The combination of the two companies will require regulatory approvals, and as the process progresses, we will keep providers informed.

Transcription

1 APRIL/MAY 2007 A Newsletter for Highmark Blue Shield Providers in Central Pennsylvania and the Lehigh Valley Lookingto the Future Highmark and Philadelphia-area Blue Plan Announce Agreement to Combine the Two Plans In late March, Highmark and the Blue Plan headquartered in Philadelphia announced an agreement to combine the two companies, which have been working closely together for more than 50 years. Both organizations are unified in our underlying goal: To make health care coverage better and more attainable for all of Pennsylvania. By combining, the two organizations will be better able to maintain affordable programs, meet customer needs in the marketplace and fund essential technology and infrastructure improvements. Following are some highlights on the agreement to combine the two organizations: ❿ The new, combined company will maintain dual headquarters in Pittsburgh and Philadelphia and will retain the same local and regional relationships throughout the state. ❿ The new company will generate more than $1 billion in economic benefits over six years to provide access to affordable, high-quality health care coverage to Pennsylvanians. It will also have the resources to help expand access to health coverage for Pennsylvania s uninsured population, and gain efficiencies that we expect will result in significant prescription drug cost and administrative fee savings for customers. ❿ The renewed strength and vitality of the combined organizations will ensure that a not-for-profit Blue Plan remains in the community which will help to support our mutual mission of reinvesting resources back into the community and funding programs for the uninsured. ❿ We will be better able to invest in technology to make our provider interactions even more efficient and cost-effective. We ll continue to enhance our existing Web-based platforms with the ultimate goal of making it easier for providers to conduct business with us. ❿ We can streamline the policies and procedures of the two organizations, including medical policy, to create a more seamless experience for providers, especially those in bordering counties. ❿ Service will remain our strength. We will maintain a local presence and familiar contacts to support you and your staff. ❿ We will expand and enhance the focused collaborations on quality and patient safety currently in place at both organizations to address the unique medical needs of our members in each region of the Commonwealth. Kenneth R. Melani, MD, will be chief executive officer of the combined company, and Joseph A. Frick, of the Blue Plan headquartered in Philadelphia, will be the president and chief operating officer of the new company. The combination of the two companies will require regulatory approvals, and as the process progresses, we will keep providers informed. Both organizations are committed to their social missions, Dr. Melani says. We know how strongly the community depends on us, and we want to assure you that we will maintain options and choices in the marketplace. I N S I D E Claims Processing Reminder...2 Cardiac Event Monitoring and Billing...2 Consumerism...2 New 1500 Claim Form...3 AHA Women s Cardiovascular Guidelines...4 Radiology Management Program...4 Coding and Non-Emergent Ambulance Services...4 Electronic Office Manual Now Available...5 Use In-Network Labs...5 Provider Relations Representative News...6 Provider Relations Telephone Number to be Eliminated...6 CHIP Expansion Covers All PA Children...7 NPI Update...8 New Parameter for Calculating COB Payments...8 Medicare Advantage Part B Medications...8 EFT Growing in Popularity...9 OASIS Benefits Option to be Eliminated...10 QualityBLUE SM 2007 Updates...10 Community Report Available Online...11 Standardized National Credentialing System...11 Behavioral Health News...12 Notifications for Providers...14 Highmark Healthy High 5 Increasing Physical Activity...15 P.O. Box 1949 No Longer in Service...15 Free Smoking Cessation Posters for Your Office...15

2 Claims Processing Reminder Effective April 13, 2007, Highmark began to make additional system checks for data completion and accuracy on all claims prior to adjudication. With these additional upfront edits, we hope to reduce claim suspensions, increase timeliness of claims processing and help you avoid time-consuming status inquiries. Also, when a claim rejects, it s important for your billing staff, clearinghouse and/or vendor to understand exactly what was wrong and what s needed to correct it. So, in addition to strengthening data validation, Highmark also implemented new claim status category codes to further define initial edit errors on electronically submitted claims. For more background information on Highmark s five-year plan to enhance core administrative functions within its information systems structure, including this first phase, see the previous issue of Behind the Shield. You can view the newsletter, and the Special Bulletin mailings on this topic, in the online Provider Resource Center, which is accessible via NaviNet or at (Please note: On the original communications, we listed Code E5128 in the list of codes that would be suspended. This code has been removed from the list and will not result in a suspension.) REMINDER: Cardiac Event Monitoring and Billing Requirements Network physicians who enlist the assistance of cardiac event monitoring practitioners to provide services in a physician office setting are reminded that only these contracted practitioners may bill Highmark for the technical component of this service. Physicians may bill Highmark separately for the professional component. If you have questions or need further clarification of Highmark s policy regarding delivery of and payment for cardiac event monitoring services, please call Provider Service, toll-free, at Providing More Information to Highmark Members Highmark s online provider directory now includes more useful data, such as electronic prescribing ability, credentialing and electronic medical records. An expanded search option also returns data on gender, language spoken and evening or weekend office hours. As noted in previous issues of Behind the Shield, we are also working to expand the scope of data to go beyond general information. Quality data is in high demand. In fact, Governor Rendell s Prescription for Pennsylvania specifically calls for transparency in this area. To meet this information need for our group customers and members, we are developing physician quality data (at the practitioner level) to be added to our consumer-facing Web site through Subimo, LLC s Healthcare Advisor TM tool. Highmark has contracted with Subimo to provide this user-friendly tool. We re working toward a July 2007 implementation. In advance of the online posting of this quality data, each physician practice will receive a summary of its quality data, how it was generated and how it will be represented online. Watch your mail, Behind the Shield and the Plan Central page of NaviNet for continued updates on the development of this quality data. 2

3 Instructions for New 1500 Claim Form Available on Provider Resource Center Since Oct. 1, 2006, Highmark has been accepting a new version of the 1500 Health Insurance Claim Form that accommodates the reporting of the National Provider Identifier (NPI). This new form, released by the National Uniform Claim Committee (NUCC), replaced the previous 1500 claim form, version 12/90, commonly referred to as the HCFA 1500 or CMS As communicated in previous newsletters, Highmark no longer supplies its version of the universal claim form (1500A). To ensure that your claims process correctly, Highmark strongly recommends using the new NUCC 1500 Health Insurance Claim Form. If you haven t already done so, you should contact your forms distributor to obtain a supply of the new form. Your forms distributor can obtain a negative or PDF of the form from TFP Data Systems or the Government Printing Office at: ❿ TFP Data Systems: , extension 1770, or 1500form@tfpdata.com. ❿ Government Printing Office: Step-by-step instructions for submitting the new claim form to Highmark are available in the Highmark Blue Shield Office Manual. The manual is available under the Administrative Reference Materials link on the Provider Resource Center, which is accessible via NaviNet or at Refer to the Claims Submission and Billing Information section in Chapter 5.2 for step-by-step instructions and for a sample of the new 1500 form. In addition to this Highmark-supplied information, other information about the new NUCC claim form and a reference instruction manual are available at Submit Only Original Claim Forms to Prevent Delays Please submit original claim forms to Highmark. Do not photocopy any claim form because it eliminates the red ink that is required by Highmark s Optical Character Recognition scanning system. If Highmark cannot scan your claims, processing will be delayed. Electronic Claims Submission: Better Than Paper The fastest way to submit claims is electronically. Some of the many benefits of electronic claims submission are elimination of claim form printing and postage costs, streamlined claims filing and faster claim payment. If you re submitting paper claims, we encourage you to begin submitting electronically. Simply contact your Provider Relations representative via Provider Services for more information on how to get started. 3

4 b Questions? Providers with Internet access will find helpful information online at NaviNet users should use NaviNet for all routine inquiries. But if you need to contact us, below are the telephone numbers exclusively for providers. HIGHMARK * Option 1 Claim status, benefits and enrollment Option 2 Customer Service/Provider Relations Option 3 Forms orders Option 4 Radiology Management Program HMS pre-certification/authorization requests (including behavioral health authorizations) Requests for HMS peer-to-peer conversations EDI Operations (electronic billing) Questions concerning Medicare Part B Option 2 Pharmacy (prescription authorizations) * This telephone number will be phased out as of Aug. 1, Please see story on page 6 for details. Margaret LeMasters, Managing Editor Adam Burau, Senior Editor Matthew Clark, Contributing Editor Comments/Suggestions Welcome We want Behind the Shield to meet your needs for timely, effective communication. If you have any suggestions, comments or ideas for articles in future issues, please write to the senior editor at: Behind the Shield Highmark Blue Shield Fax: adam.burau@highmark.com For More Information For NaviNet users, this icon following an article means that the material/information is conveniently accessible from Plan Central. Just click on Resource Center. For providers who don t yet have NaviNet access, this icon means that the material/ information is available on Highmark s Web site at Just click on the Providers tab at top right. AHA Updates Guidelines on Preventing Cardiovascular Disease in Women Highmark s physician-led Cardiology Quality Improvement Committee reminds network providers that the American Heart Association (AHA) recently updated its Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women. The updated guidelines are available at: ❿ Radiology Management Program Reminder: Call NIA to Request Retrospective Reviews Network providers who would like a retrospective review of a Highmark patient s outpatient, non-emergency-room, advanced imaging scan by National Imaging Associates (NIA) Inc. should call NIA at , Option 4.* Providers are reminded that, although most transactions such as authorizations involving Highmark s Radiology Management Program can be initiated via NaviNet, retrospective reviews cannot be requested via the NaviNet system. For more information about Highmark s Radiology Management Program, visit the Highmark Radiology Management Program link on the Provider Resource Center via NaviNet or Privileging Requirements Updated The Highmark Imaging Privileging Requirements have recently changed. Providers may view the updated requirements by visiting the Provider Resource Center. *Effective Aug. 1, 2007, this telephone number will be eliminated; please see the story on page 6 of this issue of Behind the Shield for details. Reminder: Include Proper Diagnosis Code When Ordering Non-Emergent Ambulance Services Physicians are reminded to please be sure to include the actual ICD-9 diagnosis code when ordering non-emergent ambulance services for Highmark patients. Ambulance service providers need the ICD-9 code when filing claims for non-emergent transport services. All contents 2007 Highmark Blue Shield 4

5 Electronic Office Manual Now Available! This past February marked the inaugural launch of the all-new Highmark Blue Shield Office Manual. This consolidated manual is the combination and retooling of the following former manuals: ❿ Highmark Blue Shield Reference Guide Central/Eastern/Northeastern Regions ❿ Highmark Blue Shield Reference Guide Western Region To make the transition between the manuals more efficient, the Highmark Blue Shield Office Manual was made available on the online Provider Resource Center under Administrative Reference Materials, while the now obsolete reference guides were removed from the Provider Resource Center on March 31. Combining the information contained in both manuals now gives office staff from any of Highmark s Pennsylvania regions a comprehensive understanding of Highmark s health insurance programs. The manual is designed to give you access to information such as filing claims, researching patient benefits and joining one of Highmark s networks. It also includes important information on how to communicate with Highmark through automated and electronic systems and lists additional informational resources should your questions require a more in-depth explanation. All recent changes and new or updated information in the manual are presented in blue italic print to denote the areas of revision or addition. The new, more visually attractive format works in conjunction with up-to-the-minute revision dates in the upper right corner of each page. This style is designed to show you important updates in less time. Recycle Your Old Manuals Since the manual will be housed electronically on the Provider Resource Center, Highmark is encouraging offices to recycle any paper-based versions of the Highmark Blue Shield Reference Guides that may be remaining in their offices. This move helps to conserve paper and other resources and contributes to a cleaner environment. 5 Manual Based on Provider Feedback The Office Manual incorporated suggestions that were obtained from over 30 network providers in the Central, Western and Northeastern Regions during a recent usability study. If you would like to recommend further improvements or have questions regarding the Highmark Blue Shield Office Manual, please your comments to hbsomeditor@highmark.com or fax them to , Attention: Editor, Highmark Blue Shield Office Manual. We welcome the opportunity to serve you better. Reminder: Use In-Network Providers for All Laboratory Services To provide our members with access to highquality, reliable clinical laboratory services, we maintain contracts with all network hospitals and several free-standing providers for inpatient and outpatient lab services. When ordering laboratory services for your Highmark patients, be sure to use only in-network lab service providers for both routine services and more complex services, such as genetics testing. Using in-network laboratories helps your patients avoid potential out-of-pocket expenses. You can search for network labs by using the NaviNet Provider Inquiry function.

6 Highmark Announces Provider Relations Representative Changes Improvements Result in Dedicated Representative for Behavioral Health Providers, Doctors of Chiropractic Highmark is dedicated to supporting our providers unique needs with a high level of service. Along with offering a variety of electronic communication channels to address your routine inquiries and information needs such as NaviNet, our online Provider Resource Center and the Provider Service Center Highmark believes that face-to-face contact with our providers is essential to serving their needs and addressing their concerns. For this reason, Highmark maintains a staff of knowledgeable Provider Relations representatives. Provider Relations representatives Paula DeSousa, left, and Elaine Rebman We are pleased to announce that, effective April 9, 2007, Paula DeSousa was appointed to serve as Highmark s Provider Relations representative for professional providers in Berks and Schuylkill counties. Previously, these providers were served by Elaine Rebman. Ms. Rebman now serves behavioral health providers and doctors of chiropractic in the 21-county central Pennsylvania and Lehigh Valley region. Highmark Provider Relations representatives primary responsibility is to educate providers regarding Highmark s products and initiatives, such as electronic connectivity. Provider Relations Telephone Number to be Eliminated Aug. 1, 2007 Touchtone Options Will Be Available Under Another Toll-Free Provider Number Effective Aug. 1, 2007, Highmark will eliminate its Provider Relations telephone number ( ) for its 21-county Central Region. As of that date, the touchtone options that providers have now under the current telephone number will be available but will be offered under another existing toll-free number for providers. Effective Aug. 1, providers who don t yet have NaviNet or use the applicable HIPAA transactions should call, toll-free, to check members benefits and eligibility, inquire about the status of claims, contact the Provider Service Center, order forms or request authorizations through Highmark s Radiology Management Program. As was reported in the Jan./Feb./March 2007 issue of Behind the Shield, Option 4 was changed April 2 on the current Provider Relations telephone number. If you need to address issues that require discussion with your Provider Relations representative, choose Option 2, and Provider Service staff will initiate a request for your representative to contact you. The April 2 and Aug. 1 changes mark an overall effort to improve service to providers and help those who don t yet have NaviNet or use the applicable HIPAA transactions to get answers to their questions as quickly as possible when interacting with Highmark via telephone. Ultimately, this simplification of Highmark s telephone systems will help to improve Highmark s response time to your inquiries. To learn more about the benefits of NaviNet for your practice, or to sign up for the system, contact Highmark s Provider Service Center, or see the story on page 7 of the September/October 2006 issue of Behind the Shield, which is available on our online Provider Resource Center. 6

7 CHIP NOW COVERS All Uninsured Pennsylvania Children and Teens Pennsylvania s Children s Health Insurance Program (CHIP) has expanded to now cover all uninsured children and teens, regardless of family income. It s important that children have access to a wide range of health care services in order to have a healthy start in life. The CHIP expansion offers affordable, comprehensive health care coverage to every uninsured child and teen who is not eligible for Medical Assistance or does not have health insurance. CHIP covers routine medical care, such as doctor visits and immunizations, hospitalizations, prescription drugs and dental and vision care. Many families will not have to pay for CHIP. Under the expanded CHIP program, families with higher income will have low monthly premiums and copayments for some services. CHIP Eligibility Many families do not realize that their children may be eligible for coverage under CHIP even though one or both parents are employed. CHIP covers uninsured children and teens under age 19 who are residents of Pennsylvania and U.S. citizens or permanent legal aliens or refugees as determined by the United States Immigration and Naturalization Service. They cannot be covered by other private insurance or be eligible for Medical Assistance. Additional eligibility requirements apply for those eligible for low-cost and at-cost CHIP. CHIP Income Guidelines Free CHIP is available to families with income no greater than 200 percent of the federal poverty limits (FPL) ($41,300 for a family of four). Cover All Kids expands low-cost CHIP income eligibility to families with income no greater than 300 percent of FPL ($61,950 for a family of four). For families with incomes greater than 300 percent of FPL ($61,951 for a family of four), CHIP coverage can be purchased at full cost. For More Information Highmark is one of the insurance company carriers that administer CHIP coverage throughout 49 central and western Pennsylvania counties. If you know of a family whose children do not have health insurance, please let them know about CHIP. If you would like additional information or want to request CHIP materials for display in your office, please call Highmark s toll-free number at PBS-KIDS ( ). Through the CHIP Web site, families can apply online and view additional information about premiums and benefits. 7

8 New Parameter for Calculating Payments in COB Situations Effective July 20, 2007, Highmark will add a new parameter to its calculation of payments in coordination of benefits (COB) situations. NPI UPDATE: Despite CMS Contingency Guidelines, Highmark Now Ready to Use NPI* The Centers for Medicare & Medicaid Services (CMS) recently announced contingency guidelines for HIPAA-covered entities who are not NPI compliant, effective May 23, These guidelines provide relief from penalties for HIPAA-covered entities who continue to demonstrate good-faith efforts to become HIPAA NPI compliant. CMS announcement doesn t alter Highmark s plan for NPI compliance; Highmark s information systems are ready to accept your NPI now. Highmark will continue to accept Highmark Blue Shield, or legacy, numbers along with NPIs until Highmark reassesses our customers readiness to be compliant in November 2007, at which time it will be determined when the legacy number will no longer be accepted. The contingency established by CMS is limited and requires a demonstration of good-faith effort to achieve NPI compliance. HIPAA-covered entities not showing good-faith efforts to become compliant could face penalties. Highmark will continue to comply with the mandated May 23, 2007, federal compliance deadline by accepting NPIs on electronic transactions now. Highmark encourages HIPAA-covered entities to forge ahead with their own efforts to be HIPAA NPI compliant by May 23, Although Highmark will continue to accept legacy numbers in addition to NPIs on electronic transactions at least until November 2007, we also will accept only NPIs without accompanying legacy numbers now.* To read about the CMS requirements in detail, visit NationalProvIdentStand/Downloads/NPI_Contingency.pdf to access a document titled Guidance on Compliance with the HIPAA NPI Rule. NPI information resources, including details about how to obtain your NPI and how to report it to Highmark, are available online in Highmark s Provider Resource Center via NaviNet or under the HIPAA link. Watch Behind the Shield and NaviNet s Plan Central page for additional NPI updates. *Before billing with NPI only: Contact your software vendor, clearinghouse and/or trading partner to ensure they can process transactions with NPI only, along with translation data. Even though you may have obtained an NPI and reported it to Highmark, if your software vendor, clearinghouse and/or trading partner cannot accommodate or use the NPI in their system, your claims and associated payments may be delayed. Contact Highmark EDI Operations at or EDI staff will work with you to ensure that your claim submissions and payments will not be delayed in the transition to processing with NPI only. Reference the Highmark NPI Billing Guidelines for details on what should be submitted on transactions. The guidelines are available via the NPI page on Highmark s online Provider Resource Center (see story above for navigation links). Health Care Quality Highmark underwrites the subscription fees for NaviNet a technology that enables physicians statewide to access Highmark s internal systems and receive real-time health insurance data and information on a daily basis. This helps eliminate time-consuming paper and telephone-based transactions. 8 Background In 2005, we adopted the NAIC Model COB Regulation as the standard methodology for calculating secondary (and tertiary) payments in COB situations for non-medicare Advantage business. The principle underlying the model is that the combined benefits under all available plans may not exceed the total allowable expenses. Accordingly, Highmark s secondary payment is based on the difference between the primary payment and what Highmark would have paid if it had been the primary coverage. What s New The NAIC model also permits the limitation of payment in these circumstances to the amount the member would actually be liable to pay. Highmark did not adopt that parameter at the time it initially implemented the NAIC methodology but will adopt it for claims finalized on and after July 20, For more details, watch for an article in the June 2007 issue of PRN. And, be sure your billing staff, vendor and/ or clearinghouse are aware of this change. Reminder Regarding Nebulizer and Other Part B Medications for Medicare Advantage Patients Physicians are reminded that your FreedomBlue SM patients can only obtain certain Part B drugs from a specialty pharmacy or a durable medical equipment (DME) vendor. For example, oral medication for cancer must be obtained from a specialty pharmacy; and nebulizer solution must be obtained from a DME vendor. FreedomBlue patients cannot purchase these Part B drugs at a retail pharmacy.

9 Electronic Funds Transfer (EFT) Payments Growing in Popularity Highmark participating providers who are enrolled to receive electronic funds transfer (EFT) payments are quickly learning the advantages of EFT, or direct deposit, of their claims payments. If you are eligible for EFT but haven t yet enrolled, following are a few of the many advantages. To be eligible to receive payment via EFT, you must submit all or some of your claims to Highmark electronically and have NaviNet access for all solo practitioners or assignment accounts for which you want to receive EFT. Enrolling in EFT Enrolling in EFT is easy: Simply complete, sign and send an EFT contract to Highmark either through your Provider Relations representative or via U.S. Mail to: Highmark Blue Shield P.O. Box Camp Hill, PA Attn: SP 6 West SS The advantages of EFT include: Secure receipt of payment Monies are deposited to the checking account of your choosing. Security of bank information Because NaviNet is the secured platform used to enter your banking information, and the fact that you select the office staff who will enter this banking information, you are in complete control of your personal financial information. Once the original contract is received, it will be reviewed to ensure that your practice meets all criteria required to enroll in EFT. Processing of qualifying EFT contracts takes approximately three to four weeks, after which you ll receive either a secured or registered letter containing details on how to set up your banking information. This set-up process takes approximately 20 minutes to complete via NaviNet, and you ll be ready to begin receiving direct deposit of your payments from Highmark. Stable, consistent payment time frame Deposits are made to your selected checking account each Wednesday morning, if you currently have claims processing through Highmark s Claims Processing systems. Interest received on your funds You can receive interest on your deposits, beginning Wednesday mornings, if your checking account is an interest-bearing account. Payment in times of emergency In addition, in the event of a national crisis, such as in serious stages of a health pandemic, Highmark payments will be made only to providers who are already signed up for and receiving EFT payments. (See page 1 of the Jan./Feb./March 2007 edition of Behind the Shield for more information.) While we re hopeful that such potential situations won t occur, we urge you to sign up for EFT soon to be assured of payment receipt. For more information on becoming eligible for EFT, or to sign up for this valuable service, please contact Highmark s Provider Service Center today. Maintain current accounts receivable (AR) reconciliation process Highmark s EFT process does not change your existing AR reconciliation process. Whether you receive electronic remittance advices (ERAs)* from Highmark, or if you are reconciling your AR via paper EOBs, your reconciliation process will not change. (Highmark recommends setting up your practice to receive ERAs. If you aren t yet able to receive ERAs, another Internet-based option for EOB retrieval is NaviNet. The EOB/Remittance option is located under the AR Management link on NaviNet s Plan Central page. At this time, Medicare crossover claims aren t included on this option.) * If you are receiving ERAs from Highmark and are EFT-enabled and would like to discontinue receipt of paper EOBs, please contact Highmark s Provider Service Center for more information. 9

10 Highmark to Eliminate OASIS Automated Benefits Option, Effective Oct. 20, 2007 As more and more of our providers use NaviNet or HIPAA transactions to obtain benefits information, calls to our OASIS automated telephone system for benefits inquiries have decreased dramatically. Usage today is only a fraction of what it was just a few years ago. Therefore, due to the low utilization of this service, Highmark will eliminate the OASIS automated benefits option, effective Oct. 20, Please note that this change only impacts the benefits portion of OASIS. Providers can continue to use OASIS for enrollment and claims status inquiries/updates after Oct. 20, We thank you for your continued support and use of NaviNet for quick and easy access to the routine eligibility and benefits information you need when providing service to our members UPDATES Attention PCPs: QualityBLUE Program Recognizes Additional Physician Certification Activities Highmark accepts five different physician certification activities as meeting the requirements of a Best Practice Initiative in its QualityBLUE program. The list includes: ❿ The American Board of Family Medicine Maintenance of Certification, Part IV, Performance in Practice Module, ❿ The American Board of Pediatrics Maintenance of Certification, Part IV, Performance in Practice Activities, ❿ The American Board of Internal Medicine Maintenance of Certification, Practice Improvement Modules, ❿ The American Academy of Family Physicians METRIC modules, and ❿ The National Committee for Quality Assurance Physician Recognition Programs for Diabetes, Heart/Stroke and Physician Practice Connections For complete details, please refer to the QualityBLUE section of the online Provider Resource Center. There, you ll also find the submission form to report documentation of these activities. A Spotlight On Economic Impact Highmark is a Pennsylvania-based, not-for-profit insurer and one of Pennsylvania s largest employers, contributing substantially to the local and state economies. 10

11 Community Report Now Available Online Highmark s community support has doubled in the past 10 years Highmark s communications use the line A Helping Hand in the Places We Call Home for a good reason. In 2006, our employees gave thousands of volunteer hours to community organizations, we announced the Highmark Healthy High 5 initiative to address five serious health issues facing children and we gave financial support to many Pennsylvania nonprofit organizations that make our communities stronger and healthier. Highmark recently issued its 2006 Community Report to share this good news and feature a number of organizations and initiatives that receive Highmark funding, as well as real-life stories of people who ve benefited. These programs improve our communities by: ❿ promoting community wellness and preventing childhood obesity across Pennsylvania ❿ addressing health disparities by working with underserved populations ❿ connecting health care and coverage for economically disadvantaged individuals and families As a corporate citizen, Highmark has developed a strategy for corporate giving that emphasizes programs that stand to make measurable gains in improving the community s health in the places where we do business and in the places where our employees call home, said Kenneth Melani, MD, Highmark s president and chief executive officer. We feel that this approach best embodies the social mission that was established at our founding in the 1930s, a mission we have carried out through the ensuing decades. If you d like to read more about the positive impact that Highmark is having in the community, our 2006 Community Report can be found online at Highmark to Implement Standardized National Credentialing System Highmark continually seeks ways to make our network credentialing process easier for physicians and allied health providers. As part of these efforts, we will soon begin using Universal Credentialing DataSource a single, national process developed by the Council for Affordable Quality Healthcare (CAQH) that eliminates the need for multiple credentialing applications. Highmark s targeted implementation date for using Universal Credentialing DataSource is June 1, Watch PRN, the special credentialing issue of Behind the Shield and the Plan Central page of NaviNet for more information. 11

12 Attention PCPs: Watch Your Mail for Free Behavioral Health Tool Kit Highmark offers a Behavioral Health Tool Kit for network practitioners to assist in the care of their patients. The free kit will be mailed within the next few months to network PCPs and will also be available online in our Provider Resource Center via NaviNet. The kit contains several helpful resources on depression, postpartum depression (PPD), attention deficit hyperactivity disorder (ADHD) and substance abuse. You will be able to access components of the kit via NaviNet by clicking on Resource Center at left on the Plan Central welcome page; next, hovering on Clinical Reference Materials and selecting Quality Management Resource Binder from the fly-out menu will lead you to the kit once it is available in the next few months. Enhancing the Treatment of Depression in Primary Care Highmark encourages network practitioners to consider the following quality-of-care issues related to antidepressant medication management: Optimal Practitioner Contacts: Members 18 years of age and older who are diagnosed with a new episode of depression and started on antidepressant medication should have at least three follow-up contacts with a PCP or behavioral health specialist and remain on the medication through the 12-week Acute Treatment Phase. At least one of the three follow-up contacts should be with a prescribing practitioner. Effective Acute Treatment Phase: An effective Acute Treatment Phase is defined as members 18 years of age and older who are diagnosed with a new episode of depression, treated with antidepressant medication and remain on an antidepressant during the 12-week Acute Treatment Phase. Please note the following guide to assist with depression coding: ICD-9-CM Codes to Identify Major Depression (Please submit the most specific ICD-9-CM code, when applicable.) Major depressive disorder, single episode Major depressive disorder, recurrent episode Depressive type psychosis Dysthymic Disorder Adjustment reaction with prolonged depression reaction 311 Depressive disorder, not elsewhere classified Evaluation and Management (E&M) Codes (usually used by PCPs) Office or other outpatient services (new patient) Office or other outpatient services (established patient) Office or other outpatient consultations (new or established patient) Home visit for the evaluation and management of a new patient Home visit for the evaluation and management of an established patient Inpatient preventive medicine evaluation and management of an individual Periodic preventive medicine re-evaluation of an individual Preventive medicine counseling and/or risk factor reduction Effective Continuation Treatment Phase: An effective Continuation Treatment Phase is defined as members 18 years of age and older who are diagnosed with a new episode of depression, treated with antidepressant medication and remain on an antidepressant for at least six months. 12

13 Postpartum Depression: Earn Free CME Credits Highmark Offers Free PPD Brochures for Your Patients With the overwhelming demands of motherhood, a woman often finds that taking care of herself after delivery is the last thing on her mind. A December 2006 article in the Journal of the American Medical Association (JAMA) estimated that one of seven new mothers (14.5 percent) will experience depressive disorders that will impair their maternal role function. Depression during and after pregnancy is greatly underdiagnosed and undertreated; therefore, in an effort to address this major public health problem, Highmark s Quality Management and Behavioral Health departments launched an effort in 2006 to educate the community about postpartum care issues. A concentrated effort to improve postpartum depression (PPD) screening through the use of the Edinburg Screening Tool was directed toward those practitioners who provide obstetrical care. In response to feedback we have received from providers, Highmark will continue with this educational effort about PPD in Additional providers within the community will be asked to be aware and become more educated about this topic. One way to receive this education is through a free online continuing medical education (CME) course available through Aug. 30, 2007, from the University of Virginia Health System and the Virginia Department of Health. Physicians who complete the course will earn 6 CME credits. To access the course, visit We are requesting your help with early identification of PPD by keeping the following resources in mind when seeing a new mother: If your patient has Highmark insurance coverage, the following resources are available: ❿ The Highmark Depression Management Program: , Option 1 ❿ Behavioral Health Emergency Services (24-hour access): , Option 1 ❿ Blues On Call SM : BLUE-428 ( ); 24-hour access to a Health Coach For all other insurances: ❿ National Postpartum Depression Hotline: PPD-MOMS ( ) Highmark has PPD brochures available to you at no cost, so you may keep copies in your waiting area or personally distribute them to your patients. To receive a supply of the free brochures, please fax a request to Lynette Deaver, Clinical Outcomes Consultant, at Please include the name of your practice and your mailing address on your request. Highmark Offers Real-Life Solutions for Managing Stress Did you know that your Highmark patients have access to value-added services to help them manage stress? Highmark Preventive Health Services offers programs online and in local communities within our service region. Locations are listed at Discover Relaxation Within I and II give patients the tools they need to recognize stress, become stress-resilient and develop coping skills. This classroom-based, group program is led by a Highmark-trained stress management specialist. Topics covered include the physiological, environmental and perceptual responses to stress. Participants are taught a variety of skills, including deep breathing, meditation, visualization and progressive muscle relaxation. Upon completion of this unique program, participants are armed with newfound coping mechanisms to manage daily life stressors. Highmark also offers an online stress management program; HealthMedia Relax is available to Highmark members who log onto and select the Member tab on the toolbar at the top of the page. Members can then access the program by clicking on the Your Health tab and then choosing the Improve Your Health tab. The Relax program helps participants develop tools they need to manage stress at their own pace and from the privacy of their own computers. This five-week program provides participants with tailored action plans to help improve stress coping skills, reduce stress levels and manage the physical and psychological consequences of chronic stress. To obtain free educational marketing materials for these programs to distribute or post in your office, please call toll-free,

14 Several times annually, Highmark notifies providers of important policies and guidelines. The following notifications are for your information and reference. Member Notification of Specialist Termination In the event of voluntary or involuntary termination of a specialist or specialty group from the PremierBlue SM Shield network, specialists or specialty groups are, upon request, required to cooperate with PremierBlue Shield in obtaining a list of active patients including name, address and identification number. Highmark has a process in place to notify members being seen on an ongoing basis if a specialist/specialty group would no longer be available in the network. This notification would occur prior to the effective date of the termination. Standards for Accessibility To stay healthy, members must be able to see their physicians when needed. To support this goal, we are sharing with you Highmark s Standards for Accessibility for PCPs, medical specialists and behavioral health specialists. The standards set forth specific timeframes in which practitioners should respond to member needs, based on symptoms. Patient s Need: Emergency/life-threatening care Urgent care appointments PCP AND MEDICAL SPECIALIST STANDARDS Regular and routine care appointments; non-urgent but in need of attention appointments Regular and routine care appointments; routine wellness appointments After-hours access Performance Standard: Immediate response Office visit within 1 day Office visit within 2-7 days Office visit within 30 days 24 hours a day, 7 days a week; response by telephone within 30 minutes Within 15 minutes In-office waiting time BEHAVIORAL HEALTH SPECIALIST STANDARDS Patient s Need: Performance Standard: Emergency/life-threatening care Immediate response Emergency/non-life-threatening care Care within 6 hours Urgent care Office visit within 48 hours Routine office visit Office visit within 10 business days After-hours care 24 hours a day, 7 days a week; response by telephone within 30 minutes Patient Notification of Approvals, Denials All network providers are expected to notify their Highmark patients of both approval and denial of coverage decisions as soon as possible upon their office receiving notification of the decision from Highmark. This is a Pennsylvania Department of Health requirement. 14

15 Increasing Physical Activity Today, many children spend hours in front of a computer or television screen and go weeks even months with little to no physical activity. As a result, childhood obesity is on the rise, and, with it, the early onset of chronic conditions like diabetes. But not every child needs to be a star athlete to get adequate exercise and burn excess calories. That s why Highmark Healthy High 5, launched in September 2006, is providing grants and supporting community programs to increase physical activity among children 6 to 18 years old in our community. And that s a great investment in our children s future health. For more information, visit Highmark P.O. Box 1949 No Longer in Service Please be advised that if you send 1500 or Major Medical claims to Highmark through Post Office Box 1949 that this P.O. box was closed out of service as of March 1, In recent months, Highmark has been closing P.O. boxes that have been receiving a low volume of correspondence from providers in order to streamline incoming mail. Mail received at P.O. Box 1949 is being automatically forwarded to another P.O. box for one year. However, if you routinely send mail to Highmark through P.O. Box 1949, please begin to send correspondence to the following address instead, effective immediately: Highmark Major Medical P.O. Box Camp Hill, PA Free Smoking Cessation Posters Available for Your Office Copies of Highmark s popular smoking cessation poster, titled Can You Afford NOT to Quit Smoking? and pictured here, are available free to all network providers. If you would like a supply of the posters to display in your office reception or examination areas, please call

16 This newsletter is primarily geared toward medical practitioners and their office staff, with information about: Camp Hill, Pennsylvania Blues On Call SM Annual Update to be Available Online! Beginning in June 2007, physicians can access the Blues On Call Annual Update from the Provider Resource Center via NaviNet or at It contains information about Health Coaches, the SMART Registry and Shared Decision-Making, as well as updates on clinical measures and clinical initiatives for the year. Watch the Plan Central page of NaviNet and future issues of Behind the Shield for more information. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Highmark Blue Shield serves the 21 counties of central Pennsylvania and the Lehigh Valley as a full-service health plan. Blue Shield and the Shield symbol, DirectBlue and ClassicBlue are registered service marks and Blues On Call, PremierBlue, PPOBlue, FreedomBlue, QualityBLUE and EPOBlue are service marks of the Blue Cross and Blue Shield Association. Highmark and Have a Greater Hand in Your Health are service marks of Highmark Inc. NaviNet is a registered trademark of NaviMedix, Inc. HealthMedia and Relax are registered trademarks of HealthMedia, Inc. Shared Decision-Making and the SMART Registry are registered marks of Health Dialog Services Corp. Healthcare Advisor is a trademark of Subimo, LLC. 16