CONSULT Newsletter. Volume 7 Third Quarter, Call Center Hours. Important NPI Reminder. Inside This Issue

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1 Notice If a website link within this document does not direct you to the appropriate information or website location, please contact Provider Services by telephone. The Provider Services directory is located on the last page of this document.

2 CONSULT Newsletter Volume 7 Third Quarter, 2007 Call Center Hours Important NPI Reminder Inside This Issue Call Center Hours... 1 Important NPI Reminder... 1 Change in Referral Letter Process... 2 Telephone Number Correction... 2 Imaging Moratorium... 2 Billing Reminder for Ambulance Providers... 2 Opting Out of Medicare... 3 The Primary Care Physician s Role in Out-of-Area Urgent Care... 3 Medical Services Protocol Updates... 4 PaySpan Health... 5 Referral Guidelines for In-Network Benefits... 6 HMO/POS Provider Networks: Primary Care Physicians and Specialists.. 7 Health Care Quality Improvement Overview: Outcome Reporting... 7 Perceived Denials... 8 Help for you! CMS 1500 Tips... 9 Provider Telephone & Web Site Reference Guide...Back Call Center Hours Attention Providers: You spoke and we listened! In response to your feedback, we changed our Provider Call Center hours for your convenience. Providers can now contact us from 8:00 a.m. until 7:00 p.m. Monday through Friday and Saturdays from 8:00 a.m. until 12:00 noon. Important NPI Reminder HealthNow New York Inc. has changed the date for accepting NPI only for electronic and paper claims. HealthNow will be able to accept NPI only, as of December 3, If you have not submitted your NPI to HealthNow, please do so immediately by faxing a copy of your NPI from NPPES to our Provider File Department at If you have not applied for an NPI, please do so as soon as possible. You may apply online at or call to request an NPI application form at NENY Page 1 CC 5510

3 Change in Referral Letter Process Telephone Number Correction Imaging Moratorium Billing Reminder for Ambulance Providers Change in Referral Letter Process Currently, when a member is issued a referral to a specialist, a copy of the referral letter is sent to the PCP, the Specialist and the member. However, with the availability of more efficient technology, it is our goal to help reduce both your administrative costs as well as the amount of paperwork your office receives. BlueShield of Northeastern New York is pleased to inform you that we are changing the referral letter process. Effective September 24, 2007, only the member will receive a referral letter, which can be presented at the appointment. WNYHealtheNet enables practices to request or verify patient referrals electronically online, on a real-time basis. It's quick, user-friendly and convenient, as are all of our Online Services. Electronic tools are another way that a practice can achieve high quality and efficient service. To enroll in WNYHealtheNet, please complete the sign up request for Online Services at Imaging Moratorium In May, 2006, BlueShield identified rapid growth in the number of MRI, PET and CT installations in the 18 counties of Northeastern New York over the last several years. Radiology costs have increased exponentially with the increase in installations. As a result, we are currently reviewing all options with respect to managing imaging services in the Northeastern New York region. The moratorium remains on the addition of any imaging services unless a substantial need for access to care is demonstrated. Billing Reminder for Ambulance Providers While we utilize HCPCS Code A0422 in our system, there is no separate reimbursement for this service. Please remember to use the appropriate modifiers to reflect the origin and destination of transports. Telephone Number Correction In our Second Quarter Newsletter, we provided the wrong telephone number for inquiries regarding Senior Blue 600: Medicare and Medicaid All-in-One Plan. The correct number is: We apologize for this error. Page 2

4 Opting Out of Medicare The Primary Care Physician s Role in Out-of-Area Urgent Care Opting Out of Medicare Federal regulations prohibit Medicare Advantage Organizations, including BlueShield of Northeastern New York, from paying for services rendered by physicians or providers who have opted to not participate in the Medicare program, except in limited circumstances. A Medicare Advantage organization may only contract with physicians who are approved for participation in the Medicare program and who have not opted out of providing services to Medicare beneficiaries (see Social Security Act 42 CFR ). A physician that opts out of Medicare cannot participate in BlueShield s Medicare Advantage networks Senior Blue and Medicare PPO. Please be advised that current Medicare rules do not allow a provider to re-apply for participation with Medicare until the end of the 2-year opt-out period. BlueShield will not cover any services rendered by physicians or their sponsored mid-level practitioners on or after the effective date of non-participation with Medicare, unless it is demonstrated that the service was eligible for payment as emergent or urgently needed under applicable Medicare standards. The Primary Care Physician s Role in Out-of-Area Urgent Care When members are traveling outside of our HMO/POS service area and are in need of non-emergency urgent care for medical problems such as skin rash, ear infection, sprained ankle or the flu, there are several steps that need to be followed. 1. The member must call the PCP first to discuss the medical problem. 2. If the PCP advises treatment, the member should be instructed to call BLUE ( ) to locate a provider in the BlueCross BlueShield National Network. 3. The member should make an appointment and present the membership card at the time of the appointment. 4. The PCP must call BlueShield of Northeastern New York to obtain authorization for this out-of-area care so that the claims will be promptly paid at the in-network benefit. Note: In an actual emergency, members should go to the nearest emergency room or dial 911. If they are in need of follow-up care, they must contact their PCPs to obtain authorization. Please notify BlueShield if your status with Medicare changes by contacting your Network Services Specialist at Further information regarding providers who opt out of Medicare may be obtained from the local Medicare Part B Carrier at: Page 3

5 Medical Services Protocol Updates Medical Services Protocol Updates The following clinical protocol update includes information on protocols that have been revised or are new. Their effective date is November 1, Please note that parts of this protocol update may not pertain to the members you provide care to if they relate to contracts that are not available in your geographic area. Protocol Summary 1. Ambulance (Emergency) New policy, clarifying intent of member contract language. Included additional wording for Medicare Advantage members. 2. Blood or Marrow Transplantation Revisions to description. Under medically appropriate guidelines, clarified myelodysplastic indication and added select solid tumors such as Germ cell tumors/testicular cancer and immune deficiency states such as Severe Combined Immunodeficiency. 3. Chelation Therapy Re-clarification that this is investigational because it is unproven outside the investigational setting for the already specified, but not limited to, conditions of atherosclerosis, multiple sclerosis, arthritis, hypoglycemia and diabetes. 4. Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid Added descriptions for real-time continuous glucose monitoring devices. Under guidelines, clarified that real-time devices, as purchase or rental, are investigational because they are not proven to improve the net health outcome. 5. Decompression of the Intervertebral Disc Using Laser (Laser Discectomy or Radiofrequency (DISC Nucleoplasty ) Energy, formerly part of Percutaneous Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Thermocoagulation Re-stating that Laser discectomy and DISC nucleoplasty are considered investigational as techniques of disc decompression and treatment of associated pain because they have not been proven as effective as established alternatives. Note: When Decompression procedure, percutaneous, of nucleus pulposus of intervetebral disc, using radiofrequency energy, single or multiple levels, lumbar is performed, HCPCS code S2348 is the correct code to report. 6. Meniscal Allograft Transplantation Re-clarification that procedure is investigational for all contracts because it is unproven outside the investigational setting. (continued on page 5) Page 4

6 PaySpan Health (continued from page 4) 7. Percutaneous Vertebroplasty and Kyphoplasty Under medically necessary guidelines, added that it would not be reasonable to have more than one per lifetime and that kyphoplasty would be limited to two vertebral levels in a single session. 8. Surgical Ventricular Restoration Re-clarification that procedure is investigational for all contracts because it is unproven outside the investigational setting. The Clinical Protocol section of the web site is our form of communication to you for Clinical Protocols. As mentioned in the last Provider Newsletter, we continue to add previously archived policies as well as policies that support our investigational coverage determination as indicated in Code & Comment to the Clinical Protocol section of our web site. Watch for more to be added to the web site. If you need assistance obtaining specific protocol updates, please contact Provider Service. PaySpan Health PaySpan Health by Payformance offers free, online EFT (Electronic Transfer of Funds) and ERA (Electronic Remittance Advice, also known as electronic payment voucher) to all HealthNow providers. If you have not previously enrolled, you can do so at If you have any questions or experience any problems with your PaySpan Health account(s), please do not hesitate to contact PaySpan Health s provider support by calling If you prefer to send an , please use this address: ProviderSupport@PaySpanHealth.com. Page 5

7 Referral Guidelines for In-Network Benefits Referral Guidelines for In-Network Benefits Contracts Affected: Government Programs and Traditional Blue Point-of-Service (POS) Contracts with referral requirements PCP Responsibility: If the PCP determines that a member needs care from another provider or specialist, the PCP will authorize a referral via It is the PCP s responsibility to be sure a referral is requested prior to the date of service (or within 30 days after the date of service in special circumstances). Member Responsibility: If the member has not received a copy of the referral by the time of the appointment with the specialist, he/she must call the PCP immediately to ensure that the referral was requested and to obtain the referral number. If the PCP did not initiate the referral, the member must provide the PCP with the date of the specialist appointment and ask the PCP to request the referral immediately. If the referral is not in place, the member will be required to sign a financial responsibility form. The member will be responsible for payment. Members that self-refer with a Point-of-Service Contract will be responsible for their deductible and coinsurance. Specialist Responsibility: At the time of the appointment, the specialist must verify that the referral is in place by obtaining the referral number either from the member, PCP or from us. If the referral is not in place, the member will be required to sign a financial responsibility form. The member will be responsible for payment. The specialist will bill the member for services. Members with a Point-of-Service Contract will be responsible for their deductible and coinsurance after the bill is submitted to us. A specialist that a member is seeing may want to refer the member to another specialist. It is the specialist s responsibility to contact the PCP to discuss a new referral authorizing a visit to the other specialist. Specialists may request referrals directly for physical therapy, speech therapy, occupational therapy, durable medical equipment, hearing aids and orthotics without going through the PCP. Specialists must bill us within the timely filing requirements. Page 6

8 HMO/POS Provider Networks: Primary Care Physicians and Specialists Health Care Quality Improvement Overview: Outcome Reporting HMO/POS Provider Networks: Primary Care Physicians and Specialists Our HMO/POS members may contact your office to confirm your participation in their plan network. The member identification card identifies the coverage type, provider network and referral requirements. Coverage type corresponds to the provider network. Please confirm the coverage type that appears on the front of the member identification card before you respond. Knowing your Provider Network participation status will enable you to respond correctly and avoid higher out-of-pocket costs to the member. For your convenience, the Provider Directory for HMO/POS includes information that corresponds to the Provider Networks. The notation of a 1, 2 or 3 under a provider name identifies their Provider Network. For example: Health Care Quality Improvement Overview: Outcome Reporting Annually, the Health Care Quality Improvement (HCQI) Department compiles outcome data on the progress our programs and departmental initiatives are making in improving healthcare for our members. These include: Health Management Programs Asthma Depression Diabetes Cardiac Right Start - Prenatal Program Preventive Health Men s and Women s Health Immunizations Well Child Care Wellness 1 = 200 Network 2 = 200 Plus Network 3 = 100 Network (Note: HMO 100 or POS 100 is a smaller Provider Network.) Members can be directed to the most current listing of network providers, found on our web site at or by contacting the Customer Service number on their member identification cards for assistance. Accreditation and Regulatory Requirements for: Health Plan Employer Data and Information Set Annual Survey (HEDIS) National Committee for Quality Assurance Accreditation (NCQA) New York State Department of Health Quality Reviews Centers for Medicare and Medicaid Services Quality Review Medical Record Review against documentation standards and quality review. Member Complaints to Quality and Access to Care Resolution and Analysis A detailed outcome report on the initiatives listed above is found in the Providers section of our web site at If you would like a paper copy of this report or need additional information, contact the HCQI Department at (TTY). Page 7

9 Perceived Denials Perceived Denials We support your efforts to manage the care of your Medicare Advantage HMO and Medicare PPO patients in a prudent, cost-effective manner. However, the Centers for Medicare & Medicaid Services (CMS) require that when a member perceives a denial of treatment or care, he/she is entitled to certain appeal rights under Federal Law. This includes situations in which the member s request is made directly to the provider and one of the following conditions exists: The member disagrees with your prescribed course and/or type of treatment. You decline to provide a course of treatment and/or type of treatment that the member is requesting. You discontinue a course of treatment or reduce a course of treatment. Examples of Denial Some examples of a Perceived Denial are: A patient asks to be referred to a radiologist for an MRI, but you feel that an MRI is not necessary. A new prescription drug comes out on the market and one of your patients would like you to prescribe it for him/her. You decline to write the prescription at the present time because the American Medical Association and the Food and Drug Administration have not yet approved the drug for use in the senior population. A patient asks to be referred to a dermatologist for the treatment of a rash. You decline to refer the patient because you can effectively treat him/her yourself. A patient is receiving physical therapy services and you determine that physical therapy is no longer necessary. Your Responsibility When a Perceived Denial occurs, the following must take place: You must contact the Medical Management Department the day that the denial occurs to apprise the Medicare Advantage HMO and/or Medicare PPO of the situation. It is your responsibility to ensure that our members are informed of their right to appeal. We will then issue a letter stating the details of the denial, including a description and reason for the denial. The letter will inform the member of the clinical rationale, as well as the right to obtain reconsideration and the procedure for requesting reconsideration. You will receive a copy of this letter at the same time the letter is sent to the member. The member will be advised that he/she can appeal if not in agreement with our decision about his/her health care. Please contact our Medical Management Department at or if you have any questions about Perceived Denials. Page 8

10 Help for you! CMS 1500 Tips Help for you! CMS 1500 Tips The official implementation of the CMS 1500 Paper Claim Form was effective June 1, However, many providers were not ready to use the new form for a variety of reasons and BlueShield of Northeastern New York is still receiving a large number of the old HCFA form. BlueShield s goal is to discontinue accepting the old HCFA forms at the same time that we begin using the new NPI process. The CMS 1500 The most significant changes to this form are: Provider identifiers (rendering, NPI, servicing, billing and other). Anesthesia qualifiers. NDC qualifiers. Elimination of Type of Service field. Expanded modifiers. We anticipate that some providers have not fully adapted the changes into their billing systems and/or manual procedures. Hints for Using the CMS 1500 Bill your NPI number in Field 33a and your BlueShield Provider ID number in Field 33b. Indicate the time in hour-hour minute-minute format and total numbers of minutes. This information should be entered in the Supplemental Shaded Line in Field 24 with a Qualifier 7 in the first position (with no space between the Qualifier and the information). Align the claim form changes on your printed documents; otherwise the shifting of fields may result in the appropriate information not being recognized. For example, in the modifier fields next to the diagnosis pointer field, if the information is not read accurately by our scan, it may feed into the processing systems as invalid modifiers. The following are types of supplemental information that can be entered in the shaded lines of Field 24: Anesthesia duration in hours and/or minutes with start and end times. Narrative description of unspecified codes. National Drug Codes (NDC) for drugs (Indicate the 11-digit NDC Number for a J Procedure Code or a Q Procedure Code when appropriate in the Supplemental Shaded Line in Field 24. The NDC Number should be entered with a Qualifier N4 in the first two positions with no space between the Qualifier and the information). Vendor Product Number Health Industry Business Communications Council (HIBCC). Product Number Health Care Uniform Code Council Global Trade Item Number (GTIN), formerly Universal Product Code (UPC) for products. Contract rate. Note: Anesthesia claims billed with the time information listed anywhere other than the supplemental information field risk being rejected. Page 9

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13 Provider Telephone & Web Site Reference Guide Provider Telephone and Web Site Reference Guide Provider Service or (Managed Care & Indemnity) (Government Programs) Network Management Medical Management or Health Care Quality Improvement Web Site