updatesm August 2016 New transactions on NaviNet and user guides available page 5 New functionality for CAQH ProView page 4

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1 updatesm August 2016 New functionality for CAQH ProView page 4 New transactions on NaviNet and user guides available page 5 Behavioral health: Promoting provider communication and collaboration: Part 2 page 14

2 Inside this edition Administrative Required lead time when updating your provider information Carenet outreach program continues New functionality for CAQH ProView Notification for inpatient facility maternity claims NaviNet New transactions on NaviNet and user guides available Announcements Introducing Independence LIVE! Medical Coverage requirements for applied behavioral analysis for the treatment of autism spectrum disorders New policies for Modifier 53: Discontinued Procedure Updated policies for Always Bundled Procedure Codes Upcoming changes to 2016 epass incentive opportunity Reminder: Utilization management program for genetic/genomic tests, certain molecular analyses, and cytogenetic tests now in effect Upcoming coverage position changes for certain laboratory tests Vitamin D testing policies now in effect View up-to-date policy activity on our Medical Policy Portal Quality Management Updated physician quality measure rankings Health and Wellness Behavioral health: Promoting provider communication and collaboration: Part 2 Behavioral health resources available for assessment and treatment of opioid misuse and abuse Encourage pregnant Independence members to enroll in Baby BluePrints Help your patients get healthy this summer Partners in Health Update SM is a publication of Independence Blue Cross and its affiliates (Independence), created to provide valuable information to the Independence-participating provider community. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with Independence. This publication is the primary method for communicating such general changes. Suggestions are welcome. Contact information: Provider Communications Independence Blue Cross 1901 Market Street 27th Floor Philadelphia, PA provider_communications@ibx.com Models are used for illustrative purposes only. Some illustrations in this publication copyright All rights reserved. Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association. This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card. The third-party websites mentioned in this publication are maintained by organizations over which Independence exercises no control, and accordingly, Independence 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 are presented for informational purposes only. Certain services/ treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage. NaviNet is a registered trademark of NaviNet, Inc., an independent company. FutureScripts and FutureScripts Secure are independent companies that provide pharmacy benefits management services. CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. For articles specific to your area of interest, look for the appropriate icon: Professional Facility Ancillary Articles designated with a blue arrow include notice of changes or clarifications to administrative policies and procedures. Keystone Health Plan East, Personal Choice, Keystone 65 HMO, and Personal Choice 65 SM PPO have an accreditation status of Commendable from the National Committee for Quality Assurance (NCQA).

3 ADMINISTRATIVE Required lead time when updating your provider information Independence would like to remind you that, per your Independence Professional Provider Agreement and/or Hospital, Ancillary Facility, or Ancillary Provider Agreement (Agreement), you are required to notify Independence whenever key provider demographic information changes. Submitting changes in a timely manner helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories. Professional providers* Independence requires at least 30 days advanced notice to process most updates as long as the information submitted is accurate. For a complete outline of the advanced notice time frames that Independence requires to process most updates, refer to the Administrative Procedures section of the Provider Manual for Participating Professional Providers (Provider Manual). Most of the changes to basic practice information can be quickly submitted using the Provider Change Form, available at Note: The Provider Change Form cannot be used if you are closing your practice or terminating from the network. Refer to Resignation/termination from the Independence network in the Administrative Procedures section of the Provider Manual for more information regarding policies and procedures for resigning or terminating from the network. Facility and ancillary providers As outlined in the Administrative Procedures section of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, Independence requires at least 30 days advanced written notice to process changes to your information as long as the information submitted is accurate. Per your Agreement, all changes must be submitted in writing to our contracting and legal departments at the following addresses: Independence Blue Cross Attn: Senior Vice President, Provider Networks and Value-Based Solutions 1901 Market Street, 27th Floor Philadelphia, PA Independence Blue Cross Attn: Deputy General Counsel, Managed Care 1901 Market Street, 43rd Floor Philadelphia, PA Authorizing signature and W-9 Forms Updates resulting in a change on your W-9 Form (e.g., changes to a provider s name, tax ID number, billing vendor or pay to address, or ownership) require the following signatures: For professional providers: A signature from a legally authorized representative (e.g., head physician of the practice, practice administrator) is required. For facility and ancillary providers: Written notification on company letterhead is required. An updated copy of your W-9 Form reflecting these changes must also be included to ensure that we provide you with a correct 1099 Form for your tax purposes. If you do not submit a copy of your new W-9 Form, your change will not be processed. Independence will not be responsible for changes not processed due to lack of proper notice. If you have any questions about updating your provider information, please contact your Network Coordinator. * To ensure appropriate setup in Independence systems, the timelines outlined above also apply to behavioral health providers contracted with Magellan Healthcare, Inc., an independent company, but they must submit any changes to their practice information to Magellan via their online Provider Data Change form at by selecting the Display/Edit Practice Info link or by contacting their Network Management Specialist at for assistance. August 2016 Partners in Health Update SM 3

4 ADMINISTRATIVE Carenet outreach program continues As part of an ongoing commitment to improve health outcomes for members, Independence is continuing our outreach program to encourage our Medicare Advantage HMO and PPO members with gaps in care to visit their doctors. As a participating network provider, you may receive a call from Carenet Healthcare Services (Carenet), an independent company. Calls from Carenet are intended to help our members schedule needed appointments with their primary care physician (PCP) or specialist. A Carenet representative will contact our member to see if they would like to set up an appointment. If the member accepts, Carenet will conference in the member s PCP or specialist s office to facilitate scheduling the appointment. If you have any questions, please contact your network medical director. New functionality for CAQH ProView * CAQH recently enhanced CAQH ProView with new functionality so participating organizations receive complete CAQH ProView data profiles from providers, reducing the need for follow-up with providers after attestation. In addition, certain fields are now required. New improvements include: Employment information screen: It will be easier for providers to enter their employment history. Participating organizations use this information for verification purposes during the credentialing process. Required fields: Certain fields that were previously optional are now required. Participating organizations need this information for credentialing and to update provider directories. During re-attestation, CAQH ProView will prompt providers to update their profiles based on these new field requirements. The following sections contain fields that are now required: Professional IDs section Education section Professional Training section Specialties section Practice Location section These changes to CAQH ProView will not affect a provider s status in CAQH ProView or the ability for authorized participating organizations to view their data. If you have questions about the recent changes to CAQH ProView, please them at providerhelp@proview.caqh.org. *This does not apply to providers contracted with Magellan Healthcare, Inc. Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members. August 2016 Partners in Health Update SM 4

5 ADMINISTRATIVE Notification for inpatient facility maternity claims As previously communicated, with the transition to our new operating platform, there could be some differences in claims processing and outcomes. Please be advised that a notification is needed to assure proper claims payment for maternity admissions that exceed the following lengths of stay: vaginal deliveries of 5 days or greater cesarean deliveries of 7 days or greater If you have an admission that exceeds these parameters, please contact Clinical Services at ASK-BLUE to provide notification. For any questions regarding this requirement, please contact your Network Coordinator. NAVINET New transactions on NaviNet and user guides available In recent months, we have communicated information about several new transactions being introduced to Independence providers on the NaviNet web portal, including Eligibility and Benefits Inquiry, Claims Dashboard, and Document Exchange. New user guides are now available for these transactions, and we strongly encourage you to review them to become more familiar with the updates. Eligibility and Benefits Inquiry In July, we introduced our new Eligibility and Benefits Inquiry transaction to a select number of provider offices. Starting on August 3, 2016, all remaining NaviNet-enabled participating providers will be given access to this new transaction. The member search criteria will be modified, and the presentation of the eligibility and benefits information will change. The updated transaction will continue to provide you with access to real-time, detailed eligibility and benefits information for Independence members. You will be able to view information about a member s demographics, insurance, and cost-sharing (e.g., copayment, deductible, and coinsurance). In addition, the Eligibility and Benefits Details screen will offer a list of benefit categories to view and will continue to include links to the member s capitated site information (where applicable), ID card, and product-wide provisions associated with the member s benefit plan. Please note the following about the new Eligibility and Benefits Inquiry transaction: FEP members. The new transaction will not return information for Federal Employee Program (FEP) members. You will need to obtain eligibility and benefits information for FEP members through the Eligibility and Benefits Inquiry transaction in the BlueExchange Out of Area Workflows menu option. Dates of service. The new transaction will eventually allow you to search for a member s eligibility and benefits record up to two years in the past from the current date. However, when the new transaction is first released, you will only be able to search retroactively for dates of service on or after July 1, Eligibility and benefits information will not be available through NaviNet for dates of service prior to July 1, continued on the next page August 2016 Partners in Health Update SM 5

6 NAVINET continued from the previous page Claims Dashboard We recently introduced the new Claims Dashboard transaction, which allows you to view your Accounts Receivable in a more comprehensive manner. Claims Dashboard provides you with access to view both pended and finalized claims. Note: The data presented within the transaction is provided for general informational purposes. In addition, there is a lag time between finalized and pended claims data updates. Document Exchange Later this month, Document Exchange will be introduced to Independence providers. This new feature will allow us to share more information electronically with our provider network. When Document Exchange is first released, your designated NaviNet Security Officer will control which end users, including himself or herself, associated with your NaviNet office will be given access to the following five unique Practice Document Categories: Billing/Financial Report Patient Roster Report Patient Transition Report Pharmacy Report Program Enrollment Report Once an end user is granted permission to access a specific Practice Document Category, that individual will be able to view and download any documents associated with that category. For example, if a NaviNet Security Officer grants permission to an associate to access the Billing/Financial Reports category, all reports made available by Independence under that category will be available to the associate to view or download. It is important that your designated NaviNet Security Officer manages permissions appropriately for each document category to ensure reports are accessed in a manner that is compliant with role-based access requirements of the Health Insurance Portability and Accountability Act (HIPAA). Note: Third-party vendors that have access to NaviNet will not have the ability to access Document Exchange. Initial report The first report that will be made available under Document Exchange will be the High Risk Hospitalization Predictor report from August 2016 (not February 2016, which was previously communicated). This report will be made available to targeted primary care physician practices and, based on a predictive model, identifies members treated who are at high risk of acute hospitalization in the next six months and who have one or more of the following chronic conditions: chronic obstructive pulmonary disease (COPD) congestive heart failure (CHF) coronary artery disease (CAD) diabetes If you have questions or suggestions that relate to the High Risk Hospitalization Predictor report, please contact your network medical director. For more information You can download the recently published user guides for these new transactions in the NaviNet Resources section of our Provider News Center at If you have any questions about any NaviNet transactions, please call the ebusiness Hotline at August 2016 Partners in Health Update SM 6

7 ANNOUNCEMENTS Introducing Independence LIVE! Attention! An update has been made to the content of this article. Now open to the public, Independence is pleased to announce Independence LIVE, a new, state-of-the-art, customer experience center featuring licensed agents, health and wellness programs, a tech arcade, and live cooking demonstrations. Located on the 2nd floor of 1919 Market Street in Philadelphia, the center is home to our Customer Service Department, and is staffed with full-service, licensed agents who can accept premium payments, answer benefits and claims questions, and enroll or renew Independence members. Also available for our members are daytime and evening health and wellness events including classes and programs on nutrition, fitness, stress management, and family and financial health. Members can also attend demonstrations on healthy cooking in our full kitchen! Registration for these events can be made by visiting or calling Providers participating in our network may take advantage of Independence LIVE s Community meetingtspaces, which include multiple semi-private and private meeting rooms, reception space for up to 100 guests, a board room for up to 12 guests, and much more. Reserve a room by ing the Independence LIVE inbox at IndependenceLive@ibx.com. Please share this information with your Independence patients, and join us at Independence LIVE for any or all of the events and services offered. We look forward to sharing this center with our member and provider community. August 2016 Partners in Health Update SM 7

8 MEDICAL Coverage requirements for applied behavioral analysis for the treatment of autism spectrum disorders Independence s policy on the evaluation and management of autism spectrum disorders (ASD) is being updated to communicate our continuing position of medically necessary criteria for outpatient applied behavioral analysis (ABA) services for ASD for members enrolled in Independence commercial products. As a reminder, providers must obtain prior authorization for evaluation and management services for ASD to ensure consistent benefit adjudication, as well as appropriate utilization in accordance with state mandate requirements. About ABA services Methodologies to promote learning are believed to enhance verbal and non-verbal communication, improve developmentally appropriate self-care, teach social skills, and reduce maladaptive behaviors (e.g., harm to self or others). These methodologies are based on several model programs, including behavioral, structured teaching, and/or developmental programs. Of the many treatment modalities available for the management of ASD, ABA is arguably the most studied. The ABA modality applies human behavior principles in various settings (i.e., clinics, schools, homes, and communities) to diminish substantial deficits in a recipient s adaptive functioning or significant behavior problems due to ASD. ABA is the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior (e.g., positive reinforcement). It can also be used to teach new skills and to demonstrate that the interventions used are responsible for the observable improvements in behavior. The goal of ABA methods is to replace maladaptive, interfering behaviors with more desirable, adaptive behaviors and to narrow the conditions under which maladaptive, interfering behaviors occur. As set forth in the medical policy for evaluation and management of ASD, coverage of ABA services is contingent on the following: A current (within 24 months), documented diagnosis of ASD consistent with the DSM-5 criteria, using validated assessment tools, has been made by a qualified licensed treating professional provider including a physician, physician assistant, psychologist, or certified registered nurse practitioner as is consistent with state licensing requirements. The qualified licensed treating professional provider is other than the behavior analyst practitioner performing services related to ABA services. An individualized, documented treatment plan has been developed by a licensed professional provider (e.g., MD/DO, licensed psychologist). ABA services must be provided by or under the supervision of the following professionals: a Board Certified Behavior Analyst-Doctoral (BCBA-D) or Board Certified Behavior Analyst (BCBA)-graduatelevel certification in behavior analysis. For more information and a complete list of medically necessary criteria for ABA services, review Medical Policy # o: Evaluation and Management of Autism Spectrum Disorders (ASD), which is currently posted as a Notification and will become effective on August 19, To view the Notification for this policy, visit our Medical Policy Portal at Select Accept and Go to Medical Policy Online, then select Commercial under Active Notifications. If you have any questions, please contact your Network Coordinator. August 2016 Partners in Health Update SM 8

9 MEDICAL New policies for Modifier 53: Discontinued Procedure Effective October 1, 2016, Modifier 53: Discontinued Procedure can be reported when a professional provider or other qualified health care professional terminates a procedure (e.g., surgical or diagnostic) due to extenuating circumstances that may threaten the health of a patient. When Modifier 53 is appended to a procedure, the service(s) is eligible for reimbursement at 50 percent of the provider s applicable contracted rate. Independence created the following policies, which were posted as Notifications on July 1, 2016, to address the use of Modifier 53: Commercial: # : Modifier 53: Discontinued Procedure Medicare Advantage: #MA03.018: Modifier 53: Discontinued Procedure Note: These policies apply to professional providers who bill on a CMS-1500 claim form or the electronic equivalent, 837P, for all Independence members. To view the Notifications for these policies, visit our Medical Policy Portal at and select Accept and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications. If you have any questions, please contact your Network Coordinator. Updated policies for Always Bundled Procedure Codes Always Bundled Procedure Codes are not eligible for separate reimbursement whether billed alone or in conjunction with other services. Effective October 1, 2016, the following anesthesia CPT codes will be added to the list of Always Bundled Procedure Codes: 99100, 99116, 99135, and Updates to the following policies were posted as Notifications on July 1, 2016: Commercial: # d: Always Bundled Procedure Codes Medicare Advantage: #MA00.026b: Always Bundled Procedure Codes Note: These policies apply to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837P, for all Independence members. To view the Notifications for these policies, visit our Medical Policy Portal at and select Accept and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications. If you have any questions, please contact your Network Coordinator. Upcoming changes to 2016 epass incentive opportunity Please note that you will be receiving a letter from Independence in regards to changes to Please the note 2016 that epass in the coming incentive weeks you opportunity may receive for a professional letter from Independence providers in in regards the coming to changes weeks. to the In 2016 addition, epass incentive more information opportunity for will professional be published providers. in the In addition, September more edition information of Partners about these in changes Health will be published Update. in the September edition of Partners in Health Update. August 2016 Partners in Health Update SM 9

10 MEDICAL Reminder: Utilization management program for genetic/ genomic tests, certain molecular analyses, and cytogenetic tests now in effect Independence recently introduced a new utilization management program for genetic/genomic tests, certain molecular analyses, and cytogenetic tests for all commercial Independence members. We are working with CareCore National, LLC d/b/a evicore healthcare (evicore), an independent specialty benefit management company, to manage precertification and/or prepayment reviews. Please note that the ordering provider is responsible for the prior authorization to ensure the member s care is not interrupted. Precertification requirements Ordering health care providers must contact evicore to obtain precertification for certain genetic/genomic tests, including, but not limited to, the following:* BRCA gene testing genetic panels and cancer gene expression tests genome-wide tests pharmacogenomic tests You can find the complete list of procedure codes requiring precertification at Online%20Forms/Independence%20Lab%20Prior%20 Authorization%20Codes.pdf. Submitting requests to evicore You can request precertification for genetic/genomic tests by calling evicore directly at or submitting requests via the NaviNet web portal. To submit a request on NaviNet, select CareCore from the Authorizations option in the Workflows menu, and a new window will open that sends providers directly to evicore s provider portal to initiate the precertification process. Once on evicore s portal, you will be required to create a login and password, which will be used every time you request precertification through evicore. If you have already established credentials for evicore s portal, please use your current login information. Important information for laboratories When a request for genetic/genomic testing is received, laboratories must ensure a precertification is on file before rendering services. If precertification is not on file for the member, it is the laboratory s responsibility to submit a request to evicore. Prepayment review All genetic/genomic tests, along with certain molecular analyses and cytogenetic tests are reviewed by evicore. Examples of molecular analyses and cytogenetic tests include, but are not limited to, the following:* comparative genomic hybridization (CGH) flow cytometry fluorescent in situ hybridization (FISH) immunohistochemistry (IHC) morphometric analyses Lab management policy and guidelines Review Medical Policy # : evicore Lab Management Program for more information about the utilization management program. The policy includes a link to the Lab Management Program Clinical Guidelines that evicore uses during the precertification and prepayment review processes, as well as a listing of procedure codes requiring precertification and/or prepayment review. To view this policy, visit our Medical Policy Portal at Select Accept and Go to Medical Policy Online, then select the Commercial tab from the top of the page and type the policy name or number in the Search field. More information If you have questions about any of these requirements, you can contact your Network Coordinator or call Customer Service at ASK-BLUE. *This list of services is subject to change. August 2016 Partners in Health Update SM 10

11 MEDICAL Upcoming coverage position changes for certain laboratory tests Effective October 1, 2016, our coverage position on the laboratory tests outlined below will be considered experimental/investigational. Fecal calprotectin Effective October 1, 2016, procedure code 83993: Fecal calprotectin will be considered experimental/investigational for all commercial and Medicare Advantage members. Fecal calprotectin is a calcium- and zinc-binding protein that is a potential marker of intestinal inflammation. Fecal calprotectin testing is proposed as a noninvasive test to diagnose inflammatory bowel disease (IBD). Other proposed uses are to evaluate response to treatment for patients with IBD and as a marker of relapse. Peer-reviewed evidence does not unequivocally support the clinical usefulness of this testing for management of any patient populations. Nontraditional lipid biomarkers Effective October 1, 2016, the following procedure codes will be considered experimental/investigational for all commercial members: procedure code 83695: Lipoprotein (a); procedure code 83700: Lipoprotein, blood; electrophoretic separation and quantitation; procedure code 83701: Lipoprotein, blood; high-resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation). Low-density lipoproteins (LDLs) have been identified as the major atherogenic lipoproteins and have long been identified by the National Cholesterol Education Project (NCEP) as the primary target of cholesterol-lowering therapy. Numerous nontraditional lipid and non-lipid biomarkers have been proposed as potential risk markers for cardiovascular disease. There is a lack of consensus among professional guidelines, and the quality of peer-reviewed evidence is insufficient to determine the effects of these nontraditional lipid and non-lipid biomarkers on relevant health outcomes, including any clinically important information beyond that of traditional lipid measures, in the intended patient populations. Policy updates The change in coverage position for these procedure codes is also communicated in the following policy Notifications, which were posted on July 1, 2016, and will become effective on October 1, 2016: Commercial: # ah: Experimental/Investigational Services Medicare Advantage: #MA00.005g: Experimental/Investigational Services To view the Notifications for these policies, visit our Medical Policy Portal at and select Accept and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications. If you have any questions about these changes, please contact your Network Coordinator. August 2016 Partners in Health Update SM 11

12 MEDICAL Vitamin D testing policies now in effect Vitamin D, also known as calciferol, is a fat-soluble vitamin that has a variety of physiologic effects, most prominently in calcium homeostasis and bone metabolism. Providers are reminded there should be a direct medical need or indication for testing of vitamin D serum levels. Therefore, routine testing for vitamin D deficiency in healthy adults and children is not indicated according to evidence-based reviews or clinical practice guidelines from organizations that include, but are not limited to, the U.S. Preventive Services Task Force. Vitamin D testing The following policies, effective as of August 1, 2016, were developed by Independence to communicate the medically necessary uses for vitamin D testing: Commercial: # : Testing Serum Vitamin D Levels Medicare Advantage: #MA06.031: Vitamin D Assay Testing To view these policies, visit our Medical Policy Portal at Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you would like to view. Then type the policy name or number in the Search field. When clinically appropriate, Independence-participating laboratories are capable of performing vitamin D testing. If you have any questions about participating laboratories, please contact your Network Coordinator. View up-to-date policy activity on our Medical Policy Portal Changes to Independence medical and claim payment policies for our commercial and Medicare Advantage Benefit Programs occur frequently in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity section of our Medical Policy Portal in order to keep up to date with changes to our policies. The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics include: Notifications New Policies Updated Policies Reissued Policies Coding Updates Archived Policies For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference. News & Announcements In addition to the information posted in our Site Activity section, articles related to our website and medical and claim payment policies are periodically posted within the News & Announcements section. Simply select the appropriate link (Commercial, Medicare Advantage, or MAPPO Host) under the News & Announcements header on the Medical Policy Portal homepage to stay informed of the latest information. To access the Site Activity section, go to our Medical Policy Portal at and select Accept and Go to Medical Policy Online. From here you can select Commercial or Medicare Advantage under Site Activity to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage tab from the top of the page. To access medical policies from Independence NaviNet Plan Central, select Medical Policy Portal under Provider Tools in the right hand column. August 2016 Partners in Health Update SM 12

13 QUALITY MANAGEMENT Updated physician quality measure rankings During the third quarter of 2016, Independence will submit updated physician ratings to the Blue Cross and Blue Shield Association (BCBSA), an association of independent Blue Cross and Blue Shield plans, to be displayed within their National Doctor and Hospital Finder at These ratings are also currently available on our local Find a Doctor/Hospital tool at within the Accreditation & Quality tab. The following physician quality measures are rated: Cancer Screening Breast Cancer Screening Cervical Cancer Screening Diabetes Blood Sugar (Glucose) Testing LDL-C (Bad Cholesterol) Screening Patients with Diabetes Kidney Disease (Nephropathy) Screening and Treatment Heart Disease Beta-Blocker (PBH) Treatment after a Heart Attack LDL-C (Bad Cholesterol) Screening for Heart Patients Conditions Immunizations Chicken Pox (VZV) Measles, Mumps, Rubella (MMR) Medication monitoring Monitoring for Patients (Adults) on Persistent Medications Respiratory infections Bronchitis Avoidance of Antibiotic Treatment in Adults Strep Test for Sore Throat Appropriate Use of Antibiotics Common Colds (Treatment) Avoidance of Antibiotics Women s health Breast Cancer Screening (same measure under Cancer Screening) Cervical Cancer Screening (same measure under Cancer Screening) If you wish to review your scores in advance of our submission, you can do so from August 8 through September 30. For more information on how to review your scores, please contact your Network Coordinator. August 2016 Partners in Health Update SM 13

14 HEALTH AND WELLNESS Behavioral health: Promoting provider communication and collaboration We are pleased to continue our short series of articles in Partners in Health Update that is designed to explore potential barriers and opportunities to facilitate communication and collaboration between primary care physicians and behavioral health providers and to achieve optimal outcomes for your patients. Part 2 Behavioral health resources available for assessment and treatment of opioid misuse and abuse* Pain management is a complex issue for many primary care physicians (PCP). Generally, PCPs are able to identify opioid abuse, but opioid misuse is more difficult to pinpoint especially in those patients with chronic pain. 1 Independence and Magellan Healthcare, Inc. (Magellan), an independent company, are aware that opioid management is a current and relevant problem for PCPs. As such, we are collaborating to provide resources for the assessment and management of opioid misuse and abuse. The Chabal 5-Point Prescription Opiate Abuse Checklist, available at includes questions you may have already incorporated into your daily practice. This checklist is a reliable and valid tool. Three positive responses alert you to possible abuse of prescription opiates. 2 The National Institute on Drug Abuse 3 (NIDA), a subdivision of the National Institutes of Health (NIH), provides resource tools for screening patients for opiate misuse and abuse. Two such aids include: NIDA Drug Use Screening Tool. This online screening tool assists providers in identifying risk of substance abuse and resources in patient care and support. CAGE-AID assessment tool. The CAGE-AID assessment tool is similar to the CAGE assessment tool for alcoholism, but adapted to assess for other substance use. You also can check an opioid database (state-based databases with information on patients with opioid prescriptions that provide patient-specific data on frequency, dose, and name of medication as well as a list of prescribing practitioners) for patterns in member prescriptions and opioid use. Additionally, the NIDA has a variety of assessment tools and questionnaires that patients can complete before they see their PCP. This is especially helpful if completed by new patients or patients requiring pain management for the first time. These self-reported questionnaires provide valuable information about patient history and behaviors that can contribute to opioid abuse. During the course of treatment, the PCP can re-evaluate the patient and implement strategies to more effectively manage these behaviors while providing pain management. You can access screening tools and other resources via the NIDA website at Magellan can assist with getting your patient the right services The relationship the PCP has with his or her patient with chronic pain is valuable; this relationship creates a strong base to facilitate an open discussion as well as help solve issues. As concerns arise, you may want to start a discussion with your patient about your observations and alternatives for pain management. This may be a difficult conversation to initiate because of the social stigma of abuse and addiction attached to prescription pain medication as well as the patient s own perceptions of pain and medication use. continued on the next page August 2016 Partners in Health Update SM 14

15 HEALTH AND WELLNESS continued from the previous page Fortunately, there are behavioral health providers available who can assist with your concerns about your patients behaviors. Magellan is available to assist in matching the patient with the right behavioral health provider. If you identify possible opioid abuse or misuse, you can: Encourage the patient to call the number on the back of their medical ID card to arrange a referral to a behavioral health provider. A Plan staff member will work with the member to determine the most appropriate resource based on patient need and preference, provider specialty, and provider location, as well as other specific patient requests or considerations. Contact Magellan directly (with patient permission) to request assistance with connecting the patient to the appropriate behavioral health provider. Magellan s Behavioral Health Disorders Toolkit Magellan also offers access to a variety of collaborative behavioral health materials, including substance use resources, through Magellan s Behavioral Health Disorders Toolkit. Organized by category, the materials are designed to give medical practitioners the information and screening tools needed to assist in making behavioral health referrals. You can access Magellan s Behavioral Health Disorders Toolkit, including information on CAGE and CAGE-AID screening, via our Providers webpage at or on the NaviNet web portal in the Administrative Tools & Resources section under Health and Wellness. Working together We are committed to promoting integration of medical and behavioral health services toward the goal of better overall outcomes for patients and encourage you to access these resources. Remember, you don t have to do this alone. Collaboration with a behavioral health provider can enhance the treatment regimen that you and your patient are developing to manage pain. * These guidelines are not intended to replace a practitioner s clinical judgment. They are designed to provide information and to assist practitioners with decisions regarding care. The guidelines are not intended to define a standard of care or exclusive course of treatment. Health care practitioners using these guidelines are responsible for considering their patients particular situation in evaluating the appropriateness of these guidelines. This information is not a statement of benefits. Benefits may vary and individual coverage must be verified. 1 Hartrick, C, Gatchel, R & Conroy, S. (2012). Identification and management of pain medication abuse and misuse: current state and future directions, Expert Review of Neurotherapeutics, 12:5, , DOI: /ern 12_34. 2 Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. (1997) Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors, Clinical Journal of Pain, Jun: 13(2): National Institute on Drug Abuse: Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members. August 2016 Partners in Health Update SM 15

16 HEALTH AND WELLNESS Encourage pregnant Independence members to enroll in Baby BluePrints The Baby BluePrints program supports expectant mothers and promotes a healthy pregnancy throughout each trimester. We ask that you inform pregnant Independence members about the Baby BluePrints program at their first prenatal visit and encourage them to self-enroll by calling our toll-free number, BABY. Upon calling, a Health Coach will explain the program to the member and ask her a series of questions to complete the enrollment process. Once enrolled in the program, members will receive a welcome letter that includes information on how to access educational materials on our secure member website, and the BABY phone number for questions and support during pregnancy. In addition, high-risk members eligible for condition management will be given the name and contact information for a Health Coach. Resources available Upon request, a flyer is available to place in the member s chart and distribute at the first prenatal visit to encourage her to enroll in Baby BluePrints. To order flyers, please submit an online request at or call the Provider Supply Line at If you have any questions, please call Customer Service at ASK-BLUE. Postpartum office visits As a reminder, postpartum visits should be scheduled 21 to 56 days after delivery. Adhering to this time frame provides the best opportunity to assess the physical healing for new mothers and to prescribe contraception, if necessary. These visits should be scheduled before members are discharged from the hospital. August 2016 Partners in Health Update SM 16

17 HEALTH AND WELLNESS Help your patients get healthy this summer Summer is in full swing and with warm, sunny weather comes longer days, summer trips, and visits from friends and family. For your older patients, keeping up with this increased activity can be a challenge SilverSneakers Fitness can help them conquer it. SilverSneakers is a benefit that is available at no additional cost to Keystone 65 Select HMO, Keystone 65 Preferred HMO, Keystone 65 Focus Rx HMO, and Personal Choice 65 SM PPO members. Some of these members may be eligible but not yet taking advantage of this benefit. SilverSneakers SilverSneakers benefits benefits includes: include: a a fitness fitness membership membership at a at local a local fitness fitness location location plus plus access access to 13,000+ to 13,000+ locations locations nationwide nationwide with with access to exercise access equipment, to exercise swimming equipment, pools, swimming saunas, pools, and saunas, other amenities and other (varies amenities;* by location); signature signature SilverSneakers SilverSneakers classes classes designed designed specifically specifically for older for older adults adults and taught and taught by certified by certified instructors; instructors; yoga yoga and and tai tai chi chi classes, classes, walking walking groups, groups, and and other other activities activities held held outdoors outdoors and and at at various various neighborhood neighborhood locations;* locations;* fun social events, a supportive online community, and helpful resources. fun social events, a supportive online community, and helpful resources. SilverSneakers helps millions of members gain strength, improve balance, and lead healthier lives. In fact, 62 percent of members in 2015 reported their health as excellent or very good 1 compared to only 30 percent of older adults nationally. The program works because it s easy and fun. SilverSneakers members aren t just exercising they re getting out, making friends, and improving their quality of life. Encourage your Independence Medicare Advantage patients to visit or call (TTY: 711), Monday through Friday, 8 a.m. 8 p.m. ET, and start taking advantage of this incredible health benefit. *Amenities vary by location. 1 Healthways SilverSneakers Annual Member Survey, 2015 (based on SF-12 scores) SilverSneakers is a registered trademark of Healthways, Inc. and/or its subsidaries, independent companies Healthways, Inc. All rights reserved. August 2016 Partners in Health Update SM 17

18 Important Resources Anti-Fraud and Corporate Compliance Hotline or Clinical Services Baby BluePrints / BABY (2229)* Case and Condition Management Credentialing Credentialing Violation Hotline or Customer Service Provider Services (prompt 1) ASK-BLUE ( ) Provider Automated System User Guide Electronic Data Interchange (EDI) Highmark EDI Operations FutureScripts (commercial pharmacy benefits) Prescription drug prior authorization Pharmacy website (formulary updates, prior authorization) FutureScripts Secure (Medicare Part D pharmacy benefits) FutureScripts Secure Customer Service Formulary updates Mental Health/Substance Abuse Precertification Independence Independence Administrators CHIP NaviNet web portal Independence ebusiness Hotline Registration Other frequently used phone numbers and websites Independence Direct Ship Drug Program (medical benefits) Medical Policy Provider Supply Line or *Outside 215 area code Visit our Provider News Center: