PROFESSIONAL ADMINISTRATIVE NOTICE: 2015P
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1 PROFESSIONAL ADMINISTRATIVE NOTICE: 2015P Date: November 1, 2015 To: All Capital BlueCross and Capital Advantage Insurance Company Capital Advantage Assurance Company All Keystone Health Plan Central Professional Providers New Information and/or Reminders The subjects covered in this Professional Administrative Notice are: Antibiotics Resistance Awareness Magellan Behavioral Health, Inc. Re-credentialing Process NaviNet Reminders Opportunities in Recommended Care Report Now Available Antibiotics Resistance Awareness New Information Reminder The Get Smart: Know When Antibiotics Work program, available at offers a variety of materials to promote appropriate antibiotic prescribing and use in the outpatient setting. Antimicrobial agents have been used for at least the last 70 years to treat patients who have infectious diseases. Since the 1940 s, these drugs have greatly reduced illness and death from infectious diseases. However, these drugs have been used so widely and for so long that the infectious organisms the antibiotics are designed to kill have adapted to them, making the drugs less effective. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. The Centers for Disease Control and Prevention (CDC) outlines the Principles of Appropriate Antibiotic Use. Capital BlueCross would like to remind providers to prescribe antibiotics appropriately. Upper respiratory infections, not otherwise specified: Antibiotic treatment of nonspecific upper respiratory infections in adults does not enhance illness resolution or prevent complications, and is therefore not recommended. Acute pharyngitis: The benefits of antibiotic treatment of adult pharyngitis are limited to those patients with Group A beta hemolytic streptococcus (GABHS) infection. All patients with pharyngitis should be offered appropriate doses of analgesics, antipyretics and other supportive care. Rhinosinusitis: Patients who have rhinosinusitis symptoms for less than 7 days are unlikely to have a bacterial infection. RETAIN A COPY OF THIS ADMINISTRATIVE BULLETIN WITH YOUR PROVIDER MANUAL For the most current information, visit the Capital BlueCross health plan home page via the NaviNet provider communications portal at: Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
2 Bronchitis: Routine antibiotic treatment of uncomplicated bronchitis is not recommended. Patient satisfaction with care for acute bronchitis is most dependent on the doctor-patient communication rather than on whether or not an antibiotic is prescribed. Additional information can be found at: Magellan Behavioral Health, Inc. Re-credentialing Process New Information Reminder Capital BlueCross contracts with Magellan Behavioral Health, Inc. (Magellan) to provide credentialing services for providers participating in our Capital Advantage Insurance Company and Capital Advantage Assurance Company products. In order to continue providing services to Capital BlueCross members, providers must comply with all recredentialing requests made by Magellan, on behalf of Capital BlueCross. As part of the re-credentialing process, Magellan makes several attempts to collect the information required to re-credential providers. The process is outlined below. 8 Months Prior to Credentialing Expiration: Notification is sent to providers, via USPS, using the mailing address shown on the CAQH application with requests for the following: UPDATE CAQH application online (re-attest to application or ensure that the application has a current attestation) o The CAQH link is: Universal Provider Data Source Tab Access UPD Provider Login Verify that Magellan is authorized to access the application Ensure that a current and valid malpractice face sheet is uploaded to the CAQH profile NOTE: the mailing will reference Magellan on the envelope. Make sure the CAQH application contains your most up-to-date information, including mailing address, telephone number and address. These are the three main sources of communication from Magellan. Every 120 days, CAQH sends out reminders to keep the online application up to date. For assistance with the CAQH application, please contact the Provider and Practice Manager contact at the CAQH Provider Help Desk at: or at: caqh/updhelp@acsgs.com. Most commonly requested documents for re-credentialing: o Updated CAQH application current re-attestation o Updated CV (Curriculum Vitae) or resume in month/year format to verify gaps in work history o Group Association Form (GAF) - This is a form issued by Magellan, it is bar-coded for each group Page 2
3 o Updated Malpractice Face Sheet showing coverage that will not expire before credentialing will conclude. A malpractice face sheet is needed for every group you are practicing at or coverage (malpractice face sheet) for the individual practitioner. 6 Months Prior to Credentialing Expiration: Providers who have not complied with the initial request for information will receive a SECOND notification. Contact information from CAQH will be used for the outreach. 5 Months Prior to Credentialing Expiration: Providers are notified by telephone as a reminder they are due for re-credentialing and to offer alternate options for submitting an application. Ninety (90) Days Prior to Credentialing Expiration: Providers are notified they are ninety (90) days away from termination. If providers fail to comply with this warning and do not submit the required documentation, credentialing termination and subsequent network termination will take place. Should termination occur, provider is terminated from the Capital BlueCross network. Sixty (60) Days Prior to Credentialing Expiration: Providers are notified they have been terminated from Magellan s system. Providers have sixty-three (63) days from the date of this last letter to request a reconsideration, in writing, to Magellan and submit the requested documentation. Providers who comply with the requests from Magellan will continue to move through the recredentialing process. Thirty (30) days after a provider is terminated from Magellan s system, Magellan will no longer check CAQH for an updated application. It is the provider s responsibility to contact Magellan at to have recredentialing completed. Credentialing Expiration: Providers that do not comply with the requests from Magellan will be terminated from the Capital BlueCross network. Should the provider desire to participate with Capital BlueCross, the provider will be required to begin the credentialing process, which can take as long as 180 days (per the National Committee for Quality Assurance (NCQA). No retroactive credentialing can occur. To begin the credentialing process access the Join Our Network resource that is located at On behalf of Capital BlueCross, Magellan Behavioral Health, Inc. assists in the administration of behavioral health benefits. Magellan Behavioral Health is an independent company. NaviNet Reminders New Information Reminder Communication with our providers is the first step towards establishing a solid relationship with our members. With several methods for electronic claims submission, and our secure online gateways via NaviNet, Capital BlueCross continues to expand our electronic capabilities to meet your needs. Page 3
4 We provide online tools that allow for convenient access to important information 24 hours a day, 7 days a week with limited availability on Sundays. All participating network providers and your designated third party billing agencies are encouraged to access claim status and electronic statements of remittance using NaviNet. Additionally, providers can also verify member eligibility and benefits as well as access referral entry, and obtain preauthorizations. The online tools should always be used as the first resource for obtaining information. As a registered user of NaviNet, you are able to access the Capital BlueCross Provider Library which is designed as a resource for our network providers. The Provider Library contains important reference materials such as, but not limited to, the Capital BlueCross Provider Manual, Medical Policies and Administrative Bulletins. If you do not currently have NaviNet access, please visit to register. The registration process is simple, electronic and free. Third party billing agencies have the availability of obtaining a single sign on, making researching claims online efficient and easy. For additional information, please contact NaviNet at: NaviNet is an independent company providing this provider portal service on behalf of Capital BlueCross. Opportunities in Recommended Care Report Now Available New Information Reminder The Opportunities for Recommended Care report is available electronically through the Capital BlueCross Secure File Transfer (SFT) option on our NaviNet portal. The report is now available on NaviNet in two formats including a filterable format. The filterable format is being provided in order to allow the ability to sort the report. In order to access the report you will need to follow a few easy steps: Identify the individual(s) who should receive the report and ensure that individual has a NaviNet account. Contact your practice s NaviNet Security Officer and have them assign the following role: Opportunity for Recommended Care Report to the designated individual(s). Contact NaviNet directly if your practice needs to establish a NaviNet account or need to establish a Security Officer. Once an individual has been assigned the role, the report will be available in the NaviNet SFT report listing on the date the reports are released. The most current reports were made available on October 30, 2015 If you have any questions about accessing SFT, please contact Provider Automation by sending an to the following address: ProviderAutomation@capbluecross.com or by calling , option 4. Finally, if you have any questions or suggestions about the report, please contact your Provider Relations Consultant or call the Capital BlueCross Customer Service Call Center at: NaviNet is an independent company providing this provider portal service on behalf of Capital BlueCross. Page 4
5 Questions For questions regarding the information in this Administrative Notice, please contact your Provider Relations Consultant. Page 5
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