VOLUME 14 • ISSUE 5 • MAY 2012 Administrative Practice Guideline Updates The following Administrative Practice Guidelines have been reviewed and/or updated, effective March 20: 1. Accessibility/availability: non-physician specialists and behavioral health facilities 2. Facility and environment: non-physician specialists and behavioral health facilities 3. Facility and environment: oral surgeons/dentists 4. Behavioral health medical record documentation 5. Credentialing criteria for obstetric nurses in home care 6. Credentialing criteria for newborn/ pediatric nurses in home care 7. Home care/plan of care 8. Home care medical record documentation Where Can You Find the Guidelines? Administrative Practice Guidelines are available at www.bcnepa.com. Just click on the “Provider Homepage,” then “Quality Management” and select “Quality Management Practice Guidelines.” You can also find them by logging on to NaviNet®. If you are not able to access the guidelines online and would like a hardcopy, please call Jill Sikorski at 570.200.4376, weekdays, between 8 a.m. and 5 p.m. (Policy Update 1405001) CMS Announces Delay in On April 9, the Department of ICD-10 Implementation Health and Human Services (HHS) announced a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014. This is the date by which covered entities must comply with International Classification of Diseases (ICD-10). Please note: The announcement by HHS is a “proposed rule” that must still be approved by HHS before it becomes final. Therefore, providers who are working on their efforts to transition to ICD-10 should continue along that path. Please continue to check upcoming issues of Provider Bulletin for more information on ICD-10 implementation timeframes. (Policy Update 1405002) How to Submit Claims First Priority Health® (FPH) and First Priority Life Insurance Company® for Services Provided by (FPLIC) would like to remind you that Employed Practice Extenders services given to our members are to be provided personally by the credentialed, contracted practitioner or by a licensed physician extender employed by the practitioner. We recognize the following advanced practice professionals as physician extenders: • Physician Assistant • Certified Registered Nurse Practitioner • Certified Registered Nurse Anesthetist • Certified Nurse Midwife Please submit claims for the services of an employed physician extender with the credentialed practitioner information as the performing provider, since we do not credential employed physician extenders individually. Please note: We do not provide coverage for services given by unlicensed professionals or massage therapists. (Policy Update 1405003) Table of Contents 2 New Electronic Remittance Advice (ERA/835) Request Form 4 Medical Policy Updates 3 Update: BCNEPA Expands 6 Patient Review of Physicians to Launch in July NaviNet Access to Entire Provider Network updates New Electronic Remittance Advice (ERA/835) Request Form Blue Cross of Northeastern Pennsylvania (BCNEPA) is pleased to announce that the new Electronic Remittance Advice Request Form (ERA/835) is now available on our website at www.bcnepa.com/ Providers/. The ERA/835 form allows providers/facilities to receive auto-posting capability electronically. If you submit NUCC 1500 paper claim forms, please follow these steps: 1.Use approved HCFA 08/05 claim forms. 2.Type all information within the boundaries of the fields you are reporting. Select the type of request you are submitting: • • • Steps to Submit NUCC 1500 Claim Forms New—Initial request to receive ERA Discontinue—Request to discontinue receipt of ERA Change—Request to change method of receipt (clearinghouse) of ERA 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 “Discontinue” 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 “Discontinue” and enter a “New” request. • For all 3 types of requests (New, Discontinue and Change), before sending/submitting the request, please print the form for your records. • Once your ERA/835 request is completed, you will be contacted via the email 3.Ensure all data are reported in its entirety. Following these guidelines will help ensure claims are read correctly by the scanning systems and processed correctly. For more information, visit the Highmark Provider Resource Center at https://prc.highmark.com/rscprc/hbcbs/pub. Click on “Administrative Reference Materials.” There you can find the Highmark Blue Shield Office Manual (chapter 5) that contains proper claim submission techniques. address you provided on the Request Form with the date you will begin receiving your ERA/835. Sign Up for EFT, Too! In conjunction with the ERA/835, all FPLIC providers are encouraged to receive an electronic funds transfer (EFT). An EFT will allow you to receive your claim payments promptly. With the acceptance of EFT, you will no longer receive a paper remittance advice (RA) or an explanation of benefits (EOB) statement. We will eliminate the printing and mailing of the RA and EOB. If you are interested in receiving EFT, please fax the following information to 570.200.7707: • Provider group/facility name (Policy Update 1405005) New Alpha Prefix: LPO Effective April 1, a new FPLIC PPO alpha prefix, LPO, has been added to our list of custom groups. This is not a BlueCard alpha prefix. Therefore, participating provider claims must be sent to FPLIC, not Highmark. All benefit and eligibility • Provider TIN files have been updated in NaviNet for this group. • Contact person name, phone number and email address (Policy Update 1405006) (Policy Update 1405004) 2 Reminder: Route Inquiries Through NaviNet When Possible BCNEPA NaviNet-enabled providers are reminded that all routine inquiries must be routed electronically through NaviNet, rather than by calling a BCNEPA Customer Service Representative. BCNEPA has worked diligently to enhance our enrollment & billing, claims status and claims investigation transactions to ensure you have all the information you need through NaviNet. However, you may continue to call BCNEPA Customer Service with unusual issues or concerns that require considerable investigation and/or support. BCNEPA Customer Service Representatives can tell you how to use NaviNet for enrollment & billing, claims status and claims investigation inquiries. They can redirect you to NaviNet to take advantage of the tools available to answer the inquiry. Please note: If you have multiple offices/ locations, you must ensure that NaviNet access is granted to each office/location that may need functionality. Only the provider’s NaviNet security officer has the capability to grant “user” access under each provider’s NaviNet account. More details on granting user access is available under the “Customer Support” link, once you sign on to NaviNet. If you are not yet NaviNet enabled, you may continue to contact BCNEPA’s Customer Service department when needed. Please refer to the article entitled “BCNEPA NaviNet Expansion” in this edition of the Provider Bulletin for more information on how to obtain BCNEPA NaviNet access. (Policy Update 1405007) Update: BCNEPA Expands NaviNet Access to Entire Provider Network As we informed you in previous editions of our Provider Bulletin, we understand the importance of real-time electronic capabilities and are excited to announce the expansion of BCNEPA NaviNet access to our entire provider network. We continue to work on Phase 2 of our NaviNet expansion and ask you to provide us with the following information to establish your NaviNet access, if you haven’t already done so: 1. Provider group/facility name 2. Provider TIN 3. Provider (group/facility) Type II NPI 4. Provider FPH/FPLIC legacy number(s) 5. Provider’s NaviNet security officer contact name 6. Provider’s NaviNet security officer phone number 7. Provider’s NaviNet security officer email address 8. For professional groups, please list all physicians employed with the group (include each individual provider name, NPI, FPH/FPLIC legacy numbers) Please email the above information to [email protected] Once we receive the above information, we will establish your BCNEPA NaviNet access as soon as possible. NaviNet will send you an email at the address you provided to finalize your access. Please indicate if you would like to participate in a NaviNet training webinar by a BCNEPA Provider Relations Representative in your email. A BCNEPA Provider Relations Representative will follow up with you to schedule your NaviNet training webinar. Please note: • Once you are enabled with BCNEPA NaviNet, you must use our eligibility and benefits inquiry, claims status inquiry and claims investigation transactions for routine enrollment and billing and claims inquiries instead of calling BCNEPA’s Customer Service. You will be given a 90-day grace period from the date you receive access before you are required to use NaviNet for routine enrollment and billing and claims inquiries. • PCPs who receive their BCNEPA NaviNet access in Phase 2 will no longer receive their capitation roster via regular mail. Instead, you can access your capitation rosters via NaviNet. Please continue to check future issues of Provider Bulletin for additional information on our NaviNet expansion. (Policy Update 1405008) DRG Utilization Management Process Change ve Effecti12 6/04/ Beginning June 4, BCNEPA will no longer automatically authorize 7 days’ length of stay at acute care facilities. Instead, we will assign length of stay according to the recommendations of InterQual® criteria. This change will allow us to appropriately coordinate care according to nationally recognized and accepted criteria, and enable us to better manage overall costs of care and quality outcomes. (Policy Update 1405009) 3 ve Effecti12 6/01/ Medical Policy Updates Durable Medical Equipment (DME) (MPO-490-0006) Eligibility for coverage criteria of various DME items have been added to this policy. Dynamic splinting devices and traction equipment are examples of items which will now require clinical review, and the criteria are as follows: Dynamic Splinting Devices • Dynamic Low-load Prolonged-duration Stretch (LLPS) Devices BCNEPA will provide coverage for dynamic low-load prolonged-duration stretch (LLPS) devices, when medically necessary. 1. Dynamic low-load prolonged-duration stretch devices (LLPS) for the knee, elbow, wrist or finger (including, but not limited to, Dynasplint Systems, LMB Pro-glide, EMPI Advance Ultraflex and Advanced Biomedics) may be considered medically necessary for use on the knee, elbow, wrist or finger in any of the following clinical settings: a) As an addition to physical therapy in the subacute injury or postoperative period (≥ 3 weeks but ≤ 4 months after injury or operation) in patients with signs and symptoms of persistent joint stiffness or contracture: • For an initial period of up to 4 months; and • If the patient shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated; OR b)In the subacute injury or postoperative period (≥ 3 weeks but ≤ 4 months after injury or operation) in a patient whose limited range of motion poses a meaningful (as judged by the physician) functional limitation, AND who has not responded to other therapy (including physical therapy): • For an initial period of up to 4 months; and • If the patient shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated; OR c) In the acute postoperative period for patients who have undergone additional surgery to improve the range of motion of a previously affected joint: • For an initial period of up to 4 months; and • If the patient shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated; OR d)For patients unable to benefit from standard physical therapy modalities because of an inability to exercise: • For an initial period of up to 4 months; and • If the patient shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated. 2. If there is no significant improvement after 4 months of use, dynamic LLPS devices for the knee, elbow, wrist or finger are considered not medically necessary under any circumstance, including but not limited to, use in patients unable to benefit from standard physical therapy modalities because of an inability to exercise. 4 3. Dynamic LLPS devices used for all other conditions are considered not medically necessary. 4. Dynamic LLPS devices which are specific to the ankle, toe and shoulder are considered investigational for all indications including, but not limited, to the management of chronic joint stiffness or chronic or fixed contractures. •Bi-directional Static Progressive (SP) Stretch Devices 5. Bi-directional static progressive (SP) stretch devices (e.g., Joint Active Systems Static Progressive Stretch) are considered investigational for all indications. • Patient-actuated Serial Stretch (PASS) Devices 6. Patient-actuated serial stretch (PASS) devices (e.g., ERMI Knee, MPJ, or Elbow Extensionator®, ERMI Knee/Ankle or Shoulder Flexionator®) are considered investigational for all indications. Traction Equipment BCNEPA will provide coverage for traction equipment, when medically necessary. 1. Traction equipment may be considered medically necessary when all of the above DME criteria have been met, and 2. The patient has a musculoskeletal or neurologic impairment requiring traction which prevents ambulation during the period of use. 3. Traction equipment is considered not medically necessary when the above criteria have not been met. 4. Traction equipment, including but not limited to, the following: ambulatory devices, pneumatic devices, devices attached to a headboard or a free-standing frame is considered not medically necessary. Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions Policy language has been added as follows: • Intravitreal injection of ranibizumab or bevacizumab may be considered medically necessary for the treatment of the following retinal vascular conditions: Electrical/Neuromuscular Stimulator (MPO-490-0018) Vagus Nerve Stimulation The policy was updated as follows to include 2 new investigational conditions: • Vagus nerve stimulation as a treatment of other conditions including, but not limited to, heart failure, fibromyalgia, depression, essential tremor, headaches and obesity is considered investigational. Transcatheter Embolization (MPO-490-0126) Transcatheter Arterial Chemoembolization (TACE) to Treat Primary or Metastatic Liver Malignancies a) Diabetic macular edema b) Proliferative diabetic retinopathy as an adjunctive treatment to vitrectomy or photocoagulation c) Macular edema following central retinal vein occlusion* d) Macular edema following branch retinal vein occlusion* * FDA-approved indication (Lucentis) • Intravitreal injection of bevacizumab may be considered medically necessary for the treatment of stage 3+ retinopathy of prematurity. • Intravitreal injection of aflibercept may be considered medically necessary for treatment of diabetic macular edema. • Intravitreal injection of aflibercept is considered investigational for treatment of other retinal vascular disorders, including proliferative diabetic retinopathy and central or branch retinal vein occlusion. Experimental/Investigative Services— Radiology (MPO-490-0137) Screening for Lung Cancer Using CT Scanning The following new language has been added: Our policy has been updated as follows: • Transcatheter hepatic arterial chemoembolization BCNEPA will provide coverage for screening for lung cancer using low-dose computed is considered investigational to treat unresectable tomography (CT) scanning, when medically necessary. cholangiocarcinoma. 1. Low-dose computed tomography (CT) scanning, not more frequently than Experimental/Investigative Services— Pathology/Laboratory (MPO-490-0134) Thromboxane Metabolites The following new language has been added to policy: • BCNEPA will not provide coverage for measurement of urine levels of Thromboxane metabolites (e.g., AspirinWorks®) to determine aspirin nonresponse or resistance, as this is considered investigational. Experimental/Investigative Services— Ophthalmologic (MPO-490-0136) Corneal Collagen Cross-linking annually for 3 consecutive years, may be considered medically necessary as a screening technique for lung cancer in individuals who meet all of the following criteria*: a) Between 55 and 74 years of age b)History of cigarette smoking of at least 30 pack-years c) If former smoker, quit within the previous 15 years * Patient selection criteria are based on the National Lung Screening Trial (NLST). 2. Low-dose CT scanning is considered investigational as a screening technique for lung cancer in all other situations. Experimental/Investigative Services—Medicine (MPO-490-0138) Chromoendoscopy as an Adjunct to Colonoscopy The following new statement has been added to policy: The following language has been added to medical policy: • BCNEPA will not provide coverage for chromoendoscopy or virtual chromoendoscopy • BCNEPA will not provide coverage for corneal as they are considered investigational as an adjunct to diagnostic or surveillance collagen cross-linking, as this is considered colonoscopy. investigational for all indications. Light Therapy for Vitiligo The following statement has been added to policy: • Targeted phototherapy is considered investigational for the treatment of vitiligo. (Policy Update 1405010) 5 Patient Review of Physicians to Launch in July Blue Plans are committed to providing Blue members with the tools they need to effectively partner with their doctors and make more informed health care choices. We are pleased to announce the Patient Review of Physicians Blue Consumer Engagement Initiative that will launch in July 2012 on the redesigned Blue National Doctor & Hospital Finder website. Patient Review of Physicians (PRP) This initiative allows Blue members to view and post reviews of doctors and other professional providers, based on their patient experiences. Approximately 85–90% of patient reviews are positive, and BCNEPA has implemented a rigorous process that authenticates reviews before posting on the Blue National Doctor & Hospital Finder website. Not only do patient reviews help members make more informed decisions when choosing a doctor, they are also a valuable way for physicians to gain insights into their current patients’ experiences and to attract new patients. BCNEPA to roll out patient reviews of providers BCNEPA will also display patient reviews of local providers on its “Doctor/Hospital Finder,” beginning July 2012. You can see reviews when you login to “Self-Service,” on www.bcnepa.com. These reviews will also be displayed nationally on the Blue National Doctor & Hospital FinderSM at www.bcbs.com in July 2012. Delivering Blue patient reviews to support real-time decision-making Blue Patient Review is an online review system that Blue members can use as part of their decision-making when they are selecting a doctor or other professional provider. BCNEPA delivers information about patients’ actual experiences with their physicians and other professional providers through an easy-to-use, nationally consistent online survey and aggregated results display. Because only Blue members can write Blue patient reviews, they can be trusted to accurately reflect members’ opinions, boosting the integrity of the results beyond popular public review sites. How it works BCNEPA has taken a number of steps to ensure that Blue Patient Reviews deliver valid and trustworthy data: • Use of a national question set Patients review their doctors using a nationally consistent set of questions that cover various aspects of their visit. • Authentication of all Blue members Only Blue members who login through the BCNEPA member portal can write a review. This ensures that patient review contributions remain an exclusive benefit to Blue members. • Validation of all Blue members writing reviews BCNEPA members must verify they have seen the doctor or professional provider they intend to review before they are allowed to access the review form. The verification takes place through a member attestation. • Moderation of all open text comments For security and privacy purposes, reviews that contain user-generated content (such as free-form comments) must undergo both software and human review before the content is displayed. Benefits of displaying Blue patient reviews You can trust Blue patient reviews to complement your practice improvement efforts, provide insights into your patients’ experiences and attract new patients. While patient reviews are just one of many factors patients consider when choosing a health care provider, research shows that online patient review capabilities are in high demand. User-generated patient reviews are one of the most sought-after pieces of information for consumers looking for a new doctor. To assure that your overall score is positive, encourage your patients to contribute to your reviews. Engaging and empowering consumers to make more knowledgeable health care decisions is a fundamental priority for BCNEPA. We are committed to working hand-in-hand with you to deliver information and tools that can help your patients take a proactive approach to their families’ health. 6 HERE Is AN Example OF the core patient review questions: Questions 1 and 2 are required for a review to be submitted. The remaining questions are optional, including member comments. The questions cover the same topics of care for Blue members nationwide but may vary in the exact wording. Here is an example of what PRP results will look like on the Blue National Doctor and Hospital Finder: For illustrative purposes only. The Blues will continue to collaborate with national medical specialty societies and medical boards to identify programs and resources that can be leveraged to support additional quality improvement and recognition opportunities. The Blues also provide ongoing feedback to federal health care improvement and reporting programs to support physicians and group practices and align our consumer engagement approaches. BCNEPA welcomes the opportunity to discuss these new initiatives in detail with you. Please contact your Provider Relations Consultant for more information and to schedule a meeting time. (Policy Update 1405011) 7 presorted standard u.s. postage paid wilkes-barre, pa permit no. 84 19 North Main Street, Wilkes-Barre, Pennsylvania 18711-0302 www.bcnepa.com Address Service Requested Editor: 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®. 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 Department...........................570.200.6790 (For claims adjustments, BlueCare Senior, FEP) BC Precertification Department...........570.200.6788 • BlueCare Traditional—1.888.827.7117 BlueCard® ITS Claims.............................570.200.6790 • BlueCare EPO—1.888.345.2353 FPH Claims Department........................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 SolutionsSM health and wellness resources: • Health Management Programs for disease, care and lifestyle management—1.866.262.4764 • 24/7 Nurse Now health care information— 1.866.442.BLUE and available online at www.bcnepa.com. Login to “Member Self-Service” and click on “MyHealth Coach Chat.” Report Fraud: Call our Fraud Hotline at 1.800.352.9100, or email our Special Investigations Unit at [email protected] BCNEPA Provider Relations Consultants Odette Ashby • 570.200.4658 [email protected] Cheryl Hashagen • 570.200.4670 [email protected] Jill Jenkins • 570.200.4647 [email protected] Louise LoPresto • 570.200.4674 [email protected] Provider Relations....................................570.200.6880 Manager, Provider Relations Provider Services Unit.............................570.200.6733 Dave Levenoskie • 570.200.4673 [email protected] Provider Services Inquiry......................570.200.6710 FPH Complaint/Grievance Department................................................570.200.6770 FPH Non-par Referral Requests...........570.200.6840 FPH Pharmacy Department...................570.200.6870 Manager, SPECIAL PROJECTS Kevin Quaglia • 570.200.4676 [email protected] FPH Precertification Department.........570.200.6799 QUESTIONS? CALL PROVIDER RELATIONS AT Other Party Liability (OPL)....................570.200.6790 1.800.451.4447 © Blue Cross of Northeastern Pennsylvania. 2012.
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