What Can "Q" Do for You?

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1 A publication to keep our network providers up to date on the latest news at 3rd Blue Quarter Cross 2013 and Blue Provider Shield of Network Louisiana News 3 4th Quarter 2011 networknews 3rd Quarter 2014 provider providing health guidance and affordable access to quality care INSIDE THIS ISSUE Provider Network 2 Refer to Network Labs 2 Updated Provider Manuals 2 Network Specialty Pharmacies 2 Blue Cross Reorganizes Rural Health Clinics in Our System 3 Pass-through Billing Not Permitted 3 YOUR Cost Data Is Available for Review on ilinkblue 3 Report Your Hospital-based Providers 3 Your Network Operations Team Office of Group Benefits 4 Updated Authorization Requirements for OGB 4 New OGB Benefi ts for 2015 Billing & Coding 4 Updated Drug Allowables 4 Ordering & Referring NPIs Required 4 Blue Cross Updated Code Ranges 4 File Claims Electronically 5 Specifi city of Codes 5 Taxonomy Codes 5 Revised DME Billing Guidelines 5 Modifi er 25 5 No Interim Bill Types 5 Modifi er 50 5 Rental Only for Oxygen Concentrators 6 Tips for Completing Reimbursement Review Form 6 Use the ICD-10 Delay to Prepare for Implementation 6 ICD-10 Scenario-based Testing BlueCard Out-of-State 7 Blue Cross Blue Shield of Michigan Community Blue Members Healthcare Reform 7 House Bill 601 (Act No. 555) Medical Management 8 Medical Policy Update 9 Types of Appeals 9 Dr. Cole's Corner: Blue Cross Welcomes Dr. Kenny Cole Quality Blue 7 PCP Collaborative - Register Today! 10 New QBPC Incentive 10 ilb Enhanced to Show QBPC-waived Member Cost-shares 11 QBVP to Engage More Providers in Value-based Care 23XX6753 R09/14 What Can "Q" Do for You? Blue Cross and Blue Shield of Louisiana offers our network providers opportunities to earn recognition, additional payments and other incentives through Quality Blue, a new series of innovative healthcare quality improvement programs. In keeping with our mission, we have taken a leadership role in developing programs that reward doctors for quality improvements that get better health results for patients while making healthcare more affordable. Quality Blue programs recognize those physicians who are working in partnership with Blue Cross to transform healthcare systems and improve the way care is delivered to Blue Cross members your patients to help them achieve better health outcomes. Our current Quality Blue programs include: Blue Distinction Consumer Engagement Hospital Quality and Value Improvement Program (HQVIP) Quality Blue Primary Care (QBPC) Quality Blue PT/OT Quality Blue Value Partnerships (QBVP) More on the QBPC and QBVP programs is included in this newsletter and we will continue to bring you more on Quality Blue programs in future newsletters. LEARN MORE ONLINE AT >Quality Blue

2 2 Provider Network News 3rd Quarter 2014 Provider Network Refer to Network Labs Participating providers in our networks agree to assist us in our efforts to keep our members costs down. One way to do that is to refer our members your patients to participating reference laboratory providers. Through data analysis, we continue to identify providers who are out of compliance with our laboratory referral policy. Once identified, notification reminders of our policy are being mailed to the physician of record who ordered the lab services. If you receive notification and have questions, please contact your Provider Relations representative to ensure you will not be subject to future reductions to your allowable charges. Please refer to your Professional Provider Offi ce Manual, which states that all providers participating in the Preferred Care PPO network should refer members to participating reference lab vendors when lab services are needed and are not performed in the provider s office. If a participating reference lab is not used, providers could be subject to a lower allowable charge. Preferred Care PPO and HMOLA Provider Requirements Laboratory services provided should be submitted to participating reference labs, if not performed in your office (or if not performing a stat lab test as applicable). Preoperative lab services rendered before an inpatient stay or outpatient procedure may be performed by Preferred Care PPO or HMO Louisiana, Inc. (HMOLA) participating hospitals. Otherwise, send all lab orders to one of our participating reference labs. Please help us keep our members costs down by using our preferred contracted reference labs, when appropriate, per the requirements noted above. For more information or to view our provider manuals, speed guides and tidbits, visit >Education on Demand. Below is the contact information for our statewide network reference labs: Clinical Pathology Labs Labcorp Omega Diagnostics Quest Diagnostics Clinical Laboratories MYQUEST Updated Provider Manuals The Professional Provider Offi ce Manual has been updated as follows: Added elective delivery of pregnancy billing guidelines Updated DME billing guidelines Updated infusion therapy billing guidelines Revised OGB authorization information The Member Provider Policy & Procedure Manual has been updated as follows: Added elective delivery of pregnancy billing guidelines Updated interim billing information Revised OGB authorization information Added Modifier 51 information Network Specialty Pharmacies Beginning November 1, 2014, Blue Cross will have a network of specialty pharmacies that will be listed in our provider directories as such. It is important to refer our members to these network providers for their specialty pharmacy needs. To locate network providers, go to then click on "FIND A DOCTOR OR DRUG." Blue Cross Reorganizes Rural Health Clinics in Our System We are reorganizing the way we set up rural health clinics in our system. Today, these clinics are set up in our system under one provider record for the clinic only. We do not capture the individual providers who perform services within the clinic in our system or on claims. Effective January 1, 2015, we will no longer pay rural health clinics based on a clinic level reimbursement, but instead will pay claims based on the allowables for each individual/professional provider who performs the services at a rural health clinic. With the transition to NPI only, it is important to capture services provided at the individual healthcare professional level. By reorganizing rural health clinics in our system to the individual, it will allow us to link the individual providers and their NPIs on claims. It will also allow us to list both the rural health clinic and its individual providers by specialty for each rural health clinic in our provider directories, thus making it easier for our members to locate these medical professionals when needed.

3 Pass-through Billing Not Permitted Blue Cross and HMOLA do not permit pass-through lab billing. Pass-through billing occurs when the ordering provider requests and bills for lab, but the lab is not performed by the ordering provider. Only the performing provider should bill for these services. Per our policy, providers may only bill for the following indirectly performed services: 1. The service of the performing provider is performed at the place of service of the ordering provider and is billed by the ordering provider, or 2. The service is provided by an employee of a physician or other professional provider. (Please use appropriate modifiers when billing.) e.g. physician assistant, surgical assistant, advanced practice nurse, clinical nurse specialist, certified nurse midwife and registered first assistant, who is under the direct supervision of the ordering provider and the service is billed by the ordering provider. Provider Network YOUR Cost Data Is Available for Review on ilinkblue The Estimated Treatment Cost Tool enables our Preferred Care PPO members to view information about the value you bring to the healthcare community. What members see are PPO costs displayed on the national Blue Cross Blue Shield Association (BCBSA) Hospital & Doctor Finder SM website. The tool features the costs and volumes associated with 404 elective/planned procedures. Cost estimates are developed from BCBSLA historical claims with updates, as needed, to reflect current arrangements and combined data that enable members to understand the total cost for a service without complications. We are mailing a letter to providers whose data is available on ilinkblue for review. This letter will include full details on how the cost data is pulled, where to find it and how to dispute or inquire about the data. The letter will also include the deadline to view your cost data. To view your report of cost estimates, log onto ilinkblue with your existing login ID and click the menu Estimated Treatment Costs menu option. 3rd Quarter 2014 Provider Network News 3 Report Your Hospitalbased Providers The Health Care Consumer Billing & Disclosure Act (cor Consumer's Right to Know Act) requires that facilities (acute and ambulatory surgery centers) inform health plans of their hospital-based physicians in the specialties of: Anesthesia Pathology Emergency medicine Radiology Neonatology According to the legislation, health insurers must be notified of any future changes made to this information within 30 days of the change or you could be subjected to penalties. Blue Cross asks that our network facilities submit changes on the Consumer's Right to Know Facility Reporting Form every time there is a change in hospital-based physicians for any of the specialties listed above. The form is located on our website at www. bcbsla.com/providers >Forms for Providers. Facilities may completed forms to Network.Development@bcbsla.com or mail to ATTN: Network Development, BCBSLA - NAD, P.O. Box 98029, Baton Rouge, LA Your Network Operations Team For more on the credentialing & recredentialing processes, visit us online at: BCBSLA.com Click on: >I'm A Provider >Credentialing Your Network Operations Team is here for you! Toll Free Number: Fax Number: Network.Administration@bcbsla.com Team Member Alpha Phone Baton Rouge Region Mert Terrance - provider file Linda McKay - credentialing A-Z A-Z Lafayette/Lake Charles/Alexandria Regions Linda Denicola - provider file Hope Pace - provider file Eve Jupiter - credentialing Darlene Robinson - credentialing A-L M-Z A-L M-Z Monroe/Shreveport Regions Dannay Bourgeois - provider file Kim Walker - credentialing New Orleans Region Shakeysha Gray - provider file Dana Mitchell- provider file Tamekia Jones- credentialing Cheryl Ward - credentialing A-Z A-Z A-L M-Z A-L M-Z Mercedes.Terrance@bcbsla.com Linda.McKay@bcbsla.com Linda.Denicola@bcbsla.com Hope.Pace@bcbsla.com Eve.Jupiter@bcbsla.com Darlene.Robinson@bcbsla.com Dannay.Bourgeois@bcbsla.com Kimberly.Walker@bcbsla.com Shakeysha.Gray@bcbsla.com Dana.Mitchell@bcbsla.com Tamekia.Jones@bcbsla.com Cheryl.Ward@bcbsla.com Vicki Jones, Manager Vicki.Jones@bcbsla.com Rhonda Dyer, Supervisor Rhonda.Dyer@bcbsla.com

4 4 Provider Network News 3rd Quarter 2014 Office of Group Benefits Updated Authorization Requirements for OGB Effective August 1, 2014, the outpatient prior authorization requirements for Office of Group Benefits' (OGB's) PPO, HMO and Consumer Driven Health Plan (CDHP) benefit plans changed. Some services that did not previously require an authorization for OGB's PPO and CDHP members now require an authorization. It is very important that you view and understand the services that require authorizations because failure to obtain an authorization for an OGB member will result in a claim denial that is not billable to the member. OGB members with Medicare as their primary coverage should follow Medicare s prior authorization requirements. The new authorization requirements are included in the updated OGB speed guide and our provider manuals available online at >Education on Demand. The manuals are also available on ilinkblue ( New OGB Benefits for 2015 OGB s 2015 annual enrollment begins October 1 and ends November 30. During that period, OGB members will be able to choose from multiple plan offerings that will be effective March 1, While none of the 2015 plans are exactly the same as the plans offered in 2014, some of the choices are very similar. OGB is still offering HMO, PPO and consumer-driven health plans in Be on the lookout for full details on these changes. In November, we will send you a direct mailing. Then in December, we will publish more information online and in our manuals and speed guides. For questions on OGB benefits, use ilinkblue or call OGB's dedicated Customer Service unit at Billing and Coding Updated Drug Allowables Blue Cross updated the reimbursement schedule for drug codes, effective for claims with dates of service on and after September 1, One change we made is that we no longer publish a separate drug allowable listing for durable medical equipment and infusion therapy. We aligned all listings to one standard listing that includes durable medical equipment and home infusion drug codes and allowables. These allowables are available on ilinkblue ( ilinkblue/) under the "Allowable Charge" section. You may also access PDF listings of these allowable charges under the "Provider Manuals" section of ilinkblue. Ordering & Referring NPIs Required Providers are required to file both the ordering physician NPI and the referring physician NPI (if applicable) on all claims for each procedure code listed. Failure to supply these numbers will result in delay or denial of claims payment. The ordering or referring provider NPI should be placed in block 17B of the CMS-1500 claim form. The rendering provider NPI should be placed in block 24J of the CMS-1500 claim form. If you are filing your claims with ordering or referring NPI numbers and still receive claim denials for your NPI, please contact Network Operations at , option 3 to ensure that we have your NPI(s) on file. For more information on claims filing procedures, please refer to the Professional Provider Offi ce Manual located online at providers >Education on Demand. Blue Cross Updated Code Ranges As a reminder to affected providers, we made updates to the Outpatient Procedure Services and the Diagnostic and Therapeutic Services code ranges. The outpatient code changes listed below were effective April 1, Added to the Outpatient Procedure Services code range: C9739 and C9740 Added to the Diagnostic and Therapeutic Services code range: C9021 These changes do not affect existing codes and allowable charges on the Outpatient Procedure Services and Diagnostic and Therapeutic Services schedules. It simply allows our system to accept these codes appropriately for claims adjudication. The above changes also apply for HMOLA. File Claims Electronically Blue Cross no longer accepts black and white claims. We encourage our providers to file claims electronically. Claims submitted electronically are processed more rapidly, expediting our payment to you. If you must submit paper claims, please use RED original claim forms. Do not submit black and white copies, as data recognition can be affected. Facsimile (fax) machines should never be used to submit claims. CPT only copyright 2014 American Medical Association. All rights reserved.

5 Specificity of Codes It is important to file ALL applicable diagnosis codes (supported by the patient's medical records) on a claim. It is equally important that providers code claims to the highest degree of specificity. Blue Cross discourages providers from filing not otherwise specified (NOS) diagnosis codes. Claims with NOS codes may pend for medical record review and more appropriate coding. Taxonomy Codes When billing facility claims where your facility shares an NPI with a subunit with the same tax identification number, you are required to also include the appropriate taxonomy code (block 81 of the UB-04 or its electronic equivalent). The taxonomy code selected must clearly identify the subunit where the services were rendered. For example, a multispecialty facility that provides both acute and psychiatric care under the same tax identification number should select the appropriate taxonomy code based on the services being billed. Failure to use a specific taxonomy code may cause the claim to pay incorrectly and/or reject. Revised DME Billing Guidelines In the latest revision of our Professional Provider Offi ce Manual, we included revised billing guidelines for durable medical equipment (DME) providers. This manual is available online at www. bcbsla.com/providers >Education on Demand. It is also available on ilinkblue ( under the Manuals section. Modifier 25 Did you know that you can bill both wellness and sick visit charges on the same day? It is as simple as billing the wellness evaluation and management code on the claim with the appropriate diagnosis. Then also include the sick visit code on the same claim with modifier 25 and appropriate diagnosis(es). All services should be properly documented in the patient's medical records. Billing and Coding No Interim Bill Types Facility claims must be submitted with a bill type. Bill types are three digits and each digit position represents specific information about the claim being filed. type of facility [ [ [ bill classifi cation frequency Blue Cross does not exclude for the first and second digits of the bill type. There ARE exclusions related to the third or frequency digit. Blue Cross will not accept bill types with a frequency code of 2, 3, 4, 5, 6 or 9. We do not accept interim billings for inpatient. Interim bills or replacement claims should be aggregated into one final claim for submission and be submitted using a frequency code of 1 or 7. For illustrative purposes, we will further clarify with a few examples: Acceptable Bill Types: Bill Type 111 (hospital, inpatient, admit through discharge) Bill Type 211 (skilled nursing, inpatient, admit through discharge) Bill Type 187 (swing bed, inpatient, replacement claim) Unacceptable Bill Types: Bill Type 112 (hospital, inpatient, interim-first claim) Bill Type 113 (hospital, inpatient, interim-continuing claim) Bill Type 114 (hospital, inpatient, interim-final) Bill Type 215 (skilled nursing, inpatient, late charge) Inpatient interim and late charges normally billed with bill types ending in 2, 3,4 or 5 would need to be aggregated with any additional bills to produce a final bill with all services and charges included and a bill type with a frequency code of 1. Failure to follow these guidelines will result in returned or denied claims. These guidelines and more are outlined in the Member Provider Policy & Procedure Manual, available on ilinkblue ( under the Manuals section. 3rd Quarter 2014 Provider Network News 5 Modifier 50 Billing Single/Bilateral Procedures Single Bilateral - procedures can anatomically be done bilaterally only once per session. Multiple Bilateral - procedures can anatomically be done bilaterally multiple times per session. The correct submission of a bilateral procedure is the code on one line with modifier 50 and 1 in the units field. Bilateral procedures are reimbursed as follows: 1) The primary bilateral procedures are reimbursed at 150 percent of the allowable charge. 2) The secondary bilateral procedures are reimbursed at 75 percent of the allowable charge. Proper billing of bilateral procedures ensures correct reimbursement and eliminates the need for refund requests and payment adjustments. Modifier RT and LT Clarification: Modifiers RT and LT are informational modifiers only and should NOT be used when modifier 50 applies. Modifier 50 should be used to report bilateral procedures that are performed on both sides at the same operative session as a single line item. Rental Only for Oxygen Concentrators Effective July 1, 2014, oxygen concentrator codes E1390 and E1391 must be billed as rental only using the RR modifier for a period of 15 months. Blue Cross' reimbursement includes the equipment, contents and accessories furnished during a rental month. The supplier is required to continue furnishing the equipment, supplies, accessories and contents for the remainder of the useful lifetime. Claims for maintenance and servicing of an oxygen concentrator can be billed using code K0740 every six months beginning six months after the end of the 15th month of continuous use or the end of the manufacturer s warranty.

6 6 Provider Network News 3rd Quarter 2014 Billing and Coding Tips for Completing Reimbursement Review Form Blue Cross recognizes there may be times when participating providers disagree with the way a claim was adjudicated. In those instances, providers may complete the Reimbursement Review Form. Please be sure to complete the entire form and include any supporting documentation. Please send the form to Customer Service, P.O. Box 98029, Baton Rouge, LA Follow these tips to ensure your claims get reviewed the first time: 1) Make sure that the Reimbursement Review form is the top document of your packet. This helps ensure that your review is not processed as a resubmitted claim. 2) Be sure to check the box that most closely matches your provider specialty. 3) Check the reason for requested review. You may choose from the following reasons: Disagree with Medical Coding Edit or Denial (i.e. assistant surgeon) check this box if you disagree with how codes were bundled and/ or denied. You must include the reason why the codes should be paid/unbundled or applicable operative notes. Claim not paid according to allowable charge and/or reimbursement amount is incorrect check this box if you believe that the wrong allowable charge amount was used to pay the claim. You must include the allowable charge amount that you believe should have been used. Other: must clearly explain reason for review when it is not one of the options listed above. 4) Include the appropriate supporting documentation along with the Reimbursement Review Form. For assistance in what to attach, please review the box with the heading, If these services were rendered you must submit the following information. 5) Always attach a copy of the claim. Use the ICD-10 Delay to Prepare for Implementation Earlier this year, the implementation of ICD-10 was delayed to October 1, It is important to use the extra year to prepare for the new implementation date. Consider the extension as an opportunity to improve your preparedness, not additional time to delay action. Reassess the items below to ensure that your organization s implementation progress is on track and that you will be ready before ICD-10 is mandatory. 1. Implementation Plan - meet with those involved in the implementation process and make sure active tasks are on track and underway. 2. Education/Training Plan - expand your training and readiness programs to include training for administrative personnel, clinical staff and coding staff (support staff who routinely work with codes). With the expansion of available codes ICD-10 will create, having a good training plan in place will help ensure that your claims are coded to the highest level of specificity and can save you considerable time and money. 3. Financial plan - strengthen your practice's cash position and test your financial assumptions. It is important that you are able to maintain a healthy cash flow in your practice regardless of unforeseen glitches in implementation and post-compliance activities. 4. Communication Plan - talk to your vendors about ICD-10. An important step in preparing for the transition to ICD-10 is to talk with any software vendors, clearinghouses and/or billing services you use to be sure they are ready to provide the support you need. They will need to have products and services on a schedule that allows adequate time for you to conduct testing. Never assume that your billing vendors will be fully ICD-10 compliant in time for the implementation date. You are ultimately responsible for your claims. 5. Testing Plan - look for opportunities to expand your testing internally and externally. Take advantage of clearinghouse test exchanges where you can submit claims and receive feedback in a simulated environment. ICD-10 Scenario-based Testing for Professional Providers As part of Blue Cross ICD-10 transition, we have developed a scenariobased testing portal to support professional providers with ICD-10 readiness testing. This portal will allow you to practice coding clinical scenarios applicable to your specialty using ICD-10 codes. Each specialty will have up to nine frequently encountered clinical narratives for coding. Upon completion, you will have access to compare your coding results with coding results of your peers. To learn more about ICD-10 readiness and to register to conduct scenario-based testing with us, please go to and select ICD-10 Conversion.

7 Quality Blue 3rd Quarter 2014 Provider Network News 7 PRIMARY CARE PHYSICIANS - REGISTER TODAY!! Please join us for the first Quality Blue Primary Care (QBPC) Statewide Collaborative on Thursday, November 6, 2014, at the Hilton Baton Rouge Capitol Center (downtown Baton Rouge), from noon until 5 p.m. (reception immediately following). Lunch and refreshments will be provided. Register online at Please R.S.V.P. by Monday, October 6, 2014, to guarantee your spot. BlueCard Out-of-State Blue Cross Blue Shield of Michigan Community Blue Members Blue Cross and Blue Shield of Louisiana is not the only Blue Plan that offers member benefits called "Community Blue." Blue Cross Blue Shield of Michigan (BCBSM) also offers their members a completely separate "Community Blue" product and some of these members reside in Louisiana. It is important to ask for and carefully view each Blue member's identification card and verify benefits before turning members away. It is true that our Community Blue product is only offered in select areas and our members are limited to their network of providers. However, BCBSM's Community Blue members seeking services outside of Michigan access the local Blue Plan's network of providers. That means that BCBSM's Community Blue members living in Louisiana use our network of Preferred Care PPO providers and claims are processed through our BlueCard Program. Below is a sample of BCBSM's Community Blue member identification card. Healthcare Reform House Bill 601 (Act No. 555) The Louisiana Legislature passed House Bill 601 in June Included in this bill is Act No. 555 that became effective August 1, It states: No healthcare provider that accepts a patient's health insurance coverage shall require an enrollee or insured to consent to payment for healthcare services as a condition for verification of health insurance coverage for such healthcare services. To view the full bill, go to LA/bill/HB601/2014. As a Blue Cross network provider, you have already agreed to submit claims for Blue Cross and Blue Shield members. All applicable information should be completed in full, including procedure and diagnosis codes as well as applicable medical records to support the use of modifiers or unlisted codes. Claims should include all services rendered during the patient's visit. Full information on your Blue Cross billing guidelines is included in our office manuals, available online at >Education on Demand and on ilinkblue ( under the Manuals section.

8 8 Provider Network News 3rd Quarter 2014 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 New Medical Policies Policy No. Policy Name Effective June 18, I Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) With Indium-111 Capromab Pendetide (ProstaScint ) for Prostate Cancer Effective July 16, I Molecular Panel Testing of Cancers to Identify Targeted Therapies C Genetic Testing for Li-Fraumeni Syndrome C Microprocessor-Controlled Prostheses for the Lower Limb C BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia C Genetic Testing for Mitochondrial Disorders C apremilast (Otezla ) C metreleptin (Myalept ) C vedolizumab (Entyvio TM ) Effective August 20, C Fecal Microbiota Transplantation I Vectra DA Blood Test for Rheumatoid Arthritis Effective September 1, C Elective Delivery of Pregnancy 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 N R Investigational Eligible for coverage with medical criteria Not medically necessary Retired Recently Updated Medical Policies Policy No. Policy Name Change Effective June 18, C Genetic Testing for Hereditary Breast and/or Ovarian Cancer C Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty C Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence C Screening for Lung Cancer Using Computed Tomography Scanning I Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer C buprenorphine/naloxone Combination Products Change Effective July 16, C Deep Brain Stimulation C Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders C ecallantide (Kalbitor ) C Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome C Proton Pump Inhibitors (PPIs) and Proton Pump Inhibitor/ Non-Steroidal Anti-Inflammatory Drug (NSAID) Combination C Posterior Tibial Nerve Stimulation for Voiding Disfunction Change Effective August 20, I Functional Neuromuscular Electrical Stimulation C Hyperbaric Oxygen Pressurization (HBO) C Intra-articular Hyaluronan Injections for Osteoarthritis of the Knee C Small Bowel Transplant, Small Bowel/Liver Transplant and Multivisceral Transplant C Immune Prophylaxis for Respiratory Syncytial Virus C Spinal Cord Stimulation C Selective Serotonin Reuptake Inhibitors (SSRIs)/Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs) C Sodium-Glucose Co-Transporter-2 (SGLT-2) Inhibitors and Combination Products I Genetic Testing for Mental Health Conditions Change Effective September 2, C Positron Emission Tomography (PET) Oncology Applications Provider inquiries for reconsideration of medical policy coverage, eligibility guidelines or investigational status determinations will be reviewed upon written request. Requests for reconsideration must be accompanied by peer-reviewed, scientific evidence-based literature that substantiates why a technology referenced in an established medical policy should be reviewed. Supporting data will be reviewed in accordance with medical policy assessment criteria. If you have questions about our medical policies or if you would like to receive a copy of a specific policy, log on to ilinkblue at or call Provider Services at

9 3rd Quarter 2014 Provider Network News 9 Medical Management Types of Appeals We recognize that disputes may arise between members and Blue Cross regarding covered services. Below we define the different types of appeals and disputes we accept. Medical Necessity or Investigational Appeals involve claims or authorizations denied as not meeting medical criteria for coverage due to the services not being medically necessary or being considered experimental/investigational. Administrative Appeals involve member contractual issues other than Medical Necessity or Investigational denials. Examples include adverse benefit determinations based on contract limitations or exclusions. You may file an administrative appeal on behalf of the member if authorized by the member in writing. Expedited Appeals involve pre-service denials for immediate consideration on health services that if delayed could seriously jeopardize the member s health. External Appeals generally involve medical necessity or investigational appeals but could be requested for appeals related to rescissions in coverage. Appeals which require medical judgment are eligible for an external appeal only after the first level has been exhausted. Provider Disputes involve provider contractual issues. Examples include authorization penalties and contractual allowable disputes. Bundling and claim check issues must be submitted on a Reimbursement Review Form (available online at >Forms for Providers) for an initial review for bundling, claim check issues or reimbursement reviews. Note: Corrected claims, denials for primary carrier explanation of benefits and denials for medical records are not considered as provider disputes. For more information on appeals, view the provider manuals, available online at >Education on Demand or on ilinkblue ( under the Manuals section. Medical Policy Highlight: Immune Prophylaxis for RSV Policy No Immune Prophylaxis for Respiratory Syncytial Virus (RSV) Update Effective August 20, 2014 The American Academy of Pediatrics (AAP) recently released updated guidelines for RSV prophylaxis entitled Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection. As a result of the recent guideline update, we have made changes to our corresponding medical policy. Effective for the upcoming RSV season, we will adhere to the updated medical policy, which mirrors the AAP s definitions for high risk children who qualify for RSV prophylaxis with Synagis (palivizumab). Blue Cross Welcomes Dr. Kenny Cole Blue Cross is pleased to welcome Dr. Kenny Cole. He is our Associate Chief Medical Officer and Vice President of Care Delivery as of April Dr. Cole was born in Franklin, LA and lived there until he attended Louisiana State University in Baton Rouge from 1986 to He then moved to New Orleans, where he attended Louisiana State University Medical Center from 1991 to 1995 and received his medical degree. Dr. Cole returned to Baton Rouge for his residency at LSU Medical Center from 1995 to 1998, which was followed by a year as Chief Resident from 1998 to Kenny then moved to Tampa, FL, and lived there from 1999 to 2001, where he completed an Infectious Disease Fellowship at the University of South Florida. He returned to Baton Rouge in 2001 and became a primary care physician and infectious disease specialist at the Baton Rouge Clinic, where he served as an Executive Board member and Chairman of Medicine. He served as Medical Director of Infectious Diseases from 2002 to 2009 for the Baton Rouge General Medical Center. He also served as a Clinical Assistant Professor of Medicine for the LSU Health Sciences Center and as clinical teaching faculty for the Tulane University School of Medicine. In 2013, he completed an executive education program from Harvard Business School on Managing Healthcare Delivery and obtained his Lean/Six Sigma certification. Also in 2013, he began a master s degree from Dartmouth in Healthcare Delivery Science, which will be completed in We look forward to his wealth of innovative input toward our primary care physician programs and more!

10 10 Provider Network News 3rd Quarter 2014 New QBPC Incentive Blue Cross offers our network primary care providers a Quality Blue program called Quality Blue Primary Care (QBPC). It is a primary care-focused, population health management program we introduced last year. This program is designed to transform our primary care provider network from an episodedriven, physician-care delivery model to a team-based care delivery model. We recently added a cost-savings incentive for members of our Blue Cross employee group only. Blue Cross employees can be identified by their ID cards with the group number beginning with Effective July 15, 2014, Blue Cross now waives the member copayment and/or coinsurance associated with the office visit charge only when services are performed by a QBPC provider. This means that when a Blue Cross employee seeks services from a QBPC provider: The copayment and/or coinsurance should NOT be collected at the time of service for the office visit charge. Cost-sharing expenses for all other standard applicable charges still apply. The copayment and/or coinsurance is also waived if the QBPC s nurse practitioner provides the services. The QBPC provider s payment register will reflect the waived copayment and/or coinsurance and the full allowable charge as payment for the office visit. In 2015, we will be expanding this new incentive to other Blue Cross and HMOLA members/member groups. Updates will be published in future provider newsletters as we roll out additional program changes. ilinkblue Enhanced to Show QBPC-waived Member Cost-shares for New Incentive ilinkblue has been enhanced to show the member cost-share amounts for when services are rendered by a QBPC provider so you can properly determine the correct cost-share amount to collect from the member at the time of service. Once in ilinkblue, select the Coverage Information menu option, then click on Coverage Summary and enter the member's contract number. Then on the coverage summary screen, click the Coverage Report button to view the summary of benefits report that has been enhanced as follows: 1. Under the "Co Pays" section of the report, we added a column that shows the copayment amount to collect when services are rendered by a QBPC provider. Example shows that no copayment should be collected for the offi ce visit charge for services performed by a QBPC provider. Non-QBPC providers should collect a $25.00 copayment from an HMO member. Co Pays EPO Co Pays QBPC Co Pays Offi ce Visit $25.00 N/A $ Under the "Co Insurance" section of the report, we added a field to show the QBPC Percentage to collect from the member when services are rendered by a QBPC provider. Co Insurance Par Percentage 90% Non-Par Percentage 70% EPO Percentage N/A% QBPC Percentage 100% after deductible is met Below is a breakdown by product of how the costshare (as applicable) is waived for office visit charges when Blue Cross employee group members see QBPC providers. Preferred Care PPO HMO POS Community Blue BlueSaver offi ce copay, deductible or coinsurance waived Example shows that no coinsurance should be collected for the offi ce visit charge (when deductible is met) for services performed by a QBPC provider for a BlueSaver member. office copay waived offi ce copay waived coinsurance waived after deductible met Note: in 2015 we will expand this incentive to include other Blue Cross members/member groups. PCPs Learn More About the QBPC Program We offer more information on the QBPC program at including a printable PDF of our QBPC brochure.

11 3rd Quarter 2014 Provider Network News 11 Company News QBVP to Engage More Providers in Value-based Care As the health insurance industry increasingly rewards providers for delivering higher-value care, the industry is naturally shifting from the traditional fee-for-service model, which rewards volume and can be duplicative or medically unnecessary, toward care that adds value and is cost effective. Building on the success of existing Quality Blue programs, most notably Quality Blue Primary Care (QBPC), Blue Cross is rolling out a new program to continue the transformation to value-based care. Quality Blue Value Partnerships (QBVP) launched July 1, 2014, with five large provider systems enrolled: Baton Rouge Clinic, Baton Rouge General Physicians Group, Gulf States Quality Network, Ochsner Health System and West Calcasieu Virtual Medical Home. QBVP best serves large provider groups that have an array of doctors within the same healthcare system. To participate in QBVP, doctors must already be enrolled in QBPC. By adding QBVP, large provider systems can expand beyond primary care and examine their patients treatment experiences throughout the entire system, including with specialists, hospitals and outpatient centers that they manage. These types of systems are also called Accountable Care Organizations. QBVP is an enhancement to an existing Accountable Care Organization program that Blue Cross created with Ochsner Health System and Baton Rouge General Health System. To provide the technical and analytical support needed for QBVP, Blue Cross is paying for each enrolled system to access the online TREO Solutions dashboard. Using TREO, administrators can review Blue Cross claims data to identify ways that they can better use resources, change their practice patterns, or conduct more robust engagement and outreach activities to give patients the most appropriate level of care in the best setting. For example, healthcare systems can have doctors prescribe more generic drugs, or they can reduce costly out-of-network services by referring patients to the most cost-efficient provider or to other providers within the same system for lab work or tests. These interventions effectively reduce medically unnecessary services and control costs. If the healthcare systems enrolled in QBVP demonstrate that they have followed effective cost-saving strategies, Blue Cross will reward them by paying a percentage of the savings they achieved. The first five providers will have their first opportunity to receive a payment through the program in late >I'm a Provider bluecrossla STAY CONNECTED

12 networknews P. O. BOX BATON ROUGE, LA PRST STD US POSTAGE PAID BATON ROUGE, LA PERMIT NO. 458 What s New on the Web >I m a Provider UPDATED Education on Demand Page: - Updated your provider manuals (also available on ilinkblue) - Updated the OGB speed guide (see Page 4 for details) Get This Newsletter Electronically: Your correspondence address allows us to electronically keep you abreast of the latest Blue Cross news and some communications that are sent via only. provider.communications@bcbsla.com and please include a contact name, phone number and your provider number in your . 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!