A Message from our New President, Karen Atwood INSIDE? VISIT OUR WEB SITE AT

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1 BlueREVIEWJANUARY WHAT S INSIDE? New Account Groups...2 Help Your Patients Keep Their New Year s Fitness Resolutions...3 BlueCard Tip...3 Redesigned Member Site Focuses on Usability...4 A Medical Perspective: Home Sweet Medical Home...5 Legislative Updates...6 Quick Facts About the Mental Health Parity Act...7 In the Know: What s new on the Provider Web site?...7 Professional Provider Network Consultant Spotlight...8,9 Medical Policy Updates...10 BCBSIL Receives Recognition for Compliance and Ethics...11 New Year, New Look! We have given the Blue Review a makeover for You will still receive the monthly news and updates you have come to rely on from BCBSIL. However, we hope you will find our new format to be easier to read and navigate quickly. Tell us what you think! In addition to your article ideas and input, we welcome your feedback on our newsletter design. We invite you to drop us a line via at bluereview@bcbsil.com. FOR CONTRACTING INSTITUTIONAL AND PROFESSIONAL PROVIDERS A Message from our New President, Karen Atwood 2010 As the new President of Blue Cross and Blue Shield of Illinois (BCBSIL), I look forward to meeting the challenges ahead as our industry moves toward health care reform. I am confident that our organization is making the right choices for our members, our customers, our employees and our providers. While the future will continue to bring challenges to all of us in health care, I believe we are in a strong position to meet those challenges by making strategic investments in products, programs and technology. INVESTING IN THE HEALTH OF OUR MEMBERS All of us can agree on the need to control rising health care costs. A major contributor to the cost of care is the treatment of chronic diseases. BCBSIL has made a long-term commitment to intensify our focus on wellness by offering programs and resources that help our members adopt preventive care habits and make lifestyle changes that may result in better health outcomes. We continue to collaborate with the independently contracted network providers to develop innovative programs such as our Patient-Centered Medical Home pilot project. This new program has been designed to focus on chronic care patients, to help identify and fill gaps in care, enhance quality and reduce medical costs by improving the coordination of care. We have also formed alliances with local organizations to support a variety of initiatives, such as childhood obesity prevention and working to promote healthy lifestyles among children. We want our members, your patients, to be aware of all the options available to them to help better manage their health. INVESTING IN HEALTH CARE TECHNOLOGY Our partnership with technology vendors who bring cutting edge solutions to the desktop allows you to access enhanced and more detailed health care information. We are also working to improve and expand the functionality of the electronic options we offer, to provide you with faster and more actionable information. One example of these investments includes our partnership to expand patient safety efforts with MedMined, an electronic infection surveillance program designed to provide hospitals real-time access to and management of infection-related data. The goal of the program is to improve the quality of care and produce measurable cost savings by reducing hospital-acquired infections across all hospital patients, regardless of payer association. Our new Care Comparison Tool, available on our Web site, provides open access to information that can help our members make better-informed decisions about their health care. When members and providers are equipped with the right tools, our members are empowered to seek the best service possible, leading to better health care outcomes. We enter the New Year looking forward to continuing our strong partnerships with you. We value your participation in our network and your confidence in our organization s efforts to improve the health of our members. On behalf of all of us at BCBSIL, we would like to wish you a happy and healthy New Year. VISIT OUR WEB SITE AT

2 NEW ACCOUNT GROUPS All of the accounts listed below have Blue Cross and Blue Shield Coverage, unless otherwise indicated. Group Name Group Number Alpha Prefix Product Type Effective Date Barrington Broadcasting Group LLC BXV HSA(Portable) Jan. 1, 2010 Centene NER PPO(Portable) Jan. 1, 2010 Culligan , CLP PPO(Portable) Jan. 1, 2010 Edison International XOF PPO(Portable) Jan. 1, 2010 Flex N Gate FNG PPO(Portable) Jan. 1, 2010 Grant Thornton GTH PPO(Portable) Jan. 1, 2010 HIG Chemicals EFZ PPO/CDHP(Portable) Jan. 1, 2010 IDEX Corp DX IDX PPO(Portable) Jan. 1, 2010 KIK Custom Products , KIK PPO/CDHP(Portable) Jan. 1, 2010 Komatsu KOM PPO(Portable) Jan. 1, 2010 U.S. Tsubaki TRK PPO(Portable) Jan. 1, 2010 UAL - Mileage Plus (Part of United Airlines) UAL PPO(Portable) Jan. 1, 2010 United Maritime Group UKM PPO(Portable) Jan. 1, 2010 UPS , , , , , UPA PPO(Portable) Jan. 1, , , UHO CMM Tegrant UTG PPO(Portable) Jan. 1, 2010 Woodward P25859, P25860, WWF PPO/CDHP(Portable) Jan. 1, 2010 NOTE: Some of the accounts listed above may be new additions to BCBSIL, some accounts may already be established, but may be adding member groups or products. The information noted above is current as of the date of publication; however, BCBSIL reserves the right to amend this information at any time without notice. The fact that a group is included on this list is not a guarantee of payment or that any individuals employed by any of the listed groups, or their dependents, will be eligible for benefits. Benefit coverage is subject to the terms and conditions set forth in the member s certificate of coverage. 21 VISIT OUR WEB SITE AT

3 Help Your Patients Keep Their New Year s Fitness Resolutions Our Blue Care Connection program has a new Fitness Program feature that can help make it easier for your patients to add exercise to their daily routine. Available Jan. 1, 2010, the Fitness Program will be offered to all group plan members (age 18 and older) who have Blue Care Connection as part of their health care benefit plan. The Fitness Program is an exclusive membership program that offers: A one-time $29 enrollment fee and $29 monthly dues* No long-term contracts, with a flexible month-to-month membership BlueCard Tip: Watch for New ID Cards Issued to Walmart Associates Unlimited access to a nationwide network of popular independently contracted fitness clubs, such as Bally s Total Fitness, 24-Hour Fitness and participating YMCAs The option to work out close to home, the office or while traveling Enrolling in the Fitness Program is quick and easy. Members can log in to their Blue Access for Members account at where they can click the My Health tab to find the Fitness Program button, search for participating locations, and complete their enrollment. Members can also enroll by calling Customer Service at (888) 762-BLUE (2583). * The one-time enrollment fee and monthly membership fee for the Fitness Program are both subject to applicable taxes. The Fitness Program is a discount program available to BCBSIL members. This program is not covered under the member s health insurance benefit plan. Members should refer to their benefit booklet or call the customer service number on the back of their ID card for specific benefit information under their health plan. Use of the Fitness Program does not affect their premium, nor do costs of Fitness Program services or products count toward their calendar year or lifetime maximums and/or plan deductibles. Members are responsible for all fees, dues, taxes and other charges related to the Fitness Program, and can refer to the program terms and conditions for further details. BCBSIL does not guarantee or make any claims or recommendations regarding the services or products offered under the Fitness Program. Members are advised to consult with their physician prior to use of these services and products. BCBSIL reserves the right to discontinue or change this discount program at any time without notice. Healthways, Inc. is an independent contractor which administers the Prime Network of independently-owned and managed fitness centers. New ID cards, effective Jan. 1, 2010, have been issued to Walmart associates. Some ID cards will include a new alpha prefix as part of the member s ID number. To help ensure that claims are processed correctly: Verify the ID card at every visit and make sure you have the correct one on file. File all claims with BCBSIL using the exact ID card number, inclusive of alpha prefix. Do not add, omit or alter any characters from the member ID number. Continue to contact BCBSIL for assistance. To check eligibility, benefits and pre-certification requirements, send an electronic eligibility inquiry to BCBSIL via your preferred online vendor portal, or call (800) 676-BLUE (2583). Questions? If you have any questions, please contact our Provider Telecommunications Center at (800) We value your feedback! Share your out-of-area member servicing experiences with us via at provider_relations@bcbsil.com. JANUARY

4 FAIRNESS IN CONTRACTING In an effort to comply with Fairness in Contracting Legislation and keep our independently contracted providers informed, BCBSIL has designated a column in the Blue Review to notify you of any changes to the physician fee schedules. Be sure to review this area each month. Effective Dec. 1, 2009, code was updated. Annual and quarterly fee schedule updates can be requested by downloading the Fee Schedule Request Form at provider/forms.htm. Specific code changes that are listed above can also be obtained by downloading the Fee Schedule Request Form and specifically requesting the updates on the codes listed in the Blue Review. VIEW MANAGED CARE UPDATES ONLINE HMO Updated Policies and Procedures On a monthly basis, we post updated policies and procedures on our Web site under Updates. Go to to view the updated policies. HMO Appointment/ Reappointment Report On a monthly basis, we post a report of the Appointed and Reappointed providers on our Web site. To access this report, go to provider. Select Appointed/ Reappointed PCPs/PSPs under the Credentialing/Contracting section. The cumulative data is normally updated by the third Wednesday of each month. Redesigned Member Site Focuses on Usability Straightforward Content Caters to the Consumer More than ever, it is important for your patients to understand their options so that they can make better-informed decisions about their health care. Our redesigned public Web site, launched in early December, offers user-friendly content and construction to help online visitors navigate more easily. Searching for a doctor is now easier. The Find a Doctor section is more prominently located in the center of the home page. The Glossary section provides definitions of health insurance words and phrases. The Getting Started tutorial includes articles, guidelines and tips on how your patients can get the most out of their health plans. The Health and Wellness section provides information on topics such as coping with illnesses, preventive care, exercise, diet, behavioral health and more. The Plans for Different People section is a guide that helps your patients identify health care coverage that may best match their needs. New straightforward content helps make health insurance more understandable. Before unveiling the redesigned site, we engaged an audience of BCBSIL member and health care consumer test users. More than 90 percent of these users were able to complete tasks easily and with confidence. Most users felt comfortable with the new site architecture. Feedback on the new consumer education areas revealed that users felt the information was trustworthy and would be helpful when making a decision about health insurance. The changes to our public Web site represent our commitment to helping consumers as they shop for health insurance, while adding value for our members who may utilize information on both the public and secure Blue Access for Members sites. We encourage you and your patients to access the online educational, health and wellness resources available on our public Web site at As always, we value your input, so feel free to click on Feedback [+] when browsing any section of our Web site to let us know what you think. 4 VISIT OUR WEB SITE AT

5 A Medical Perspective: Home Sweet Medical Home Richard Gayes, MD, MBA Medical Director, Network Management Based on an article in the Winter issue of Benefit Management Briefing, a BCBSIL employer group publication. SCENARIO 1 Betty, 56 years old and overweight, has just learned that she has diabetes. Dr. Smith, her primary care physician, measured her blood sugar and hemoglobin A1c, and prescribed medication. He told Betty to eat less and exercise more, and return in two weeks for another blood test. Well-respected in the community, Dr. Smith performed his medical tasks according to the book. He made the right diagnosis. He wrote the right prescription. But let s see what happened next. Feeling highly motivated to improve her health, Betty gave up eating salad, because she wanted to eat less. She started climbing the stairs in her building for exercise, but soon got out of breath and sprained her ankle. And those pills were so big and expensive, she thought the smaller ones in her drawer would work better. When Betty came back for her next appointment, her health was worse and she was discouraged. SCENARIO 2 Now let s consider another possibility. After giving Betty her prescription, Dr. Smith introduces her to Nurse Carol, who will work with Betty to help her manage her diabetes in the context of her personal life situation. Carol spends time with Betty to find out what she knows about diabetes, and talks about living with this condition. She discusses the importance of the new medicine, when to take it and possible side effects. She gives Betty an educational booklet and information about online resources, such as the American Diabetes Association. Also, Carol makes an appointment for Betty to see a dietitian to learn about healthier eating. At another office visit, Carol explores Betty s likes and dislikes regarding physical activity, and together they design a progressive walking program. Whenever a question arises, Betty knows she can call Carol for advice. Betty can also use the doctor s secure to report her blood sugar levels and have her medication dose adjusted. At her next checkup, Dr. Smith proudly shows Betty the average blood sugar statistics for all his diabetic patients, and expresses confidence that Betty is well on her way to similar results. Which scenario sounds like the health care your patients would prefer? INTRODUCING PATIENT-CENTERED MEDICAL HOMES Patient-Centered Medical Homes are designed with the goals of enhancing quality and reducing growth in medical costs by improving the coordination of care. This concept was created by the American Academy of Pediatrics in 1967 to provide comprehensive care for children with complex medical needs. Those doctors saw that traditional health care was doing a poor job of addressing the ongoing needs of patients with chronic illnesses. They felt that success with a chronic condition was not won or lost so much by what took place at the doctor visit, but by the effectiveness of the patient partnership that fostered successful self-care. Supporting patients between visits, through case management, needed to become an integral part of primary health care helping patients lead productive lives, and avoiding costly visits to the emergency room and hospital. Today, the medical home concept is emerging as an important strategy to help address an aging adult population, where the prevalence of chronic disease has topped 50 percent.* This close collaboration calls for innovations in the way that primary care medicine is practiced and financed. BCBSIL LAUNCHES MEDICAL HOME PILOTS BCBSIL has recently launched a Patient-Centered Medical Home pilot project with three respected medical groups in the Chicago area: Pronger Smith Medical Center, Elmhurst Clinic and DuPage Medical Group. More than 50,000 BCBSIL members will be enrolled in the pilot programs the first of their kind in Illinois involving multi-site medical practices and a single private payer. BCBSIL is providing data and reporting tools to the medical groups that will be used to help coordinate care, track progress and analyze outcomes to determine the impact on quality, costs and patient satisfaction. It is our hope that these pilots will prove successful in enhancing care and helping to control costs, ultimately serving as a national model to help improve the health care system. *Source: JANUARY

6 MEDICARE PART D PHARMACY UPDATES Every month, we post a new Medicare Part D-related article in the Pharmacy section of our Web site at Here is a brief summary of this month s article, which features the following topic: Formulary Changes in 2010 In mid-october, the 2010 BCBSIL Medicare Part D formulary was approved by the Centers for Medicare and Medicaid Services (CMS). Some of the changes for the new year were mandated by CMS (safety concerns, drugs that no longer meet CMS s definition of a Part D medication, etc.), but others were a result of dynamic changes in the pharmaceutical marketplace. BCBSIL s 2010 Medicare Part D formulary includes the addition of some new drug therapies, as well as the migration to some important generic equivalents that became available in Visit the Medicare Part D Updates archives in the Pharmacy section of our Provider Web site at for the complete article, which includes a listing of the Top 25 medications affected by the 2010 formulary changes. Legislative Updates As the 2009 Legislative calendar draws to a close, members of the Illinois General Assembly have begun filing legislation addressing health care reforms to be considered in January when the Illinois Legislature returns for the second year of the 96th General Assembly. During the 2009 Veto Session, the following bills that impact BCBSIL, our members and stakeholders were acted upon: HB INSURANCE REFORMS HB 3923 requires: Mandatory standard applications for individual and small groups effective Jan. 1, [The Department of Insurance (DOI) will create a workgroup with industry representation to create uniform applications beginning in 2010.] Mandatory second level external independent review with accelerated turnaround times of an adverse determination on an appeal when requested by a member (standard appeal turnaround time is 15 days and urgent appeal is no more than two business days) effective July 1, Bi-annual reporting to the DOI by line of business of all administrative expenses (broken down by category) and premiums collected, medical loss, membership numbers, discounts, taxes, etc. Information will be made public by the DOI on its Web site effective Jan. 1, Status: HB 3923 was passed by both Chambers and is expected to be signed by the Governor in the next 90 days. HB ORTHOTIC AND PROSTHETIC MANDATE HB 2562 requires coverage of prosthetic and customized orthotic devices (and repairs). The law is subject to the other general exclusions, limitations, and financial requirements of the policy. This includes coordination of benefits, participating provider requirements, utilization review of health care services, including review of medical necessity, case management, and experimental and investigational treatments, and other managed care provisions under terms and conditions that are no less favorable than the terms and conditions that apply to substantially all medical and surgical benefits provided under the plan or coverage. HB 2652 applies to all insured business - individual, group and HMO. It does not apply to selfinsured municipalities, counties or schools. Status: Passed both Houses. HB 2652 is expected to be signed into law within the next 90 days. Proposed effective date is June 1, However, according to the legislation, contracts must be in compliance by six months after the effective date. For additional information and to review exact language of any new laws, please visit the Illinois General Assembly Web site at 61 VISIT OUR WEB SITE AT

7 Quick Facts About the Mental Health Parity Act The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was signed into law on Oct. 3, The requirements of the law are effective for plan years beginning on or after one year from the date the legislation was signed into law. As a result, the provisions apply to new contracts and renewals on or after Oct. 3, For example, a group that renews on July 1 will need to be in compliance with this new law by July 1, For group health plans offering behavioral health services or substance use disorder benefits, the Mental Health Parity Act requires that financial requirements (e.g., deductibles, copays, coinsurance) and treatment limitations (day/visit limits) for behavioral health services must be similar to the group health plans medical and surgical benefits. For many of your patients with BCBSIL coverage, this means there is no longer a limit on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment for behavioral health or substance use disorders. Use the Mental Health/Chemical Dependency telephone number listed on the back of the member s ID card to confirm eligibility and benefits. Please watch the What s New section of our Provider Web site at for additional information and updates. You may also contact your assigned Provider Network Consultant for assistance. The information provided above is only intended to be a brief summary of legislation that has been proposed or laws that have been enacted and is not an exhaustive description of the law or a legal opinion of such law. This material is for informational purposes only and is not legal advice. If you have any questions regarding this legislation, you should consult with your legal advisor. IN THE KNOW What s new on the BCBSIL Provider Web site? Our Provider Web site is constantly evolving to help meet your informational needs. Here are some of the most recent changes at The Forms section of our Provider Library, at provider/forms.htm, has been updated with interactive PDF versions of all forms. This means you can fill out the form online to save and or print and return to BCBSIL by fax or mail. It is very important to visit the Forms section of our Provider Web site each and every time you need to use a form, as documents on our Web site are updated frequently. For example, the Predetermination Request Fax Form now features the following new fax number: (800) This new fax number will help us route your request more efficiently. Continue to visit us online for the most up-to-date information! On our Provider home page, a new Education Center icon has been created. Place your cursor over the Workshops button to visit our Education page and view available workshops and Webinars. Choose the Tutorials button and you ll land on a page with all of our available online Tutorials at your fingertips. The Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA) page in the Electronic Commerce section of our Provider Web site now features an Electronic Options Tutorial to walk you through the basics of EFT, ERA and the Electronic Payment Summary (EPS). You ll also find a link to this new resource on the Tutorials page of our online Education Center. JANUARY

8 BCBSIL Wins BlueWorks Award for Asthma Program The Blue Cross and Blue Shield Association (BCBSA), in collaboration with the Harvard Medical School Department of Health Care Policy, has recognized BCBSIL with a BlueWorks award for its program, The Positive Impact of Asthma Action Plans. BlueWorks awards are presented annually to Blues Plans demonstrating innovative, successful and replicable approaches to improving health care quality, value and accessibility for consumers. Each year since 2000, BCBSIL has included the Asthma Action Plan Project in the Quality Improvement Fund, a major initiative used to enhance care for HMO members. Throughout the year, BCBSIL works with the contracted Independent Practice Associations (IPAs) to identify members with asthma, and to encourage physicians to provide asthmatic patients with a written asthma action plan each year. BCBSIL also sends these patients a Personal Asthma Management brochure. Since the Asthma Action Plan Project was implemented, the percentage of HMO members with asthma who have received a written action plan has increased dramatically, from 21 percent in 2000, to 80 percent in For members with asthma included in the plan for five consecutive years, those who received a written asthma plan for at least three years had fewer ER visits or inpatient admissions for asthma than those who received a plan for two years or less. Professional Provider Network Consultant Spotlight In our ongoing effort to support our goals and provide you with the best possible service, our Professional Provider Network Consultants (PNCs) serve as liaisons between BCBSIL and our independently contracted provider network. Their goal is to develop and maintain cooperative working relationships with you and your office staff, and be accessible when you need help with any BCBSIL concerns. In this edition we are pleased to introduce you to the newest members of the team, Vickey Jones and LaVella Friley. MEET VICKEY JONES Vickey Jones assumed the Provider Network Consultant position in June, Her assigned territory is the City of Chicago, where she services over 500 providers in select city zip codes. Vickey has been employed at BCBSIL since 1974, beginning her years of service as a mail clerk in the Major Medical Department. From there she transferred to the Blue Shield Unit, working as a claims processor, claims examiner and technician. By the 1980s, Vickey was serving as a technician in the Major Municipal Accounts Full Service Unit, where she eventually received a promotion to Supervisor, a position she held for 15 years. In 2002, Vickey left the member services side of health care and joined the Provider Relations staff as a claims specialist in the Provider Operations Department, focusing on resolving complex claim issues. With 35 years of experience in the health care industry, Vickey most enjoys meeting physicians and working with diverse groups of office staff. Her most challenging issues range from adding new providers to a group practice to solving complicated billing concerns. No issue is too big or too small for her to tackle. Vickey feels a sense of accomplishment when she is able to convince her providers to sign up for any of our e-business solutions and conduct more transactions online, especially Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA) and Electronic Payment Summary (EPS). She wants her providers to know: I am here to assist you with any provider-related issues you have. I want you to understand that I am always available to be of service. Vickey Jones can be reached at (312) or via at jonesv@bcbsil.com. These results demonstrate our commitment to implementing wellness programs that will ultimately help our members make positive changes leading toward healthier lifestyles. 8 VISIT OUR WEB SITE AT

9 MEET LAVELLA FRILEY BCBSIL now offers customized on-site training, workshops, and Webinars for provider billing services. LaVella Friley is the designated Provider Network Consultant who serves as our representative for billing services in the Chicago metropolitan area. LaVella, who assumed this position in August 2009, holds a Bachelor s Degree in Business from Rockford College. Before joining the BCBSIL staff, she worked as a Rehabilitation Technician at a group home for the physically disabled. She began her career at BCBSIL in 1989 at the Rockford Full Service Unit, where she held a number of positions, including claims processor, customer service representative, and expanded her knowledge of the PPO, POS and HMO products. In 2005, LaVella relocated to our Chicago headquarters and joined the Subscriber Services Division s Technical Support area, performing systems training. In 2007, she assumed the position of Supervisor of Provider Education, where she was responsible for developing training programs, conducting workshops, Webinars and specialty training sessions for new and experienced providers throughout Illinois and northwest Indiana. LaVella receives a great deal of satisfaction assisting providers and helping them understand how to find solutions to their issues. In this new position, she expects our providers to let their PNCs know who their billing services are, so she can make the connection. BCBSIL is committed to creating and offering innovative tools for providers to utilize. LaVella hopes to make the billing services who serve our contracting providers aware of all of the resources available to them so providers can continue to deliver the best service to our members. LaVella Friley can be reached at (312) or via at frileyl@bcbsil.com. Please Note These PNC Contact Information Changes Two of our Senior Provider Network Consultants (PNCs) Amanda Williams and Terry Swan have moved to a different office location at 3200 Robbins Road, Springfield, Illinois, New telephone numbers are noted below. Amanda provides service to physicians, medical groups and hospital providers in central Illinois. She can be reached at her new telephone number, (217) , or via at williamsa4@bcbsil.com. Terry provides service to hospitals, their hospital-owned and billed professional groups, and other freestanding facilities in western Illinois. His territory includes the St. Louis Metro East, Decatur, Jacksonville, Quincy, and Springfield regions. Terry can be reached at his new telephone number, (217) , or via at swant@bcbsil.com. A Reminder to Ancillary Providers Did you know that BCBSIL contracts with over 2,000 ancillary providers in Illinois and northwest Indiana? This population of providers includes: Skilled Nursing Facilities (including outpatient therapy) Home Health Agencies Hospice Home Infusion Therapy Durable Medical Equipment suppliers Dialysis facilities Orthotic/Prosthetic suppliers Private Duty Nursing agencies BCBSIL has a dedicated team of Ancillary Provider Network Consultants with many collective years of servicing experience to assist with the specialized needs of this important component of our provider community. If you are an ancillary provider, please contact one of our Ancillary PNCs Sherry Heise-Jaskolka at (312) , or Elaine Williams at (312) for personalized assistance. You may also direct your requests and inquiries to us via at ancillarynetworks@bcbsil.com, or call (312) JANUARY

10 Do not Bill for Treatment of Family Members Standard BCBSIL benefits are not available for services rendered by providers to their immediate family members. An immediate family member is defined as: current spouse eligible domestic partner parents and step-parents children and grandchildren siblings (including natural, step, half or other legally placed children) BCBSIL does not expect to receive claims for these services and will not make payment on claims submitted for services rendered by or for immediate family. Should it be determined that a benefit has been paid in error, we will request a refund of the original payment. MEDICAL POLICY UPDATES Approved new or revised Medical Policies and their effective dates are usually posted on our Web site the first day of each month. Medical Policies are used as guidelines for coverage determinations in health care benefit programs for BCBSIL members, unless otherwise indicated. These policies may impact your reimbursement and your patients benefits. You may view active new and revised policies, along with policies pending implementation, by visiting the Medical Policies section of the Provider Library on our Web site at After reading the Medical Policies Disclaimer, click on I Agree. You will then have two options, View all Active Policies or View all Pending Policies. Effective Date Policy Number Policy Name Jan. 1, 2010 RX You may also view draft Medical Policies that are under development or are in the process of being revised by selecting Draft Medical Policies from our online Provider Library. After confirming your agreement with the Medical Policies Disclaimer, you will be directed to the Draft Medical Policies page. Just click on the title of the draft policy you wish to review, and then select Comments to submit your feedback to us. While some information on new or revised Medical Policies may be published in this newsletter for your convenience, please rely on our Web site for access to the most complete and up to date Medical Policy information. Subcutaneous Hormone Implants Rationale / Comments Testosterone subcutaneous pellets are now considered a convenience item and not medically necessary. Medical policy title changed from Estradiol Pellets. Jan. 1, 2010 MED Immune Cell Function Assay in Solid Organ Transplantation New policy is EIU. Jan. 15, 2010 OTH Photodynamic Therapy for Subfoveal Choroidal Neovascularization Jan. 15, 2010 SUR bu Radiofrequency Facet Joint Denervation Jan. 15, 2010 SUR bu Facet Joint Injections Feb. 1, 2010 RX Rituxan (Rituximab) for Treatment of Cancer and Hematologic Conditions New medical policy: Coverage position is conditional addressing FDA labeled and offlabel indications. Feb. 15, 2010 DME Negative Pressure Wound Therapy (NPWT) the Treatment of Wounds (VAC Versatile 1) Policy criteria for less than 30 days, and autoimmune, tendon exposure, steroid use and transplant drugs. Feb. 15, 2010 DME Lifts and Elevator Systems 10 1 VISIT OUR WEB SITE AT

11 BCBSIL Receives Recognition for Compliance and Ethics At a time when health insurers are being scrutinized as part of the health care reform debate, we re proud to announce that BCBSIL has once again received national recognition for its commitment to compliance and ethics. Our company recently won its ninth straight Compliance Best Practice Award from the Health Ethics Trust, a division of the Council of Ethical Organizations. We were recognized for the investigative efforts through a Corporate Integrity Hotline and Incident Tracker, both of which are administered by the investigations area of the Corporate Compliance Department (CCD). Since its launch in 1998, the hotline has proven to be an effective tool for reporting concerns and answering employee questions. Each year, the number of hotline calls has increased, demonstrating the trust employees have in the company s commitment to maintaining an ethical culture. What does this mean for you? Our high standards for compliance and ethics help us to deliver better service to all of our customers. BCBSIL employees are equipped with guidelines and tools to help ensure that provider and member Sensitive Personal Information and Personal Health Information are properly handled on a daily basis. Discontinued: Voice Mailbox for Pre-certifications* In our November Blue Review, we announced the December 1 implementation of a confidential voice mailbox for our Customer Care Call Center (Pre-certification Department). This voice mailbox was intended to give you the option to leave pre-certification information during high-volume call times, rather than waiting on hold to speak with a Customer Advocate. It has been reported that this new voice mailbox feature has caused service disruptions for some providers and has therefore been discontinued. We apologize for any inconvenience. *also may be known as preauthorization or pre-notification Timely Filing Requirement Changes The following revision to the BCBSIL Provider Manual will be effective April 1, 2010: The Contracting Provider agrees to bill the Plan in a timely manner and in a method acceptable to the Plan for payment prior to charging the Covered Person for any deductible or coinsurance amount. The Plan agrees to pay the Contracting Provider directly, on a timely basis, for Covered Services rendered to a Covered Person as described in the Covered Person s applicable health care benefit contract. In no event will the Plan, its Designee, a Covered Person, a Covered Person s representative, a Payor, or any other person or entity be obligated to pay all or any portion of any Claim for Covered Services that is not received by the Plan within the one hundred eighty (180) day period following: (i) the date of discharge or transfer for inpatient Health Services, (ii) the date of service for all other Health Services, that are not inpatient, or (iii) 180 days after the date of the Contracting Provider s receipt of the explanation of benefits from primary payor when Plan is the secondary payor. The Plan will consider any request for a reasonable extension of the 180 day time period for filing claims, on a case by case basis, if the Contracting Provider provides notice to Plan along with appropriate evidence, of circumstances beyond the reasonable control of the Contracting Provider that resulted in the delayed submission of the claim. The Plan reserves the right, in its sole discretion, to determine whether a reasonable extension of the timely filing requirement should be granted. JANUARY

12 Care Comparison Tool Offers Data Transparency In September 2009, we unveiled a new online Care Comparison tool that allows our members to review costs for specific procedures performed at hospitals, ambulatory surgery centers and free-standing radiology centers in the BCBSIL provider network. Members also can review the volume of services performed by each facility, and they can obtain other information based on factors most important to them. The Care Comparison tool is available to all BCBSIL members and providers on our Web site at In our ongoing initiative to enhance transparency availability and accessibility of Care Comparison data, a Flash demo will be added in April 2010 to assist members with their navigation and procedure searches. Additionally, the number of inpatient and outpatient procedures displayed will increase from 35 to 54. The data reported will cover procedures performed from July 1, 2008, through June 30, 2009, paid through Sept. 30, BCBSIL is committed to sharing useful, accessible, and easy to understand information with our members to help encourage them to take a more active role in managing their health care expenses. Watch the What s New section of our Provider Web site at for additional announcements and information regarding this and other BCBSIL initiatives. Blue Review is a monthly newsletter published for Institutional and Professional Providers contracting with Blue Cross and Blue Shield of Illinois. We encourage you to share the content of this newsletter with your staff. Blue Review is located on our Web site at The editors and staff of Blue Review welcome letters to the editor. Address letters to: BLUE REVIEW Blue Cross and Blue Shield of Illinois 300 E. Randolph Street 25th Floor Chicago, Illinois bluereview@bcbsil.com Web site: Publisher: Stephen Hamman, VP, Network Management Editor: Gail Larsen, DVP, Provider Relations Managing Editor: Jeanne Trumbo, Sr. Manager Editorial Staff: Margaret O Toole, Marsha Tallerico and Allene Walker BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions regarding any of the products or services mentioned in this periodical, you should contact the vendor directly. VISIT OUR WEB SITE AT REVIEW BlueFOR CONTRACTING INSTITUTIONAL AND PROFESSIONAL PROVIDERS PRSRT STD U.S. POSTAGE PAID PERMIT NO. 581 CHICAGO, IL A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association