For Participating Medical Practitioners September 2011

HMSA s For Participating Medical Practitioners September 2011 HMSA and Healthways Hawaii Welcome John Baleix, M.D. What s Inside Electronic 2 Procedures 2 Plans and Policies 2 Policy News 5 Pharmacy News 6 TRICARE 7 HMSA and Healthways Hawaii welcome John Baleix, M.D., as joint medical director for HMSA s patient-centered medical home initiative. Baleix provides clinical leadership to HMSA and Healthways Hawaii in program design, implementation, measurements, care support, and practice improvements. He works with providers across the state, including physician organizations, physicians in individual practices, and physician professional societies. Baleix is tasked with bringing the latest innovations and best practices to HMSA s patientcentered medical home initiative. Baleix is board-certified in occupational medicine and served as a health initiatives consultant with the Military Health System Multi-service Market Management Office in Honolulu. He advised senior leaders and managed clinical working groups with staff from Army, Navy, Air Force, and Coast Guard treatment facilities. His focus was on patientcentered care, medical management, physical therapy, health promotion, patient education, and disease management. Before that, Baleix was director of public health at the Naval Health Clinic in Honolulu, where he led a staff of 68 professionals in preventive health services including audiology, occupational medicine, environmental health, industrial hygiene, and health promotion. 1100-0176 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 September 2011 electronic HHIN 2.0 Replaces HHIN Classic HHIN Classic will no longer be available after Oct. 24, 2011. Limited availability of HHIN Classic starts in September. To avoid technical delays, please log in to HHIN 2.0 and complete your registration. Your practice should be ready to use HHIN 2.0 beginning Oct. 25, 2011. One of the new features available on HHIN 2.0 is aroundthe-clock access to the status of submitted QUEST claims. If you have questions about HHIN or would like to schedule training, please contact Traci Tabladillo at 948-5851 on Oahu 1 (800) 603-4672, ext. 5851, toll-free on the Neighbor Islands, or via email at traci_tabladillo@hmsa.com. Enhancing the Patient Experience The latest update to HMSA s Online Care, the Practice Edition, gives you the option to provide your patients with online care that coordinates with your daily practice. The Practice Edition includes staff accounts on HMSA s Online Care so your staff can help you add patients to your patient panel via your EMR system and manage secure messages. They also will be able to prep your patients before online visits and perform follow-up tasks such as scheduling future online visits. The Practice Edition allows providers to create distinct online practices, each with a customizable landing page for patients to view information such as office hours, contact information, and a list of providers and staff. Patients can instantly connect with any listed provider available at the time. The patient experience on HMSA s Online Care includes entering a waiting room, answering questions, nurse preparation, provider visit, and follow-up details. The new Online Care workflow and staff assistance will make it easier for your patients to have seamless online visits. To schedule an appointment for a hands-on training session with an HMSA coordinator, go to hmsa.com/providers. If you have questions about the Practice Edition or other questions about HMSA s Online Care, call 948-6013 on Oahu or 1 (866) 939-6013 toll-free on the Neighbor Islands. Procedures Provider Credentialing Changes HMSA was recently informed that the Hawaii Credential Verification Service, Inc. (HCVS) has been dissolved and will no longer provide services. As a result, HMSA now performs all provider credentialing and re-credentialing procedures, which will now occur every three years instead of every two years. To ease these processes, a new application form is available online. Find the new HMSA Provider Enrollment and Credentialing Application and its instructions in the HMSA Provider Resource Center at hmsa.com. HMSA will send out the re-credentialing applications to providers four months before they are due to be recredentialed to ensure adequate time to process the application. Please contact HMSA s Provider Data & Contracting unit at 952-7847 on Oahu or your HMSA representative if you have any questions. Plans and PROGRAMs Billing for Prolonged Services As part of HMSA s utilization management activities, we have identified an area of concern regarding billing for prolonged services (CPT code 99354). CMS defines prolonged physician services in the office or other outpatient setting as direct face-to-face patient contact that requires one hour beyond the usual service. Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and for prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician to show that they personally engaged in direct face-to-face time with the patient as specified in the CPT code definitions. Start and end times of the visit should be documented in the medical record with the date of service. For more information, please refer to www.cms.gov/ MLNMattersArticles/downloads/MM5972.pdf.

3 Provider Update - Medical Practitioners September 2011 Plans and PROGRAMs (continued) Annual Well-woman Exams Annual well-woman exams can be performed without a referral by an HMSA participating provider. Services from a nonparticipating provider require administrative review. Documentation Changes to Support ICD-10 ICD-10 codes require more accurate and precise clinical information that starts with the medical record. Thorough documentation should include: Laterality. ICD-10-CM introduces laterality to diagnosis coding. It is now a required data element to document on which side of the body the disease or injury occurred. Combination codes. ICD-10-CM greatly expands the use of combination codes, where a single code is used to classify two diagnoses or a diagnosis with an associated secondary process or complication. This relationship cannot be assumed or inferred; the documentation must clearly state the relationship. Episodes of care. ICD-10-CM relies more heavily on categorizing the episode of care for injuries and illnesses. For fractures, in particular, it must be indicated if the service is the initial or subsequent encounter. Greater specificity. ICD-10-CM is much more specific in identifying diseases and conditions and the documentation will need to reflect this. Additionally, ICD-10-CM codes are much more specific in terms of anatomy or anatomical location of the disease or condition. MAC Fee Changes Annual influenza vaccine fee updates Payment for the intranasal flu vaccine (90660) and five preservative-free vaccine codes (90654, 90655, 90656, 90660, and 90662) will be based on the same maximum allowable charges (MAC) that HMSA pays for the standard flu vaccine codes (90657 and 90658). Please refer to the accompanying table. The intranasal vaccine and preservative-free vaccines will also be subject to balance billing to our members for the difference between HMSA s payment and the provider s charge, with the member s agreement. When administering any of these six codes, a modifier GA should be appended, indicating that the member has been informed of and has accepted their financial obligation to pay the balance. A copy of the waiver should be kept in the member s file. Federal Plan members (coverage code 87) receiving any of these six vaccines will be reimbursed the full New Average Wholesale Price (AWP) amount by HMSA. The provider may not collect the difference between HMSA s eligible charge and the higher bill charges. MACs for the following codes increased effective Sept. 1, 2011: (Chart on following page) As part of your preparation for the use of ICD-10 diagnosis codes, review the specificity of your current medical record documentation. Will your records support the use of ICD- 10 diagnoses on claims? Resources to help you and your office prepare for the transition to ICD-10 can be found at hmsa.com/portal/provider/zav_pel.aa.icd.100.htm.

4 Provider Update - Medical Practitioners September 2011 CPT Code Description Fed plan New MAC 90654** Influenza virus vaccine, split virus, preservative free, for intradermal use $18.60 $13.26 90655 Influenza virus vaccine, split virus, preservative free, for children 6-35 15.78 6.63 months of age, for intramuscular use 90656 Influenza virus vaccine, split virus, preservative free, for use in individuals 14.83 13.26 3 years and above, for intramuscular use 90657 Influenza virus vaccine, split virus, for children 6-35 months of age, for 6.63 intramuscular use 90658 Influenza virus vaccine, split virus, for use in individuals 3 years of age 13.26 and above, for intramuscular use 90660 Influenza virus vaccine, live for intranasal use 22.74 13.26 90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity 31.80 13.26 via increased antigen content, for intramuscular use 90670 Pneumococcal conjugate vaccine, 12 valent, for intramuscular use 122.47 ** Rate effective Aug. 18, 2011. Medical vision fee updates Effective Aug. 1, 2011, the MAC fees for eye exams with medical diagnoses are as follows: CPT Code Description Ophthalmologist MAC Optometrist MAC 92004 Comprehensive ophthalmologist exam, new patient $153.35 $115.00 92014 Ophthalmological series, medical evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits 127.50 95.60 Special vision fee updates Effective Jan. 1, 2012, Special Vision (participating and nonparticipating providers) and HMO vision acuity exam and refraction rates are as follows: CPT Code Description New MAC 92002 Ophthalmological services, medical examination and evaluation with initiation of $60.45 diagnostic and treatment program, intermediate, new patient 92004 Comprehensive, new patient, one or more visits 60.45 92012 Ophthalmological services, medical examination and evaluation with initiation 60.45 or continuation of diagnostic and treatment program, intermediate, established patient 92014 Comprehensive, established patient, one or more visits 60.45 92015 Determination of refractive state 8.65

5 Provider Update - Medical Practitioners September 2011 Policy News Provider Input Solicited for Annual Policy Review September 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 Sept. 30, 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 that 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. 3D Reconstruction. Apnea Monitor for Infants. Bariatric Surgery. Endoscopic Radiofrequency Ablation for Barrett s Esophagus. Home Phototherapy for Neonatal Jaundice. Photochemotherapy. Photodynamic Therapy for Treatment of Actinic Keratoses and Other Skin Lesions. Preimplantation Genetic Diagnosis (PGD). Pulse Oximeter for Children. Readmissions and Transfers. Annual Review of Medical Policies The following policies have been reviewed and updated. Please refer to the Provider Resource Center to view the individual policies; copies are available on request. Artificial Disc Replacement, Cervical. Biological Agents for the Treatment of Plaque Psoriasis. Bortezomib (Velcade). Brachytherapy, Intravascular. Breast Cancer. Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma. Multiple Myeloma. Non-Hodgkin Lymphomas. Primary Amyloidosis. Waldenstrom Macroglobulinemia. Implantable Ventricular Assist Device and Total Artificial Hearts. Prophylactic Mastectomy. Teriparatide (Forteo). 90-day Notices Effective Dec. 1, 2011, the Biological Agents for the Treatment of Plaque Psoriasis policy has been revised to state that a patient must have tried methotrexate or cyclosporine for at least three months at a therapeutic dose and found the treatment ineffective, or both of the therapies are not tolerated or are contraindicated. Also, code J3357 (injection, ustekinumab, 1 mg.) was added in January as a new code for the drug Stelara (as a replacement for J3590). Effective Dec. 1, 2011, the Hematopoietic Stem-Cell Transplantation (HSCT) for Non-Hodgkin Lymphomas policy has been revised extensively to specifically separate mantle cell lymphoma and peripheral T-cell lymphoma. For mantle cell lymphoma, coverage limitations were added. Autologous HSCT as salvage therapy and allogeneic HSCT to consolidate a first remission are not covered. Criteria have been added for coverage of allogeneic HSCT for salvage therapy. For peripheral T-cell lymphoma, criteria were added for autologous HSCT to consolidate first remission in specific situations and autologous and allogeneic HSCT for salvage therapy. A coverage limitation was added regarding allogeneic HSCT to consolidate a first complete remission.

6 Provider Update - Medical Practitioners September 2011 Effective Dec.1, 2011, the Teriparatide (Forteo) policy has been revised to add a criterion that the use of denosumab (Prolia) must have been considered and ruled out. Precertification requests must include documentation indicating that the use of denosumab (Prolia) has been considered and ruled out as well as the reason its use is not an option. Codes that Do Not Meet Payment Determination Criteria and Claim Documentation Requirements Effective Dec. 1, 2011, the following codes will be removed from the Codes that Do Not Meet Payment Determination Criteria list and will be added to the Claim Documentation Requirements list: Code Description 95965 Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization). 95966 Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization). 95967 Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (e.g., sensory, motor, language, or visual cortex localization). (List separately in addition to code for primary procedure.) Pharmacy News QUEST Pre-certification Inquiries Beginning Oct. 15, 2011, inquiries regarding FDAapproved, non-formulary oral and topical drugs requiring pre-certification for The HMSA Plan for QUEST Members should be sent to Medco, which performs pharmacy benefit management services on behalf of HMSA, an independent licensee of the Blue Cross and Blue Shield Association. Single-source Generics: Higher Copayments for High-cost Generics During plan open enrollments throughout 2011, HMSA members will acquire a benefit that shows an increase in copayments for single-source generic drugs at retail pharmacies that will help them manage costs. HMSA asks that providers work with their patients to keep their prescription drugs as affordable as possible. While this strategy is currently in place for some HMSA drug plans, it is anticipated that the majority of HMSA plans will have this single-source benefit soon. When generic versions of a brand drug become available, they are usually manufactured by a single pharmaceutical company, often resulting in higher prices for the generic for a six- to eight-month period of exclusivity. Plans costs rise as a result of increased use of these new, expensive generic drugs. 1) Benefits for single-source generic drugs At participating retail pharmacies, single-source generics will incur tier 2 (preferred brand) copayments. Once a generic drug is available from more than one company and its price is reduced, HMSA will consider reducing its copayment to a tier 1 (generic). If HMSA members purchase single-source generics through HMSA s mail order program, their copayments will be a tier 1 (generic) copayment. If a member continues to take a brand name once the generic version is available, their copayment will increase significantly to their drug plan s highest copayment level. Depending on the drug plan, this can be as much as $45 more than the amount they have been paying for a 30-day supply.

7 Provider Update - Medical Practitioners September 2011 Pharmacy News (cont d) 2) List of HMSA single-source generic drugs The following is HMSA s list of single-source generic drugs as of Aug. 1, 2011. Generic Name Brand Name Use Atorvastatin Lipitor (soon to Cholesterol be released) Atorvastatin/ amlodipine Olanzapine Olopatadine Caduet (soon to be released) Zyprexa (soon to be released) Patanol (soon to be released) Cholesterol/ Blood Pressure Behavioral Health Allergy Levocetirizine Xyzal Allergy Methyl- Concerta Attention phenidate Deficit Disorder For future reference, updates to the list can be accessed online at hmsa.com or by contacting your HMSA representative. TRICARE Are You Ready for HIPAA 5010? TRICARE Management Activity, TriWest Healthcare Alliance (TriWest), and Wisconsin Physicians Service Insurance Corp. (WPS) are taking action to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) version 5010 transaction standards. HIPAA requires all covered entities in the health care industry to implement and use mandated standards in the electronic transmission of health care transactions, including claims, remittance, eligibility, claims status requests, their related responses, and privacy and security standards. As you prepare for the implementation of HIPAA 5010, take the important step of contacting your vendor, clearinghouse, billing service, or payer if they supply your software. They will provide detailed information on what steps your office or facility needs to take toward a smooth transition. Here are some readiness questions that you should ask: Will HIPAA 5010 and ICD-10 software upgrades or changes be provided in one or multiple releases? What will be the cost of upgrades or changes to my practice? When will upgrades or changes be available for testing? When can I begin testing each transaction (e.g., 837 Claims, 835 Remittance Advice)? Will I be required to test with each trading partner or payer? What are the steps and timeframe for completing a testing cycle? Can 4010 and 5010 transactions be processed concurrently? How will I know my implementation has been successfully completed? What is your contingency plan if your systems are not compliant on Jan. 1, 2012? For more information, please see WPS 5010 Readiness Schedule at www.wpsic.com/edi/5010-readiness-schedule. shtml and 5010 Companion Guide at www.wpsic.com/edi/ pdf/5010-tricare-companion.pdf. You can also refer to TriWest s EDI/ERA/EFT web page at TriWest.com/provider. TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.