CLAIM ADJ USTMENT REQUEST FORM, (C-349)

PROFESSIONAL ADMINISTRATIVE BULLETIN: 2012P-07-008 Date: July 1, 2012 To: All Capital BlueCross and Capital Advantage Insurance Company Participating Professional Providers All Keystone Health Plan Central Participating Professional Providers Effective Date: September 1, 2012 (Unless otherwise indicated) A description of new and/or changed professional provider requirements and/or reimbursement policies, including the products impacted, is shown below. The subjects covered in this Administrative Bulletin are: Claim Adjustment Request Form, (C-349) Coverage Determination Request Forms Now Available Online Long Term Acute Care Hospital (LTACH), (MP-3.011) Obesity Management CLAIM ADJ USTMENT REQUEST FORM, (C-349) CBC Traditional and Comprehensive CBC POS SeniorBlue PPO Keystone Health Plan Central CBC PPO SeniorBlue HMO The following applies only to DME, IV Therapy, Ambulance and Orthotics/Prosthetics providers Ancillary providers submitting services on a HCFA 1500 claim form will be required to submit claim adjustment requests using the Capital BlueCross Provider Claims Adjustment Request Form (C-349) beginning September 1, 2012. An adjustment is considered a correction to a finalized claim. Instructions for submitting an adjustment are located on the back of the form. A copy of the form and instructions for completion are available in Exhibit 4 of the 2012 Provider Manual. Completed claim adjustment forms should be sent to the address located at the bottom of the form. Claim adjustment request outcomes are reported on the provider Statement of Remittance (SOR). If you currently submit your adjustments electronically, please continue doing so. Retain a copy of this Administrative Bulletin with your Provider Manual For the most current information, visit www.capbluecross.com Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

PROFESSIONAL ADMINISTRATIVE BULLETIN: 2012P-07-008 COVERAGE DETERMINATION REQUEST FORMS NOW AVAILABLE ONLINE CBC Traditional and Comprehensive CBC POS SeniorBlue PPO Keystone Health Plan Central CBC PPO SeniorBlue HMO To help promote appropriate utilization, certain medications require prior authorization to be eligible for coverage under the prescription drug benefit prior to the medication being dispensed by the pharmacy. Providers may initiate authorization of these medications by contacting CVS Caremark either by telephone or in writing. For your convenience, the coverage determination forms are now available in the Pharmacy Information and Forms section of the Provider Library on the Capital BlueCross health plan home page via the NaviNet portal. These forms are for Commercial members only and are not applicable for Medicare members. Please call CVS Caremark at 1-800-844-0719 to request forms for SeniorBlue HMO members or call 1-800-861-1737 to request forms for SeniorBlue PPO members. Completed forms may be faxed to the number listed on the form or they can be mailed to the following address: CVS Caremark ATTN: PA Department 1300 E Campbell Road Richardson, TX 75081 Please be sure that you utilize the appropriate form when requesting coverage. NaviNet is an independent company providing this provider portal service on behalf of Capital BlueCross. LONG TERM ACUTE CARE HOSPITAL (LTACH), (MP -3.011) CBC Traditional and Comprehensive CBC POS SeniorBlue PPO Keystone Health Plan Central CBC PPO SeniorBlue HMO Capital BlueCross will retire Medical Policy, 3.011 titled Long Term Acute Care Hospital (LTACH) effective July 1, 2012. The content from the medical policy will not change but be transitioned into the attached Guidelines. All requests for admissions or transfers to an LTACH facility must be reviewed by a plan medical director who will make an individual decision in each case based upon the member s reported clinical status and other relevant factors related to the transfer to a different facility type. The attached guidelines are not a guarantee of approval or coverage. Page 2

PROFESSIONAL ADMINISTRATIVE BULLETIN: 2012P-07-008 OBESITY MANAGEMENT CBC Traditional and Comprehensive CBC POS SeniorBlue PPO Keystone Health Plan Central CBC PPO SeniorBlue HMO Effective July 1, 2012, the following intensive behavioral therapy services may be covered for members covered by either SeniorBlue HMO or SeniorBlue PPO with obesity (defined as a BMI 30 kg/m2) when performed by a primary care practitioner: One face-to-face visit every week for the first month One face-to-face visit every other week for month 2-6 One face-to-face visit every month for month 7-12, if at the 6 month visit it is determined that the member lost 3 kg during the course of the first 6 months of counseling Capital BlueCross recommends a Body Mass Index (BMI) measurement at least every 2 years. This is a nationally recognized quality measure. Additionally, Capital BlueCross recommends education and counseling related to weight loss strategies for SeniorBlue HMO and SeniorBlue PPO members who are overweight or obese. The following resources are available: Body Mass Index (BMI) Charts: height ranges from 4 8 to 6 5 and whose weight ranges from 80 to 260 pounds. See attached chart. Printable BMI charts are available on the Capital BlueCross health plan home page via the NaviNet portal. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults Developed cooperatively by the North American Association for the Study of Obesity (NAASO) and the National Heart, Lung, and Blood Institute (NHLBI). Evidence-based methodology to develop key recommendation for assessing and treating overweight and obese patients Available at: http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm QUESTIONS For questions regarding the information in this Administrative Bulletin, please contact your Provider Relations Consultant. ATTACHMENTS Long Term Acute Care Hospital (LTACH) Guidelines Page 3

PROFESSIONAL ADMINISTRATIVE BULLETIN: 2012P-07-008 Body Mass Index (BMI) Charts Page 4

ADMINISTRATIVE BULLETIN: 2012P-07-008 Attachment 1 Long Term Acute Care Hospital (LTACH) Guidelines: All requests for admission or transfer to an LTACH facility must be reviewed by a plan medical director. Care and services in an LTACH may be considered medically necessary for the following categories of patients described in detail below: Prolonged Ventilator Weaning LTACH admission may be considered medically necessary for patients determined to be ventilator dependent as defined by: A minimum of one week failed ventilator weaning in an ICU or acute care facility supervised by a pulmonary or intensivist specialty physician, or The inability to attempt weaning due to an underlying medicla condition such as pneumothorax or flail chest, and Weaning potential is not precluded by an underlying condition such as brain death The following criteria must also be met: The patient must be medically stable so that transfer from an acute care hospital setting to an acute LTACH setting is medically feasible as determined by the following conditions being satisfied. The patient does not require ongoing multi-specialty care or consultation; and The patient is neurologically stable, and The patient is not actively bleeding or requiring blood products, and All major diagnoses are established and no significant diagnostic testing requiring an acute hospital setting are present, and The patient has not been determined to be permanently ventilator dependent The ability to wean the patient from the ventilator would be enhanced by the equipment and staff available in an LTACH Retain a copy of this Administrative Bulletin with your Provider Manual For the most current information, visit www.capbluecross.com Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

ADMINISTRATIVE BULLETIN: 2012P-07-008 Attachment 1 Complex Wound Care LTACH admission may be considered medically necessary for complex Stage III and IV wounds with need for intensive assessment and treatment that meet the following criteria: Complex dressings and therapies are expected to require at least 25 days to complete, and Significant co-morbidities exist that require additional support unavailable at an acute care hospital or at a lower level of care such as a skilled nursing facility, and Treatment is precluded at an acute care hospital due to: Lack of onsite wound care services and specialty care; or Lack of high technology equipment (i.e., wound vac, etc) Treatment is precluded at a skilled nursing facility due to: Lack of onsite wound care services and specialty care; or Lack of high technology equipment; or Nursing care exceeds 6.5 hours per 24 hour period Medically Complex Patients Care at an acute LTACH may be considered medically necessary for patients with complex medical problems who cannot be managed in the acute hospital setting or at a lower level of care due to lack of either high technology equipment or specialty care. In addition, the length of stay should be expected to exceed 25 days. In order to be considered eligible, the patient must not have any of the following: Active bleeding or requirement for frequent blood products Blood pressure instability or significant cardiac arrhythmia Requirement for ongoing multiple specialty consultation that would require an acute hospital setting Neurological and/or Musculoskeletal Disorders Requiring Comprehensive Medical and/or Rehabilitation Care Care at an acute LTACH may be considered medically necessary for patients requiring comprehensive rehabilitation such as brain and spinal cord injuries, multiple trauma cases, joint replacements, etc., whose care cannot be administered at an acute rehabilitation setting. Continuation of General LTACH Admission Guidelines: Medical necessity and appropriateness of all LTACH admissions, transfers, and approved lengths of stay will be made in accordance with program-specific benefits and the guidelines set forth in this document. Page 2

ADMINISTRATIVE BULLETIN: 2012P-07-008 Attachment 1 In some cases, a member may meet the criteria for admission to an LTACH; however, if in the opinion of the reviewing medical director, care can be best provided by keeping the member at the acute hospital care level, then admission to the LTACH may be considered not medically necessary. If care can be provided in the setting of an inpatient rehabilitation facility or a skilled nursing facility, then LTACH admission is considered not medically necessary. Continued stay determinations will be made by a concurrent care nurse in coordination with a Plan medical director. When a member in an LTACH has progressed to a point where ongoing inpatient care is still required but can be provided at a skilled nursing facility or inpatient rehabilitation facility, continuation of stay in the LTACH setting may be considered not medically necessary. Patients with any of the following are not considered eligible for treatment in an LTACH setting: Requirement for ongoing multiple specialty consultation that would require an acute hospital setting; Ancillary services such as dialysis in the setting of acute renal failure (dialysis for chronic renal failure is an eligible condition), ultra filtration, plasmaphoresis, etc., that may be better done in an acute hospital setting; Active bleeding or requirement for frequent blood products; or Blood pressure instability or significant cardiac arrhythmia. Page 3

Body Mass Index (BMI) Charts http://www.vertex42.com/exceltemplates/bmi-chart.html 2009 Vertex42 LLC WEIGHT Body Mass Index (BMI) Table for Adults Obese (>30) Overweight (25-30) Normal (18.5-25) Underweight (<18.5) HEIGHT in feet/inches and centimeters 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" lbs (kg) 142cm 147 150 152 155 157 160 163 165 168 170 173 175 178 180 183 185 188 191 193 196 260 (117.9) 58 56 54 53 51 49 48 46 45 43 42 41 40 38 37 36 35 34 33 32 32 31 255 (115.7) 57 55 53 51 50 48 47 45 44 42 41 40 39 38 37 36 35 34 33 32 31 30 250 (113.4) 56 54 52 50 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 30 245 (111.1) 55 53 51 49 48 46 45 43 42 41 40 38 37 36 35 34 33 32 31 31 30 29 240 (108.9) 54 52 50 48 47 45 44 43 41 40 39 38 36 35 34 33 33 32 31 30 29 28 235 (106.6) 53 51 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29 28 230 (104.3) 52 50 48 46 45 43 42 41 39 38 37 36 35 34 33 32 31 30 30 29 28 27 225 (102.1) 50 49 47 45 44 43 41 40 39 37 36 35 34 33 32 31 31 30 29 28 27 27 220 (99.8) 49 48 46 44 43 42 40 39 38 37 36 34 33 32 32 31 30 29 28 27 27 26 215 (97.5) 48 47 45 43 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26 25 210 (95.3) 47 45 44 42 41 40 38 37 36 35 34 33 32 31 30 29 28 28 27 26 26 25 205 (93.0) 46 44 43 41 40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25 24 200 (90.7) 45 43 42 40 39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24 24 195 (88.5) 44 42 41 39 38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24 23 190 (86.2) 43 41 40 38 37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23 23 185 (83.9) 41 40 39 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22 180 (81.6) 40 39 38 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 175 (79.4) 39 38 37 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 170 (77.1) 38 37 36 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 165 (74.8) 37 36 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 20 160 (72.6) 36 35 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19 19 155 (70.3) 35 34 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19 18 150 (68.0) 34 32 31 30 29 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18 18 145 (65.8) 33 31 30 29 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18 17 140 (63.5) 31 30 29 28 27 26 26 25 24 23 23 22 21 21 20 20 19 18 18 17 17 17 135 (61.2) 30 29 28 27 26 26 25 24 23 22 22 21 21 20 19 19 18 18 17 17 16 16 130 (59.0) 29 28 27 26 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16 15 125 (56.7) 28 27 26 25 24 24 23 22 21 21 20 20 19 18 18 17 17 16 16 16 15 15 120 (54.4) 27 26 25 24 23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15 14 115 (52.2) 26 25 24 23 22 22 21 20 20 19 19 18 17 17 16 16 16 15 15 14 14 14 110 (49.9) 25 24 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15 14 14 13 13 105 (47.6) 24 23 22 21 21 20 19 19 18 17 17 16 16 16 15 15 14 14 13 13 13 12 100 (45.4) 22 22 21 20 20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 12 12 12 95 (43.1) 21 21 20 19 19 18 17 17 16 16 15 15 14 14 14 13 13 13 12 12 12 11 90 (40.8) 20 19 19 18 18 17 16 16 15 15 15 14 14 13 13 13 12 12 12 11 11 11 85 (38.6) 19 18 18 17 17 16 16 15 15 14 14 13 13 13 12 12 12 11 11 11 10 10 80 (36.3) 18 17 17 16 16 15 15 14 14 13 13 13 12 12 11 11 11 11 10 10 10 9 Note: BMI values rounded to the nearest whole number. BMI categories based on CDC (Centers for Disease Control and Prevention) criteria. www.vertex42.com BMI = Weight[kg] / ( Height[m] x Height[m] ) = 703 x Weight[lb] / ( Height[in] x Height[in] ) 2009 Vertex42 LLC [42] The information provided is meant for a general audience. It is not a substitute for services or advice received from your health care providers who are the only ones that can diagnose and treat your individual medical conditions. Capital BlueCross and its affiliated companies believe this health education resource provides useful information but do not assume any liability associated with its use. If you have any questions about the information, please contact your health care provider. Individual coverage for any services that may be discussed in this resource depends on your benefits plan. To determine coverage for any health care service, please refer to your Certificate of Coverage or Evidence of Coverage or call Customer Service at the toll-free number on your Member identification card. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. GR-H5-93.indd (5/7/2012)