BlueFor contracting institutional and professional providers

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1 REVIEW BlueFor contracting institutional and professional providers What s Inside? BeSmart. BeWell Videos Now Available on DVD... 2 How We re Helping Members Manage Chronic Conditions...3 Special Beginnings Maternity Program...3 Professional Provider Network Consultants...We re here to assist you!...4, 5 Formulary Change for Some Prescription Prenatal Vitamins...8 August/September Provider Learning Opportunities... 8, 9 CORRECTION to July Blue Review Article: Billing for Medically Unnecessary and/or Medically Unproven Services...10 In the Know: erm Simplifies Overpayment Reconciliation...10 Copay Reminder for Mental Health Parity and Addiction Equity Act of Introducing Our NEW Provider Website!.. 12 Clarification: Billing with National Drug Codes (NDCs) The June Blue Review included an article on p. 3 titled, Billing with National Drug Codes (NDCs). The purpose of this article was to provide updates and guidelines regarding use of NDCs on paper and electronic claims. We would like to clarify that this article was intended for professional providers. AUGUST 2010 Blue Care Connection : Empowering Members to Take Charge of Their Health Blue Cross and Blue Shield of Illinois (BCBSIL) is committed to an integrated, evidence-based and member-focused approach to medical care management that can help affect real change for our members. That is why in 2004, we launched Blue Care Connection (BCC), a suite of programs and services that supports healthy behaviors and outcomes for our members, and that helps them feel an increased level of responsibility for their own health and wellness. BCC offers many tools to help engage members in all phases of health, from wellness and prevention through complex and catastrophic care. Whether it is targeting members who overutilize the emergency room, engaging members in new medical management programs or helping employers deliver customized messages, BCC is our mechanism. In this edition of the Blue Review, we want to familiarize you with the BCC health care initiatives and member outreach efforts we have implemented to deliver on our vision of providing affordable and accessible care to as many of our members as possible. It is important to note that these programs are not a substitute for the medical advice of a physician. Members are instructed to discuss any health questions or concerns they have with their physician. Care/Utilization Management (UM) Following industry and national standard of care guidelines, our UM program helps identified members receive the appropriate level of care in the most cost-effective setting, through shortterm discharge planning, facilitating transitions between levels of care or pre-admission and/or post-discharge calls. Outcome report results indicate our Pre-Admission and Post-Discharge Call Programs help to reduce complications and re-admissions factors that add significantly to already high inpatient claims costs. Nurses contact identified members before and after discharge from a scheduled inpatient hospitalization or surgery to provide guidance, assistance and education, as needed. Case Management We have been providing personal attention, resources and support to members with complex or special health care needs for more than 30 years. Our case management program is a collaborative process that engages the member, provider, case manager, and Blue Care Advisor (a registered nurse or other health care professional). Together they work to help improve the member s quality of life and attempt to slow the progression of the condition. Lifestyle Management BCBSIL is committed to promoting healthy lifestyles for our members and finding innovative ways to utilize technology. Our lifestyle management programs offer resources and tools for influencing positive behavioral changes that can last a lifetime, such as helping members manage their weight, quit smoking and more. (Next page) Visit our Web site at bcbsil.com/provider

2 Be Smart. BeWell. Videos Now Available on DVD In an effort to share important health and wellness information and messages with our members, and your patients, we are making available to you topic-specific DVDs which contain the videos presented on our BeSmart. BeWell. website. Each DVD contains all of the videos related to that specific health topic. Topics addressed on the site include traumatic brain injury, drug safety, mental health, caregiving, pregnancy risks, childhood obesity, sexually transmitted diseases and domestic violence. The list of topics is also available on the site at besmartbewell.com. If you would like to obtain one or more of these topic-specific video collections on DVD for your practice, please send an identifying your topic of interest to Susan Zimny at or contact your assigned Provider Network Consultant. Wellness Initiatives for Blue Cross Blue Care Connection : Empowering Members to Take Charge of Their Health (Cont. from Cover) Personal Health Manager Our Personal Health Manager (PHM) allows individual members the ability to collect and store their own health information, and share Protected Health Information (PHI) with their physician and others as they choose, all within a secure environment. Members have access practically anytime and anywhere to their health information on our secure Blue Access for Members website. Members can grant access to their physician to upload pertinent electronic information into their PHM. It stores the member s test results, medication data, vaccination lists and medical history so that wherever they go, their medical information is readily accessible. Members can receive targeted health related information through the Web via secured messaging to help manage specific medical conditions, including alerts for screening tests and the ability to set up reminders for medical appointments. Note: All medical information is forwarded within a secure environment, and is encrypted on a website that is HIPAA compliant. Ask a Health Professional Through a secure messaging system, members can use web-based inquiry technology to Ask a Nurse, Trainer, Life Coach or Dietitian, health-related questions and receive an electronic response within one business day. Nurses do not provide medical advice, but share information already available that meets national standards of care. Fitness Our Fitness Program is the newest feature of Blue Care Connection. Available exclusively to BCBSIL members and their covered dependents (over age 18), the Fitness Program provides: Flexible membership, no long-term contract required. Easy online enrollment; automatic monthly payment withdrawal. Online views of the member s fitness center visits. Blue Points SM Members can earn points and redeem them for popular health and wellness merchandise and services. Unlimited access to a nationwide network of participating fitness centers and select YMCA locations. Members enroll in our Fitness program by visiting our website at bcbsil.com and logging in to their Blue Access for Members account, or they can also enroll by calling (888) 762-BLUE (2583). Behavioral Health Care Management As we previously announced in the June Blue Review, effective Jan. 2011, BCBSIL will manage behavioral/ mental health and substance abuse/chemical dependency services for all non-hmo members, replacing Magellan Health Services. Behavioral health care management will be more integrated with medical care management, as part of Blue Care Connection, to better assist continuity and coordination of care between medical and behavioral health physicians and professional providers. This new model will be supported by technology that provides advanced data mining capabilities, communication tools, automated member and provider information, online resources and vigorous reporting. We believe this change will help to improve outcomes, enhance continuity of care and clinical efficiency, and reduce costs over time. Using advanced technology, our qualified behavioral health professionals will help covered members navigate the health care system and will also refer members* to other BCC medical care management programs, as needed. BCC programs also include Condition Management and Maternity Risk Management; see articles on facing page for more details. * Members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications may be referred to BCC programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals, and physician referrals. If members do not have BCC as part of their group health plans, they will not be referred to other BCC programs. 21 Visit our Web site at

3 and Blue Shield of Illinois Members How We re Helping Members Manage Chronic Conditions When members need information, services and support to help manage a chronic medical condition, our BCBSIL Condition Management Team provides a wide range of resources to help them make positive changes happen. Our Condition Management Program, offered to members in our PPO and BlueChoice Select products, and those enrolled in the Federal Employee Health Benefit Program (FEP), seeks to identify members with the top five targeted conditions that represent roughly 40 percent** of claims costs: 1. Diabetes 2. Heart Failure 3. Asthma 4. Coronary Artery Disease 5. Chronic Obstructive Pulmonary Disease (COPD) We then work with members and providers to develop and implement the appropriate coordinated health care interventions and education based on National Standards of Care (evidence-based medicine) for the purpose of helping members adopt healthier lifestyle choices and better manage their condition(s). Member Outreach Members with any of these conditions are encouraged to enroll in the Condition Management Program through Blue Care Connection. Our team of registered nurses conducts telephone outreach to those members in the moderate and severe risk disease categories. We advise and inform members of the many health care options available to them, assist in coordination of services, and provide wellness and condition specific health education. Through this program we hope to improve member behavior and treatment patterns to produce better health outcomes. When members enroll, their primary physician receives a letter to inform them that their patient is engaged in this program. Our goal is to support your care and recommendations and not to interfere with the physician/patient relationship. This interaction between the member, a BCBSIL nurse, and the physician should help the member close any identified gaps in care. Our team collaborates with you to effectively help manage the member s chronic conditions by preventing complications through adherence to medication regimens and provider follow-up. You may be receiving a call or fax from us in regard to closing these gaps in care for your members enrolled in the program. Our Medical Management Department is always available to assist providers and facilities with benefit authorization and coordination of medical services for our members. If you have any questions about our Condition Management Program, please call (866) Special Beginnings Maternity Program Our Special Beginnings* maternity program provides expectant members with support and education, risk factor identification and ongoing communication and monitoring from early pregnancy until six weeks after delivery. Our experienced program staff helps your patients better understand and manage their pregnancies, to give the baby a healthy start. New Online Resource Available An additional resource is now available for the Special Beginnings program. All expectant members who have this maternity program as part of their health plan have access to a new online resource that began in late July Located on Blue Access for Members, our secure member website, the online resource offers: A pregnancy calendar to help the member keep track of the pregnancy and what to expect in each trimester A pregnancy due date calculator Videos about pregnancy and childbirth featuring medical professionals Educational articles A level of support your patients may anticipate receiving during Special Beginnings program participation Additional features will be added later this year. Help your patients get off to a healthy start! Encourage them to enroll in the maternity program by calling (888) , 8 a.m. to 6:30 p.m., CT. Members should enroll in the program before 12 weeks of gestation, but are accepted until week 34 of their pregnancy. **Source: Health Care Service Corporation (HCSC) claims incurred from June May * Special Beginnings is not available to HMO members AUGUST

4 Ancillary Provider Network Consultants BCBSIL contracts with more than 2,000 ancillary providers in Illinois and northwest Indiana. Our Ancillary Provider Network Consultant (PNC) team focuses specifically on the services provided by Skilled Nursing Facilities, Home Health Agencies, Hospice, Home Infusion Therapy, DME, Orthotics and Prosthetics, Dialysis Centers, and Private Duty Nursing agencies. The following Ancillary PNCs are available to meet with your staff regarding BCBSIL policies and procedures, billing, and contractual issues: Sherry Heise-Jaskolka, (312) Elaine Williams, (312) You may also contact Sherry and Elaine via at or leave a message at (312) Professional Provider Network Consultants...We re here to assist you! Professional Provider Assignments by County, City and Zip Code (Revised June 2010) Our Professional Provider Network Consultants (PNCs) serve as the liaison between BCBSIL and our independently contracted provider community, developing and maintaining cooperative working relationships with professional providers in our network throughout Illinois and northwest Indiana. The team also includes a designated Billing Services Representative (see facing page for details). Your Professional PNC has a thorough knowledge of the PPO product, and is available to meet with you on a routine basis to educate your staff on BCBSIL procedures, help ensure provider contract compliance, and work with you to resolve any operational issues. To find the name of your Professional PNC, refer to the Illinois county map on the facing page. The Professional Provider Network Consultant List and map are also available in the Education and Reference Center on our website at bcbsil.com/provider. Note: Due to the number of providers in DuPage and Cook County (Code 22 and Code 16), provider assignments are broken down by suburban city and Chicago zip codes, as indicated below. IL TERRITORY BREAKDOWN BY COUNTY CODE Northern (8, 43, 49, 56, 81, 89 and 98) Gina Plescia Southern (2, 3, 7, 11, 12, 13, 14, 15, 17, 18, 24, 25, 26, 28, 30, 31, 33, 35, 39, 40, 41, 42, 44, 51, 59, 60, 61, 64, 67, 68, 73, 76, 77, 79, 80, 82, 83, 84, 87, 91, 93, 95, 96, 97 and 100) Teresa Trumbley Western (6, 36, 37, 48, 52, 62, 66, 78, 88 and 94) Katie Gordon Midwest (1, 5, 9, 10, 20, 21, 23, 27, 29, 34, 38, 53, 54, 55, 57, 58, 63, 65, 69, 70, 72, 74, 75, 85, 86, 90, 92 and 102) Amanda Williams North Metro (4, 19, 45, 47, 50, 71 and 101) Cathy Dismuke South Metro (32, 46 and 99) Dorothy Paul Northwest Indiana Lynn Sorensen Cook County (16) See below for Cook and DuPage County Breakdown information. DuPage County (22) See below for Cook and DuPage County Breakdown information. COOK AND DUPAGE COUNTY BREAKDOWN BY CITY AND ZIP CODE Ana Hernandez Codes: 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60608, 60610, 60611, 60612, 60614, 60616, 60622, 60629, 60633, 60634, Cathy Dismuke Cities: Bartlett, Bloomingdale, Bloomington, Elburn, Geneva, Hanover Park, Hillisburg, Medinah, Roselle, St Charles, Wayne Gina Plescia Cities: Arlington Heights, Hoffman Estates, Schaumburg Katie Gordon Cities: Alsip, Bellwood, Berkeley, Berwyn, Blue Island, Bridgeview, Broadview, Brookfield, Burbank, Chicago Ridge, Cicero, Elmwood Park, Evergreen Park, Forest Park, Franklin Park, Harwood Hts, Hillside, Hines, Hometown, Indian Head Park, Justice, Knoxville, La Grange, La Grange Park, La Grange Highlands, Lyons, Maywood, Melrose Park, Merrionette Park, Norridge, North Riverside, Northlake, Oak Lawn, Oak Park, Park Ridge, River Forest, River Grove, Riverside, Schiller Park, Stone Park, Summit Argo, Westchester, Western Springs Lynn Sorensen Cities: Aurora, Burr Ridge, Calumet City, Chicago Heights, Darien, Dolton, Flossmoor, Ford Heights, Glen Ellyn, Glendale Heights, Glenwood, Homewood, Lansing, Lisle, Lynwood, Matteson, Naperville, Olympia Fields, Park Forest, Richton Park, Riverdale, Sauk Village, South Holland, Steger, Summit, Thornton, Warrenville, Willowbrook, Woodridge Michelle Brownfield-Nance Cities: Addison, Calumet Park, Carol Stream, Country Club Hills, Countryside, Crestwood, Downers Grove, Elk Grove Village, Evanston, Harvey, Hazel Crest, Hickory Hills, Homer Glen, Lemont, Markham, Midlothian, Oak Forest, Orland Hills, Orland Park, Palos Heights, Palos Hills, Palos Park, Posen, Robbins, Skokie, Streamwood, Tinley Park, West Chicago, Wheaton, Willow Springs, Winfield, Worth Ramona Espino Cities: Bensenville, Clarendon Hills, Des Plaines, Elmhurst, Glencoe, Glenview, Golf, Hinsdale, Inverness, Itasca, Kenilworth, Lincolnwood, Lombard, Morton Grove, Mt. Prospect, Neenah, Niles, Northbrook, Northfield, Oak Brook, Oak Brook Terrace, Palatine, Prospect Heights, Rolling Meadows, Rosemont, South Barrington, Villa Park, Westmont, Wheeling, Wilmette, Winnetka, Wood Dale Vickey Jones Zip Codes: 60609, 60613, 60615, 60617, 60618, 60619, 60620, 60621, 60623, 60624, 60625, 60626, 60627, 60628, 60630, 60631, 60632, 60635, 60636, 60637, 60639, 60640, 60641, 60642, 60643, 60644, 60645, 60646, 60648, 60650, 60647, 60649, 60651, 60653, 60657, 60652, 60654, 60655, 60656, 60658, 60659, 60660, 60661, 60666, 60668, 60669, 60670, 60673, 60674, 60675, 60676, 60677, 60678, 60680, 60681, 60686, 60689, 60690, 60693, 60694, 60695, Visit our Web site at bcbsil.com/provider

5 Code County 1 Adams 2 Alexander 3 Bond 4 Boone 5 Brown 6 Bureau 7 Calhoun 8 Carroll 9 Cass 10 Champaign 11 Christian 12 Clark 13 Clay 14 Clinton 15 Coles 16 Cook 17 Crawford 18 Cumberland 19 DeKalb 20 Dewitt 21 Douglas 22 DuPage 23 Edgar 24 Edwards 25 Effingham 26 Fayette 27 Ford 28 Franklin 29 Fulton 30 Gallatin 31 Greene 32 Grundy 33 Hamilton 34 Hancock 35 Hardin 36 Henderson 37 Henry 38 Iroquois 39 Jackson 40 Jasper 41 Jefferson 42 Jersey 43 JoDaviess 34 Amanda Williams (217) Michelle Brownfield-Nance (312) Teresa Trumbley (618) Cathy Dismuke (312) Lynn Sorensen (312) * Katie Gordon (312) Gina Plescia (312) Dorothy Paul (312) Ramona Espino (312) Ana Hernandez (312) Vickey Jones (312) Billing Services Representative LaVella Friley is the designated Provider Network Consultant to serve as the representative for all billing services in the Chicago Metro area. For more information on customized on-site training, workshops, and Webinars for billing services, contact LaVella at (312) or via at frileyl@bcbsil.com Code County 44 Johnson 45 Kane 46 Kankakee 47 Kendall 48 Knox 50 LaSalle 49 Lake 51 Lawrence 52 Lee 53 Livingston 54 Logan 58 Macon 59 Macoupin 60 Madison 61 Marion 62 Marshall 63 Mason 64 Massac 55 McDonough 56 McHenry 57 McLean 65 Menard 66 Mercer 67 Monroe 68 Montgomery 69 Morgan 70 Moultrie 71 Ogle 72 Peoria 73 Perry 74 Piatt 75 Pike 76 Pope 77 Pulaski 78 Putnam 79 Randolph 80 Richland 81 Rock Island 83 Saline 84 Sangamon 85 Schuyler 86 Scott 87 Shelby 82 St Clair 88 Stark 89 Stephenson 90 Tazewell 91 Union 92 Vermilion 93 Wabash 94 Warren 95 Washington 96 Wayne 97 White 98 Whiteside 99 Will 100 Williamson 101 Winnebago 102 Woodford Key: Cook County (16) and DuPage County (22) are split between Michelle, Cathy, Lynn, Katie, Gina and Ramona. City of Chicago is split between Ana and Vickey. *NW Indiana is assigned to Lynn. AUGUST

6 From the Medical Director s Library David Stein, M.D. offers the following message and reading recommendations: The article and its accompanying editorial that I selected for this month are both from the Journal of the American College of Cardiology (JACC). They address the need to provide informed decision-making for both the treating physician and the patient. They address current risk prediction for percutaneous coronary intervention based on clinical factors, not angiographic results. I think the clinical information is very valuable for use in daily clinical practice. I hope you enjoy them. Article: Peterson, Eric, et. al. Contemporary Mortality Risk Prediction for Percutaneous Coronary Intervention. JACC (18)1924 to Editorial: Kereiakes, Dean. Cultivating Prognosis Following Percutaneous Coronary Intervention. JACC (18) The above articles are for informational purposes only. The views and opinions expressed in these articles are solely those of the authors, and do not represent the views or opinions of BCBSIL, its medical directors or Dr. Stein. EFT, ERA and EPS: Beyond the Basics, Part 2 In July, we shared feedback from providers who expressed interest, but needed more information prior to enrolling for Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA) and Electronic Payment Summary (EPS). The first Beyond the Basics article focused primarily on enrollment details and prerequisites. The collection of questions included in this month s article examines how you will receive your payment and remittance information, as well as how EFT, ERA and EPS work better when utilized together. 1. How often will the electronic checks be deposited? Upon enrollment for EFT, you have a choice between daily and weekly payments, or you can remain on your current payment cycle. If no option is selected on the EFT enrollment form, the default is weekly. Once your EFT enrollment is processed, you will receive a letter from our Electronic Commerce Services department with your effective date and related information. 2. I am not sure I understand how the ERA works. The ERA is just one of many electronic solutions that can help you streamline the administrative process and bring each claim full circle as quickly and easily as possible. The ERA is a HIPAAcompliant electronic file that contains claims payment reconciliation data. The purpose of the ERA is to support automated posting of payments to your patient accounts. Once you enroll for ERA, you will also receive the EPS an electronic companion file that replaces your paper PCS. The EPS file contains the same information as the PCS, including individual claim details on each patient, along with the total amount of the payment you are due. The big advantage of the ERA and EPS files is that you receive them the day after claim finalization. This means that, if you are also enrolled for EFT, you will be able to reconcile your patient accounts prior to receiving your payment from BCBSIL. 3. How do I retrieve the ERA? You must be registered with Availity prior to enrolling for ERA. Once your ERA enrollment process is completed, you or your billing agent will use an assigned Receiver ID to obtain your ERA and EPS information, which is delivered to your electronic mailbox on Availity s online provider portal. If you currently have a Submitter ID for Electronic Media Claims (EMCs), the same Submitter ID may be used to retrieve the ERA. If your software is ERA-capable, you can transfer an ERA to your computer. Some software also offers the option to print the ERA data for review. If you have designated a billing agent (billing service or clearinghouse) to receive the ERA and EPS on your behalf, it s a good idea to contact your billing agent directly with any questions about how they will utilize the information and/or pass it along to you. 4. In what format will I receive the EPS? The EPS is delivered by BCBSIL as a text file so that you can receive it in conjunction with your ERA. You can save the EPS as an electronic file for future retrieval; or, you may choose to select and print some or all of the document. The EPS contains all of the same information as your paper PCS. You can even make the electronic document look like the paper PCS by opening the file in Microsoft Word or a similar application, setting the page layout as landscape, and selecting 8-point Courier New for the font. If you use a billing agent or clearinghouse, check with them to make sure they are aware of your formatting preferences. 5. Do I need to have a person with advanced computer skills to set up and use the ERA? No. You don t need a technical person on your staff, but you do need to consult your software vendor to ensure that your practice management system can accept and translate the electronic data. This is because the ERA, also known as the ANSI 835, is a HIPAA-compliant transaction that must be configured according to specific regulations and guidelines. These regulations and guidelines are available for your vendor to access on the BCBSIL website at bcbsil.com/provider. Ask your vendor if there is any additional charge for ERA-compatible or auto-posting software. A partial listing of ERA-compatible software vendors is available on the Availity website at www. availity.com (click on Info for Providers, then select View Availity technology company partners). Ready to move on to the next level? Watch for our next EFT, ERA and EPS: Beyond the Basics article, which will continue to address recent questions and concerns from providers. Meanwhile, we invite you to visit the Claims and Eligibility section of our website at bcbsil.com/provider for Electronic Commerce resources, such as our Electronic Options Tutorial, EFT and ERA enrollment forms, and more! For a listing of upcoming learning opportunities that focus on electronic options available to BCBSIL providers, see p. 8 of this newsletter, or visit our online Education and Reference Center. If you have questions about EFT and ERA enrollment, contact our Electronic Commerce Center at (800) Availity is a registered trademark of Availity, L.L.C., an independent vendor that is solely responsible for its products and services. 6 Visit our Web site at bcbsil.com/provider

7 Provider Telecommunications Center Hours of Operation Calls to our Provider Telecommunications Center (PTC) at (800) are automatically received by our Interactive Voice Response (IVR) phone system. Simply follow the prompts to obtain eligibility and basic benefits information, and other claim-related information for BCBSIL members. The IVR system is available Monday through Friday, 6 a.m. to 11:30 p.m., CT, and Saturday, 6 a.m. to 3 p.m., CT. For assistance with navigating the automated system, refer to the IVR Caller Guides, located in the Education and Reference Center of our website at bcbsil.com/provider. As of Sept. 13, 2010, PTC Customer Advocate (CA) hours of availability will be changed to 8 a.m. to 6 p.m., CT, Monday through Friday. At BCBSIL, we recommend conducting transactions electronically to help improve operational efficiencies. For more information on electronic options available to BCBSIL providers, visit the Claims and Eligibility section of our website at bcbsil.com/provider. Why the Web is a Better Option You need answers fast when requesting claim status. Telephone transactions can take time and may not get you where you need to go. Redirecting your inquiries to online self-service tools puts you in the driver s seat When you call our PTC for basic claim status, our automated IVR phone system may return a message that your claim has been pended. This simply means that your claim is still in process, and further information is not yet available through the IVR. In July, the option to speak with a Customer Advocate (CA) regarding pended claims was removed from the IVR menu, since those claims are still in process, and additional details are not yet available. A message has been added to the IVR to remind you to utilize online claim status options instead, such as the Availity Claim Research Tool (CRT)*, or other enhanced claim status tools offered by your preferred vendor portal. Registered Availity users can use the CRT at no charge for up-to-the minute electronic transactions that are secure, unlimited and printable. By utilizing the Availity CRT, or other online claim status tools provided by your preferred vendor portal, you help keep our CAs available to assist you when you have claim issues beyond basic claim status requests. We encourage you to take advantage of all available electronic options before, during and after your claim is processed! Visit the Claims and Eligibility section of our website for more information, or attend our e-match Expo, where you can meet health information technology vendors and learn about the products and services they offer in support of electronic transactions. (See page 9 in this issue for a complete list of e-match Expo dates and locations.) Significant Edits Related to ClaimCheck Denials STOP! Save time! Prior to calling our PTC regarding ClaimCheck denials, please check the Significant Edits list to see if your code is listed. The Significant Edits list is located under Professional Coding Information in the Standards and Requirements section of our website at bcbsil.com/provider. The Significant Edits list is a partial listing of codes that are considered incidental when billed in conjunction with other procedures. Also listed are re-bundled and mutually exclusive procedures. Keep in mind this list is not all inclusive. The list includes codes that are most commonly reported. Reminder: Clear Claim Connection TM (C3) is a free online reference tool that displays the results of code-auditing software. You can use C3 to help determine how coding combinations on a particular claim may be evaluated during the adjudication process. To gain access to C3, you must be registered with Availity or RealMed. Register with Availity online at www. availity.com, or contact Availity Client Services at (800) AVAILITY ( ). To register with RealMed, call (877) REALMED ( ). Once you are registered, you may connect directly to C3 via your preferred vendor portal. There is also a link to C3 from the BCBSIL website at bcbsil.com/provider, in the Provider Tools section of our online Education and Reference Center. ClaimCheck and Clear Claim Connection are registered trademarks of McKesson Information Solutions, Inc. RealMed is a registered trademark of RealMed Corporation. McKesson Information Solutions, Inc. and RealMed Corporation are independent vendors and are solely responsible for their products and services. * Note: A CRT Tip Sheet is available in the Education and Reference Center of our website at bcbsil.com/provider. To register with Availity, visit or call (800) AVAILITY ( ) for assistance. AUGUST

8 Fairness in Contracting In an effort to comply with Fairness in Contracting Legislation and keep our independently contracted providers informed, BCBSIL has designated a column in the Blue Review to notify you of any changes to the physician fee schedules. Be sure to review this area each month. Effective June 18, 2010, code J0598 was updated. Effective July 1, 2010, codes 90378, J1830, J0220, J0364 and S0088 were updated. Effective Aug. 1, 2010, code Q3026 was updated. Annual and quarterly fee schedule updates can be requested by downloading the Fee Schedule Request Form, available on our website at bcbsil.com/ provider, in the Forms section of our online Education and Reference Center. Specific code changes that are listed above can also be obtained by downloading the Fee Schedule Request Form and specifically requesting the updates on the codes listed in the Blue Review. Formulary Change for Some Prescription Prenatal Vitamins Effective July 1, 2010, many prescriptionstrength prenatal vitamins are now considered to be brand drugs. This determination was made by the company we use to classify drugs, which is a nationally recognized pricing source. All members who take a prescription prenatal vitamin that currently is classified as a generic have recently received correspondence informing them of this change in classification, and the related change in their copayment. To help ensure that members have options at a lower out-of-pocket expense, some prescription-strength prenatal vitamins have been added to the second formulary tier. To view the complete BCBSIL formulary, visit the Pharmacy Program section of our website at bcbsil.com/provider. August/September Provider Learning Opportunities Our Provider Relations team hosts a variety of complimentary training sessions, whether you prefer to participate from your office in an online Webinar, or join us in person for an onsite workshop. Webinars are offered for independently contracted PPO providers, billing services, clinical and administrative staff who are new or already participating in the BCBSIL network. Our New Provider Workshop presents an overview of BCBSIL products and programs, with an emphasis on conducting business electronically. Visit the Education and Reference Center of our website at bcbsil.com/provider for more details and to register online. If you have questions or need assistance, us at provider_relations@bcbsil.com, or call (312) WEBINARS BCBSIL New Provider 101 Sept. 15, to 10 a.m. BCBSIL Products Sept. 15, a.m. to noon Eligibility and Benefits Sept. 22, to 10 a.m. Electronic Alternatives (EFT, ERA, EPS and EMC*) Electronic Refund Management (erm) WORKSHOPS * Electronic Media Claims Aug. 4, 2010 Aug. 11, 2010 Aug. 18, 2010 Aug. 25, 2010 Sept. 22, 2010 Sept. 1, 2010 Sept. 8, 2010 Sept. 15, 2010 Sept. 22, 2010 Sept. 29, a.m. to noon 2 to 3 p.m. New Provider Workshop Sept. 29, :30 a.m. to 3 p.m. Medical Policy Updates Approved new or revised Medical Policies and their effective dates are usually posted on our website the first day of each month. Medical Policies, both new and revised, are used as guidelines for coverage determinations in health care benefit programs for BCBSIL members, unless otherwise indicated. These policies may impact your reimbursement and your patients benefits. You may view active new and revised policies, along with policies pending implementation, by visiting the Medical Policies section of our Provider Library on our website at bcbsil.com/provider. After reading the Medical Policies Disclaimer, click on I Agree. You will then have two options, View all Active Policies or View all Pending Policies. You may also view draft Medical Policies that are under development or are in the process of being revised by selecting Draft Medical Policies. After confirming your agreement with the Medical Policies Disclaimer, you will be directed to the Draft Medical Policies page. Just click on the title of the draft policy you wish to review, and then select Comments to submit your feedback to us. While some information on new or revised Medical Policies may be published in this newsletter for your convenience, please rely on our website for access to the most complete and up to date Medical Policy information. 8 Visit our Web site at

9 Make an Electronic Business Connection at our e-match Expo Vendor Fair Pairing up with a secure, third party vendor portal is essential to conducting electronic business transactions with BCBSIL. But what vendors are available? And how can you determine which one is the best electronic match for your practice? We invite you to explore your options at a complimentary e-match Expo, hosted by the BCBSIL Provider Relations team and coming soon to a location near you! Meet representatives from innovative health information technology vendors, including Availity, MEDecision, Passport/Nebo Systems and RealMed. Use our handy reference and checklist materials when asking questions and recording answers to take back to others in your office. Enroll on-the-spot in EFT, ERA and EPS with the assistance of the BCBSIL Electronic Commerce team, and take a tour of our Electronic Refund Management (erm) tool. e-match Expo Dates & Locations Expo hours are 9 a.m. to noon. Stop in at any time, and stay as long as you like! Refreshments will be served. Note: There is no admission fee; however, registration is required if you are planning to attend. Aug. 11, 2010 Aug. 18, 2010 Aug Sept. 1, 2010 Carbondale, IL Springfield, IL Chicago, IL Belleville, IL (The Expo at this location has been cancelled due to low enrollment.) St. John s Hospital Bunn Auditorium 800 East Carpenter Street BCBSIL 300 East Randolph Street St. Elizabeth s Hospital Centennial Room 211 South Third Street Register online today! Visit the Education and Reference Center on our website at bcbsil.com/ provider for details. If you have any questions, send an to provider_relations@bcbsil.com, or call (312) Availity, L.L.C., Passport/Nebo Systems, MEDecision and RealMed Corporation are independent vendors and are solely responsible for their products and services. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by these third-party vendors. If you have any questions, you should contact the vendor directly. New Account Groups Group Name: Dover Corporation Group Number: , , Alpha Prefix: Product Type: , , DVR PPO (Portable) Group Number: , Alpha Prefix: Product Type: DVR HSA (Portable) Effective Date: Jan. 1, 2011 Group Name: Group Numbers: Alpha Prefix: Product Type: Johnson Controls, Inc. LJC CMM (Portable) Effective Date: July 1, 2010 Group Name: Sysco Corporation Group Numbers: , Alpha Prefix: Product Type: SYY HDHP (Portable) Effective Date: Jan. 1, 2011 NOTE: Some of the accounts listed above may be new additions to BCBSIL; some accounts may already be established, but may be adding member groups or products. The information noted above is current as of the date of publication; however, BCBSIL reserves the right to amend this information at any time without notice. The fact that a group is included on this list is not a guarantee of payment or that any individuals employed by any of the listed groups, or their dependents, will be eligible for benefits. Benefit coverage is subject to the terms and conditions set forth in the member s certificate of coverage. AUGUST

10 CORRECTION to July Blue Review Article: Billing for Medically Unnecessary and/or Medically Unproven Services We would like to correct the effective date, and clarify information in the article on page 6 of the July Blue Review regarding changes to the Billing and Reimbursement section of the BCBSIL Provider Manual. Changes referenced in this article were originally scheduled to be effective in October The corrected effective date and additional information are noted below. Effective February 2011, charges associated with an inpatient hospital stay or any outpatient procedure or other service which is determined by our utilization management area to be Medically Unnecessary and/or Medically Unproven will deny with a message that the member will not be financially responsible for the charges. Unless you obtained prior written authorization from the member, in which the member accepted financial responsibility, you will be prohibited from billing the member for these services. Important reminders: Always verify eligibility and benefits in advance of providing services to BCBSIL members. If you and your patient are aware that a proposed service will be deemed Medically Unnecessary and/or Medically Unproven and you decide to proceed, you should obtain a written disclosure/authorization from the member informing the member that services are not covered by BCBSIL and the patient is assuming all financial responsibility for those services. If the member has not signed an authorization acknowledging that the member has accepted financial responsibility, you will be prohibited from billing the member for those services. IN THE KNOW erm Simplifies Overpayment Reconciliation Our Electronic Refund Management (erm) tool offers you a flexible, convenient and user-friendly alternative to the paper refund request and payment process. The erm tool is available to all independently contracted BCBSIL providers. You must be registered with Availity or RealMed to be able to gain access to the erm application. Here are some of the benefits of erm: It s easy to use! There s a three-step status bar on every page in erm. For every transaction, you have the opportunity to review your selection or data before you submit the information to BCBSIL. Webinars are ongoing to assist new users; see Training and Support information below. Instead of receiving the paper request for claim refund (RFCR) letter, you can opt to receive a daily or weekly summarizing overpayment requests from BCBSIL. Once you receive an electronic notification of overpayment, you can choose to deduct from a future payment or pay by paper check.* (Coming soon! ACH option Pay by check using routing number and account info.) If you have any questions, inquiries can be made right through the erm system. No need to call BCBSIL you ll receive a response electronically. If there s a need to appeal or dispute a request, you can upload your documentation directly to the erm system. If you need to fax your information, the system will generate a cover sheet with a bar code to ensure your documentation is matched with the appropriate refund. You may also use the system to view trans-actional history for each request, or generate a report related to multiple new, outstanding and or closed refund requests that contain an NPI related to your office/facility. Training and Support We offer free, ongoing Webinar sessions to help you learn about erm. Webinars feature a live demo of the tool, as well as a presentation on how to get started. If you ever need to come back for a refresher, you are always welcome. See p. 8 for a listing of upcoming Webinar sessions. If you have any questions or need assistance, send an to erm@bcbsil.com. You must be registered with Availity or RealMed to gain access to the BCBSIL erm tool. To register with Availity, visit their website at or call (800) AVAILITY ( ). For information on RealMed registration, call the RealMed Customer Service Center at (877) REALMED ( ). * Uniform Payment Program (UPP) providers also have the option to have the refund deducted from their monthly statement. In the next few months, we will be providing you with additional updates and resources to help you prepare for this upcoming change. If you have any questions, please contact your assigned Provider Network Consultant. 10 Visit our Web site at

11 Copay Reminder for Mental Health Parity and Addiction Equity Act of 2008 The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, signed into law on Oct. 3, 2008, requires that the financial requirements and treatment limitations for group health plans offering behavioral health services must be similar to a group health plans medical and surgical benefits. How will this affect your patients? If you are a mental health provider, for many of your patients with BCBSIL coverage, this means: 1. There is no longer a limit on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment for behavioral health or substance use disorders. However, treatment for the member s condition/symptoms must meet the medical necessity criteria set forth under the member s benefit plan. 2. Effective July 1, 2010, or upon an employer group s renewal, you can no longer charge the specialist office visit copay, but must charge patients the primary physician office visit copay. Other financial requirements (e.g., deductibles, coinsurance and out-of-pocket expenses) will be determined in the same way as medical and surgical benefits. To confirm a member s eligibility and benefits, please refer to the Mental Health/Chemical Dependency telephone number listed on the back of the member s ID card. Effective Date The requirements of the new law are effective for plan years beginning on or after one year from the date the legislation was signed into law. As a result, the provisions apply to new contracts and renewals on or after Oct. 3, For example, a group that renews on July 1, 2009, must be in compliance with this new law by July 1, Please watch our provider website at bcbsil.com/provider for additional News and Updates. You may also contact your assigned Provider Network Consultant if you need assistance. For certain groups subject to collective bargaining agreements, there will be no affect until renewal. The information provided above is only intended to be a brief summary of the law that has been enacted and is not an exhaustive description of the law or a legal opinion of such law. If you have any questions regarding the information mentioned above, you should consult with a legal advisor. Where to Send Provider Appeals BCBSIL routinely receives appeal requests from providers to reconsider a denial made by our Medical Management area, relating to a length of stay, treatment setting, transplant, etc. We realize that these types of clinical appeals may directly affect a member s health outcome. That s why we want to ensure we receive your appeal request as soon as possible so there is sufficient time for review by a physician or clinical peer. Please submit all appeal requests in writing as noted below. Appeals regarding Utilization Management (UM) or Condition Management (CM) denials should include all related medical records, and be sent to: Attention: Appeal Coordinator Blue Cross and Blue Shield of Illinois Consumer Services Management Dept. 300 E. Randolph Street Chicago, Illinois Review requests not related to UM/CM denials (i.e., claims), typically initiated by contacting our Provider Telecommunications Center (PTC), should be sent to: Claim Review Request Blue Cross and Blue Shield of Illinois P.O. Box Chicago, Illinois AUGUST

12 Introducing Our NEW Provider Website! We are pleased to announce the unveiling of our new BCBSIL provider website at bcbsil.com/provider. This site, created with your feedback, features a new design that we hope will help you and your office staff navigate quickly to gain immediate access to the information you need. The new Provider Home page features quick links to the latest News and Updates about BCBSIL, Blue Review newsletters, online forms for Updating your Provider Information, and more. It also includes new section tabs, as follows: Network Participation Claims and Eligibility Education and Reference Center Clinical Resources Pharmacy Program Standards and Requirements You will find that the site layout, with its left-hand navigation links on each page, allows you to scan the topics in each section before you make your selection. We hope the new site meets with your satisfaction. Please share your comments by sending an to our Blue Review mailbox at bluereview@bcbsil.com, or you may contact your assigned Provider Network Consultant. Blue Review is a monthly newsletter published for Institutional and Professional Providers contracting with Blue Cross and Blue Shield of Illinois. We encourage you to share the content of this newsletter with your staff. Blue Review is located on our Web site at bcbsil.com/provider. The editors and staff of Blue Review welcome letters to the editor. Address letters to: Blue Review Blue Cross and Blue Shield of Illinois 300 E. Randolph Street 25th Floor Chicago, Illinois bluereview@bcbsil.com Website: bcbsil.com/provider Publisher: Stephen Hamman, VP, Network Management Editor: Gail Larsen, DVP, Provider Relations Managing Editor: Jeanne Trumbo, Sr. Manager Editorial Staff: Margaret O Toole, Marsha Tallerico and Allene Walker BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions regarding any of the products or services mentioned in this periodical, you should contact the vendor directly. Visit our Web site at bcbsil.com/provider REVIEW BlueFor contracting institutional and professional providers PRSRT STD U.S. POSTAGE PAID PERMIT NO. 581 CHICAGO, IL A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association