NEWS MARCH 2016 INSIDE. A publication for participating providers and their office staffs

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1 A publication for participating providers and their office staffs NEWS MARCH 2016 INSIDE Update: Private Option claim refund requests and 1 remittance offsets Help Private Option enrollees keep coverage 2 AHIN Professional Services 3 AHIN overpayment notification 3 Taxonomy code requirement 4 New pharmacy benefit manager 5 Reminders update about HIPAA and HITECH 5 Controlled substance safety and monitoring 6 program Omalizumab (Xolair) requires prior authorization 6 New group vision plans offered patient-centered medical home program 8 Blue Cross and Blue Shield of Alabama oncology 9 select program Arkansas Blue Cross and Blue Shield 2016 HEDIS 9 season ASE/PSE bariatric surgery program recommenced 10 CMS issues guidelines for online provider 11 directories Annual compliance training requirements Medi-Pak Advantage risk/quality improvement 13 program Medi-Pak Advantage chronic care improvement 14 Medi-Pak Advantage 2016 fee schedule updates 14 recently released by CMS Technical guidance on implementation of the Medi- 15 Pak Advantage Part D prescriber enrollment Medicaid eligibility and claims for Blue Cross plans 15 outside Arkansas Medicaid claims handling for Medicaid members spring provider workshops 23 Fee schedule: additions and changes 24 Fee schedule: injection codes 36 Update: Private Option claim refund requests and remittance offsets The Department of Human Services (DHS) has announced that Centers for Medicare & Medicaid Services (CMS) has agreed to fund health insurers, including Arkansas Blue Cross Blue Shield, for the reinstatement of Private Option enrollees that had been retroactively terminated. On February 16, 2016, a determination to reinstate policies was received in a press release from DHS. CMS has agreed to reinstate the monthly premiums recouped from Arkansas Private Option health plans. Arkansas Blue Cross health plans will no longer need to recoup monies paid to healthcare providers for claims paid during this retroactive period on Private Option members who will be reinstated. The determination was made following Governor Asa Hutchinson s meeting with U.S. Department of Health and Human Services Secretary, Sylvia Burwell. The Governor asked the Secretary to consider allowing the premiums to be reinstated. DHS will be providing information on how and when the reinstatements will be made, and has reported policy changes to prevent retroactive closures in the future.

2 PROVIDE SERVICES TO Private Option Enrollees? HELP THEM KEEP THEIR COVERAGE! TELL THEM THE IMPORTANCE OF CONTACTING DHS AS SOON AS POSSIBLE! The Department of Human Services has contacted many enrollees in the Arkansas Healthcare Independence Program (or Private Option) who must verify their eligibility to continue receiving health coverage in Arkansas Blue Cross and Blue Shield is also contacting these enrollees to encourage them to submit any necessary information. Please help us communicate to Private Option enrollees that if they received a letter from DHS or Arkansas Blue Cross they must contact and submit information to DHS immediately or their coverage could end. Private Option enrollees should call or visit their local DHS county office. NOTE: Asking Private Option members to verify their eligibility with DHS will help to keep them enrolled. Thank you for your help! 2 MARCH 2016 PROVIDERS NEWS

3 AHIN Professional Services AHIN Professional Services is a results-driven division of the Advanced Health Information Network (AHIN), dedicated to the needs of the healthcare industry, offering advanced functionality and integrated capabilities at competitive pricing. We can provide you with the ability to manage clinical, financial and administrative functions through a single point of contact. It is our goal to help you navigate the ever-changing healthcare landscape. Our team has expertise in revenue cycle management, fully integrated PM/EHR system implementation and support, billing services, practice assessments, clearinghouse services and much more. Your office can focus on providing the best medical care for your patients, while we focus on quality-driven solutions for your clinic. We assist hospitals, physician practices and multi-specialty medical groups in designing, developing and implementing solutions to help businesses reach higher levels of success. Utilizing our services can help your practice prepare for the future, even during times of constant change. At AHIN Professional Services, it is our belief every medical practice is different, requiring unique solutions based on your individual situation. Our team will immerse themselves in your organization to understand your goals, challenges, business philosophy and the environment in which you operate. Through oneon-one consultation with our experienced Arkansasbased consultants, we will partner with you to develop customized implementation strategies and ideal solutions placing your practice in a position for continued success. We recognize our success depends on the success of our clients. Let the AHIN Professional Services team help you, not only achieve, but surpass your goals by collaborating with your team and providing resources to create a healthcare legacy lasting a lifetime. Contact us today to get started. We look forward to hearing from you soon. Phone: Web: ahinservices.com info@ahinservices. com. AHIN overpayment notification Do you have an AHIN workstation? Providers can notify Arkansas Blue Cross and Blue Shield, Health Advantage, the Federal Employee Program (FEP), and BlueAdvantage Administrators of Arkansas regarding overpaid claims. AHIN includes a function to allow electronic notification and response from the appropriate claims division. This tool is for overpaid claims only. Please do not submit corrected claims or customer service questions via this tool. For assistance with AHIN, please contact AHIN Customer Support at This article was previously published in the December 2015 issue of Providers News. PROVIDERS NEWS MARCH

4 Taxonomy code update Over the years, a provider s taxonomy code has become more important in the payer industry. Healthcare provider taxonomy codes are designed to categorize the type, classification, and/or specialization of healthcare providers. Most providers developed awareness of the taxonomy codes through the requirement to obtain their national provider identifier (NPI). The National Plan and Provider Enumerator System (NPPES) required providers to self-report and enter this 10-digit expanded specialty code when obtaining their NPI. Many medical providers were likely not very concerned with the selfreported taxonomy code and even less likely to have given their taxonomy a second thought since obtaining their NPI. Arkansas Blue Cross and Blue Shield, its affiliates and subsidiaries have at least two purposes for taxonomy codes requiring accuracy on the NPPES record. First, the Arkansas Insurance Department (AID) will now be using a provider s taxonomy code to assist in determining the network adequacy of the payers involved in the Health Insurance Marketplace/ Exchange. In conjunction with the information being sent to the AID from the payers, the AID will utilize the taxonomy code attached to a provider s NPI that is on file at the NPPES. If a provider s taxonomy has changed or a provider believes his/her taxonomy codes need to be more specific, the provider should go to the NPPES and revise their taxonomy code. Second, Arkansas Blue Cross will begin using provider taxonomy codes on file when processing claims in the BlueCard Program. Claims adjudication may be affected by the taxonomy code, as it is today with provider specialty codes. Arkansas Blue Cross has the taxonomy information providers submitted on their respective NPI notification from NPPES. We will continue to use taxonomy information on file within our provider data systems instead of any taxonomy information submitted on a claim record. If your NPI needs to be revised, please do so through the NPPES. Next, send the NPPES information with the revisions and any taxonomy changes to Arkansas Blue Cross Network Operations via providernetwork@ arkansasbluecross.com. A few reasons a taxonomy code may need to be revised: 1. A physician might have completed an additional fellowship. 2. A certified nurse practitioner may have started collaborating with a specialist and is no longer in the primary arena. 3. A facility may have built a new wing for additional services. Please update any necessary information to ensure correct benefit adjudication, and Arkansas Blue Cross can accurately determine network adequacy. 4 MARCH 2016 PROVIDERS NEWS

5 Reminders about HIPAA and HITECH that affect providers As a Qualified Health Plan participating in the Federal Facilitated Marketplace (FFM), including the Multi State Plan Program (collectively known as the Exchange), this is Arkansas Blue Cross and Blue Shield s reminder to all network participating providers that they must be compliant with their applicable sections of the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economics and Clinical Health (HITECH) in order to be in our provider networks. Please be aware that: 1. Providers must comply with applicable interoperability standards and demonstrate meaningful use of health information technology in accordance with the HITECH Act, and 2. Subcontractors, large providers, providers, vendors and other entities required by HIPAA to maintain a notice of privacy practices, must post such notices prominently at the point where an Exchange enrollee enters the website or web portal of such subcontractors, large providers, providers and/ or vendors. For more detailed information, please visit: hhs. gov/ocr/privacy/index.html. New pharmacy benefit manager The Arkansas State Employees and Public School Employees will have a new pharmacy benefit manager, MedImpact, on June 1, The new specialty pharmacy will be US Bio Services. Providers will continue to call EBRx at for drug prior authorization. PROVIDERS NEWS MARCH

6 Controlled substance safety and monitoring program Arkansas Blue Cross and Blue Shield is encouraging physicians to use the Arkansas Prescription Monitoring Program. The number of opioid prescriptions, emergency department visits related to opioid drug misuse or abuse, and drug overdose deaths involving opioid pain relievers are exponentially increasing. Arkansas Blue Cross has a Prescription Safety and Monitoring Solution Program that identifies members who are potentially abusing or misusing controlled substances. The main focus is to ensure quality patient care and safety. High-risk members are identified through an algorithm based on pharmacy claims history and are flagged when there are prescriptions for several controlled substances, prescriptions filled at several pharmacies, and prescriptions written by several physicians. When a high-risk member is identified, a letter is sent to each physician who prescribed a controlled medication in the last nine months to verify and evaluate the patient s drug therapy. Based on physician responses and further investigation by the Arkansas Blue Cross Special Investigations Unit, these members are frequently evaluated for unusual medication utilization patterns. As a provider, you can assist by verifying patients drug therapy and patterns using the Arkansas Prescription Monitoring Program (AR PMP). All prescriptions for controlled substances, whether paid for by any insurance or cash, will show up on your patients profile. The AR PMP recently added a delegate function so physicians can delegate someone on staff to access the database on their behalf. Checking the AR PMP is a helpful tool to proactively identify high-risk patients before they are flagged by the Arkansas Blue Cross Prescription Safety and Monitoring Solution Program. Register or access the database at arkansaspmp.com/. Omalizumab (Xolair) prior authorization The Omalizumab: coverage policy lists coverage criteria for use to treat asthma or chronic idiopathic urticaria. Arkansas Blue Cross and Blue Shield requires prior authorization be obtained for this drug prior to initial administration and concurrent authorization as specified for those members previously approved. This request must contain medical record documentation verifying coverage criteria are met. Severe Persistent Asthma Initial authorization of Omalizumab for asthma requires medical record documentation of: 1. Moderate to severe persistent asthma, AND 2. a positive skin test or in vitro reactivity to a perennial aeroallergen, AND 3. age > 12 y/o, AND 4. FEV1<80%, AND 5. documentation that member is not an active smoker, AND 6. evidence of inadequate controlled asthma with standard therapy (daily use of inhaled corticosteroids, long-acting beta agonists, and other drugs), AND 7. an IgE level greater than 30 IU/ML and less than 700 IU/ML and body weight are necessary to determine dose. Initial authorization will approve six months use. (Continued on page 7) 6 MARCH 2016 PROVIDERS NEWS

7 Omalizumab (Xolair) prior authorization (Continued from page 6) Subsequent authorizations will permit use for 12 months and will require medical record documentation of: Improved FEV1 over baseline. Decreased use of rescue agents. Decrease in acute exacerbations. The appropriate asthma diagnosis to document need for Omalizumab is ICD-10 codes J45.40 or J45.50 (ICD for claims prior to October 2015). Severe Chronic Idiopathic Urticaria Chronic idiopathic urticaria (or chronic spontaneous urticaria) is defined as spontaneous hives and/or angioedema with no specific cause persisting at least six weeks. THe American Academy of Allergy, Asthma & Immunology (AAAAI) notes For patients with chronic urticaria with otherwise unremarkable history and physical examination findings, skin or in vitro testing for IgE to inhalants or foods and/or extensive laboratory testing are not recommended because such testing is not cost-effective and does not lead to improved patient care outcomes. * Initial authorization of Omalizumab will be for four months and requires the following medical record documentation: Age >12 y/o Minimum of three months of symptoms: six weeks to establish diagnosis of CIU and 6wks of treatment with stepcare approach as recommended by AAAAI (includes H1 antihistamines, H2 antihistamines, and leukotriene receptor antagonists).* Step 1: Monotherapy with second generation antihistamine. Step 2: One or more of the following as appropriate: Dose advancement of second generation antihistamine used in step 1; Add another second generation antihistamine, AND/OR Add H2 antagonist, AND/OR Add leukotriene receptor antagonist, AND/ OR Add first generation antihistamine to be taken at bedtime. Step 3: Dose advancement of potent antihistamines (e.g. hydroxyzine or doxepin) as tolerated. Step 4: Add an alternative agent Omalizumab or cyclosporine OR Other anti-inflammatory agents, immunosuppressants, or biologics. Subsequent authorizations will be for a period of 12 months and will require medical record documentation of: Clinically meaningful improvement in symptoms (i.e. urticaria activity score UAS7) by least 50 percent. If remission is achieved, recurrence of CIU when omalizumab is withheld. *Bernstein, JA, et al, The Diagnosis and Management of Acute and Chronic Urticaria: 2014 Update, JACI 2014: The appropriate CIU diagnosis to document need for Omalizumab is ICD-10 L50.1 (ICD for claims submitted before October 1, 2105). Omalizumab for the treatment of other allergic conditions, other forms of urticaria, or any other condition is not covered. Prior authorization requests with all necessary documentation may be faxed to PROVIDERS NEWS MARCH

8 New group vision plans offered: transition of many plans to VSP Arkansas Blue Cross and Blue Shield now is working with Vision Service Plan (VSP) to offer a new selection of vision plans for members whose coverage is through their employer in Arkansas. We re excited about the opportunity to provide these new plans, and our members are excited about the expanded benefits and large network of vision service providers. The majority of current Arkansas Blue Cross vision groups are transitioning on renewal from Davis Vision to VSP. All transitioned group members are getting a vision plan ID card that identifies the cardholder as an Arkansas Blue Cross vision plan member. Another bloc of Arkansas Blue Cross business that was with Life & Specialty Ventures (LSV) is transitioning to the new Arkansas Blue Cross vision plans for a March 1, 2016, effective date. Approximately 180 groups fall into this transition. These members have not previously had a vision plan ID card, but will be receiving one upon the effective date. Although not every Arkansas Blue Cross vision plan will be transitioned to VSP, the majority will. Some group vision plans will remain with Davis. For questions about network participation, please contact the VSP Provider Relations Department at or fill out the online form at vspglobal.com/cms/ doctors/be-a-vsp-doctor. html. Vision claims and customer service questions can be addressed using the telephone numbers found on the member s vision plan ID card patient-centered medical home program The Primary Care team will host learning sessions for the Patient-Centered Medical Home program. The sessions will include webinars and regional training sessions for those enrolled in the PCMH program. The first in the series will be a webinar covering: Foundational aspects of a patient centered medical home The quality metrics tracked in the ABCBS PCMH program The three month practice transformation activities to be completed by participating practices Enrollment information for each session will be published through AHIN alerts, Providers News, PCMH portal alerts and notifications. For additional information please contact us at primarycare@arkbluecross.com or MARCH 2016 PROVIDERS NEWS

9 Blue Cross and Blue Shield of Alabama oncology select program Blue Cross and Blue Shield of Alabama (BCBSAL) has many members living in Arkansas. BCBSAL has chosen to work with an independent third party vendor, AIM Specialty Health (AIM), to create the Oncology Select program, which will promote evidencebased treatment. For medical oncology, evidence-based treatment with medical best practices (including evidence-based treatment regimens, and cancer care pathways for all tumor types) drives the clinical appropriateness review of the cancer treatment plan (e.g., chemotherapy drug regimen). The AIM portal has been available for all providers to use for courtesy predetermination of treatment plans since September 1, 2015, with predetermination decisions being upheld when rendered. Providers should continue to utilize the Blue Exchange tool to verify eligibility and benefits. If applicable, they can access the AIM precertification system through the Blue Exchange tool. Effective April 1, 2016, BCBSAL requires precertification for BCBSAL members treated in Arkansas for in-scope drugs. Arkansas Blue Cross and Blue Shield 2016 HEDIS season Arkansas Blue Cross and Blue Shield is committed to participating in quality of care improvement initiatives with the physicians and providers who care for our members. To support our HEDIS audit requirements, we need to collect data from medical records which detail the care you have provided to our members, your patients. In 2016, Arkansas Blue Cross is working with Inovalon to help us collect these medical records. We want to work efficiently and effectively, with as little burden as possible to your practice. A representative will be contacting you to schedule an appointment and will make every effort to meet the scheduling needs of your office during the late February and early March timeframe. We appreciate your cooperation with this important effort. PROVIDERS NEWS MARCH

10 ASE/PSE: bariatric surgery program recommenced Enrollment into the Bariatric Surgery Pilot Program resumed on January 4, For members accepted into the program, ARBenefits will provide coverage for surgery to include: Gastric bypass surgery Adjustable gastric banding surgery Sleep gastrectomy surgery Duodenal switch biliopancreatic diversion The Arkansas State and Public School Life and Health Insurance board must approve additional procedures. Surgical procedures must be pre-certified by the surgeon and supported as medically necessary by the primary care physician prior to surgery. to treat a condition, they must enroll in a disease management program.) 3. The employee under the plan must have been a plan participant for a minimum of one plan year prior to enrollment in the bariatric program. A full list of participation criteria and link for frequently asked questions is available at ARBenefits.org and by clicking on resources and links in the Health Enhancement section of the EBD homepage. Please note that this program will only cover the first bariatric procedure per lifetime. (Employees who have had previous bariatric procedures are ineligible.) The eligibility criteria are as follows: 1. Only Arkansas State and Public School employees, ages 25-55, with a BMI greater than 35 will be considered for bariatric surgery (no dependents or spouses). 2. If the employee s BMI is between 35 and 40, candidates must have co-morbid conditions, such as cardiopulmonary disease, sleep apnea, hypertension or diabetes. (If the member is followed by the physician for, or are on medications Any requirements are subject to change. Members must call EBD at or to enroll.each year the Arkansas State Legislature gives the plan a set amount of funds that go towards fighting obesity. Those funds are split between the ASE and PSE plans. With only a set amount of funds available, enrollment into the program will cease once those funds are exhausted. 10 MARCH 2016 PROVIDERS NEWS

11 CMS issues guidelines for online provider directories The Centers for Medicare & Medicaid Services (CMS) is requiring all Medicare Advantage plans to provide its enrollees with the most up-to-date information regarding participating providers on their online provider directories. CMS has issued guidelines that all Medicare Advantage plans and participating providers must follow. Under the new CMS program, Medicare Advantage plans must have regular, ongoing communications with providers to ascertain their availability and, more specifically, whether they are accepting new patients. Plans are required to maintain accurate online provider directories by: Displaying all active participating providers Identifying providers whose practice is closed or providers not accepting new patients Updating online provider directories in real-time Communicating with providers monthly regarding their network status and information accuracy Medicare Advantage plans are expected to require participating providers to inform the plan of any change to street addresses, phone numbers, office hours or any other change that can affect their availability. Medicare Advantage plans are also required to develop and implement a protocol to effectively address inquiries and complaints related to enrollees being denied access to a participating provider and make immediate corrections to their online provider directory. In order to meet these CMS requirements, providers participating in the Medi-Pak Advantage PFFS, Medi-Pak Advantage LPPO, and Medi-Pak Advantage HMO plans are now required to maintain and updated their information with Arkansas Blue Cross and Blue Shield. To assist providers, Arkansas Blue Cross is developing an information update screen on the AHIN website. Providers will be able to update information such as their status of accepting new patients, joining or terminating from an existing clinic, and their hours of service. On the AHIN provider detail page, providers will be able to update their patient restrictions under the network tab and update their office hours under the provider association tab. Reminders will also be published in subsequent editions of the Providers News as well as monthly reminders on AHIN. This article was previously published in the September and December 2015 issues of Providers News. PROVIDERS NEWS MARCH

12 Annual compliance training requirements Arkansas Blue Cross and Blue Shield is required to develop and maintain a compliance program as a contractor with Centers for Medicare & Medicaid Services (CMS) and a QHP through the U.S. Department of Health and Human Services (HHS) through the Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010 (together referred to as the Affordable Care Act). The compliance program requires ensuring annual compliance training is satisfied by our first-tier, downstream and related entities (FDRs) and delegated entities (DEs). According to the Federal Register Notice CMS FC and 45 C.F.R. Subpart D , providers are considered first tier and/ or delegated entities when there is a direct contract for Medicare/ACA Services between Arkansas Blue Cross and each provider. The Office of Inspector General (OIG) has issued guidance with reference to effective compliance programs for specific healthcare providers. The guidance is available at oig.hhs.gov/fraud/ complianceguidance.asp. As a CMS plan sponsor, Arkansas Blue Cross must ensure that our FDRs/DEs receive general compliance training as well as fraud, waste, and abuse (FWA) training. FDRs deemed to have met the FWA training and education certification requirements through enrollment into Parts A or B of the Medicare program or through accreditation as a supplier of DMEPOS are NOT exempt from the general compliance training requirement. Methods for completing the training Guidance states that FDRs/ DEs have three (3) options ensuring that general compliance training requirement is satisfied: 1. FDRs/DEs can complete the general compliance and/or FWA training modules located on the CMS MLN. Once an individual completes the training, the system will generate a certificate of completion. The MLN certificate of completion must be accepted by Plan Sponsors. 2. Sponsors and FDRs/ DEs can download and incorporate the content of the CMS standardized training modules from the CMS website into their organizations existing compliance training materials/systems. 3. Sponsors and FDRs/ DEs can incorporate the content of the CMS training modules into written documents for providers (e.g. provider guides, participation manuals, business associate agreements, etc.). To ensure this requirement is met and to largely reduce the duplicative training required of FDRs/DEs by multiple organizations with whom you contract, CMS developed web-based compliance training. The CMS compliance training module contains general compliance and FWA training courses. Training courses are available on the CMS Medicare Learning Network (MLN): cms.gov/ MLNProducts. While the training does not qualify for continuing education credits through CMS, the contact hours are included on the certificate of completion. This training provides separate content for compliance and FWA, and is available through web-based or downloadable versions for the learner. The training content is generic since various entities (e.g., health plans, labs, hospitals, etc.) complete the training. A certificate of completion (Continued on page 13) 12 MARCH 2016 PROVIDERS NEWS

13 Annual compliance training requirements (Continued from page 12) is generated upon passing a short test with a score of 70% or higher at the end of the training module. Who must complete the training? Annual compliance training should be completed by the provider, the provider s staff with contact (indirect or direct including billing, receptionist, lab, and clinical staff) with Medicare beneficiaries and ACA members. What do we do with our training records? All training documents, including a copy of the training materials and training logs, must be retained by your organization for 10 years, in accordance with CMS/HHS record retention guidelines. No documentation should be returned to Arkansas Blue Cross at this time. However, Arkansas Blue Cross is developing an attestation that will be administered through AHIN, for a representative to attest that each FDR/DE has completed the appropriate general compliance and FWA training either through their organization or through the Medicare Learning Network (MLN). When should the training be completed? The general compliance training must occur within 90 days of initial hiring and annually thereafter. The annual training can be completed any time between January 1 December 31 of any given contract year. All documentation is subject to random audit by Arkansas Blue Cross or may be requested as part of a Compliance Program Audit by CMS/HHS or CMS/HHS designees Medi-Pak Advantage risk/quality improvement program Arkansas Blue Cross and Blue Shield is continuing our partnership efforts with our valued network providers in providing high quality, affordable healthcare to our members, your patients by designing program goals/ incentives to accurately capture, close and report on quality and risk gaps. Arkansas Blue Cross will introduce our 2016 program goals and a preliminary review of the 2015 program results by end of February/ early March. These programs continue to promote enhanced physician and patient encounters by providing actionable and relevant data to better assist in improving quality outcomes and accurately capturing the necessary coding to ensure compliancy with defined CMS guidelines. Watch for applicable program details and supporting educational documentation before end of first quarter. PROVIDERS NEWS MARCH

14 Medi-Pak Advantage chronic care improvement plan In September 2011, the Department of Health and Human Services launched the Million Hearts Initiative. The goal was to prevent one million heart attacks and strokes by The Centers for Medicare & Medicaid Services (CMS) partnered with Million Hearts and announced their own initiative the Chronic Care Improvement Program (CCIP) focused on reducing cardiovascular disease over the next five years within the Medicare patient population. Arkansas Blue Cross and Blue Shield is a proud supporter of the CCIP initiative supported by our Medi-Pak Advantage health plan. The Medi-Pak Advantage health plans will focus will on helping our Medicare Advantage members with diabetes and hypertension that lack: Consistent primary care visits A1C testing and other self-management measures LDL screenings Statin use Blood pressure control Medication adherence Diet and exercise compliance We have care management teams focused on these issues, and we are here to support you as you care for our members, your patients. We can assist you with activities such as coordination of care, home visits, caregiver support, health education, medication adherence, health plan benefits, community resources and much more. We look forward to working with you to help increase the quality of care and improve health outcomes for our members. If you have any questions about our role in the CCIP initiative, please call us at Medi-Pak Advantage: 2016 fee schedule updates recently released by CMS The Centers for Medicare and Medicaid Services (CMS) published Medicare Fee Schedules and Pricer Updates for the first quarter in Medi-Pak Advantage updated their payment system to price the following claims with the updated fee schedules. Ambulatory Surgical Centers (ASC) Anesthesia Conversion Factor (CF) Average Sales Price (ASP) Clinical Lab (service rendered in provider s office) Clinical Lab (service rendered at an independent lab) End Stage Renal Disease (ESRD) Outpatient Prospective Payment System (OPPS) Medicare Physician Fee Schedule (MPFS) Skilled Nursing Facility (SNF) Medicare Physician Pricers Claims impacted by the updates will be reprocessed. If you have any questions, please contact your network development representative. 14 MARCH 2016 PROVIDERS NEWS

15 Technical guidance on implementation of Medi-Pak Advantage Part D prescriber enrollment requirement The Centers for Medicare & Medicaid Services (CMS) is providing technical guidance to Part D sponsors and their pharmacy benefit managers (PBMs) to apply once the Part D Prescriber Enrollment requirement is enforced beginning June 1, The term Part D Prescriber Enrollment Requirement refers generally to the provisions in the two applicable rules: 1) final rule CMS-4159-F Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs (79 FR 29843; May 23, 2014); and 2) the interim final rule with comment ( IFC ) CMS6107- IFC Medicare Program; Changes to the Requirements for Part D Prescribers (80 FR 25958; May 6, 2015). Additionally, the term Part D sponsor in this document means the Part D sponsor and its PBM unless noted otherwise. This guidance addresses topics CMS acknowledged in the preamble to the IFC that would need further guidance and is also based on comments received on the IFC as to areas needing further technical guidance. CMS also intends to publish a final rule addressing timely comments received on the May 6, 2015 IFC. This and other previously issued and posted guidance on the Part D Prescriber Enrollment Requirement can be found at cms.gov/medicare/ Prescription-DrugCoverage/ PrescriptionDrugCovGenIn/ Prescriber-Enrollment- Information.html and go.cms. gov/prescriberenrollment. This article references previously published article Medi-Pak Advantage Part D prescriber requirements in the September and December 2015 issues of Providers News. Medicaid eligibility and claims for Blue Cross plans outside Arkansas The Blue Cross and Blue Shield Association has provided information for providers in handling eligibility and claims for Blue Cross Plans that currently administer Medicaid programs in their states. Providers should use the regular BlueCard eligibility phone line, BLUE or submit the inquiry using BlueExchange for all eligibility inquiries. Prior authorization information can be obtained through the regular electronic provider access tool. The ID cards will have the Blue Cross logo but some member s cards will not indicate the member has a Medicaid product. The back of the ID card will provide information about benefit limitations and copays, coinsurance and deductibles. Texas and Tennessee are neighboring states administering Medicaid programs, but there are 17 in the United States. BlueCard Medicaid claims should be filed to Arkansas Blue Cross and reimbursement will be the (Continued on page 16) PROVIDERS NEWS MARCH

16 Medicaid eligibility and claims for Blue Cross plans outside Arkansas (Continued from page 15) Medicaid fee schedule that applies in the member s home state. Providers should check the Medicaid website of the state where the member resides for information on Medicaid billing requirements. Providers must be enrolled in that states Medicaid Program in order to file claims. When claims are submitted from an unenrolled provider, they will be denied until enrollment is completed. Billing out-of-state Medicaid members for the amount between Medicaid allowed charges and charges for covered services is prohibited by federal regulations. Medicaid claims handling for Medicaid members Blue Cross and Blue Shield Plans currently administer Medicaid programs in California, Delaware, Hawaii, Illinois, Indiana, Kentucky, Michigan, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and Wisconsin as a managed care organization (MCO), providing comprehensive Medicaid benefits to the eligible population. Because Medicaid is a state-run program, requirements vary for each state, and thus each Blue Plan. Medicaid members have limited outof-state benefits, generally covering only emergent situations. In some cases, such as continuity of care, children attending college out-of-state, or a lack of specialists in the member s home state, a Medicaid member may receive care in another state, and generally the care requires prior authorization. Identifying Medicaid Members to Determine Eligibility and Benefits Blue Plan ID cards do not always indicate that a member has a Medicaid product. Blue Plan ID cards for Medicaid members do not include the suitcase logo that you may have seen on most Blue Cross ID cards, but they do include a disclaimer on the back of the ID card providing information on benefit limitations. For members with such ID cards, you should obtain eligibility and benefit information and prior authorization for services using the same tools as you would for other Blue Plan members. Submit an eligibility inquiry by calling the BlueCard Eligibility Line at BLUE. Submit an eligibility inquiry using BlueExchange. Obtain pre-service review using the electronic provider access (EPA) tool. Medicaid Reimbursement and Billing Claims for all Blue Cross Medicaid members should be submitted to your local Blue Plan. If you are contracted with your local Blue Plan for Medicaid, your local Medicaid rates will only apply for Arkansas Blue Cross and Blue Shield members; they do not apply to out-of-state Medicaid members. When you see a Medicaid member from another state and submit the claim, you must accept the Medicaid fee schedule that applies in the member s home state. Please remember that billing outof-state Medicaid members for the amount between the Medicaid-allowed amount and charges for Medicaid-covered services is specifically prohibited by Federal regulations (42 CFR ). If you provide services that are not covered by Medicaid (Continued on page 17) 16 MARCH 2016 PROVIDERS NEWS

17 Medicaid claims handling for Medicaid members (Continued from page 16) to a Medicaid member, you will not be reimbursed. You may only bill a Medicaid member for services not covered by Medicaid if you have obtained written approval from the member in advance of the services being rendered. In some circumstances, a state Medicaid program will have an applicable copayment, deductible or coinsurance applied to the member s plan. You may collect this amount from the member as applicable. Note that the coinsurance amount is based on the Medicaid fee schedule for that service. Medicaid Billing Data Requirements When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on Medicaid billing requirements. Providers should always include their National Provider Identifier (NPI) on Medicaid claims, unless the provider is considered atypical. Providers should also bill using National Drug s (NDC) on applicable claims. These data elements and other data elements that are important to submit, when applicable, on Medicaid claims. Effective March 2016, applicable Medicaid claims submitted without these data elements will be denied. Prior to March 2016, applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received: National Drug Rendering Provider Identifier (NPI) Billing Provider Identifier (NPI) Applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received: Billing provider (Second) address line Billing provider middle name or initial (Billing) provider taxonomy code (Rendering) provider taxonomy code (Service) laboratory or facility postal zone or ZIP code (Ambulance) transport distance (Service) laboratory facility name (Service) laboratory or facility state or province code Value code amount Value code Condition code Occurrence codes and date Occurrence span codes and dates Referring provider identifier and identification code qualifier Ordering provider identifier and identification code qualifier Attending provider NPI Operating physician NPI Claim or line note text Certification condition applies indicator and condition indicator (early and periodic screening diagnosis and treatment (EPSDT)) Service facility name and location information Ambulance transport information Patient weight Ambulance transport reason code Round trip purpose description Stretcher purpose description Medicaid Encounter Data Reporting The data elements mentioned above need to be included on Medicaid claims, so that Blue Plan MCOs are able to comply with encounter data reporting requirements applicable in their respective state. Provider Enrollment Requirements You may be required to enroll in another state s Medicaid program, which will be determined upon submitting an eligibility or benefit inquiry (Continued on page 18) PROVIDERS NEWS MARCH

18 Medicaid claims handling for Medicaid members (Continued from page 17) to the out-of-state Medicaid program. You should enroll in that state s Medicaid program before submitting the claim. If you submit a claim without enrolling, your out-of-state Medicaid claims will be denied and you will receive information from your local Blue Cross Plan regarding the Medicaid provider enrollment requirements. Commonly Asked Questions How do I submit Medicaid claims? Medicaid claims should be submitted to your local Blue Plan in the same manner as you submit claims for other Blue Plan members. You will also receive your payment in the same manner, although the payment amount will likely be different from your contracted rate, or different from the Medicaid rate in the state in which you practice. How do I know that I am seeing a Medicaid member? Members enrolled in a Blue Plan Medicaid product are issued Blue Plan ID cards. Blue Plan Medicaid ID cards do not always indicate that a member is enrolled in a Medicaid product. Blue Plan ID cards for Medicaid members: Will not include a suitcase logo. Will contain disclaimer language on the back of the ID card indicating benefit limitations for provider awareness, for example, This member has limited benefits outside of Arkansas Blue Cross. Providers should request eligibility/benefit information. Providers should always submit an eligibility inquiry if the Plan ID card has no suitcase logo and includes a disclaimer with benefit limitations, using the same tools available for BlueCard: BlueCard Eligibility Line BlueExchange Because Plan member ID cards will not always indicate that the member is enrolled in a Medicaid product, you should always obtain eligibility and benefit information. With an eligibility response, you should receive information on Medicaid coverage. What amount should I expect to receive for members that reside outside of Arkansas Blue Cross service area? When billing for services rendered to an out-of-state Medicaid member, you will be reimbursed according to the member s home state Medicaid fee schedule, which may or may not be equal to what you are accustomed to receiving for the same service in your state. My state does not require me to include an NPI or NDC code and many of the other data elements listed above on a Medicaid claim. Why do I have to include these codes? Most state Medicaid programs require NPI and NDC codes and the additional data elements (when applicable) to be populated on claims submitted for Medicaid members for encounter data reporting purposes. To ensure compliance with state Medicaid requirements, providers who bill for Medicaid members should include these data elements on applicable Blue Plan Medicaid claims or the claims may be pended or denied. I do not often see Medicaid members from another state. Why must I enroll as a Medicaid provider outside of my own state when billing for some Medicaid members in other states? Many state Medicaid programs require providers to enroll before reimbursement may be provided by the Blue Plan. If you do not enroll with the state where required, the claim could be denied. Whom do I contact if I have questions? If you have questions, please call Arkansas Blue Cross toll free at (Continued on page 19) 18 MARCH 2016 PROVIDERS NEWS

19 Medicaid claims handling for Medicaid members (Continued from page 18) Exhibit 1 Medicaid Billing Data Elements Required Data Elements for Medicaid Claims NOTE: Effective March 2016, applicable Medicaid claims submitted without these data elements will be denied. 837 Reference 837 Professional 1 Data Element Reference 837 Institutional 2 Data Element Reference Professional Paper Claim Item Reference (CMS1500) 3 Institutional Paper Claim Form Locator (UB04) 4 National Drug Loop 2410 LIN03 Loop 2410 LIN03 Item Number 24 Shaded Portion Form Locator 43 Rendering Provider Identifier (NPI) Loop 2310B NM109 unless overridden when reported in Loop 2420A NM109 ONLY when Rendering is different from Loop 2010AA Billing Provider Loop 2310D NM109 unless overridden when reported in Loop 2420C NM109 ONLY when Rendering is different from Loop 2310A Attending Provider Item Number 33A NPI# or Item Number 24J (Unshaded) Rendering Provider ID# Form Locators Form Locator 43 Line Level Billing Provider NPI Loop 2010AA NM109 Loop 2010AA NM109 Item Number 33A NPI# Form Locator 56 Other Data Elements for Medicaid Claims NOTE: Applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received. 837 Reference 837 Professional 1 Data Element Reference 837 Institutional 2 Data Element Reference Professional Paper Claim Item Reference (CMS1500) 3 Institutional Paper Claim Form Locator (UB04) 4 Billing Provider (Second) Address Line Loop 2010AA N302 Loop 2010AA N302 Item Number 33 Billing Provider Information and Phone Number Line 2 Form Locator 1 Line 2 Billing Provider Middle Name or Initial Loop 2010AA NM105 Loop 2010AA NM105 Item Number 33 Billing Provider Information and Phone Number Line 1 Form Locator 1 Line 1 (Billing) Provider Taxonomy Loop 2000A PRV03 Loop 2000A PRV03 Item Number 33B Other ID # Form Locator 81 (Rendering) Provider Taxonomy Loop 2310B PRV03 unless overridden when reported in Loop 2420A PRV03 Not applicable for institutional claim Item Number 24I ID Qualifier Number Not applicable for institutional claim (Continued on page 20) PROVIDERS NEWS MARCH

20 Medicaid claims handling for Medicaid members(continued from page 19) Other Data Elements for Medicaid Claims NOTE: Applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received. 837 Reference 837 Professional 1 Data Element Reference 837 Institutional 2 Data Element Reference Professional Paper Claim Item Reference (CMS1500) 3 Institutional Paper Claim Form Locator (UB04) 4 (Service) Laboratory or Facility Postal Zone or Zip Loop 2310C N403 unless overridden when reported in Loop 2420C N403 Loop 2310E N403 Item Number 32 Service Facility Location Information Line 3 Form Locator 1 Line 3 (Ambulance) Transport Distance Loop 2300 CR106 unless overridden when reported in Loop 2400 CR106 Loop 2400 SV205 with applicable revenue code Not reportable on 1500 form Form Locator 42 with applicable revenue code (Service) Laboratory Facility Name Loop 2310C NM103 unless overridden when reported in Loop 2420C NM103 Loop 2310E NM103 Item Number 32 Service Facility Location Information Line 1 Form Locator 1 Line 1 (Service) Laboratory or Facility State or Province Loop 2310C N402 unless overridden when reported in Loop 2420C N402 Loop 2310E N402 Item Number 32 Service Facility Location Information Line 3 Form Locator 1 Line 3 Value Amount Not applicable for professional claim Loop 2300 HI in 5th position within the composite data element (Value Information HI) Up to 24 value codes may be reported with a corresponding amount Not applicable for professional claim Form Locators Up to 12 value codes may be reported with a corresponding amount Form Locator 81 after above are exhausted Value Not applicable for professional claim Loop 2300 HI in 2nd position within the composite data element (Value Information HI) Up to 24 value codes may be reported Not applicable for professional claim Form Locators Up to 12 value codes may be reported Form Locator 81 after above are exhausted Condition Loop 2300 HI in 2nd position within the composite data element (Condition Information HI) Up to 24 condition codes may be reported Loop 2300 HI in 2nd position within the composite data element (Condition Information HI) Up to 24 condition codes may be reported Item Number 10d Form Locators Up to 11 condition codes may be reported Form Locator 81 after above are exhausted 20 (Continued on page 21) MARCH 2016 PROVIDERS NEWS

21 Medicaid claims handling for Medicaid members(continued from page 20) Other Data Elements for Medicaid Claims NOTE: Applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received. 837 Reference 837 Professional 1 Data Element Reference 837 Institutional 2 Data Element Reference Professional Paper Claim Item Reference (CMS1500) 3 Institutional Paper Claim Form Locator (UB04) 4 Occurrence s and Dates Not applicable for professional claim Loop 2300 HI in 2nd and 4th positions within the composite data element (Occurrence Information HI) Up to 24 occurrence codes and associated dates may be reported Not applicable for professional claim Form Locators Up to 8 occurrence codes and associated dates may be reported Form Locators (FROM field) may be used when available Form Locator 81 after above are exhausted Occurrence Span s and Dates Not applicable for professional claim Loop 2300 HI in 2nd and 4th positions within the composite data element (Occurrence Span Information HI) Up to 24 occurrence codes and associated dates may be reported Not applicable for professional claim Form Locators Up to 4 occurrence span codes and associated dates may be reported Form Locator 81 after above are exhausted Referring Provider Identifier and Identification Qualifier Loop 2310A NM108/09 or REF01/02 unless overridden when reported in Loop 2420F NM108/09 or REF01/02 Loop 2310F NM108/09 or REF01/02 unless overridden when reported in Loop 2420D NM108/09 or REF01/02 Item Number 17a Other ID# or 17b NPI # Form Locators Ordering Provider Identifier and Identification Qualifier Loop 2420E NM108/09 or REF01/02 when a different from the service line Rendering Provider Not applicable for institutional claim Item Number 17a Other ID number or 17b NPI number Not applicable for institutional claim Attending Provider NPI Not applicable for professional claim Loop 2310A NM109 Not applicable for professional claim Form Locator 76 Line 1 Operating Physician NPI Not applicable for professional claim Loop 2310B NM109 unless overridden when reported in Loop 2420A NM108/09 Not applicable for professional claim Form Locator 77 Line 1 Claim or Line Note Text Loop 2300 NTE02 unless overridden when reported in Loop 2400 NTE02 (Line Note NTE) Loop 2300 NTE02 Item Number 19 Additional Claim Information Form Locator 80 (Continued on page 22) PROVIDERS NEWS MARCH