.
• Complementary Alternative Medicine.
• Forteo (Teriparatide).
• Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia.
• Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, including Multiple Myeloma and
POEMS Syndrome.
• Home Phototherapy for Neonatal Jaundice.
• Low Molecular Weight Heparin.
• Remiciade (infliximab).
• Transcutaneous Electrical Nerve Stimualtions (TENS).
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Commercial QUEST
Medicare
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HealthPro News - Health Care Providers, Facilities, and Staff
November 2014
POLICY NEWS (continued)
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90-Day Notice for Policy Changes
The following policies have been updated and are effective February 1, 2015.
• Durable Medical Equipment, Prosthetics, and Orthotics (private business); the administrative guidelines include
revisions that can be found at hmsa.com/portal/provider/zav_pel.aa.DUR.501.htm.
• Durable Medical Equipment, Prosthetics, and Orthotics (small group and individual plans, Fed87, and QUEST
Integration): The administrative guidelines include revisions that can be found at
hmsa.com/portal/provider/zav_pel.aa.DUR.601.htm.
• Home continuous inotropic infusion therapy: The criteria/guidelines and references include revisions that can
be found at hmsa.com/portal/provider/zav_pel.aa.HOM.351.htm.
• Occupational therapy: The criteria/guidelines, administrative guidelines, and references include revisions that
can be found at hmsa.com/portal/provider/zav_pel.aa.OCC.601.htm.
• Physical therapy: The limitations/exclusions and references include revisions that can be found at
hmsa.com/portal/provider/zav_pel.aa.PHY.601.htm.
• Zevalin (Ibritumomab tiuxetan): The criteria/guidelines, limitations/exclusions, and references include revisions
that can be found at hmsa.com/portal/provider/zav_pel.ph.ZEV.500x.htm.
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New Policies
A new policy for Afirma goes into effect February 1, 2015. We encourage you to read the criteria before the
effective date.
Please refer to the current medical policy online for more information, including precertification requirements,
at hmsa.com/prc0006.
Correction: The following policies were mistakenly listed in the October HealthPro News with the wrong effective
date. They will go into effect February 1, 2015.
• Posterior Tibial Nerve Stimulation.
• Tilt Table Testing.
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Specialty Drugs that Require Precertification
Effective September 5, 2014, the following drugs require precertification as provided for under our policy that all new
specialty drugs require precertification, effective on the date of approval by the FDA.
CPT Codes
J3490/J3590
Description
Ruconest (recombinant human C1 esterase inhibitor)
Effective September 18, 2014, the following drugs require precertification as provided for under our policy that all
new specialty drugs require precertification, effective on the date of approval by the FDA.
CPT Codes
J3490/J3590
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Commercial QUEST
Medicare
Description
Keytruda (pembrolizumab)
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HealthPro News - Health Care Providers, Facilities, and Staff
November 2014
CALENDAR
QUEST Integration
Informational Session
SAVE THE DATE!
A QUEST Integration informational session
is coming soon, so book the date so you
don’t miss out!
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For more information, refer your patients to
hmsa.com/wellness-programs/workshops or have them
call 1 (855) 329-5461 toll-free to register.
Germ Busters
Find out about common respiratory illnesses and their
symptoms, treatment, and prevention.
• 11/3, 5:30–6:30 p.m.
Kauai Healthways Office
Explore ways to obtain necessary nutrients for a
healthy lifestyle without eating meat.
• 11/6, 6–7 p.m.
Kapi‘olani Women’s Center at Artesian Plaza,
Honolulu
Season’s Eatings
Discover strategies to maintain your health and
weight during the tempting holiday season.
• 11/10, 10–11 a.m.
HMSA Kailua-Kona Office
Diabetes 101
Learn about recommended tests and procedures for
diabetes and ways to improve your blood glucose levels.
• 11/19, 12:30–1:30 p.m.
Kalihi YMCA
• 11/7, 4:30–5:30 p.m.
HMSA Center @ Honolulu
• 11/8, 9:30–10:30 a.m.
Kaimuki Plaza, Kaimana Room
• 11/17, 10–11 a.m.
HMSA Kailua-Kona Office
• 11/18, 5:30–6:30 p.m.
HMSA Center @ Hilo
Medicare
Meatless Alternatives
• 11/15, 5:30–6:30 p.m.
Kaimuki Plaza, Kaimana Room
• 11/4, 10–11 a.m.
HMSA Maui Office, Kahului
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If you can’t make it to the session in person,
we’re also making it available live via the Web,
so you can view the session at one of our
offices or at your home or office. We’ll also
record the session and make it available online
in the HMSA Provider Resource Center.
Well-Being Workshops
The workshops listed below are available to HMSA
members at no cost. These informative sessions are
presented by Healthways health educators and can help
your patients improve their health and well-being.
Commercial QUEST
November 19, 2014
Noon-2 p.m.
QMC Conference Center
Exercise: the Magic Bullet
Learn fun and convenient ways to be more active.
• 11/13, 5:30–6:30 p.m.
HMSA Center @ Pearl City
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November 2014
CALENDAR (continued)
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Community Classes
Walk With a Doc on Hawaii Island
Adult Fitness at Queen’s
Meet up, rain or shine, for some beneficial, low-impact
exercise. Walk includes a brief warm-up/stretch and
an informative talk from a community doctor or
medical student. First-time walkers get a free T-shirt
and pedometer. For more information, see
wwadbigisland.org.
The Queen’s Medical Center, Women’s Health Center
Classroom. Six classes for $66. Call 691-7117 to register.
• Every Sunday, 8 a.m.
Liliuokalani Gardens, Hilo
The Great American Smokeout
Ready to quit smoking? We can do it together!
The Queen’s Cancer Center, The American Cancer
Society, and I Ola Lahui will be hosting an awareness
event on the hazards of smoking. Get informational
materials from the American Cancer Society and talk
to a professional facilitator about free smoking cessation
classes with incentives. No registration needed. Call
691-8984 for more information.
• November 20, 2014, 11 a.m.-1 p.m.
Queen’s Medical Center Harkness Kiosk
Health & Education at Queen’s
The Queen’s Medical Center, Women’s Health
Center Classroom
• Genetics Class: Learn about prenatal genetic
screening and tests to check the health of your baby.
Call 691-7633 for times and information. Free.
• Lamaze Class: Sundays, 1 p.m.–4 p.m. Get birthing
techniques from a Lamaze-certified instructor in
this birth-partner-focused class. $150 per couple for
five sessions.
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Commercial QUEST
Medicare
• Pilates and Yoga with Fitness Cue: Mondays,
noon–1 p.m. Strengthen and lengthen muscles and
improve spinal health and alignment. Instructor:
Li Si Yang.
• Bollywood and Beyond: Tuesdays, 4:30–5:30 p.m.
Perform upbeat and expressive movements from
around the world. Instructor: Willow Chang.
• Journey to Fitness Pyramid: Wednesdays, noon –
1 p.m. Learn corrective exercises and five principles
of good health and fitness. Instructor: Li Si Yang.
• Kickboxing Fitness: Thursdays, 6–7 p.m. Tone your
body using mitts, kick pads, and standing heavy
bags. Instructor: Mineyo Shimojo.
• Jazzercise: Fridays, noon –1 p.m. Dance-based
cardio and strength training. Instructor:
Sheri Yamashita.
Wellness at Castle Medical Center
Castle Medical Center, Castle Wellness Auditorium,
Kailua. Call 263-5400 or visit castlemed.org to register.
• Fit and Fantastic Feet: Tuesday, November 4,
1–2:30 p.m. Healthy feet will make for a happier you.
Shed your shoes for this session on foot exercises
and self-massage techniques for your feet. Presented
by Eileen Towata, Ph.D, PMA® certified Pilates
teacher. $15/person. Registration required.
• Lymphedema/Breast Cancer Clinic: First and third
Wednesdays, 1–2 p.m. Learn exercises to prevent
lymphedema (swelling of the arms). Free.
• In Sickness & In Health: Modern Treatment of
Varicose Veins: Thursday, November 13, 6–7:30 p.m.
Learn the latest techniques to relieve leg pain
and swelling. Outpatient treatments in a physician’s
office are now available. Presented by Dr. Sonny
Wong. Free.
• Mammogram and Cervical Cancer Screening:
Every other Friday, 8 a.m.–noon. Free for women
ages 50–64, uninsured or underinsured, or low
income. Call 691-7726 for times and eligibility
information.
• Eat Well For Life: Pupus for Parties: Thursday,
November 20, 6–7:15 p.m. Just in time for the
holiday entertaining, these tasty and healthy nibbles
are sure to be a hit at your holiday gatherings.
$10/person. Registration required.