NEW HMSA MEMBERSHIP CARDS WITH QR CODES

HMSA s For Participating Medical Practitioners October 2011 What s Inside Quarterly Audits Scheduled by BCBSA 2 Electronic 2 Plans and Programs 2 Policy News 5 TriWest 6 CHANGES TO AKAMAI ADVANTAGE PLANS, INTRODUCING SELECT PLUS Significant changes for HMSA Akamai Advantage plans are effective Jan. 1, 2012. In January, HMSA also launches its latest plan, Akamai Advantage Select Plus, available to Oahu members only. Select Plus includes medical and drug coverage, access to the Healthways SilverSneakers fitness program, and enhanced vision benefits. More information on our new plans, benefits, training sessions, and more will be sent to your office soon. Please visit the Provider Resource Center s Medicare E-Library section for more information, including the Summary of Benefit Changes and copayment tables. Akamai Advantage Secure, Preferred, Assured, and Select plan changes include fees related to vision, doctor office visits, inpatient facility stays, outpatient services, ambulance transport, and drug plan copayments. Pre-certification requirement changes will also go into effect Jan. 1, 2012, and can be found in the Medicare E-Library section. HMSA FORMULARY FOR MEDICARE PLANS AVAILABLE ONLINE Visit the Provider Resource Center s Medicare E-Library Pharmacy and Formulary section to find formularies for HMSA s Medicare plans. You will also find related information about price structures for members enrolled in the Akamai Advantage Secure, Preferred, Assured, Select, and the new Select Plus plans. Also in the E-Library are links for pre-authorization, including those for drugs that have quantity limits or require step therapy. NEW HMSA MEMBERSHIP CARDS WITH QR CODES HMSA is rolling out a new version of its membership cards to members who change their plans or request new cards. All other members can continue to use their current cards. The new cards will feature a digital Quick Response (QR) code used to store retrievable information. HMSA s current use of the QR codes is limited to the subscriber identification number. In the future, HMSA will use QR codes to enhance its member and provider services. 1100-0177 Hawaii Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI 96808-0860 Phone: (808) 948-5110 Branch offices located on Hawaii, Kauai and Maui Internet address: www.hmsa.com Provider Resource Center: hhin.hmsa.com

2 Provider Update - Medical Practitioners October 2011 QUARTERLY AUDITS SCHEDULED BY BCBSA Auditors contracted by the Blue Cross and Blue Shield Association (BCBSA) will be in touch with HMSA participating providers for quarterly audits. Providers can expect to hear from the auditors Oct. 10 24 to verify their location, telephone numbers, and other demographic information for the BlueWeb Doctor Finder System. Thank you in advance for your cooperation with this audit. ELECTRONIC HIPAA 5010 Readiness HMSA encourages providers to be ready when the new electronic data interchange (EDI) Version 5010 standards go into effect Jan. 1, 2012. That is when all HIPAA electronic transactions, including 837 claims and QUEST claims submissions, must comply with Version 5010. HMSA recommends that providers contact their software vendor to confirm that all EDI services are functional before the 2012 deadline. To avoid rejected claims, please be sure to: Indicate MC for Medicaid when filing QUEST 5010 claims. Include QUEST members unique ID. All QUEST claims should be submitted with the patient listed as subscriber in the subscriber portion (not in the patient portion of the claim). The patient portion of the claim is used only when the patient is a newborn who has yet to receive their own member ID. HHIN Classic Countdown HHIN Classic will no longer be available after Oct. 24, 2011. To avoid technical delays, please log in to HHIN 2.0 and complete the registration. An email will be sent with a link to complete the registration process. Workshops for HHIN 2.0 are coming soon, and details are available on the HHIN homepage. One of the new features available on HHIN 2.0 is member eligibility for vision benefits. On the member s eligibility detail page, select AL-VISION (Optometry) where member copayment and deductible information is displayed. You can also view vision benefit limitations and date of the last paid services. Helpful contact information: HHIN Help Desk 948-6446 on Oahu or 1 (800) 760-4672 toll-free on the Neighbor Islands, or email hhinhelpdesk@hmsa.com. HHIN Outreach 948-5851 on Oahu or 1 (800) 603-4672, ext. 5851, toll-free on the Neighbor Islands, or email traci_tabladillo@hmsa.com. PLANS AND PROGRAMS Health Care Reform Update: Preventive Services for Women HMSA will share with you as much information with regard to Health Care Reform as it becomes available. As you know, the Affordable Care Act requires health plans to cover certain preventive health services at no charge to your patients. A list of these preventive services is available on HMSA s website at hmsa.com/reform. In August, the federal government added the following preventive health services for women that health plans are required to cover without a member cost share. This is not effective until Aug. 1, 2012, and applies to nongrandfathered health plans with plan years beginning on or after Aug. 1, 2012. Screening for gestational diabetes for pregnant women between 24 and 28 weeks and at their first prenatal visit if they are at high risk for diabetes. Human papillomavirus (HPV) DNA testing for women at high risk, age 30 and older, every three years for cervical cancer. Annual counseling on sexually transmitted infections (STIs) for all sexually active women regardless of STI risk. Annual HIV screening and counseling for all sexually active women. Breastfeeding support, counseling, and rental costs for breastfeeding equipment. Annual wellness preventive care visit. Annual screening and counseling for interpersonal and domestic violence. FDA-approved contraception methods and sterilization procedures as prescribed, along with education and counseling.

3 Provider Update - Medical Practitioners October 2011 PLANS AND PROGRAMS (CONTINUED) Procedures for Self-injectable Prescriptions for Fed Plan 87 Effective Jan. 1, 2012, specific self-injectable drug prescriptions for Federal Plan 87 members must be filled through HMSA s participating specialty pharmacies (CVS Care Plus, Pharmacare, or Walgreens). Pre-certification requests should be sent to HMSA s Medical Management department for approval. The list of the self-injectable drugs is included below. Ingredient Name Brand Name J Code HMSA Policy Information Adalimumab Humira J0135 www.hmsa.com/portal/provider/zav_pel. aa.eta.501.htm Adomorphine Apokyn J0364 HCL Enfuvirtide Fuzeon J1324 Etanercept Enbrel J1438 www.hmsa.com/portal/provider/zav_pel. aa.eta.501.ht Glatiramer Copaxone J1595 Golimumab Simponi J3590 Interferon Alfacon-1 Interferon Beta-1A Interferon Beta-1B Peginterferon Alfa-2A Peginterferon Alfa-2B Somatropin Infergen J9212 Hepatitis C Treatment with Interferons and Ribavarin www.hmsa.com/portal/provider/ zav_pel.aa.hep.500.htm Rebif J1825 Betaseron Extavia J1830 Pegasys S0145 Hepatitis C Treatment with Interferons and Ribavarin www.hmsa.com/portal/provider/ zav_pel.aa.hep.500.htm Peg Intron S0146 Hepatitis C Treatment with Interferons and Ribavarin Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ, Saizen, Serostim, Zorbtive, Tev-Tropin J2941 www.hmsa.com/portal/provider/zav_pel. aa.hep.500.htm Nutropin/Nutropin AQ preferred Growth Hormone Therapy Policy www.hmsa.com/portal/provider/zav_pel. aa.gro.500.htm Teriparatide Forteo J3110 www.hmsa.com/portal/provider/zav_pel. aa.ter.200.htm (continued on next page)

4 Provider Update - Medical Practitioners October 2011 PLANS AND PROGRAMS (CONTINUED) (from previous page) Prescriptions must be sent to the specialty pharmacy directly by the physician s office. HMSA will reject claims for the selfinjectable drugs listed above when filed by physicians who prescribe and fill them. Members will be charged a 20 percent copayment (unless the copayment threshold has been met), for these self-injectable drugs. If the member has dual coverage, the specialty pharmacy should submit a claim to the secondary insurer. Members can make special arrangements for pickup or delivery with the specialty pharmacy. Members using a specialty pharmacy will be trained to administer their injectable drug by the pharmacy. Additional information can be found on HMSA s website at hmsa.com; through HMSA s Interactive Web tool, My RxChoices ; or by contacting the Medco Pharmacy Service Help Desk at 1 (800) 922-1557 toll-free. For more information, please contact HMSA s Customer Relations department at 948-6330 on Oahu or 1 (800) 790-4672 toll-free on the Neighbor Islands. CAHPS Member Survey HMSA members remain satisfied with their personal physicians, specialists, and health plan, according to survey results from the Consumer Assessment of Healthcare Providers and Systems (CAHPS ). When it comes to getting the care they need, HMSA s Preferred Provider Plan (PPP) members rated their providers in the 90th percentile in 2011, up from the 75th percentile in 2010. Our members indicated they could see a doctor in less than 12 hours when seeking care for a sudden illness or injury. When asked how well their doctors communicated with them, these same members responded with a 90th percentile rating in 2011, also up from the 75th percentile in 2010. These results are based on questions about how well their doctors listen and explain, spend enough time with them, and show respect for their feelings. CAHPS Survey Composite Category PPP 2011 PPP 2010 HPH 2011 HPH 2010 NCQA Percentile NCQA Percentile Getting Needed Care 90th 75th 75th 75th Getting Care Quickly 75th 75th <25th 25th How Well Doctors Communicate 90th 75th 75th 75th Claims Processing 90th 90th NA * 75th Customer Service NA * NA * NA * 25th Rating of Health Care 90th 90th 90th 90th Rating of Personal Doctor 90th 90th 90th 90th Rating of Specialist 90th 90th 90th 90th Rating of Health Plan 90th 90th 90th 90th * NA indicates this composite received less than the required 100 responses.

5 Provider Update - Medical Practitioners October 2011 POLICY NEWS Provider Input Solicited for Annual Policy Review - October HMSA s medical directors welcome comments and suggestions from participating physicians regarding medical policies that are undergoing annual review. HMSA is currently soliciting input for the policies listed below. Comments are due by Oct. 31, 2011. Physicians may comment by fax to 948-6340 on Oahu or by email to medical_policy@hmsa.com. Comments will be taken into consideration during the annual review process. However, HMSA does not guarantee any specific proposed change will be included in the final policy. HMSA s policies rely on the use of evidencebased medicine, typically from peer-reviewed literature. Physicians submitting comments should include supporting citations for source material to help HMSA s medical directors evaluate the comment or proposed change. Home Health Care. SRS - Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy. Spinal Cord Stimulators for Pain Management. Oscillatory Device for Bronchial Drainage (The Vest). Negative Pressure Wound Therapy. DME Durable Medical Equipment, Prosthetics, & Orthotics. Updated Medical Policies The following policies have undergone review and have been updated. Please refer to the Provider Resource Center to view the individual policies; copies are available upon request. Immune Globulin Therapy. Medical Foods for Inborn Errors of Metabolism. Modafinil (Provigil) and Armodafinil (Nuvigil). Omalizumab (Xolair). Hematopoietic Stem-Cell Transplantation in the Treatment of Germ-Cell Tumors. Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia. Cognitive Rehabilitation and Sensory Integration Therapy. Ambulatory Blood Pressure Monitoring. Palivizumab (Synagis). Panitumumab (Vectibix). 90-Day Notice for Policy Changes Effective Jan. 1, 2012 Erythropoiesis Stimulating Agents: The policy has been revised to include updated coverage criteria and precertification requirements. Intrastromal Corneal Ring Segments for Keratoconus (INTACS) Akamai Advantage Plans: Akamai Advantage will no longer provide coverage of INTACS. Akamai Advantage will follow guidelines from Palmetto GBA, the Medicare Part B contractor for Hawaii, which has determined this service is not reasonable and necessary. New Policy Drafts Online for Review New medical policies are now posted online for your review. Please check the E-Library in the Provider Resource Center for drafts of policies that may affect your practice. Comments should be sent before the due date indicated online and may be emailed to medical_policy@hmsa.com or faxed to 948-6340. Questions? Call Provider Services at 948-6377 on Oahu or 1 (800) 603-4672, ext. 6377, toll-free on the Neighbor Islands. Akamai Advantage Pre-certification Requirements Removed Correction It was announced in the August 2011 Provider Update that certain services would no longer require pre-certification under Akamai Advantage. Two services were incorrectly included on the list. Ranibizumab (Lucentis) and pegaptanib sodium (Macugen) continue to require precertification for off-label indications.

6 Provider Update - Medical Practitioners October 2011 POLICY NEWS (CONTINUED) Codes that Do Not Meet Payment Determination Criteria and Claim Documentation Requirements Effective Jan. 1, 2012, rocedure code S2404, Repair, myelomeningocele in the fetus, procedure performed in utero, will be taken off the Codes that Do Not Meet Payment Determination Criteria and will be added to the Claims that Need Additional Documentation list. TRIWEST TRICARE Online Education Available If you are new to TRICARE, have new staff in your office, or want to learn more about TRICARE, you and your staff are invited to register for a TRICARE provider webinar or eseminar. TriWest Healthcare Alliance (TriWest) developed these training programs to help you better understand the basics of the TRICARE program to administratively care for your TRICARE patients. TRICARE Webinars Webinars are training sessions from your own computer with a live instructor. You will hear the instructor by joining a conference call on your telephone. You can ask questions and also hear questions asked by other providers attending the training. Webinars are available on the following topics: TRICARE 101. Behavioral Health TRICARE 101. Ambulatory Surgery Center Reimbursement Methodology. Autism. Electronic Data Interchange (EDI). Physical Therapy/Occupational Therapy/Speech Therapy (PT/OT/ST). Secure Website - Claims. Secure Website - Referrals and Authorizations. Vision Coverage. TRICARE eseminars eseminars allow providers and their staff to learn about TRICARE and TriWest in the comfort of their own office, home, or any location with Internet access. To take an eseminar, you will need headphones or speakers on your computer. Here is a list of the current eseminars that are available: TRICARE 101. Behavioral Health TRICARE 101. Autism. Electronic Data Interchange (EDI). Extended Care Health Option (ECHO). Home Health Agency Prospective Payment System. Outpatient Prospective Payment System (OPPS). TRICARE s Hospice Benefit. Vision Coverage. Just select your preferred eseminar. It s that easy! TriWest has many options available for you to get the information you need to learn about TRICARE. For more information on these options, visit the Stay Updated section of www.triwest.com/provider. TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. Coming soon: Skilled Nursing Facility.