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1 P ROVIDER N E W S L E T T E R WINTER A publication for providers participating with PARTNERS National Health Plans of NC, Inc. PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS) is making changes! Blue Medicare and Blue Medicare are the new names for our PARTNERS health care benefit plans. HMOSM PPOSM *Beginning January 1, 2008, your patients enrolled in PARTNERS health care benefit plans have new identification cards. The new member identification cards display a Blue Medicare name, a Blue Cross and Blue Shield emblem and the Blue Cross and Blue Shield of North Carolina company name. We ve made these changes to identify PARTNERS as an affiliate of the larger Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. PARTNERS affiliate designation allows us to begin branding our products with the more broadly recognized Blue Cross and Blue Shield symbols. While our product names are changing, our commitment to improving the health of our PARTNERS members is ever present. We appreciate the care that you provide to our members your patients, and we ll continue the same personalized provider services, claims services and health care management services from our Winston-Salem-based locations. In many ways it s business as usual. Once you have obtained a Blue Medicare member s new identifying information, submit claims for Blue Medicare members to PARTNERS in Winston Salem, just as you always have. And if you have questions, contact us at the same phone numbers with which you re already familiar. Our member health care benefit plans are receiving new names and our PARTNERS membership ID cards have been redesigned with a new look! Medicare charge limitations may apply North Carolina Hospitals or physicians file claims to: PO BOX Winston-Salem, NC Hospitals or physicians outside of North Carolina, file your claims to your local BlueCross and/or BlueShield Plan Members: See 2008 Member Information on Booklet for covered services medicare Customer Service: TDD/TTY: Provider Line: Mental Health/SA Members send Correspondence to: Member Name <John Doe> Member ID <YPWJ > Blue Medicare HMO PO BOX Winston-Salem, NC BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association. Group No <123456> Effective Date <01/01/2007> Rx BIN <123456> Rx PCN <123456> Rx Group <ABCDEFG> Issuer <123456> Medicare charge limitations may apply Member Name <John Doe> Member ID <YPFJ > North Carolina Hospitals or physicians file claims to: PO BOX Winston-Salem, NC Hospitals or physicians outside of North Carolina, file your claims to your local BlueCross and/or BlueShield Plan Standard Plan is offered by PARTNERS National Health Plans of North Carolina, Inc. a BCBSNC Company <Office Visit> <$15/30> <ER/Urgent Care> <$50/30> <IP Hospital> <$950> <MHCD Outpatient> <$30> <DME> <20%> Contract # H Members: See 2008 Member Information Booklet for covered services * Blue Medicare HMO and Blue Medicare PPO are offered by PARTNERS National Health Plans of North Carolina, Inc., a BCBSNC Company. Group No <123456> Effective Date <01/01/2007> Rx BIN <123456> Rx PCN <123456> Rx Group <ABCDEFG> Issuer <123456> medicare Customer Service: TDD/TTY: Provider Line: Mental Health/SA Members send Correspondence to: Blue Medicare HMO PO BOX Winston-Salem, NC BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association. Enhanced Plus Plan is offered by PARTNERS National Health Plans of North Carolina, Inc. a BCBSNC Company In-Network <Office Visit> <$10/20> <IP Hospital> <$350> Out of Network <Office Visit> <$20/20> <IP Hospital> <$350> Contract # H Please note that this newsletter contains a formal notice under your Medicare Provider Agreement... Page 4 Visit the providers page at bcbsnc.com/providers l page 1

2 New Blue Medicare member identification cards effective January 1, 2008 Effective January 1, 2008, PARTNERS members have new identification cards. The new cards replaced our member s Medicare Choice and Medicare Options identification cards. Cards have been redesigned to include the Blue Cross and Blue Shield symbols and are effective for arranging and reporting service on or after January 1, Displayed below is a sample of the design: Blue Cross and Blue Shield recognizable symbols Displays member s name and identification code J Member specific identification code Member Name <John Doe> Member ID <YPWJ > Group No <123456> Effective Date <01/01/2007> Rx BIN <123456> Rx PCN <123456> Rx Group <ABCDEFG> Issuer <123456> Standard Plan is offered by PARTNERS National Health Plans of North Carolina, Inc. a BCBSNC Company <Office Visit> <$15/30> <ER/Urgent Care> <$50/30> <IP Hospital> <$950> <MHCD Outpatient> <$30> <DME> <20%> Contract # H Displays member s Blue Medicare plan type: PPO or HMO Highlighted area displays that the Blue Medicare member s health plan is offered by PARTNERS National Health Plans of North Carolina, Inc. A Blue Medicare member s complete identification code includes four essential pieces of information: Use the sample member identification code from the sample card image above as example. YPW member s alpha prefix the alpha prefix helps to identify what plan type the member has been enrolled (YPW = HMO and YPF = PPO). J a single alpha character that is used in conjunction with the member s identifying numeric code and essential for claims routing and processing part of the member s identifying numeric code as part of our on-going efforts to help protect member s privacy, PARTNERS assigns member identification codes by use of randomly selected numbers instead of using Social Security numbers. 01 member s numeric suffix the numeric suffix helps to identify the specific member covered under the subscriber s policy. When submitting claims for Blue Medicare members, the first three alpha characters are not required for claims submission. However, claims must always include the member s alpha character J, the member s numeric code and the member s two-digit suffix J (Continued on page 3) Page 2 l

3 New member identification cards effective January 1, 2008 (Continued from page 2) Displays PARTNERS claims mailing address Important note: Be sure to send your claims for Blue Medicare members to PARTNERS and not BCBSNC Medicare charge limitations may apply North Carolina Hospitals or physicians file claims to: PO BOX Winston-Salem, NC Hospitals or physicians outside of North Carolina, file your claims to your local BlueCross and/or BlueShield Plan Members: See 2008 Member Information Booklet for covered services medicare Customer Service: TDD/TTY: Provider Line: Mental Health/SA Members send Correspondence to: Blue Medicare HMO PO BOX Winston-Salem, NC BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association. Displays PARTNERS provider service line and Blue Medicare contact information Important reminder: Effective January 1, 2008, all Medicare Choice and Medicare Options membership will be enrolled in the newly named Blue Medicare products. In order to receive accurate and timely payment for your services, please ensure that claims are submitted to PARTNERS using the member s Blue Medicare information. Members are required to present their new Blue Medicare identification card, in advance, or at the time of scheduled appointments. Providers are encouraged to make copies of both the front and back images of the member s Blue Medicare identification card. Copies should be kept in the member s file for your records and please ensure that any discarded copies are properly destroyed to help protect the patient s identity. PARTNERS Blue Medicare new alpha prefixes Alpha prefixes help you to identify which Blue Medicare plan a member has enrolled, even if you do not have the member s identification card in hand. YPW Blue Medicare HMO SM YPF Blue Medicare PPO SM YPJ Blue Medicare HMO SM for Reynolds American Inc. retirees It s easy to distinguish between Blue Medicare HMO members and Blue Medicare PPO members. Just look at the alpha prefix at the beginning of the member s Blue Medicare identification code. The alpha prefix YPW lets you know that the member s coverage type is an HMO plan, and if you see YPF, you ll know the coverage type is PPO. Additionally, Reynolds American Inc. retirees have a customized alpha prefix of YPJ, making them easy to identify as having a unique HMO plan. By using the member s alpha prefix, you can tell at a glance if a member has a HMO or PPO plan, and by submitting claims with the member s identification code (including the alpha prefix letter of J), we can quickly direct claims for processing, speeding up eligible payments to you. Visit the providers page at bcbsnc.com/providers l page 3

4 About our product name changes Our products name changes are possible as a result of a business arrangement that began in 2001 when Blue Cross and Blue Shield of North Carolina (BCBSNC) purchased PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS). Following the 2001 purchase, PARTNERS requested and received a license to identify itself as an affiliate of the larger Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Providers with questions about our new product names should contact their local PARTNERS Network Management field office for assistance. PARTNERS Provider Line Call us at , or locally at At PARTNERS, our Provider Line is available for your provider service needs. Just call us at or to find answers to your questions about Blue Medicare HMO SM and Blue Medicare PPO SM member s claims, benefits and eligibility. If after January 1, 2008, you find that you have a question about services provided at an earlier date for a PARTNERS Medicare Choice or PARTNERS Medicare Options member, and you want to ask how claims for those services were handled; the Provider Line will be available to assist with those questions, too. Remember: HealthTrio connect can quickly an easily assist with questions about claims, benefits, eligibility and much more, all from the convenience of your computer and without any wait time. PARTNERS products How to recognize our logos Offered by PARTNERS National Health Plans of North Carolina, Inc. Offered by PARTNERS National Health Plans of North Carolina, Inc. PARTNERS Blue Medicare product logos are easily recognizable. They incorporate the signature Blue Cross and Blue Shield blue and provide text that the plans are: Offered by PARTNERS National Health Plans of North Carolina, Inc. Notice of change to your agreement Since Blue Medicare is now licensed under the Blue Cross and Blue Shield Association, this serves as notice of a change to your PARTNERS Medicare Provider Agreement. Please note the following change to the definition of PARTNERS Member or Member : PARTNERS Member or Member shall also include members of Medicare Advantage plans issued by any Blue Cross and/or Blue Shield company, or any direct or indirect subsidiary of such company, to the extent described in the Provider Manual. Page 4 l

5 Blue Medicare claims filing The way claims are filed for PARTNERS members is not changing! We still want your claims filed electronically to PARTNERS. However, if you re still submitting claims on paper, we want those, too! Send your paper claims for Blue Medicare members to our same Winston-Salem mailing addresses. Mailing addresses for PARTNERS Blue Medicare HMO SM and Blue Medicare PPO SM Main mailing address FedEx, UPS and 4th Class PARTNERS P.O. Box Winston-Salem, NC PARTNERS 5660 University Parkway Winston-Salem, NC The products names are changing but claims filling remains the same. Beginning January 1, 2008, services provided to PARTNERS members are for members enrolled in Blue Medicare HMO and Blue Medicare PPO. Claims for Blue Medicare members should be submitted electronically (or by paper when necessary) to PARTNERS National Health Plans of North Carolina, Inc. Claims sent in error to BCBSNC for Blue Medicare HMO and PPO members (filed electronically or by mail) will be returned to the submitting provider, which will result in delayed payments. Important information about our new product logos: Don t be confused when sending claims Our new product logos make our Blue Medicare and Blue Medicare plans more recognizable as an HMOSM PPOSM affiliate of the Blue Cross and Blue Shield Association. However, it s important to remember that Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc., and claims for services should be filed to PARTNERS and not Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS products Offered by PARTNERS National Health Plans of North Carolina, Inc. Offered by PARTNERS National Health Plans of North Carolina, Inc. BCBSNC products (Continued on page 6) Visit the providers page at bcbsnc.com/providers l page 5

6 Important information about our new product logos (Continued from page 5) Blue Medicare HMO and Blue Medicare PPO are PARTNERS replacement names for our Medicare Choice and Medicare Options HMO and PPO health care benefit plans. Blue Medicare Rx SM is prescription drug coverage for Medicare beneficiaries, which is sponsored by Medicare and provided through BCBSNC. Blue Medicare Supplement SM are supplemental health plans offered by BCBSNC for Medicare beneficiaries enrolled in Medicare Part B. To learn more about Blue Medicare Rx and/or Blue Medicare Supplement visit the BCBSNC Web site at: blue-medicare-providers/ As you can see, the logos for the PARTNERS products and the BCBSNC products appear very similar. However, you can easily distinguish between PARTNERS products and BCBSNC from two helpful clues: 1) Logos for PARTNERS Blue Medicare HMO and Blue Medicare PPO both include in their design, text that reads Offered by PARTNERS National Health Plans of North Carolina, Inc. 2) Logos for PARTNERS Blue Medicare HMO and Blue Medicare PPO include in their design either a HMO or PPO designation. So remember, when filing claims for Blue Medicare, always send claims for Blue Medicare HMO and Blue Medicare PPO members to PARTNERS National Health Plans of North Carolina, Inc. Claims for Blue Medicare Rx and Blue Medicare Supplement should be filed to BCBSNC. Important reminder: Send your claims for PARTNERS members to PARTNERS National Health Plans of North Carolina, Inc. Whether you re sending a claim for services provided in 2007 to a Medicare Choice or Medicare Options member, or if in 2008 you re filing on behalf of a Blue Medicare member, we want your claims to come to us at PARTNERS. Please help us to process your claims for PARTNERS members quickly. Whenever you re filing a claim for a PARTNERS member, be sure to send the claim to PARTNERS and not BCBSNC. Please also be sure that when filing a claim to PARTNERS, you re BCBSNC proprietary provider number is not listed on the claim form. HMO enhancement coming January 1, 2008 In addition to our benefit enhancements for 2008, PARTNERS HMO members* will no longer be required to obtain referrals from their primary care physician in advance of receiving care from a participating specialist or when obtaining home durable medical equipment. However, until January 1, 2008, referrals by the HMO member s primary care physician are still required as part of the Medicare Choice member s 2007 benefits plan. Please note that this change in HMO procedure will not impact prior plan approval guidelines and pre-certification/certification requirements. Additionally, members will still be required to choose a primary care physician, and primary care physicians will continue their responsibility to coordinate HMO members care. Blue Medicare HMO members will have the freedom to obtain care from a PARTNERS participating network specialist without a referral by a primary care physician.* *Referrals from primary care physicians in advance of receiving care from a specialist or when obtaining home durable medical equipment remains a requirement for Blue Medicare RAI members after January 1, (RAI, Reynolds American Incorporated). Page 6 l

7 PARTNERS is expanding Recently, PARTNERS requested and received approval from the Centers for Medicare & Medicaid Services (CMS) to offer our Medicare Advantage products in 37 North Carolina counties including the Triangle, Piedmont Triad and Charlotte areas. These changes took effect for employer groups on August 1, 2007, and are in effect for individuals as of January 1, Web site information at partnershealth.com is moving PARTNERS makes information available on the Web. Publishing on the Web helps us to ensure that the information you receive from PARTNERS is the most current and accurate information available. The Web can be accessed to find information about PARTNERS prior plan approval, health care coverage options and benefits, medication formularies, network providers, provider newsletters and manuals, and more. Beginning January 1, 2008; you ll find us at the BCBSNC Web site bcbsnc.com. PARTNERS will continue to provide you with the most up-todate information only from a new, centralized Blue address. Benefit plan information available on the Web PARTNERS Medicare Choice and Medicare Options benefit plans for 2007 can be accessed on the PARTNERS Web site partnershealth.com. However, if you re interested in seeing the new Blue Medicare member benefits offerings for 2008, you ll find them on the Web at bcbsnc.com. The PARTNERS Web site partnershealth.com will remain active beyond January 1, 2008 for a short duration as a reference site. Visitors to partnershealth.com searching for active information after January 1, 2008 will be redirected to bcbsnc.com. Visit the providers page at bcbsnc.com/providers l page 7

8 Important reminder about billing for vaccine administration Physicians and other providers who bill Medicare carriers or Medicare Administrative Contractors (A/B MACs) for the administration of Part D-covered vaccines to Medicare beneficiaries should be aware of article Special Edition (SE) This article provides 2008 payment guidance for the administration of Part D-covered vaccines. However, this is not new policy guidance; it s just a reminder of the policy for Remember, effective January 1, 2008, physicians can no longer bill Medicare Part B (i.e. PARTNERS medical claims) for the administration of Medicare Part D-covered vaccines, using the special G code (G0377). Instead, you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to their Part D plan for reimbursement. You should make sure that your billing staff is aware of this Part D-covered vaccine administration guidance for Section 202(b) of the Tax Relief and Health Care Act of 2006 (TRHCA) established a permanent policy for payment by Medicare for administration of Part D-covered vaccines, beginning in Specifically, the policy states that, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of covered Part D drug under the Part D statute. During 2007, in transition to this new policy, providers were permitted to bill Part B for the administration of a Part D vaccine using a special G code (G0377). SE0723 now reminds providers of the requirement that payment for the administration of Part D covered vaccines only during Therefore, effective January 1, 2008, you can no longer bill the G code to Part B; rather you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement. Important note: This guidance does not affect Part B-covered vaccines. You might want to look at MLN Matters articles MM5486 (Payment by DME MACs and DMERCs for the Administration of Part D Vaccines), released December 29, 2006; and MM5459 (Emergency Update to the 2007 Medicare Physician Fee Schedule Database (MPFSDB)) released January 11, You can find these articles at MLNMattersArticles/downloads/ MM5486.pdf and cms.hhs.gov/mlnmattersarticles/ downloads/mm5459.pdf, respectively. You may also want to review SE0727 (Reimbursement for Vaccines and Vaccine Administration under Medicare Part D), which may be found at MLNMattersArticles/downloads/ SE0727.pdf on the CMS Web site. If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found at hhs.gov/mlnproducts/downloads/ CallCenterTollNumDirectory.zip. New advance directives legislation in North Carolina Since Medicare certified hospitals and other health care providers must provide information to Medicare beneficiaries about their rights under state law to make health care decisions, including the right to make advance directives, PARTNERS wants to inform you of a new North Carolina law impacting advance directives. On August 30, 2007, Governor Easley signed into law House Bill 634, An Act to Clarify the Right to Make Advance Directives. The Act makes several amendments to previous laws on advance directives. One example is the language change from life-sustaining procedures to life-prolonging measures. Another example is the inclusion of statutory forms for Health Care Power of Attorney and Advance Directive for a Natural Death. There are several more changes, including modifications to the rules on informed consent. To view the law and its changes, please visit the North Carolina General Assembly's Web site at ncga.state.nc.us/homepage.pl and search for HB 634. Page 8 l

9 Improving osteoporosis management Overview As of September, PARTNERS has implemented a new program to improve osteoporosis management after a fracture. The overall goal of this program is to prevent or manage osteoporosis and reduce the recurrence of fractures by helping older women understand osteoporosis and their previous fractures are a strong risk factor for recurrent fractures. Health employer data information system (HEDIS 1 ) Osteoporosis Measure Because women who suffer a fracture are at an increased risk of additional fractures and are more likely to have osteoporosis, the first osteoporosisspecific HEDIS performance measure was developed in 2004 to assess how well plans manage women at high risk for a second fracture. The HEDIS measure on osteoporosis management is defined as: the percentage of women age 67 or older who suffer a fracture who received either a bone mineral density test or prescription treatment for osteoporosis within six months of the date of the fracture. Key program components This program is a comprehensive osteoporosis management program that targets female members (age 65 or older) who meet the HEDIS measure for osteoporosis management and the doctors who treat them. Overall, this program provides education about the causes of osteoporosis, the value of prevention and early detection, and options for treatment. The following program components are designed to provide a comprehensive overview and understanding of specific elements related to osteoporosis management. Member component (post-fracture follow-up kit): 1) Cover letter introduces members (with fractures) to the link between fractures and osteoporosis, encouraging members to be proactive about their bone health. 2) What every woman should know about osteoporosis booklet discusses the warning signs of the disease and who is most at risk; shows practical ways to prevent and treat osteoporosis as well. 3) Power of 3 planner offers calcium-rich recipes to help maintain bone health. 4) What you can do to prevent falls brochure provides information on how to prevent fractures. 5) Bone up on calcium magnet reminds members to get their daily calcium. 6) Osteoporosis checklist offers bone health questions that help members discuss osteoporosis with their health care provider. Physician component (post-fracture follow-up kit): 1) Cover letter briefly describes the prevalence of osteoporosis and explains the importance of timely detection and treatment. 2) Post-fracture patient follow-up report notifies the primary care physician when a member experiences an initial bone fracture; if a member experiences subsequent fractures, those fractures are also noted on future reports. 3) Pocket guide to prevention and treatment of osteoporosis provides information to help physicians gain a better understanding of the prevalence and seriousness of osteoporosis and guidelines for osteoporosis prevention and treatment. For more information about this program, contact PARTNERS quality improvement program manager at , ext Visit the providers page at bcbsnc.com/providers l page 9

10 CMS expedited appeals process when coverage ends for: skilled nursing facilities, home health agencies or comprehensive outpatient rehabilitation facilities Members of PARTNERS National Health Plans of North Carolina, Inc., (PARTNERS) have the right to an expedited review by a quality improvement organization (QIO) when they disagree with a PARTNERS decision that coverage of their services from a skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) should end. The Centers for Medicare & Medicaid Services (CMS) final ruling of April 2003 stated that skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities must provide an advance Notice of Medicare non-coverage (NOMNC) to PARTNERS members no later than two days before coverage of their services will end. If the patient does not agree that covered services should end, they may request an expedited review of the case by the quality improvement organization in that state. The member s plan must furnish a detailed notice explaining why services are no longer necessary or covered. Rule compliance To ensure compliance with the April 2003 ruling, the PARTNERS policy and procedure is as follows: All contracting and noncontracting providers must ensure delivery of the notice to the member no later than two days/visits prior to the proposed termination of SNF, HHA or CORF services, and they must obtain the member s or authorized representative s signature on the NOMNC. 1. The provider must place the original NOMNC in the member s case file, provide a copy to the member, and fax a copy of the notice to PARTNERS Healthcare Services Department at A copy of the NOMNC and the final rule may be downloaded from the CMS Web site at gov/mmcag/. How to Appeal PARTNERS members have the right to an immediate review of the decision to end the coverage while the services continue. The member must submit a timely request for the immediate review directly to the QIO by noon of the day following receipt of the NOMNC. When the member receives the NOMNC more than two days/ visits prior to the date that coverage is expected to end, the member may request an appeal to the QIO by noon of the day before coverage ends (effective date of notice). Notification required for hospital admissions Hospital admissions, elective and urgent/emergent, require plan notification and medical necessity review. Hospitals are required to notify the plan and submit clinical information for a medical necessity review prior to an elective admission or within one business day of an urgent/emergent admission. Failure to notify the plan can result in a denial of service and claims nonpayment. Please remind your business office and utilization management department to notify PARTNERS Healthcare Services of these admissions by calling Page 1 0 l

11 Hospital discharge appeal rights PARTNERS wants to remind you that effective July 2, 2007, the Centers for Medicare & Medicaid Services (CMS) implemented new requirements for the delivery of notices regarding hospital discharge appeal rights. Under the requirements, a PARTNERS member being considered for discharge is to receive an explanation of their rights as a hospital patient, including discharge appeal rights. To explain these rights hospitals are to use a revised version of the Important Message from Medicare (IM [a statutorily required notice]). The IM notice must be issued within two calendar days of admission; a signature of the member or his or her representative must be obtained on the IM, and a copy of the IM provided to the member or his or her representative at that time. Hospitals must also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than two calendar days before discharge. If a PARTNERS member requests a quality improvement organization (QIO) review, PARTNERS will deliver a detailed notice of discharge (detailed notice) as soon as possible, but no later than noon of the day after the QIO s notification. Both the IM and the detailed notice must be the standardized notices provided by CMS. Copies of the standardized notices are available from the CMS Web site at Hospitals may not deviate from the content of the form except where indicated. The OMB control number must be displayed on the notice. These requirements apply to any facility providing care at the inpatient hospital level, whether that care is short term or long term, acute or non acute, limited to specialty care or providing a broader spectrum of services, and includes critical access hospitals. However, swing beds in hospitals are excluded because they are considered a lower level of care and additionally religious non-medical health care institutions are also excluded. To learn more about hospital discharge appeal notices and their requirements, visit the CMS Web site at HospitalDischargeAppealNotices.asp. Visit the providers page at bcbsnc.com/providers l page 11

12 Medical Coverage Policy updates PARTNERS Quality Improvement Committee and PARTNERS Physician Advisory Group reviewed and approved the following Medical Coverage Policies. These policies have been updated since the last provider newsletter. Please contact PARTNERS Healthcare Services at if you have questions: Policies for Biannual Review: Policy Ambulance transportation Ambulatory cardiac monitoring/telemetry (ACT) Cardiac rehabilitation Chemical peel Dental hospital or outpatient facility or ambulatory surgery center renamed Dental procedures in a hospital, outpatient facility or ambulatory surgery center Dental service Major Changes Added bullet The member s condition is such that the time needed to transport a member by land to the nearest appropriate medical facility poses a threat to the member s health for air ambulance transport Added transportation for excluded services is not covered under when coverage will not be approved New policy Removed MET level requirement Changed title Clarified description of procedure Added Reconstruction of a ridge if performed as a result of & at the same time as the surgical removal of a tumor to criteria for coverage approval Added Insertion of metal implants if the implants are used to assist in or enhance the retention of a dental prosthetic as a result of a covered service to criteria for coverage approval Removed abscess or infection (medical) treatment of dental abscess from coverage approval Removed fluoride application from coverage approval Continued on page 13 Page 1 2 l

13 Medical Coverage Policy updates Continued from page 12 Policies for Biannual Review: Policy Dental services due to injury Lithotripsy (extracorporeal) for orthopedic problems MOHS micrographic surgery (MMS) Neuropsychological testing Parenteral nutrition Pulmonary rehabilitation Refractive surgical procedures Sacral nerve stimulators for urinary incontinence Wound care clinic Major Changes Added Dental services are not covered for treatment of the breaking or chipping of a tooth while biting or chewing to when coverage will not be approved Added high energy guideline limitations Description of procedure updated Added number 3 and number 4 criteria required for coverage approval Added second and third bullets under when coverage will not be approved Added special notes section Separated from Enteral Nutrition policy Added language to clarify IPN as investigational and not covered Clarified PFT readings to align with the GOLD standard No further criteria changes made Removed one-year history of symptoms from criteria required for coverage approval No further criteria changes made Re-wording to make policy easier to interpret Added directions on when nurses can approve visits without medical director review first Added wound care requests are reviewed by the case management staff within Healthcare Services No further criteria changes made Continued on page 14 Visit the providers page at bcbsnc.com/providers l page 13

14 Medical Coverage Policy updates Continued from page 13 Policies for Biannual Review: Policy Botulinum toxin Surgery for morbid obesity Temporomandibular joint surgery and/or occlusal splints Treatments for obstructive sleep apnea and breathing related sleep disorders Vagus nerve stimulator (VNS) for epilepsy Breast implant removal Breast reduction Deep brain stimulation for essential tremor and Parkinson s disease Durable medical equipment (DME) Major Changes Added description of botulinum toxin type A & botulinum toxin type B to description of procedure Added treatment of neurogenic urinary. incontinence or neurogenic detrusor overactivity to coverage approval when oral therapy has failed Added open adjustable gastric banding, open and laparoscopic sleeve gastrectomy, and long limb gastric bypass as procedures not covered No further criteria changes made Clarified description of procedure Added chart on stages of TMJ for reference only Added glossary of terms No further criteria changes made Clarified compliance with using the device as prescribed can be obtained from the member, the treating physician and/or the compliance chip Increased age limit to receive VNS to older than twelve (12); previous age limit four (4) Added language to clarify definition of partial onset seizure Removed height requirements for weight of breast tissue removed. Anticipated weight of breast tissue to be removed should be greater than 350 grams regardless of the patient s height. Clarified those individual items, with a contracted rate $600 does not require prior authorization to assist claims personnel (exception: all prosthetic components require prior authorization regardless of price) Continued on page 15 Page 1 4 l

15 Medical Coverage Policy updates Continued from page 14 Policies for Biannual Review: Major Changes Policy Impotence Vertebroplasty and kyphoplasty, percutaneous Removed medications from coverage approval due to exclusion from CMS coverage New No formatting changes made criteria changes made Visit the providers page at bcbsnc.com/providers l page 15

16 Spring 2008: Medical Coverage Policy updates PARTNERS Quality Improvement Committee and PARTNERS Physician Advisory Group reviewed and approved the following Medical Coverage Policies. These policies became effective as of February 20, Please contact PARTNERS Healthcare Services at if you have questions: Policies for Biannual Review: Policy Policy Durable Medical Equipment (DME) Enteral Nutrition External Infusion Pumps Implantable Infusion Pumps Lymphedema Observation Orthognathic Surgery Oxygen Major Major Changes Changes Added Replacement of lost or stolen equipment and repairs (instead of replacement) of purchased equipment are covered at the discretion of PARTNERS to the Replacement DME section No further criteria changes made Formatting and grammatical changes Added C-Peptide testing requirement and Beta cell autoantibody test to criteria for coverage Added drugs Gallium Nitrate, Ziconotide, and Subcutaneous immune globulin to list of drugs covered in limited situations Added The presence of malocclusion alone does not qualify for surgical consideration without demonstrated severe functional impairment to when coverage will not be approved Clarified For sleep oximetry criteria, the 5 minutes does not need to be continuous Added section on Home Sleep Oximetry Studies Changed guidelines to follow Medicare: will rent oxygen for 36 months, then convert to purchase and the member will own the equipment: (See article on oxygen in the Medical Coverage Policies) Continued on page 17 Page 1 6 l

17 Medical Coverage Policy updates Continued from page 16 Policies for Biannual Review: Policy Speech Language Pathology Major Changes Formatting and grammatical changes Clarified Description of Procedure Clarified therapeutic interventions for language Clarified criteria for swallowing interventions Added section on VitalStim under when coverage will not be approved Added sections on plan of care and maintenance program under Special Notes Strabismus Surgery Vertebroplasty and Kyphoplasty, Percutaneous** X-Stop Changed duration of non-invasive medical therapy for kyphoplasty to 6 weeks for consistency with verteobroplasty This procedure does not require prior approval for Blue Medicare PPO members New policy *All of the above policies comply with Medicare National and Local Coverage Determinations and require prior approval for Blue Medicare HMO Members. All policies also require prior approval for Blue Medicare PPO except those designated with **. Visit the providers page at bcbsnc.com/providers l page 17

18 NPI contingency plan update Identifier Primary providers: Billing/pay to; rendering Secondary providers: Referring, ordering, operating, other Legacy ID only NPI + legacy NPI only Legacy IDs only will continue to be submitted/accepted through May 22, 2008 NPI + legacy started to be submitted accepted October 1, 2006 NPI + legacy will continue to be submitted/accepted through May 22, 2008 NPI only started to be submitted/ accepted October 1, 2006 NPI only will be required to be sent/ received starting May 23, 2008 Legacy IDs will not be permitted after May 22, 2008 Legacy IDs only will continue to be submitted/accepted through May 22, 2008 NPI + legacy started to be submitted/ accepted October 1, 2006 NPI + legacy will continue to be submitted/ accepted through May 22, 2008 NPI only started to be submitted/ accepted October 1, 2006 NPI only will be required be sent/ received starting May 23, 2008 Legacy IDs will not be permitted after May 22, 2008 Note: for definition of primary and secondary providers see CMS FAQ Key questions and answers What requirements does the health plan have for sharing NPIs prior to production use? We have requested that all providers register NPIs directly with Blue Cross and Blue Shield of North Carolina (BCBSNC). BCBSNC will share registered NPIs with PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS). When both legacy and NPI are present in the same transaction, which ID is used for processing? If the NPI is registered with PARTNERS, PARTNERS will use the NPI to confirm the internal PARTNERS mapping. If the NPI and PARTNERS provider ID submitted on the transaction agree with the NPI and PARTNERS provider ID in the PARTNERS claims processing system then PARTNERS will process using the NPI. If the NPI and PARTNERS provider ID submitted on the transaction does not agree with the NPI and PARTNERS provider ID in the PARTNERS crosswalk, then PARTNERS will fail the transaction with a business edit. If the NPI is not registered with PARTNERS, PARTNERS will use the PARTNERS provider ID to process the transaction. How does the health plan recommend providers test transactions with NPI? PARTNERS strongly recommends that the provider submit transactions with both the NPI and the current provider identifier. This will allow both the provider and PARTNERS to verify the mapping of NPI to current PARTNERS internal provider identifiers. What are the timelines and transition requirements for paper claims? NPIs should not be sent on the paper claim forms being phased out. NPIs may be sent on the new UB04 and the new CMS1500. PARTNERS Provider IDs may be sent on the new forms, as well. PARTNERS will also accept both the NPI and the PARTNERS provider ID on the new forms. If you have not registered your NPI(s) with BCBSNC, please contact Page 1 8 l

19 Network Management is here for you Network Management is responsible for developing and supporting relationships with the provider community. Network Management staff is dedicated to serving as a liaison between you and PARTNERS and are available to assist you with a variety of issues, including: Questions regarding PARTNERS contracts, policies and procedures Changes to your organization including: Opening/closing locations Change in name or ownership Change in tax ID number, address or phone number Merging with another group Educational needs Network Management field offices are located throughout the state and are assigned to support the provider community by specific geographical region. Please contact one of our Network Management offices whenever you need our assistance. Hickory Office P.O. Box 1588 Hickory, NC Phone: Fax: Greenville/Fayetteville/ Wilmington Offices 2005 Eastwood Road Suite 201 Wilmington, NC Phone: Fax: Charlotte Office P.O. Box Charlotte, NC Phone: Fax: Contact Information Greensboro Office The Kinston Building 2303 W. Meadowview Rd Greensboro, NC Phone: Fax: *please note new address Raleigh Office P.O. Box 2291 Durham, NC Phone: Fax: Claims mailing addresses We want to process your claims quickly and if you re still sending claims to us through the mail, we want to be sure that you have our correct addresses. And remember, whether you re sending claims for services provided in 2007 for Medicare Choice and/or Medicare Options members, or you re sending claims for services provided to Blue Medicare members on or after January 1, 2008, all claims for PARTNERS members come to the PARTNERS mailing addresses listed at the right. Main mailing address (general correspondence) PARTNERS National Health Plans of NC, Inc. P.O. Box Winston-Salem, NC FedEx, UPS and 4th Class PARTNERS National Health Plans of NC, Inc University Parkway Winston-Salem, NC Visit the providers page at bcbsnc.com/providers l page 19

20 P ROVIDER N E W S L E T T E R Editor: Howard Barwell PO Box 2291 Durham, NC PRSRT STD U.S. POSTAGE PAID Raleigh, NC Permit No. 59 Address Service Requested HealthTrio connect PARTNERS together with HealthTrio connect, utilizes the power of the Internet to deliver a comprehensive suite of administrative transactions all with secure messaging to enable HIPAAcompliant communication. HealthTrio connect allows you to perform the following easily from your desktop and in real-time: Check claim status View an EOP of a processed claim or claims Verify member eligibility and benefits information Check referral status Obtain provider demographics HealthTrio connect streamlines many office management tasks that have traditionally been manual, paper or done by phone. To find out more about HealthTrio connect and how to connect for your office, visit us on the Web at bcbsnc.com/providers/ blue-medicare-providers/electroniccommerce/ or call PARTNERS Provider Services Important message for providers who participate with BCBSNC and utilize Blue e SM HealthTrio connect is the secure Internet site for conducting electronic transactions with PARTNERS National Health Plans of North Carolina, Inc. If your health care business utilizes Blue e for electronic transactions, it s important to note that Blue e can t conduct transactions for Blue Medicare HMO SM or Blue Medicare PPO SM PARTNERS products. Claims activity for Blue Medicare HMO and Blue Medicare PPO by use of Blue e will be rejected by the Blue e system. (See page 5 for more information about how to process Blue Medicare paper claims.) Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS), a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association. Providers should be aware that neither an individual s possession of a Blue Medicare member identification card nor information contained in this mailing represents a guarantee of member s benefits, eligibility or coverage in a Blue Medicare plan. Member s actual Blue Medicare eligibility and benefits should always be verified in advance of providing services. U4766 1/08 Visit the providers page at bcbsnc.com/providers l page 20