networknews provider Blue Cross Welcomes New Chief Medical Officer - Page 10 Blue Cross Bidding for Louisiana Medicaid s Business

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1 2 Provider A publication Network to News keep our 1st Quarter network providers up to date on the latest news at Blue Cross July and 2008 Blue Shield Provider of Louisiana Network News 3 networknews 1st Quarter 2011 provider providing health guidance and affordable access to quality care Blue Cross Welcomes New Chief Medical Officer - Page 10 INSIDE THIS ISSUE Provider Network 2 Pieces of Blue for a Better You 2 Admitting Privilages for Key Physicians 3 Accreditation for DME 3 Network Urgent Care May Be Better Benefi t for Members 3 Contacting Electronic Services Billing & Coding 4 Wellness Visit with Sick Results 4 File Referring Physician on Claims 4 Policy for NPs, PAs or CRNFAs 5 Billing for TENS Units and Supplies 5 Place of Service no Longer Converted 5 Allowable Updates Are Coming Federal Employee Benefits Federal Employee Program (FEP) Benefi t Changes Electronic Services 6 EFT and ilinkblue Required for Network Providers 6 ICD-10-CM HIPAA and 5010 is Coming BlueCard Program 7 Ancillary Claims Filing BlueCard Program Survey 7 eprescribing Identifi cation on National Finder Website Medical Management 8 Medical Policy Update 9 Medical Policy Consistency Survey Results Are Up 9 HEDIS - It s That Time Again Company News 10 Blue Cross Welcomes Dr. Phenow 10 Customer Satisfaction High 11 Calling All Angels! 11 Updates Made to Provider Manuals 11 Save Time and Mailbox Space with s from Blue Cross Blue Cross Bidding for Louisiana Medicaid s Business It s exciting to have the opportunity to participate in the transformation of the Louisiana Medicaid program. Our state is transitioning its Medicaid program from a traditional fee-for-service model to a system of coordinated care networks that will be designed to create a more cost-effective delivery system and improve the overall health of Medicaid recipients. At Blue Cross and Blue Shield of Louisiana, we re proud to be part of this transformation. We ve been serving Louisiana families since 1934 long before the creation of Medicaid and hope to be part of its future. The Louisiana Department of Health & Hospitals is well underway with creating an improved delivery system for the Medicaid program, using the Coordinated Care Network (CCN) model. The CCN is an organized healthcare delivery system designed to improve access and quality of care, as well as promote healthier outcomes by establishing medical home systems of care. We see this as a unique opportunity to improve Louisiana s health rankings and build a model of care for others to emulate. We support this model of delivery because we are concerned about our fellow citizens. In fact, our mission is to improve the lives of Louisianians by providing health guidance and affordable access to quality care. That s why we believe it s important to participate in the process to reform the Medicaid program. Our 1,800+ employees live here and have strong ties to the communities we serve. We are Louisiana-owned and operated and have a presence in every corner of the state. We do business ONLY in Louisiana we are a not-for-profit, mutual company that contributes to the state s economy by paying millions in taxes, salaries, grants and local investments. That s the way we ve always done it and that s our plan for the future. Our company intends to submit a bid for the prepaid risk-bearing managed care organization model (CCN-P). In order to be successful in these efforts, the proposal for the CCN-P must demonstrate that a broad, cost-effective network of providers is willing to work with a health plan to serve Louisiana s Medicaid beneficiaries. We hope you will join Blue Cross in working to support the enhanced CCN and sign the non-binding Letter of Intent (LOI) that we sent to providers that will be part of the model. Signing the non-binding LOI means you are willing to work with us for the provision of Medicaidcovered services to Louisiana Medicaid recipients enrolled in a Blue Cross Coordinated Care Network. Of course, this will depend on whether Blue Cross is a successful bidder. Many of you have longstanding partnerships with us and we hope to continue these reliable relationships. Detailed information on the CCN program can be found on the DHH Making Medicaid Better website at Thank you for your time and consideration. We look forward to working with you on this exciting endeavor! 23NW6753 R3/11

2 2 Provider Network News 1st Quarter 2011 Provider Network 2011 Provider Workshops in your area! Please register online today to join us for a provider workshop! Each workshop lasts one full day and includes two separate training sessions that will cover important topics such as: EDI: Training on ICD-10 & HIPAA 5010 Pieces of Blue Training Electronic Claims Filing Healthcare Reform Preparing for ICD-10 Claims and BlueCard Preparing for HIPAA 5010 Navigating the NEW BCBSLA.com and more!!! and more!!! Office managers and insurance and business office personnel are encouraged to attend Provider Workshops Schedule March 15 - Shreveport March 16 - Monroe March 17 - Alexandria March 29 - Metairie March 30 - Metairie March 31 - Houma April 4 - Lafayette April 5 - Lafayette April 12 - Baton Rouge April 13 - Baton Rouge April 14 - Baton Rouge April 26 - Covington April 28 - Lake Charles Register Online Now click on RSVP for an Event in the top right corner and enter code 4LNZDJXPD3A. There is a $25 per person registration fee. Admitting Privileges for Key Physicians As you may already know, Blue Cross Traditional/Key product has not been marketed in more than two years; consequently, as of the end of 2010 we moved the majority of these members to a Preferred Provider Organization (PPO) or where applicable, an HMO Louisiana, Inc. based product. Our goal is to completely phase out the Traditional/Key Physician network by the end of In the past, physicians who participate in the Traditional/Key network have not been required to have hospital privileges at a Blue Cross network hospital. However, for 2011, our new policy requires hospital privileges for most physicians who participate in the Traditional/Key network. This standard is already required for participation in both our Preferred Care PPO and HMOLA networks. If you participate in the Key/Traditional network only, and currently have privileges, or when you do obtain privileges at a participating hospital, please fax this information to us at , Attn. Network Operations Department, so that we may update our records.

3 Network Urgent Care May Be Better Benefit for Members Nearly every full service acute care hospital in Louisiana is part of our provider networks. But, that does not necessarily mean that the emergency room doctors at some of these hospitals are also in-network. Consequently, our members could be treated for an emergency at an in-network hospital, but receive care from a doctor who is out-of-network, which leads to balance billing and higher costs for the member. Blue Cross and HMO Louisiana, Inc. (HMOLA) are dedicated to finding ways to control the rising cost of healthcare. One way we are doing this is by publishing a listing of all hospital based physicians for each network acute care hospital and indicating these physicians par/ non-par status or whether or not the physcians participate in our networks. These reports are available at www. bcbsla.com >Find a Doctor >Find a Hospital-based Physician. Provider Network How You Can Help... One way you can help is by referring patients to urgent care centers for non life-threatening cases, when you are not available to see the patient. Example: The primary care physician (PCP) cannot immediately see a patient for a non life-threatening issue and refers the patient to the nearest hospital where the emergency room doctors happen to be out-of-network. The patient is covered in-network for the facility, but out-of-network for the physicians and may be balance billed for any charges above our allowable charges. Accreditation for DME 1st Quarter 2011 Provider Network News 3 We are implementing a new accreditation requirement that affects all new and existing durable medical equipment (DME) providers who participate in our networks. This accreditation requirement has been enforced by Medicare since As of September 1, 2010, Blue Cross began requiring all new DME providers be accredited by the appropriate accrediting body as a condition of network participation. Effective April 1, 2011, all existing DME providers must be accredited by one of the following accrediting bodies to continue participation in our provider networks: Accreditation Commission for HealthCare, Inc. (ACHC) American Board for Certification in Orthotics & Prosthetics, Inc. Board of Certification/Accreditation International Commission on Accreditation of Rehabilitation Facilities (CARF) Community Health Accreditation Program (CHAP) HealthCare Quality Association on Accreditation (HQAA) National Association of Boards of Pharmacy (NABP) The Compliance Team, Inc. The Joint Commission The National Board of Accreditation for Orthotic Suppliers Blue Cross will review each provider s accreditation status during the provider s regularly scheduled recredentialing cycle. Providers are recredentialed by Blue Cross every three years in accordance with URAC standards. Providers must maintain the required accreditation and abide by Blue Cross credentialing guidelines to remain in all Blue Cross and HMO of Louisiana networks. Contacting Electronic Services Electronic services allow both Blue Cross and our providers to keep costs down by improving processes and reducing administrative expenses. Clip out the contact information below for future reference. ilinkblue Provider Suite BLUE (2583) ) ilinkblue.providerinfo@bcbsla.com Urgent care centers offer an option for care in non-emergency or non life-threatening situations when an office visit is not available. To find in-network urgent care centers in your area, visit our comprehensive online provider directories at >Find a Doctor. Electronic Funds Transfer Network Administration , option 3 or network.administration@bcbsla.com EDI Clearinghouse Services EDI Clearinghouse Support Desk edich@bcbsla.com

4 APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA P 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED S I.D. NUMBER (For Program in It CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) (Medicaid #) (Sponsor s SSN) (Member ID#) (SSN or ID) (SSN) (ID) 2. PATIENT S NAME (Last Name, First Name, Middle Initial) 3. PATIENT S BIRTH DATE SEX 4. INSURED S NAME (Last Name, First Name, Middle Initial) MM DD YY M F 5. PATIENT S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED S ADDRESS (No., Street) Self Spouse Child Other CITY STATE 8. PATIENT STATUS CITY STA Single Married Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Cod Full-Time Part-Time Employed Student Student 9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT S CONDITION RELATED TO: 11. INSURED S POLICY GROUP OR FECA NUMBER a. OTHER INSURED S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) YES NO a. INSURED S DATE OF BIRTH MM DD YY SEX M F b. OTHER INSURED S DATE OF BIRTH SEX b. AUTO ACCIDENT? b. EMPLOYER S NAME OR SCHOOL NAME MM DD YY PLACE (State) M F YES NO c. EMPLOYER S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES NO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO If yes, return to and complete item READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I autho 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or sup to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPAT MM DD YY INJURY (Accident) OR GIVE FIRST DATE MM DD YY MM DD YY MM DD PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICE MM DD YY MM DD 17b. FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO PRIOR AUTHORIZATION NUMBER A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT OR Family ID. RENDER MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER REC. # 6 STATEMENT COVERS PERIOD 5 FED. TAX NO. FROM THROUGH 8 PATIENT NAME a 9 PATIENT ADDRESS a b b c d 10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 29 ACDT STAT STATE 31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a b c d 42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES REL. 53 ASG. 50 PAYER NAME 51 HEALTH PLAN ID 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 INFO BEN. A 57 B OTHER C PRV ID 58 INSURED S NAME 59 P. REL 60 INSURED S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. A B C 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A B C 68 DX 69 ADMIT 70 PATIENT 71 PPS DX REASON DX CODE ECI 74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 CODE DATE CODE DATE CODE DATE 76 ATTENDING QUAL LASTT FIRST c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE CODE DATE CODE DATE 77 CODE DATE OPERATING QUAL LAST FIRST 81CC 80 REMARKS a 78 OTHER QUAL b LAST FIRST c 79 OTHER QUAL d LAST FIRST UB-04 CMS-1450 APPROVED OMB NO. THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HE 7 e Nation NUBC Billing C LIC92 42 Provider Network News 1st Quarter 2011 Wellness Visit with Sick Results It s not uncommon for a member to go to their doctor for a wellness visit and an abnormality or pre-existing problem is found during the preventive exam. The member expects that the visit should be covered under his/her wellness benefits, but instead is filed and covered as a sick visit. Providers may bill a preventive evaluation and management (E & M) service ( ) on the same day as a problem-oriented E & M service ( ). The abnormality or pre-existing problem found during the preventive exam must be significant enough to require additional work to perform the key components of the problem-oriented E & M service. Medical records must have separate and distinct notes to justify both services and modifier 25 must be appended to the problem-oriented E & M code. Also, please file all appropriate diagnosis codes as they apply for all services performed during the well/ sick visit. The member s preventive benefits will be applied to the wellness services and his/her regular benefits will apply toward the sick visit. CPT guidelines state, An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine E & M service and which does not require additional work and the performance of the key components of a problem-oriented E & M service should not be reported. Billing and Coding File Referring Physician on Claims When performing services for a patient who was referred to you by another physician, please include the referring physician information. This is required for paper and electronic claims. Report this information as follows: CMS-1500 Block 17 - Referring Physician 17 = Name 17a = Enter non- number of the referring physician 17b = Enter the for the referring physician HEALTH INSURANCE CLAIM FORM UB04 Block 78 - Referring Physician = Enter the for the referring physician Last = Enter last name of the referring physician First = Enter last name of the referring physician In addition, if a preventive E & M service is being rendered to a new patient and a problem-oriented E & M service is also being performed, the problemoriented E & M must be billed with an established E & M service code ( ). PAGE OF CREATION DATE TOTALS G A B C D E F H I J K L M N O P Q a b c 78 OTHER QUAL LAST FIRST CPT is a registered trademark of the American Medical Association Policy For NPs, PAs or CRNFAs At this time, Blue Cross does not have a network for nurse practitioners (NPs), physician assistants (PAs) or certified registered nurse first assistants (CRNFAs). These provider types should file claims under the supervising physician s national provider identifier () number and the appropriate modifier. NPs, PAs and CRNFAs who do not render services under a supervising physician are able to obtain a non-network provider number solely for the purpose of submitting claims for direct payment. Having this provider number does not mean they will be listed in our provider directories, because there isn t a network available. Claims filed for NPs, PAs or CRNFAs should include the following modifiers for their services: AS NPs, PAs or CRNFAs assisting at surgery (reimbursement is at 85 percent of the assistant surgeon allowable charge.) SA NPs should use this modifier when billing for services other than assistant surgery (reimbursement will be at 85 percent of the physician s allowable charge.)

5 Billing and Coding 1st Quarter 2011 Provider Network News 5 Billing for TENS Units and Supplies Below are the Blue Cross Billing/Reimbursement guidelines for TENS Units and Supplies. Please refer to this chart when filing claims for those services. Please Note: Payment for the codes listed in this table is not guaranteed. Coverage is subject to each member/subscriber s written contract. Billing/Reimbursement Guidelines for TENS Unit and Supplies TENS Unit Codes Code Description Frequency Billing/Reimbursement Guidelines E0720 TENS 2 lead unit Rental - one per month Purchased - determined by member s benefit Supplies for the unit are included in the rental allowance. When purchased, supplies are included in the allowance for the first month of purchase. E0730 TENS 4 lead unit Rental - one per month Purchased - determined by member s benefit Supplies for the unit are included in the rental allowance. When purchased, supplies are included in the allowance for the first month of purchase. E0731 TENS Garment n/a Only covered with supporting documentation of medical necessity. A4557 Lead wires 1 - annually Replacement of lead wires will be covered when they are inoperative due to damage and the TENS unit is still medically necessary. A4595 Electrical stimulator supplies, 2 lead, per month 1 or 2 units - monthly Purchased units only - 1 unit per month for 2 lead 2 units per month for 4 lead Please note, other supplies including but not limited to the following, will NOT be separately allowed: A replacement electrodes A alcohol wipes Battery charger used with a TENS unit A replacement batteries A conductive paste or gel Place of Service no Longer Converted Blue Cross will no longer convert claims filed with the wrong place of service (POS). Example: letter O, or numbers 3, 15, 26 or 54 have previously been accepted and converted to a POS 11 during processing. Effective immediately, if a claim is filed with the wrong POS, it will be returned to the provider for the correct POS. Allowable Updates Are Coming... Each year Blue Cross makes changes to the allowable charges for drug, durable medial equipment (DME) and HCPCS codes. We give providers a 90-day advance notice before these changes are effective. Be on the lookout for s regarding allowable charge updates for the following services: DME - Notification is sent on April 1 of each year with an effective date of July 1. HCPCS - Notification is sent on April 1 of each year with an effective date of July 1. Drug Allowable Charges - Updates are made to drug allowable charges twice per year with effective dates of March 1 and September 1. The next scheduled notification will go out on June 1, Providers with access to ilinkblue already have instant access to current codes and their allowable charges. And, when we make updates to allowable charges or add codes to our claims processing system, these updates will also be made available on ilinkblue.

6 6 Provider Network News 1st Quarter 2011 Federal Employee Program (FEP) 2011 Federal Employee Program (FEP) Benefit Changes Listed below are some of the 2011 changes for FEP contract holders. Note: This list is not all inclusive. If you have specific questions on any of these benefits, please call FEP Customer Service at Smoking Cessation Program - Smoking cessation treatment, classes and individual counseling services are available with no co-pay or deductible when provided by a covered Preferred provider. Residential Treatment Centers (RTC) - Services covered are limited to professional providers. Professional services are not covered if billed by the RTC. Preventive Care - Preventive care benefits are covered in full for adults and children when provided by a Preferred provider. Maternity Related Depression - Benefits for up to four mental health visits per year are provided in full (no copay if performed by a Preferred Provider) for treatment of maternity-related depression during pregnancy or postpartum or both. Mental Health and Substance Abuse Treatment - Members are no longer required to obtain prior approval before receiving outpatient professional or outpatient facility care for mental health and substance abuse treatment. Hearing Aids - Benefits are paid in full for hearing aids up to $1000 per ear per calendar year for children, and $1000 per ear per 36 months for adults age 22 and older when provided by any qualified hearing aid provider. Speech-Generating Devices - Benefits are paid in full up to $1000 per calendar year for speech-generating devices obtained from any qualified provider. Osteopathic and Chiropractic Manipulative Treatment - Benefits for osteopathic and chiropractic manipulative treatment, including extra spinal manipulations performed by chiropractors are limited to a combined total of 12 manipulation visits per year under Standard Option and 20 manipulation visits per year under Basic Option. Surgery for Morbid Obesity - Members must now meet specific pre-surgical criteria before receiving surgery for morbid obesity. Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to pre-surgical requirements. Intensity-Modulated Radiation Therapy (IMRT) - Members are no longer required to obtain prior approval for outpatient intensity-modulated radiation therapy (IMRT) related to the treatment of head, neck, breast or prostate cancer. EFT and ilinkblue Required for Network Providers We strive to keep pace with technology that improves processes and reduces administrative expenses. Both the ilinkblue Provider Suite and electronic funds transfer (EFT) are helping us in this effort. That is why these tools are mandatory for network providers. If you do not have ilinkblue and EFT: You do not have access to your payment registers as Blue Cross does not send out hardcopy payment registers. Claims payments are not automated and may take longer to receive. To sign up for ilinkblue and EFT, go to com > I m a Provider > Electronic Services. If you have questions regarding ilinkblue or EFT, please ilinkblue.providerinfo@bcbsla.com or contact the LINKLine at BLUE (2583). Electronic Services HIPAA 5010 & ICD-10 is Coming! The compliance dates for HIPAA 5010 and ICD-10 are getting closer. Mark your calendars with these important dates: January 1, 2012 All healthcare organizations must be compliant with: The American National Standards Institute Transaction Version 5010 (ANSI v5010). The National Council for Prescription Drug Programs standard, Version D.0, for electronic transactions such as healthcare claims. HIPAA replacing 4010A1 for electronic transactions. October 1, 2013 CMS will implement the replacement of ICD-9 codes and procedure code sets with ICD-10-PCS (procedures). Claims with a date of service on or after October 1, 2013, will no longer be accepted with an ICD-9 or procedure code set. Claims with a date of service prior to October 1, 2013, may still be filed with ICD-9 and procedure code sets.

7 10 Provider Network News 4th Quarter 2010 BlueCard Program / Out-of-State 1st Quarter 2011 Provider Network News 7 Ancillary Claims Filing Ancillary claims for Independent Clinical Laboratory, Durable/Home Medical Equipment and Supply, and Specialty Pharmacy are filed to the Local Plan in whose service area the ancillary services were rendered if these services were performed in Louisiana, the Local Plan is Blue Cross and Blue Shield of Louisiana. Lab DME Specialty Pharmacy Local Plan The Plan in whose Service Area the specimen was drawn. The Plan in whose Service Area the equipment was shipped to or purchased at a retail store. The Plan in whose Service Area the ordering physician is located. Note: Claims are determined to be in- or out-of-network based on the rendering provider s local plan s provider contracting arrangement BlueCard Program Survey Your feedback is important to help us make improvements in our processes and makes your interactions with Blue Cross and Blue Shield of Louisiana a smooth and simple experience. The Blue Cross and Blue Shield Association (BCBSA) is conducting a survey again this year, and you will have an opportunity to tell us how we are doing via phone and/or online satisfaction survey. At any point throughout the year, you may receive a call on our behalf seeking input on your experience with services for BlueCard members. BCBSA s research vendor, Synovate, may invite you to participate in online surveys and collect your address. If your office is contacted, we encourage you to participate in these surveys. We take your feedback seriously and incorporate it into enhancements of our services to you. If you need information about the BlueCard Program or have suggestions for improvements, there are two ways to contact us: Talk to your provider relations representative. To locate the representative for your area, go to > I m a Provider > Provider Tools > Provider Representative Map. Contact provider services at Thank you in advance for your participation. We appreciate your feedback. eprescribing Identification on National Provider Finder Websites eprescribing allows doctors to send computer-generated prescriptions directly to the pharmacy. Electronic prescriptions are sent through a network that is intended to be private, secure and closed to protect the privacy of individuals health information. What does this mean for your patients? Safety eprescriptions are designed to eliminate handwriting issues and reduce the possibility of adverse drug interactions. Convenience Member prescriptions should arrive at the pharmacy without the need to drop it off. Cost Effectiveness eprescriptions may give doctors a better opportunity to check for the most economical choice for their patients based on their insurance coverage. Medicare Advantage Quick Guides Our provider quick guides for Medicare Advantage PPO and PFFS are available on our website at > I m a Provider > Education on Demand > Speed Guides.

8 28 Provider Network News 1st Quarter 2011 Medical Management Medical Policy Update Blue Cross regularly develops and revises medical policies in response to rapidly changing medical technology. Our commitment is to update the provider community as medical policies are adopted and/or revised. Benefit determinations are made based on the medical policy in effect at the time of the provision of services. Please view the following updated medical policies, all of which can be found on ilinkblue at Medical Policy Coverage Legend These symbols are referenced next to medical policies listed on this page and indicate Blue Cross coverage indications as follows: I C Investigational Eligible for coverage with medical criteria New Medical Policies Policy No. Policy Name Effective Date I Novel Lipid Risk Factors Dec. 15, 2010 in Risk Assessment and Management of Cardiovascular Disease C Fingolimod (Gilenya ) Dec. 15, C Proteomics-Based Testing for Dec. 15, 2010 the Evaluation of Ovarian (Adnexal) Massess I Endobronchial Valves Dec. 15, C Denosumab (Xgeva ) Jan. 19, C C1 Esterase Inhibitor Feb. 16, 2011 (Berinert ) C C1 Esterase Inhibitor Feb. 16, 2011 (Cinryze TM ) I KIF6 Genotyping for Predicting Feb. 16, 2011 Cardiovascular Risk and/or Effectiveness of Statin Therapy I Systems Pathology for Feb. 16, 2011 Predicting Risk of Recurrence in Prostate Cancer - Prostate Px Text Recently Updated Medical Policies December C Respository Corticotropin Injection (ACTH Gel, H.P. Acthar Gel ) January C Radiofrequency Ablation of Primary or Metastatic Liver Tumors Medical Policy Highlights Policy & Berinert and Cinryze These drugs are indicated for Hereditary Angioedema (HAE), a potentially life-threatening genetic disorder. It is estimated that HAE affects 6,000 to 30,000 individuals in the U.S. HAE is a serious problem with the immune system caused by either low levels or improper function of a protein called C1 inhibitor. It causes swelling, particularly of the face, airways and the gastrointestinal track, but can occur in any area of the body. Most severe attacks cause asphyxiation or bowl obstruction. Berinert is indicated for acute attacks and Cinryze, for routine prophylaxis. Both drugs are FDA approved. Policy # Gilenya (Fingolimod) This recently FDA approved drug is indicated for relapsingremitting type of Multiple Sclerosis (MS). It appears to have a unique mechanism of action as it blocks the blood cells in the lymph nodes from migrating to the brain and spinal cord to cause damage. It is the first oral drug that appears to slow the progression of disability and reduce the frequency and severity of symptoms. Gilenya is one of many drugs available for treatment of MS. Provider inquiries for reconsideration of medical policy coverage, eligibility guidelines or investigational status determinations Provider inquiries for reconsideration rati of medical policy coverage, eligibility guidelines or investigational al status tus will be reviewed upon written request. Requests for reconsideration must be accompanied by peer-reviewed, scientific determinations ions will l be reviewed upon written request. Requests for reconsideration ration must be accompanied by peerreviewed, ewed, scientific evidence-based e-ba literature ture that substantiates why a technology referenced in an established medical Supporting data will be reviewed in accordance with medical policy assessment criteria. If you have questions about our evidence-based literature that substantiates why a technology referenced in an established medical policy should be reviewed. policy should be reviewed. Supporting port data will be reviewed in accordance with medical policy assessment criteria. If you medical policies or if you would like to receive a copy of a specific policy, log on to ilinkblue at or have questions about our medical policies ies or if you would like to receive a copy of a specific policy, log on to ilinkblue at call Provider Services at w.bcbsla.com/i link bl or call Provider Services es at

9 2 Provider Network News 1st Quarter Medical Management 1st Quarter 2011 Provider Network News 9 Medical Policy Consistency Survey Results Are Up In 2009, Blue Cross and Blue Shield of Louisiana (BCBSLA) was part of a pro-competitive and proconsumer initiative that the Blue Cross and Blue Shield Association (BCBSA) adopted. The goal was to measure medical policy consistency among the family of Blue Plans. This initiative is viewed as an important aspect of the BCBSA System in terms of improving customer (i.e. physician, member and national account) satisfaction. For 2009, BCBSLA achieved a consistency of 87 percent exceeding our goal of 85 percent. We are proud to announce that based on review of medical policies for 2010, we increased our consistency to a favorable 97 percent. When compared with other Blue plans, BCBSLA ranks in the top percentile for consistancy of our medical policies. Still, the results of the 2010 survey showed significant improvement compared to the 2009 survey, for both the overall results for all Blue Plans as well as BCBSLA s results. Dr. Thomas Kim, director of medical policy for BCBSLA, has a focus for 2011 to not only maintain but to increase the consistency of our medical policies. We continue to update medical policies based on the evidence-based practice of evaluating new technologies and medications, says Kim. It is important to not only achieve, but also to maintain and continue to improve the standard of consistency for our medical policies. HEDIS - It s That Time Again! As many of you may already be aware, the current HEDIS review season is upon us. For those unfamiliar with the term, HEDIS is a set of standardized performance measures that include health issues, such as cancer, and customer experience areas, such as claims processing. Blue Cross reviews HEDIS measures annually, identifying opportunities for improvement as well as noting those areas in which Blue Cross is at or above the South Central Benchmark. To obtain the best values for HEDIS measures, a combination of claims and chart review data is needed. Last year we relied solely upon our administrative (claims) data for HEDIS. At this time Blue Cross is resuming data collection in the form of chart reviews. This means that your office may be contacted by representatives from Blue Cross or a contracted vendor acting on our behalf for record reviews. There are several factors involved in this process and while it is designed to be minimally disruptive to your offices, we appreciate your cooperation in the timely scheduling and disclosure of the chart reviews. Need Health Insurance? Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. offer a wide variety of plans for individuals, families, seniors and employer groups. You are sure to find a Blue Cross or HMOLA plan that fits your life and your budget as we offer PPOs, HMOs, consumer-directed health plans with health savings accounts and more. To find out more, visit

10 10 Provider Network News 1st Quarter 2011 Company News Blue Cross Welcomes Dr. Phenow Blue Cross and Blue Shield of Louisiana has named Dr. Ken Phenow, MD, MPH as its chief medical officer and senior vice president of clinical affairs. In this role, Phenow will provide clinical leadership and oversee the company s medical staff. He will also lead quality-based clinical improvement and wellness programs and administer medical policy development. Phenow joins Blue Cross after serving as the senior market medical executive for CIGNA Healthcare in North Texas and Oklahoma. Before he joined CIGNA, he worked with United Healthcare in various medical leadership roles, including serving as market medical executive for Southwest Ohio, Indiana and Kentucky. He began his managed care career with Scott & White Clinic as an associate medical director in the College Station, Texas market. Phenow is board certified in family medicine. He received his medical degree from the Medical College of Wisconsin through the Navy Health Professions Scholarship Program. He completed residency training at the Naval Medical Center, San Diego and the Naval Hospital Camp Pendleton. Phenow also served tours of duty as a Navy physician in San Diego and Japan. Phenow earned a master s degree in health services administration and policy analysis from the University at California at Los Angeles School of Public Health. He also attended the University of California at San Diego, where he achieved bachelor s degrees in biochemistry and political science. Blue Cross President and CEO Mike Reitz said that Phenow was chosen specifically for his experience and knowledge in improving healthcare quality and affordability. Dr. Phenow s appointment signifies Blue Cross continuing commitment to cutting-edge quality improvement programs, Reitz said. Phenow is already at work on several key initiatives. We have two immediate priorities, he said. First, we need to empower Louisianians to be more accountable by participating fully in their healthcare and thereby improving their health status. Second, we need to change the pay model for healthcare to one where physicians are reimbursed for the quality of care and outcomes they achieve, rather than how many services they provide. Phenow also said he believes it s time to spread the word about wellness. It s true that about 70 percent of chronic disease can be prevented by lifestyle changes. Our challenge is to speak to the hearts of 100 percent of people and get them involved in the easy process of healthy living. Customer Satisfaction High In a recent member satisfaction survey, those responding expressed a high level of satisfaction with Blue Cross and Blue Shield of Louisiana and with their healthcare. Our independent researchers asked the following two questions to determine levels of satisfaction: 1)How would you rate the health plan in the last 12 months? 2)How would you rate all of your healthcare in the last 12 months? Of those surveyed, 90 percent are satisfied with their health plan and their healthcare. More than 60 percent of members are highly satisfied with their health plan, and more than 80 percent of members are highly satisfied with their healthcare. We appreciate our members confidence in Blue Cross and promise that we will continue to work hard to earn it. We also plan to maintain our good relationship with Louisiana s healthcare providers, so we can work together to earn our mutual customers trust.

11 Calling All Angels! Company News Once again, the Blue Cross and Blue Shield of Louisiana Foundation will present its Angel Award to eight Louisianians who do extraordinary volunteer work that improves the lives of our state s at-risk children. Because making a difference in Louisiana s communities requires time and money, the Angel Award includes a $20,000 grant from the Blue Cross Foundation for each honoree s charity. If you know someone who has been an angel in the lives of children, nominate him or her by May 13 at Click on About Blue >Company >Angel Award. You can also Angel.Award@ bcbsla.com for a nomination packet. 1st Quarter 2011 Provider Network News 11 Connect with us on facebook. Follow Blue Cross & CEO Mike Reitz on Twitter. Watch us on YouTube. Updates Made to Provider Manuals The Professional Provider Office Manual has been updated as follows: Added non-network provider section to Federal Employee Program Member Provider Policy and Procedure Manual has been updated as follows: Added non-network provider section to Reimbursement Save Time and Mailbox Space with s from Blue Cross! Some communications from Blue Cross are sent via only. If we don t have your address, you are not receiving these mailings. Also, providers who have an address on file with us get the latest information first. Even better, with , you can easily share our communications with others in your office. Don t wait to receive newsletters, correspondence and other important provider updates; send us your address today! There are two ways you can let us know your address: * Submit an online interactive Provider Update Form. The form is easy to complete and located at > I m a Provider > Forms for Providers. * Send an to us at Network.Admininstration@bcbsla.com and let us know you want to be added to our list.

12 What s New on the Web New updates under I m a Provider > Education on Demand Professional Provider Office Manual Medicare Advantage PPO speed guide Office of Group Benefits (OGB) Speed Guide New update under I m a Provider > Provider Tools Provider Representatives Map DME/HCPCS Allowable Charge Updates Go to Allowable Charges and enter a code in the CPT Code field. (Please disregard the disclaimer regarding availability of allowable charges to Pain Management, Anesthesiology, Behavioral Health and Durable Medical Equipment). Have an Idea? NetworkNews is your newsletter, designed to serve you, our valued network providers. The views of our readership are important to us. If you have ideas for articles or suggestions about how we can improve this newsletter, please us at provider.communications@bcbsla.com. Network News Network News is a quarterly newsletter for Blue Cross and Blue Shield of Louisiana network providers. We encourage you to share this newsletter with your staff. The content in this newsletter is for informational purposes only. Diagnosis, treatment recommendations and the provision of medical care services for Blue Cross members are the responsibilities of healthcare professionals and facility providers. If you would like to receive this newsletter by , please contact us at provider.communications@bcbsla.com. View this newsletter online at > I m a Provider > News Important Contact Information Authorization See member s ID card BlueCard Eligibility BLUE(2583) Claims Filing P.O. Box Baton Rouge, LA EDI Clearinghouse EDICH@bcbsla.com FEP Fraud & Abuse fraud@bcbsla.com ilinkblue & EFT BLUE(2583) ilinkblue.providerinfo@bcbsla.com Network Administration Fax: network.administration@bcbsla.com Provider Services Call Center Please share this newsletter with your insurance and billing staff! PRST STD US POSTAGE PAID networknews P. O. BOX BATON ROUGE, LA BATON ROUGE, LA PERMIT NO. 458 Your Health. Our Commitment.