UPDATE NEWS FOR THE NETWORK

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1 PROVIDER UPDATE NEWS FOR THE NETWORK May DAY NOTIFICATIONS Coverage Updates for Commercial Products Changes to Existing Prior Authorization Programs The following changes are effective for dates of service on or after July 1, 2014: } Power Wheelchairs Effective July 1, 2014, Tufts Health Plan will not cover the following wheelchair modifications and accessories: Power seat elevation (E2300) Power standing option or a standing wheelchair (E2301) Power wheelchair seat cushion (E2610) Refer to the Medical Necessity Guidelines for Power Wheelchairs for additional information. } Autologous Chondrocyte Implant of the Knee Coverage for treatment may be authorized for the diagnosis of patellar lesion when criteria documented in the Medical Necessity Guidelines for Autologous Chondrocyte Implant of the Knee are met. } Genetic Testing: Multi-Site BRCA3, Single-Site BRCA1 or BRCA2, and BART Changes to coverage criteria have been made to more closely align with the National Comprehensive Cancer Network Guidelines for Hereditary Breast and/or Ovarian Cancer. The age of diagnosis for personal history with no other risk factors for women not of Ashkenazi descent was changed from age 50 or younger to age 45 or younger. The updated guidelines also allow for coverage for a newly defined family history that includes coverage of the testing for women who meet the following criteria: A personal history of breast cancer diagnosed before age 45 and a family history of breast cancer, diagnosed at any age in one or more 1st- or 2nd-degree relatives on the same side of the family A family history of one or more 1st- or 2nd-degree relatives with the diagnosis of epithelial ovarian cancer A family history of two or more 1st- or 2nd-degree relatives with pancreatic or aggressive prostate cancer diagnosed at any age (aggressive prostate cancer defined as having a Gleason score of 7 or higher) A limited family history, defined as an individual with fewer than two 1st- or 2nd-degree female relatives or female relatives surviving beyond age 45 in either lineage For more information about these changes, refer to the Medical Necessity Guidelines for Genetic Testing: BRCA1 and BRCA2 and Multi-Site BRCA3. Other Updates } Noncovered Services The following procedure is not covered by Tufts Health Plan, as it is considered experimental/investigational, and has been added to the Medical Necessity Guidelines for Noncovered Investigational Services: PICO Single-Use Negative Pressure Wound Therapy System (NPWT) (Smith & Nephew) (no code) Tufts Health Plan s Medical Necessity Guidelines are available in the Clinical Resources section at or upon request by calling Provider Services. continued on page 2

2 Effective July 1, 2014 Change to Claims Submission Policy: Paper CMS-1500 Forms Paper claims sent to Tufts Health Plan are scanned using optical character recognition (OCR) technology. This technology allows the data on the form to be read while the actual form fields, headings and lines remain invisible to the scanner. Tufts Health Plan currently requires that all paper CMS-1500 claims be submitted on standard red claim forms. Beginning July 1, 2014, paper CMS-1500 claims submitted to Tufts Health Plan must also conform to the scale and OCR color of CMS-1500 forms. This requirement will apply for all Tufts Health Plan products. Although copies and representations of the CMS-1500 form are available and can be downloaded, those representations of the form may not accurately replicate the scale and OCR color of the form required for accurate OCR scanning and will not be accepted. Resized representations of the form will not be processed and will be rejected and returned with a request to resubmit on the proper claim form. Tufts Health Plan contracting providers can purchase industrystandard CMS-1500 forms that conform to CMS scale and color specifications at a discounted rate from W.B. Mason. To order by fax or , use the Supply Order Form, available in the Forms section at. If purchasing from a supplier other than W.B. Mason, please make sure the forms meet CMS standard for scale and OCR color. These and other claim submission requirements are documented in the Claims Submission Policy. Effective July 1, 2014 Proof of Timely Submission for EDI Claims Effective for commercial claims submitted electronically to Tufts Health Plan on or after July 1, 2014, a report indicating that the claim was accepted by Tufts Health Plan, as evidenced by a Tufts Health Plan claim number, will be required as proof of timely submission. A report indicating rejection at Tufts Health Plan or at the clearinghouse will not be considered proof of timely submission and the claim will not be considered for reprocessing. It is the provider s responsibility to obtain and review Explanations of Payment and all reports from the clearinghouse and Tufts Health Plan. Claims not accepted for processing must be corrected, resubmitted and accepted by Tufts Health Plan in order to meet the filing deadline. This requirement is documented in the Provider Payment Dispute Policy and in the Claim Requirements chapter of the Commercial Provider Manual. Coverage Updates for Commercial Products (continued from page 1) } Reminder: Billing Preventive Services With Modifier 33 Tufts Health Plan accepts and recognizes the use of modifier 33 when billed with services on the U.S. Preventive Services Task Force List that have an A or B rating. The American Medical Association created this modifier to allow providers to identify a service that is inherently not preventive but was rendered for a preventive purpose and for which patient cost sharing does not apply under the Patient Protection and Affordable Care Act. This federal law prohibits patient cost sharing for preventive services for non-grandfathered plans. Modifier 33 is appropriate for use with a CPT or HCPCS code that is a diagnostic/treatment service being performed as a preventive service. Modifier 33 is not appropriate to use with CPT or HCPCS codes that are inherently preventive services (e.g., screening mammography 77057, pneumococcal vaccine 90669). CPT codes not appropriately appended with modifier 33 will process under the member s medical or preventive benefits, based on the diagnosis and CPT/HCPCS codes submitted. Effective July 1, 2014 Electronic Explanations of Payment As of August 2013, Tufts Health Plan offers electronic funds transfer, electronic remittance advice and explanations of payment to providers through PaySpan Health. Effective July 1, 2014, Tufts Health Plan will no longer mail paper explanations of payment to providers through PaySpan. Electronic versions of EOPs will instead be available for download and printing only on the PaySpan website. If you are already registered with PaySpan for electronic EOPs, no action is required. If you are not yet registered, you must register with PaySpan to access your EOPs after July 1. For instructions on how to register, visit the PaySpan Health website at payspanhealth.com or the Electronic Services section at. 2

3 Claim Edits Effective July 1 The following claim edits will be effective for dates of service on or after July 1, These policies are derived from CMS, the AMA CPT Manual, the NCCI Policy Manual, Anesthesia Guidelines, Specialty Review Panel, and Tufts Health Plan policy. } Ambulatory EEG Monitoring Tufts Health Plan will not compensate for ambulatory EEG when a resting EEG has not been billed on the same day or within the previous 12 months. Refer to CMS for more information. This change is documented in the Outpatient Payment Policy. } Prostate-Specific Antigen (PSA) Tufts Health Plan will not compensate for a prostate-specific antigen (PSA) test more than once per year unless there is a change in the patient s medical condition. Refer to the CMS Internet-only Manual for more information. This change is documented in the Outpatient Payment Policy. } Vitamin D Testing Tufts Health Plan will not compensate for a vitamin D (25-hydroxy) test more than once per year unless a diagnosis of vitamin D deficiency is also on the claim. Refer to the CMS LCD for more information. This change is documented in the Outpatient Payment Policy. } Prostate Cancer Screening Tests Tufts Health Plan will not compensate for prostate cancer screening tests performed more than once every 11 months. Refer to the CMS Internet-only Manual for more information. This change is documented in the commercial, Tufts Medicare Preferred HMO, and Tufts Health Plan Senior Care Options Oncology payment policies. } Vitrectomy Tufts Health Plan will not compensate for vitrectomy unless vitreous loss, retinal detachments secondary to vitreous strands, proliferative retinopathy, or vitreous retraction is also reported on the claim. Refer to the CMS NCD Manual for more information. This change is documented in the commercial Vision Services Payment Policy. } Daily Max Units Tufts Health Plan will not compensate for more than one unit per date of service for procedures indicated in the CPT manual as one unit, regardless of the modifier. Refer to the AMA CPT Manual for more information. This change is documented in the commercial Podiatry and Modifier payment policies. } ESRD Facility Prospective Payment System Tufts Health Plan will not separately compensate for any drug included in ESRD consolidated billing when billed with place of service 65. Refer to CMS for more information. This change is documented in the Dialysis Services Payment Policy. } Hemodialysis Peritoneal Dialysis Frequency Tufts Health Plan will not compensate for hemodialysis or peritoneal dialysis more than three times in a six-day period when billed with an office, home, temporary lodging, outpatient hospital, or ESRD treatment facility place of service. Refer to the CMS Internet-only Manual for more information. This change is documented in the commercial Dialysis Services Payment Policy. } E&M Services With Anesthesia Services Tufts Health Plan will not compensate for evaluation and management services billed with anesthesia services on the same date of service or the day prior to surgery. Refer to the AMA CPT Manual, the NCCI Policy Manual and Anesthesia Guidelines for more information. This change is documented in the commercial Anesthesia Payment Policy. } Inpatient Admission or Consultation Services Tufts Health Plan will not compensate for hospital care services when an initial hospital care claim has been submitted in the previous three days with the same diagnosis by the same provider. This policy is based on Specialty Review Panel and Tufts Health Plan policy and is documented in the commercial Inpatient Payment Policy. } Discharge Services Tufts Health Plan will not compensate for more than one hospital discharge day management service per member per hospital stay. Tufts Health Plan will not compensate for the discharge day management service unless the physician of record is on the claim. Refer to the AMA CPT Manual and the CMS Internet-only Manual for more information. This change is documented in the commercial Inpatient Payment Policy. } Intensive Behavioral Therapy for Obesity Tufts Health Plan will not compensate for face-to-face behavioral counseling for obesity unless a diagnosis of Body Mass Index 30 or greater is also on the claim. Refer to the CMS Internet-only Manual for more information. This change is documented in the Outpatient Payment Policy. continued on page 5! ICD-10 Delay Tufts Health Plan continues to move forward with its commitment to be ICD-10 compliant. 3 Recently passed legislation delays ICD-10 implementation, and Tufts Health Plan is assessing its overall implementation schedule. Visit the ICD-10 Resources section of our website for the most recent information regarding the impact of the delay on our work activities and overall timeline. You can also send questions about Tufts Health Plan s ICD-10 transition to ICD10questions@tufts-health.com.

4 Five-Day Response Time for Member Grievances Upon receipt of a member grievance by the plan, providers or their office managers are generally notified verbally or in writing about a member grievance and asked for their response. Providers are expected to respond to a request for information in a timely manner so that the grievance review can be completed within the specified time frame. Effective July 1, 2014, Tufts Health Plan will adopt a five-business-day turnaround time as its standard for providers to respond to the plan s request for information in investigating member grievances. This turnaround time is required to ensure that the plan meets its regulatory and accreditation requirements to the member and remains compliant with all state and federal (CMS) requirements. Modifier 25 Changes for Commercial Claims Effective for dates of service on or after July 1, 2014, Tufts Health Plan will not compensate for evaluation and management services billed with modifier 25 on the same day as a procedure with a 0-day, 10-day or 90-day postoperative period if the member has been seen by the same provider in the last eight weeks for the same condition. Refer to the AMA s CPT Coding Manual for a description of appropriate use of modifier 25. For more information, refer to the Modifier and Evaluation and Management payment policies.! Reminder: ICD Diagnosis and Procedure Codes Required for Inpatient Notifications As previously communicated and effective January 1, 2014, for all Tufts Health Plan products, ICD diagnosis and procedure codes are required when appropriate for inpatient notification requests submitted through Tufts Health Plan s intake channels. These include the secure website, telephonic notification, and fax channel. CPT codes are considered invalid for inpatient services and will not be accepted for inpatient notification requests submitted through any of those channels. CPT codes are appropriate only when submitting requests for prior authorization of a procedure to Tufts Health Plan. Drugs and Biologicals Claim Edits Effective July 1 Effective for dates of service on or after July 1, 2014, Tufts Health Plan will implement additional claim edits for drugs and biologicals. These edits will apply to commercial, Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options plans. Tufts Health Plan s policies regarding drugs and biologicals are derived from evaluation of drug manufacturers prescribing information and the following sources: } AMA s CPT Manual } CMS and CMS HCPCS Level II Manual } National Comprehensive Cancer Network Drugs & Biologics Compendium } National Government Services Inc. Medicare Article } Thomson Reuters Micromedex and DRUGDEX These policies support appropriate diagnosis codes, indications, dosages and frequencies. In some instances, off-label indications also will be allowed where there is evidence of efficacy. This information is documented in the Outpatient and Oncology payment policies at tuftshealthplan.com/ providers. Physician, Outpatient Hospital Fee Schedules to Be Updated July 1 Tufts Health Plan reviews its commercial physician and outpatient hospital fee schedules quarterly to ensure that they are current, comprehensive and consistent with industry standards to the extent supported by our systems. In most cases changes involve adding fees for new or existing codes to supplement the fees already on the fee schedule. The next update will occur on July 1, Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician immune globulin, vaccine and toxoid fees. Detailed information about changes to existing fee schedules will be distributed to provider organization and hospital leadership. Independent physicians who have questions about fee schedule changes should contact Tufts Health Plan s Network Contracting Department at , ext

5 ! Find Current Pharmacy Information on the Web For the most current information regarding the Tufts Health Plan pharmacy benefit including tier changes, online formularies and descriptions of pharmacy management programs go to the Pharmacy section of our website. Pharmacy information on our website is updated regularly. Check Pharmacy Updates for postings of formulary changes, notification of new pharmacy programs, and important information about drug recalls and alerts from the FDA or drug manufacturers. Copies of information regarding our pharmacy management programs can also be provided upon request by calling Provider Services at Correct Coding Reminder As a normal business practice, claims are subject to payment edits that are updated at regular intervals and generally based on Centers for Medicare & Medicaid Services guidelines, specialty society guidelines, evaluation of drug manufacturers package label inserts, and the National Correct Coding Initiative. Procedure and diagnosis codes undergo annual and quarterly revision by CMS, the American Medical Association, and NCCI. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes during the second calendar quarter of Payment policies will be updated to reflect the addition and replacement of procedure codes where applicable. PLAN UPDATES New Plan Offering: Christie Student Health Tufts Health Plan will offer a student health insurance plan through its affiliate Christie Student Health (CSH), with plan effective dates beginning the third quarter of This student health plan will be offered to institutions of higher learning and will utilize the Tufts Health Plan commercial provider network in Massachusetts and Rhode Island for students in those states. All provider and member servicing, claims submission and adjudication processes, and payment will be administered by CSH. Additional information about this new plan will be provided in the coming months. Claim Edits Effective July 1 (continued from page 3) } Procedure Code Guidelines for Mental Health Provider Type Modifiers Reminder: Tufts Health Plan will not compensate for services performed with an E&M service by the same provider unless modifier AH, AJ, HM, HN, HO, HP, SA, TD or TE is also on the claim. Refer to the AMA CPT-4 Manual and CMS HCPCS Level II Manual for more information. This policy is documented in the commercial Mental Health and Substance Abuse (Outpatient) Professional Payment Policy. } Neonatal Services Tufts Health Plan will not compensate for the following: More than one neonatal or pediatric critical care service per member per same date of service More than one neonatal intensive care service per same date of service by the same provider Initial neonatal and pediatric critical care services if the member received inpatient critical care services the previous day Initial hospital or birthing center care services if the member received initial or subsequent newborn care services the previous day Refer to the AMA CPT Manual for more information. These changes are documented in the Newborn Payment Policy. } Clinical Trials Tufts Health Plan will not compensate for any routine costs associated with a clinical trial unless modifier Q0 or Q1 and the diagnosis to indicate participation in a clinical trial or research study are also on the claim. Refer to the CMS Internet-only Manual for more information. This change is documented in the commercial Clinical Trials Payment Policy. Referral Not Required for Behavioral Health Services in SNF, TCU Effective January 1, 2014, a referral is no longer required for Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options members to receive behavioral health services taking place within place of service 31 or 32. This change is documented in the Tufts Medicare Preferred HMO, Tufts Health Plan Senior Care Options Skilled Nursing Facility and Transitional Care Unit Facility Payment Policy at tuftshealthplan.com/ providers. 5

6 Care Model Training for Tufts Health Plan Senior Care Options Providers The Centers for Medicare & Medicaid Services requires Tufts Health Plan Senior Care Options (SCO) to provide its Special Needs Plan provider network with training on its model of care. This training is required at the time of contracting for newly contracted SCO providers and annually thereafter for current SCO providers. To facilitate this training, we have developed an online educational webcast specifically for PCPs that includes the following: } An overview of the plan } Care model information } Provider roles and resources The online training is available on our website and can be completed in approximately 30 minutes. To access the training, go to the Provider Office Staff Education section at. Under Webcasts, click on Product Overviews & Descriptions and then Tufts Health Plan SCO Care Model Training. Once you have completed the webcast, please complete the evaluation survey at the end of the training and attest that you have reviewed the information to document your participation. If you have any questions about the training or how to access the webcast, or should you wish to have an on-site training delivered by a Tufts Health Plan SCO clinical team member, please contact Provider Relations at PROVIDER UPDATE NEWS FOR THE NETWORK Tufts Health Plan 705 Mount Auburn Street Watertown, MA Presorted Standard U.S. Postage PAID Brockton, MA Permit No. 301? For More Information ADDRESS SERVICE REQUESTED } } Tufts Health Plan s Provider Services Department } Tufts Health Plan Medicare Preferred Provider Relations WHAT S INSIDE Coverage Updates for Commercial Products... 1 Change to Claims Submission Policy: Paper CMS-1500 Forms... 2 Proof of Timely Submission for EDI Claims... 2 Electronic Explanations of Payment... 2 Claim Edits Effective July Five-Day Response Time for Member Grievances... 4 Modifier 25 Changes for Commercial Claims... 4 Drugs and Biologicals Claim Edits Effective July Physician, Outpatient Hospital Fee Schedules to Be Updated July