INSIDE THIS ISSUE. ICD-10 Update on ICD-10 timeframe. MANUAL UPDATES A new Hospital Manual is now available BLUECARD

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1 Keep your information up to date Have you made any changes to your key practice information, such as your mailing address or the name of your practice? If so, please be sure to notify us. We value your help in keeping our data files current. Accurate data files allow us to continue to provide you with important information on billing, claims, changes or additions to policies, and announcements of administrative processes. You may submit this information to us electronically via the Provider Change Form, which is available on /forms, or through NaviNet. You may also call your Network Coordinator or Customer Service to report changes. Please note: Thirty days advance notice is required for processing. For articles specific to your area of interest, look for the appropriate icon: Professional Facility Ancillary Working Together For Quality Health Care INSIDE THIS ISSUE ICD-10 Update on ICD-10 timeframe MANUAL UPDATES A new Hospital Manual is now available BILLING Laboratory services reminder Laboratory services clarification for Level I, II, and III outpatient laboratory testing services Reminder: claims submitted without a valid, registered NPI will reject PRODUCTS Medicare Advantage Private Fee-for-Service: plan payment BLUECARD MEDICAL Winter 2008 edition of Inside IPP now available Policy notifications posted as of December 16, 2008 Medicare members must receive notice of noncovered/excluded services and member payment responsibility Timely submission of maternity patient questionnaires important for early outreach Reminder: referrals not needed for services provided through Direct Access OB/GYN SM Reminder: changes to precertification requirements for most outpatient mental health services Reminder: new look for member ID cards PHCQA s initiative to relay hospital measures to patients Reminder: transition to all-electronic authorization inquiry and submission continues SPECIALTY PHARMACY Important changes about self-injectable drug coverage coming January 1, 2010 Valid NDC required on claims submitted for drugs (e.g., J codes and other drug codes) PREVENTIVE HEALTH SMART Registry release for SM Connections Health Management Programs: supporting our members, your patients

2 icd-10 Update on ICD-10 timeframe The U.S. Department of Health and Human Services (HHS) recently announced a new regulatory requirement for health plans and providers to transition from the currently used ICD-9 to the new ICD-10. We want to bring you up to date on recent activities surrounding this requirement. Under the current proposal, health plans and providers will be required to fully implement ICD-10 by October 1, 2011; however, due to the extensive changes providers will need to make to their business practices to accommodate this requirement, several efforts have been made to demonstrate the need for an extension of the implementation date. We, along with the American Medical Association (AMA) and nearly all state medical societies, have urged HHS to give the industry more time to transition to ICD-10 in its final regulation. Specifically, we support the timeframe as recommended by the National Committee on Vital and Health Statistics (NCVHS), a key advisory body to HHS, that allows: two years to complete the second generation of nine HIPAA transactions ( 5010 ) a prerequisite to ICD-10 before beginning work on ICD-10 (not simultaneously); and an additional three years to complete ICD-10. If the NCVHS process were followed and started now, the soonest ICD-10 could be completed is late A coalition of provider organizations in Washington has worked closely with HHS officials requesting the need for a workable timeframe for this transition. In addition, the AMA, along with a majority of state medical societies has urged the HHS to give the industry more time to complete this transition. We support this recommendation. Please visit our site /icd_10 frequently for updated information on ICD-10. manual updates A new Hospital Manual is now available An updated Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual) is now available through NaviNet. The new Hospital Manual has been enhanced, expanded, and updated to include valuable resources and vital information regarding our policies, procedures, and programs not only for hospitals, but for ancillary facilities and ancillary providers as well. This comprehensive new Hospital Manual is a complete replacement of the prior Hospital Manual, 2005 edition, as revised. It also replaces any ancillary provider-specific provider manual, such as the Ambulatory Surgical Center, Renal Dialysis Center, Skilled Nursing Facility, Home Health Agency, Durable Medical Equipment, and Home Infusion Provider Manuals. The Provider Manual for Participating Professional Providers remains unchanged and is also available through NaviNet. You will be able to access the Hospital Manual through easy-to-navigate PDFs that are organized into color-coded sections. Within those sections are links that will take you to important information, such as our Companion Guides, with a simple click of your mouse. Manual name change for hospitals, ancillary facilities, and ancillary providers The reference to Hospital Manual or Provider Manual as defined in current IBC Member Hospital Agreements, Managed Care Hospital Agreements, IBC and Affiliate Ancillary Facility Provider Agreements or other Independence Ancillary Facility or Ancillary Provider Agreements, shall apply to this comprehensive Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers. References to Hospital Manual or Provider Manual in IBC Member Hospital Agreements, Managed Care Hospital Agreements, IBC and Affiliate Ancillary Facility Provider Agreements or other Independence Ancillary Facility or Ancillary Provider Agreements remain unchanged. If you do not have access to NaviNet, you may request a print version of either the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers or the Provider Manual for Participating Professional Providers by calling the Provider Supply Line at

3 Billing Laboratory services reminder We encourage professional providers to set up accounts with designated laboratory sites to accommodate testing needs, improve record-keeping, promote communication between the laboratory and the physician, and facilitate timely receipt of laboratory supplies. Keep in mind that any referral to a nonparticipating laboratory or nonparticipating provider requires preapproval/precertification from Independence Blue Cross. For more information for professional providers designating a laboratory site, please look in the Provider Manual for Participating Professional Providers under Laboratory Services in the Specialty Programs and Laboratory Services section. You can find the laboratory indicator on the front of the member ID card, on NaviNet, and/or the Interactive Voice Response (IVR) system. Please refer to the following list of participating contracted laboratories for outpatient services: Laboratory name Laboratory indicator Phone number Abington Memorial Hospital Laboratory Abington Health Network Laboratories HNL Hospital of the University of Pennsylvania Laboratory* UPHS Laboratory Corporation of America Lab Corp Mercy Health Laboratory Mercy Quest Diagnostics, Inc. Quest SMA Medical Laboratories SMA Thomas Jefferson University Laboratory* Jefferson *Available to specific practices only Specialized pathology testing is offered by the designated laboratories as well as by the following specialized participating laboratory providers: Laboratory name Specialty Phone number AmeriPath New York, Inc. Dermatopathology only CBLPath Dermatopathology/pathology DIANON Systems, Inc. Dermatopathology/pathology Genomic Health Oncotype DX only Genzyme Genetics Reproductive/Genetic/Oncology testing only (Reproductive and genetic testing) (Oncology testing) Institute for Dermatopathology Dermatopathology only Litholink Kidney stone prevention Monogram Biosciences Trofile Co-Receptor tropism assay only Myriad Genetics BRACAnalysis, Colaris and Colaris AP only Penn Cutaneous Pathology Dermatopathology only continued on page 4

4 billing Laboratory services reminder (continued) Home phlebotomy may be available when members are homebound. Services may be arranged by contacting one of the contracted home phlebotomy provider listed at right. Some designated laboratories also offer home phlebotomy for patients who reside in assisted-living or non-skilled nursing homes. This service is covered only as defined by Medicare Guidelines. Medicare Guidelines are applied for all members regardless of coverage. We have contracted with Brookside Clinical Labs and Professional Technicians to perform home phlebotomy services for all members. These providers will perform the home draw only and deliver the sample to a participating designated laboratory (HMO) or participating laboratory/hospital (PPO). In addition, DeJohn Medical Lab is contracted as a home-draw provider for Keystone 65 Complete members. Laboratory name Phone number Brookside Clinical Labs Professional Technicians DeJohn Medical Lab HMO/POS: All routine laboratory services for HMO/ POS members must be directed to and processed by the PCP s designated laboratory site. This is not a statement of benefits. Benefits may vary based on state requirements, Benefit Program (HMO, PPO, etc.), contract, or employer group. Individual member coverage must be verified with IBC. Please contact Customer Service for more information on specific benefit coverage. Laboratory services clarification for Level I, II, and III outpatient laboratory testing services 4 We would like to take this opportunity to reiterate our policy regarding Level I, II, and III outpatient laboratory services provided in the physician office. The Specialty Programs and Laboratory Services section of the October 2007 Provider Manual for Participating Professional Providers states: Covered Level I and Level II outpatient laboratory tests may be performed in the physician s office. If a laboratory test is not listed as Level I or Level II, it is considered a Level III test. Level III outpatient laboratory tests must be referred to a commercial laboratory or one of the network hospitals that has contracted with the Personal Choice network to perform outpatient laboratory services. If using a commercial laboratory, a requisition form from the lab must be completed. Home phlebotomy may be available when patients are homebound. Services may be arranged by contacting a contracted home phlebotomy provider. Some designated labs also offer home phlebotomy for patients living in assisted living or non-skilled nursing homes. This service is covered only as defined by Medicare Guidelines. Medicare Guidelines are used for all Members regardless of coverage. We also want to remind you that if you are a participating physician provider, you may bill us only for covered services that you or your staff perform. Participating physician provider offices are not permitted to submit claims for services that they have ordered but that have not been rendered (also known as pass-through billing). Pass-through billing of laboratory services performed by a contracted or noncontracted laboratory is not reimbursable. For a list of participating clinical laboratories in our network, please refer to the article on page 3, or the Specialty Programs and Laboratory Services section of the Provider Manual. Please call Customer Service or contact your Network Coordinator with any questions. For more information regarding Level I, II, and III outpatient laboratory testing services, please see the Pennsylvania Limited Survey Survival Guide at 167&q= or Understanding clinical laboratory regulations in Pennsylvania, as they apply to physician office laboratories at labs/understanding_clinical_laboratory_regulations_107. ps.pdf.

5 billing Reminder: claims submitted without a valid, registered NPI will reject NPIs must be registered with IBC As previously communicated, claims submitted to us without a registered NPI began rejecting as of May 23, 2008, per the Centers for Medicare & Medicaid Services mandate. NPIs can be registered online by submitting an NPI provider registration web form at /npi/provider_registration.html. Claims submitted with invalid NPIs will reject Each claim must pass an NPI check-digit validation to ensure that it has a valid NPI. To date, some claims are still not passing this check-digit validation. The most common reasons why claims are not passing the NPI check-digit validation are: The wrong provider identifier is entered in an NPI field. The NPI is entered incorrectly. The number entered is not a valid NPI. Processing of claims For purposes of processing a claim in accordance with the reimbursement terms of your provider contract, you may continue to provide your 10-digit legacy number in addition to your valid, registered NPI. The sole purpose for providing the 10-digit legacy number is to facilitate accurate claims payment not to identify the claim for acceptance into our system. Only a valid NPI will be accepted by us as the primary identifier on the claim. If you need more information about NPI claims submission, please refer to our National Provider Identifier (NPI) Toolkit: Tips for Proper Electronic and Paper Claims Submission, located at toolkit.pdf. Learn more about NPIs. Our previous communications, FAQs, and additional resources, are available at /npi. Please note: We will receive contracted behavioral health providers NPI information directly from Magellan Behavioral Health, Inc., an independent company. For more information, please contact Magellan National Provider Services Center at , or visit Magellan at 5

6 products Medicare Advantage Private Fee-for-Service: plan payment On January 1, 2008, we launched Select Advantage, a new Medicare Advantage Private Fee-for-Service (PFFS) plan. This Medicare Advantage PFFS plan is a non-network, nonmanaged care product that does not include utilization management or require referrals. However, all services must meet Original Medicare Guidelines for coverage and are subject to retrospective review audit. Providers have the right to decide whether to treat Select Advantage PFFS members on a patient-by-patient and visit-by-visit basis. A decision to treat a specific member does not require the provider to treat other Select Advantage PFFS members. Select Advantage reimburses deemed providers who treat Select Advantage members at the amount they would have received as participating or nonparticipating physicians, as applicable under Original Medicare for Medicarecovered services, minus any member required cost-sharing, for all medically necessary services covered by Medicare. We will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, then we will pay interest on the claim according to Medicare Guidelines. Payment to providers for which Medicare does not have a publicly published rate will be based on the estimated Medicare amount. For more detailed information about our payment methodology for all provider types, go to select_advantage/for_providers.html. Deemed providers furnishing such services must accept the fee schedule amount, minus applicable member cost-sharing, as payment in full. For additional information, please visit our website at. Also, be sure to check future editions of Partners in Health Update for additional information about this Medicare Advantage PFFS plan. bluecard Winter 2008 edition of Inside IPP now available Inside IPP is our publication geared towards facility and ancillary providers to increase provider awareness of and satisfaction with the BlueCard Program. The publication introduces new initiatives related to BlueCard processing and highlights plans for improvement. The winter edition of Inside IPP features the following articles: Reminder about preauthorization/precertification for services Provider Satisfaction Survey Consumer directed health care and health care debit cards Glossary of BlueCard Program terms Quick tips on filing claims A complete archive of past issues of Inside IPP is available at /blue_card. Paper copies of Inside IPP are available at the Provider Supply Line upon request. Reminder about precertification/ preauthorization for services W I N T ER 2008 HIGHLIGHTS Please remind your BlueCard patients Providers may also contact the Consumer directed that they are responsible for obtaining member s Home Blue Plan for 2 health care and precertification/preauthorization for approval on his or her behalf by: health care debit inpatient and outpatient services as calling the BlueCard Eligibility cards required under their Home Blue Plan. line at BLUE (2583) Learn the difference In non-diagnosis-related group/case and asking to be transferred to the between a consumer rate situations when the length of utilization review area; directed health care (CDHC) an inpatient hospital stay extends submitting an electronic HIPAA debit card and a combined past the previously approved length 278 transaction (referral/ CDHC debit/member ID of stay, any additional days must be authorization) to Independence card. approved prior to or by the last day of Blue Cross. the original approved days. Failure to The member s Home Blue Plan may Glossary of obtain approval for the additional days contact providers directly for clinical BlueCard may result in claims processing delays 3 information and medical records prior Program terms and potential payment denials. to treatment or for concurrent review Familiarize yourself with or disease management for a specific these important BlueCardrelated terms. member. Provider Satisfaction Survey Quick tips on filing Your office may be contacted to participate in our provider satisfaction survey 4 claims to assess your satisfaction with servicing out-of-area members. Your opinions are Get helpful ideas for filing important to us, and we encourage you to participate in the survey. Your feedback claims. helps us to evaluate our performance and improve claims processing, customer service, and electronic transaction submittals. Please inform the office staff member who handles BlueCard claims filing and/ or billing that your office may receive a letter from our research vendor in early. The letter will invite the staff member who is most knowledgeable of claims processing to participate in an online survey. The vendor will then conduct a follow-up phone call between January 7 and February 4, 2009, to offices who have not responded to the online survey asking the designated staff person if he or she would prefer a telephone survey. 6

7 medical Policy notifications posted as of December 16, 2008 In order to better inform you, we have developed a Policy Notifications web page where our policies are posted prior to their effective date. Below is a listing of the policy notifications posted to the site as of December 16, Policy effective date Notification title Notification issue date January 1, h Botulinum Toxin Type A and Type B October 1, 2008 January 1, b Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth October 1, 2008 January 1, Oxaliplatin (Eloxatin ) October 1, 2008 January 1, Never Events and Preventable Adverse Events December 10, 2008 January 9, f Prophylactic Mastectomy December 10, 2008 January 13, e Cranial Remolding Orthoses (Helmets) October 15, 2008 January 13, c Durable Medical Equipment (DME) October 15, 2008 January 21, a Treatment of Autism with Secretin December 4, 2008 January 27, d Chemical Peels October 29, 2008 January 27, c Procedures for the Treatment of Acne October 29, 2008 January 27, a Scar Revision October 29, 2008 January 27, d Selective Photothermolysis Using Pulsed-Dye Lasers (PDL) October 29, 2008 January 27, c Wound Care: Bioengineered Skin Substitutes October 29, 2008 February 10, e Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) November 12, 2008 February 11, e External Counterpulsation (ECP) November 12, 2008 February 24, d Intraoperative Neurophysiological Monitoring (INM) November 26, 2008 February 25, Femoroacetabular Surgery November 26, 2008 March 1, f Diagnostic Radiology Services Included in Capitation December 1, 2008 March 17, a Foot Orthotics and Other Podiatric Appliances November 12, 2008 March 17, b Lower Limb Prostheses November 12, 2008 March 17, b Therapeutic Shoes and Orthopedic Shoes November 12, 2008 To access these notifications and view the policies in their entirety, follow these instructions: 1. Visit 2. Select Accept and Go to Medical Policy Online. 3. Select the Commercial and Other Medicare Advantage policies link. 4. Select Policy Notifications from the Medical Policy column on the left sidebar. Be sure to check back often, as the site is updated frequently. 7

8 medical Medicare members must receive notice of noncovered/ excluded services and member payment responsibility As a reminder, providers must furnish Keystone 65 or Personal Choice 65 SM members with written notice before providing noncovered/excluded services that the services are not covered and the members will be responsible for payment. Examples of noncovered/excluded services include, but are not limited to: comfort and convenience items, such as a total electric hospital bed; equipment inappropriate for home use, such as a standing frame system; equipment that is not primarily medical in nature, such as some power wheelchair accessories, such as power seat elevation system, power standing feature, and remote operation; equipment with features of a medical nature that are not required by the individual s condition, such as a water-circulating cold pad with pump; other examples include non-elastic binders, gradient compression stockings (HCPCS codes A6530; A6533- A6549). This requirement for written notification of noncovered/ excluded services and payment responsibility is contained in Section 2.10 of the Professional Group Provider Agreement (or 2.9 of the Professional Provider Agreement), which provides that in the event the Provider provides Excluded services to the Beneficiary, the Provider must inform the Beneficiary in advance in writing: (i) of the service(s) to be provided; (ii) that Independence [Blue Cross] will not pay for or be financially liable for said services; and (iii) that the Member will be financially liable for such services. If the provider does not give written notice of noncovered services to the member, he or she is required to hold the member harmless. The approved form of the Centers for Medicare & Medicaid Services, Notice of Denial of Medical Coverage, is included within this issue of Partners in Health Update and may be used when the member requests service(s) that are not covered because the services are not Medicare-covered benefits. This easy-to-use form requires the provider to list the item or service that is not covered and the reason for the noncoverage decision. Generally, the reason for noncoverage should be that Medicare does not cover the item or service. A copy of the form should be given to the member and a copy should be made part of his or her medical record. The form also provides the member with appeal rights. Please visit for more information about noncovered services. Timely submission of maternity patient questionnaires important for early outreach Registering maternity members into our Baby BluePrints high-risk perinatal program is imperative for early outreach. The Initial Maternity Patient Questionnaire form should be mailed right after the first prenatal visit to ensure timely registration into this program. In some instances, forms are being batched and mailed at a later date our goal, however, is to reach out to members identified as having risk factors within the first trimester of pregnancy. The program offers many benefits to members, such as educational materials and coupons for parenting classes, lactation consultants, and breast pumps. Additionally, our obstetric nurses offer case management to members who need help with such diagnoses as: gestational diabetes mellitus pregnancy-induced hypertension pre-term labor hyperemesis gravidarum Please remind your staff to send in the registration forms immediately after the first prenatal visit. Member registration into the program and prenotification for delivery will be completed at the same time. 8

9 medical Reminder: referrals not needed for services provided through Direct Access OB/GYN SM Direct Access OB/GYN allows HMO/POS members to receive certain services from any network obstetrical/ gynecological (OB/GYN) specialist or subspecialist without a referral for preventive care visits, routine OB/GYN care, or problem-related OB/GYN conditions. Specialties and subspecialties not requiring referrals include, but are not limited to, the following: OB GYN (including urogynecologist) OB/GYN gynecologic oncologist reproductive endocrinologist/infertility specialist maternal fetal medicine/perinatologist midwife Services not requiring referrals from primary care physicians (PCPs) or OB/GYNs include, but are not limited to, the following: all antenatal screening and testing fetal or maternal imaging hysterosalpingogram/sonohysterogram You must continue to use the OB/GYN Referral Request Form for the following services: pelvic ultrasounds, abdominal X-rays, intravenous pyelograms (IVPs), and DEXA scans (these tests must be performed at the member s capitated radiology site); initial consultations for HMO members for endocrinology, general surgery, genetics, gastrointestinal, urology, pediatric cardiology, and fetal cardiovascular studies (visits beyond the initial consultation still require a PCP referral). Please remind your patients about referral requirements, and contact your Network Coordinator with any questions. Reminder: changes to precertification requirements for most outpatient mental health services As of January 1, 2009, we have eliminated the requirement for providers to obtain precertification and continuing authorizations for routine and medication management outpatient mental health services under most Independence Blue Cross (IBC) benefits plans. Magellan Behavioral Health, Inc., an independent company that manages the behavioral health (mental health and substance abuse) benefits for the majority of IBC plans, communicated this change to its mental health providers prior to the effective date. Please note that precertification requirements that were previously in place for substance and alcohol abuse services, mental health inpatient services, partial hospitalization programs, and intensive outpatient programs will continue to be required. Note: Magellan Behavioral Health, Inc. manages mental health and substance abuse benefits for most members. When HMO/POS and PPO members receive services from Magellan Behavioral Health, Inc. providers, the provider will be responsible for obtaining any required precertifications. 9

10 medical Reminder: new look for member ID cards ID cards for some Pennsylvania members have a new look. The new cards are issued to members when a change, such as choosing a new primary care physician (PCP), adding a dependent, or renewing benefits, is made to their coverage. Until such a change is made, members will continue to use their current card. The new design divides the front of the card into four quadrants, each separated by a horizontal line. Each quadrant contains information specific to the member, such as member name and ID number, PCP information, and cost-sharing information. The back of the card provides important telephone numbers. To simplify the process of obtaining information on our members, providers can now use one number, ASK-BLUE, to request precertification for covered services and obtain eligibility information. NaviNet is also available to confirm member eligibility. If you have questions about the new ID cards, please contact your Network Coordinator. Note: For behavioral health services, providers should still call the number on the member s ID card under Mental Health/Substance Abuse. Keystone Health Plan East Personal Choice front front back back 10

11 medical PHCQA s initiative to relay hospital measures to patients Created in 2006, the Pennsylvania Health Care Quality Alliance (PHCQA) was formed with the mission of improving the quality of patient health by first developing a consistent statewide approach to quality measures, beginning with hospital measures. The PHCQA reports findings from these measures to the consumer, provider, professional, and insurer public through a new website, Through this initiative, the PHCQA seeks to: enable consumers to compare hospital performance; allow health care professionals to evaluate and improve the quality of their patient care; help insurers to evaluate the performance of their provider networks. Several groups work together to achieve the alliance s mission, including: the Hospital & Healthsystem Association of Pennsylvania (HAP), which represents more than 225 hospitals and health systems across the state; the Delaware Valley Healthcare Council of HAP; the Hospital Council of Western Pennsylvania; the state s four independently licensed Blue plans (Blue Cross of Northeastern Pennsylvania, Capital BlueCross, Highmark, Inc., and Independence Blue Cross); the Pennsylvania Medical Society (PMS); representatives from the Governor s Office of Health Care Reform and the U.S. Department of Health and Human Services. In addition to having a PMS representative on the alliance s executive committee, a number of hospital physicians and insurers actively participate in the workgroups that decide on what measures to use and how to convey that information to the public. The groups that comprise the alliance share the goal of promoting quality and transparency in health care. The PHCQA debuted its website in March This site compiles hospital-quality data in a searchable format to allow consumers to see and compare hospital performance in a variety of quality measures. The health care quality measures available on this site include process metrics that are endorsed by the Hospital Quality Alliance and reported to the Centers for Medicare & Medicaid Services for these four clinical areas: heart attack heart failure pneumonia infection prevention The site provides individual performance scores for each of the process measures associated with the four clinical areas listed above, as well as aggregate measures called Appropriate Care Measures, voluntarily reported measures indicating the percentage of patients who received all recommended care for their respective conditions. Outcome measures in three of the clinical areas above can also be found on the site. Additionally, the upgraded website has added the Hospital Consumer Assessment of Healthcare Providers and Systems survey responses, which are patient experience measures. The PHCQA website cautions users that the information provided at is not intended to replace professional medical advice, nor should it be relied upon for medical diagnosis or treatment. Patients are always reminded to seek the advice of their physician or another qualified health care provider with any questions regarding specific medical conditions and to never disregard medical advice or delay in seeking it because of something contained in the website. The data in the website is not intended to serve as advice, a recommendation, or an endorsement about what health care providers should use. 11

12 medical Reminder: transition to all-electronic authorization inquiry and submission continues New enhancements to the provider interactive voice response (IVR) system will be launched soon. These enhancements will provide you with the ability to submit electronic authorization or precertification requests for outpatient and office medical and/or surgical procedures.* This service will be directly accessible through Customer Service at ASK-BLUE, prompt 2 for Provider Services. The updated system will be available soon as part of our phased approach toward an all-electronic format for authorization inquiries and submissions. When making a request with the updated system, the following information is required: your provider ID number; the last four digits of your tax ID number or your national provider identifier (NPI); member s ID number; member s name and date of birth; date of service; setting, procedure code; diagnosis code; the name, address, and telephone number of both the servicing provider/facility and the requesting provider. A tutorial for using the enhanced IVR system will be included in a future edition of Partners in Health Update. *For behavioral health services, providers should still call the number on the member s ID card under Mental Health/Substance Abuse. specialty pharmacy Important changes about self-injectable drug coverage coming January 1, In an effort to provide better access to self-injectable drugs with greater value for our commercial HMO, POS, and PPO members, we are changing the way we cover self-injectable drugs, effective January 1, These changes, in tandem with a series of billing code changes described in this Specialty Pharmacy section, are part of our evolving overall approach to managing specialty pharmaceutical benefits. We will be communicating a series of changes over the next two years, all aimed at ensuring that members are getting the right drug in the right setting at the right time for the best value. Members will be notified of the changes to self-injectable drug coverage beginning in and may have questions for you. Below is a brief description of the scheduled changes to help you answer questions that your patients may have. Starting on January 1, 2010, we will no longer provide benefits for most self-injectable drugs under our medical benefits program. However, if an HMO, POS, or PPO member has Independence Blue Cross pharmacy coverage, his or her self-injectable drugs will continue to be covered under his or her pharmacy benefits in If members have prescription coverage from another carrier, they should check to see whether their plan includes coverage for self-injectables. The self-injectable drugs that will no longer be covered under our medical benefits programs are those that patients typically administer themselves and do not require physician monitoring. We will continue to cover those self-injectables under the medical benefits program at the appropriate cost-sharing levels that: cannot be administered without medical supervision; are mandated by law to be covered (e.g., insulin); are required for emergency treatment under the medical benefits program, such as self-injectable drugs that effectively counteract allergic reactions (e.g., EpiPen ). If you have any questions about these impending changes, please call ASK-BLUE, prompt 2 for Provider Services.

13 specialty pharmacy Valid NDC required on claims submitted for drugs (e.g., J codes and other drug codes) As part of our overall approach to managing specialty pharmaceutical benefits, we will be communicating to you over the next two years about some changes that will help members to get the right drug in the right setting at the right time for the best value. We want to share with you some changes to the National Drug Code (NDC) submission. Please be advised that a new edit is now in place to validate the NDC on any paper or electronic claims submitted with an unlisted and non-specific drug code. By requesting this detailed drug billing information, we can provide greater transparency for our members and providers. Please review the billing requirements below for your applicable provider type. Certain claims for unlisted and non-specific drug codes that are not accompanied by an NDC in the correct format and location as described on the following page will not be processed and will be returned to you for correction prior to processing. For professional providers: Effective January 1, 2009, claims for all unlisted and non-specific drug codes (CPT or HCPCS) require submission of an NDC in the correct format and location, as described on the following page. If the NDC is not submitted in the correct format or is missing, the claim will not be processed and will be returned to you for correction prior to processing. The complete list of unlisted and non-specific codes that require the submission of an NDC is below. For home infusion providers: Effective January 1, 2009, all drug claims (not just the unlisted and non-specific CPT or HCPCS codes in the table below) require the submission of an accompanying 11-digit NDC. This includes claims for hemophilia factor products that are currently submitted with specific J codes. For institutional providers: Tentatively scheduled for mid-first quarter 2009, all claims for outpatient services containing the following pharmacy revenue codes and an unlisted and non-specific (CPT or HCPCS) code will require a valid NDC when submitted: , 262, 263, 331, 332, 335, 343, 344, and NDC billing information Please submit the NDC number using the format when billing with hyphens (e.g., ). NDC numbers without hyphens (e.g., ) will also be accepted. Please do not include spaces, decimals, or other characters in the 11-digit string or the claim will be returned for correction prior to processing. Unlisted codes that will require submission of an NDC* Code Description Unlisted immune globulin Unlisted vaccine/toxoid A4641 Radiopharmaceutical, diagnostic, not otherwise classified A9150 Nonprescription drug A9152 Single vitamin/mineral/trace element, oral, per dose, not otherwise specified A9579 Injection, gadolinium based magnetic resonance contrast agent, not otherwise specified, per ml A9698 Nonradioactive contrast imaging material, not otherwise classified, per study A9699 Radiopharmaceutical, therapeutic, not otherwise classified A9700 Supply of injectable contrast material for use in echocardiography, per study C2698 Brachytherapy source, stranded, not otherwise specified, per source C2699 Brachytherapy source, nonstranded, not otherwise specified, per source C9399 Unclassified drugs or biologicals J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg J3490 Unclassified drugs 13 continued on page 14

14 specialty pharmacy Valid NDC required on claims submitted for drugs (continued) Code J3530 J3535 J3590 J7199 J7599 J7699 J7799 J8498 J8499 J8597 J8999 J9999 Q3001 Q4082 Q4096 S5000 S5001 Description Nasal vaccine inhalation Drug administered through a metered dose inhaler Unclassified biologics Hemophilia clotting factor, not otherwise classified Immunosuppressive drug, NOC NOC drugs, inhalation solution administered through DME NOC drugs, other than inhalation drugs, administered through DME Antiemetic drug, rectal/suppository, not otherwise specified Prescription drug, oral, nonchemotherapeutic, NOS Antiemetic drug, oral, not otherwise specified Prescription drug, oral, nonchemotherapeutic, NOS NOC, antineoplastic drug Radioelements for brachytherapy, any type, each Drug or biological, not otherwise classified, Part B drug competitive acquisition program (CAP) Injection, von Willebrand factor complex human, ristocetin cofactor (not otherwise specified), per I.U. VWF:RCO Prescription drug, generic Prescription drug, brand name *These codes are subject to change pending routine updates. Listing these codes on the table does not imply that a separate payment will be made for the code but that all current and future coding edits apply, and that these codes should only be reported when there is not a more specific code. Please submit an NDC in the following fields: Electronic professional claims: 837P Loop 2410/Data Element LIN02 = N4 qualifier and Data Element LIN03 = NDC Example: LIN**N4* ~ Paper professional claims: field 24A in the shaded area above the date of service. Report the N4 qualifier in the first two positions left-justified followed by the 11-digit NDC with no spaces in between. Example: N Electronic institutional claims: 837I Loop 2410/Data Element LIN02 = N4 qualifier and Data Element LIN03 = NDC Example: LIN**N4* ~ Paper institutional claims: box 43 (revenue code description) Report the N4 qualifier in the first two positions left-justified followed by the 11-digit NDC with no spaces in between. Example: N For information on claims submission resolution, please refer to the Claims Preprocessing Edits Claims Resolution Document at /self_service_tools/edi/forms.html. If you have questions, please contact your Network Coordinator. 14

15 preventive health SMART Registry release for The next release of the SMART Registry will be mailed to our providers this month. The SMART Registry provides information on Connections SM Health Management Program-eligible members with asthma, diabetes, heart failure, coronary heart disease (CHD), and chronic obstructive pulmonary disease (COPD). Four new template letters have been added to this SMART Registry release. Providers can use these letters for members who have heart failure, hypertension, CHD, and COPD. These letters are in addition to the asthma and diabetes template letters that were previously available. Providers can fill out and send the letters to members to remind them about needed follow-up care, such as tests, medication reviews, and office visits. A Microsoft Excel file of the names and addresses for all members on the Registry is also included to assist providers in sending out the template letters. As with the June 2008 release, all practices with more than 11 members with a chronic condition who are eligible for the Connections Program will receive their SMART Registry on CD. If you have any questions about the SMART Registry CD, please contact a Provider Service Specialist (PSS) by calling the Connections Program Provider Support Line at A PSS can work with you and your clinical office staff to sort the CD to provide the most important information for you. PSSs can also meet with you and your staff to review the SMART Registry reports and to help with making referrals to the Connections Health Management Program. To speak with a PSS about the SMART Registry or any other aspect of the Connections Program, call the Provider Support Line at SMART is a registered trademark of Health Dialog Services Corporation, an independent company. Used with permission. Excel is a registered trademark of Microsoft Corporation in the U.S. and/or other countries. Connections SM Health Management Programs: supporting our members, your patients Co n n e c t i o n s SM He a l t h Ma n a g e m e n t Pr o g r a m Co n n e c t i o n s SM Ac c o r da n tca r e TM Pr o g r a m Call the Provider Support Line at to refer a member for Health Coaching with any of the following conditions: n asthma n coronary heart n hypertension n diabetes disease (CHD) n gastroesophageal reflux n chronic obstructive n migraine disease (GERD) pulmonary disease n heart failure n peptic ulcer disease (COPD) (PUD) Health Coaches provide disease management and decision support for numerous health-related issues, such as depression, chronic pain, cancer, and weight loss surgery. Call to refer a member with any of the following diseases the Connections AccordantCare Program: n seizure disorders n rheumatoid arthritis n multiple sclerosis n myasthenia gravis n sickle cell disease n cystic fibrosis n chronic inflammatory demyelinating polyradiculoneuropathy n Crohn s disease n hemophilia (CIDP) n Parkinson s disease n scleroderma n amyotrophic lateral n systemic lupus n polymyositis sclerosis (ALS) erythematosus (SLE) n dermatomyositis n Gaucher disease Call our Care Management and Coordination department at to refer a member with end-stage renal disease on outpatient dialysis. Connections Health Management Programs information, handouts, and brochures are available by visiting /resources/connections.html. 15

16 Important Resources View our online provider directories on Partners in Health Update is a publication of the Provider Communications department for the exchange of information and ideas among the IBC provider community. Suggestions are welcome. Contact Information: John Shermer Managing Editor Charleen Baselice Production Coordinator Provider Communications Independence Blue Cross 1901 Market Street 35th Floor Philadelphia, PA provider_communications@ibx.com Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and/or Blue Shield words and symbols, Baby BluePrints, and BlueCard are registered trademarks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, Indemnity, etc.), and/or employer groups. Providers should call Provider Services, listed at right, for the member s applicable benefit information. Members should be instructed to call the Customer Service telephone number listed on their ID card. Not all benefit plans use Magellan Behavioral Health, Inc. to administer behavioral health benefits. Please check the back of the member s ID card for the telephone number to contact for behavioral health services, if applicable. The third-party websites mentioned in this publication are maintained by organizations over which IBC exercises no control, and accordingly, IBC disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefit plans. Members should refer to their benefit contract for complete details of the terms, limitations, and exclusions of their coverage. NaviMedix and NaviNet are a registered trademarks of NaviMedix, Inc. Investors in NaviMedix, Inc. include an affiliate of IBC, which has a minority ownership interest in NaviMedix, Inc., an independent company. CPT (Current Procedural Terminology) copyright 2007 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. FutureScripts and FutureScripts Secure are independent companies that provide pharmacy benefit management services. Partners in Health Update is an independent publication and is not affiliated with, nor has it been authorized, sponsored, or otherwise approved by Microsoft Corporation. CARE MANAGEMENT AND COORDINATION Case Management * Baby BluePrints BABY (2229)* Healthy Lifestyles SM Keys to Wellness * CONNECTIONS SM HEALTH MANAGEMENT PROGRAMS Connections SM Health Management Program Provider Support Line Connections SM AccordantCare TM Program CORPORATE AND FINANCIAL INVESTIGATIONS DEPARTMENT Anti-Fraud and Corporate Compliance Hotline CREDENTIALING Credentialing Hotline Credentialing Violation Hotline Customer service (Policies/Procedures/Claims) HMO and PPO ebusiness Help Desk FutureScripts Prescription Drug Authorization Toll Free Fax Direct Ship Injectable Fax ASK-BLUE, prompt 2 for Provider Services Blood Glucose Meter Hotline FutureScripts Secure Medicare Part D Formulary updates Health Resource Center Healthy Lifestyles SM Precertification NaviNet portal registration provider MEDICAL POLICY WEB PAGE provider pharmacy web page ASK-BLUE ASK-BLUE /navinet/index.html provider supply line * Outside 215 area code Visit our website: /communications 01/09

17 OMB Approval NOTICE OF DENIAL OF MEDICAL COVERAGE Date: Member ID Number: Beneficiary s name: We have denied coverage of the following medical services or items that you or your physician requested: We denied this request because: What If I Don t Agree With This Decision? You have the right to appeal. To exercise it, file your appeal in writing within 60 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline. Who May File An Appeal? You or someone you name to act for you (your representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others also already may be authorized under State law to act for you. You can call us at: ( ) to learn how to name your representative. If you have a hearing or speech impairment, please call us at TTY ( ). If you want someone to act for you, you and your representative must sign, date, and send us a statement naming that person to act for you. Form No. CMS Exp. Date 8/31/2010 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 6.3 to 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland