SM www.bluechoicescmedicaid.com Volume 4, Issue 8 September 2016 BlueBlast Is Going Electronic! This issue of BlueBlast will be the last one we print and mail to providers. Beginning next month, we will email BlueBlast to all of our providers. If you would like us to add you to the BlueBlast mailing list, please let us know. Email your request to BlueChoiceHealthPlanMedicaid@bcbssc.com. Clinic Days To ensure that all BlueChoice HealthPlan Medicaid members receive the regular care they need to stay healthy, we will partner with you to host Clinic Days. Through Clinic Days, your practice may designate a half or a full day to see BlueChoice HealthPlan Medicaid members who are not up to date with their checkups, vaccines and other preventive health services. Our staff will work with yours to review recent Gaps in Care reports and identify members who may be overdue for services or treatment based on certain Healthcare Effectiveness Data and Information Set (HEDIS) measures. We can even help your office schedule our members for their visits. As an incentive, we will provide each participating member with a $25 gift card for keeping the appointment. We ll also provide a $30-per-member incentive for your office. Clinic Days are a way to keep your patients current on their visits, while helping to keep them healthy. Please contact your provider relations representative to schedule your next Clinic Day. Who: Clinicians, office staff, members enrolled in the practice and BlueChoice HealthPlan Medicaid. What: Clinic Days will be held to see patients who are not current with certain services, vaccines, screenings and checkups. We will help schedule your patients if you need help. Where: Provider practice location. When: One day or half day set aside for a large group of appointments. Clinic Days are a joint effort between the plan and provider groups to schedule patients who are not up to date with services they need to remain happy and healthy. Members receive a $25 gift card. Practices receive a quality incentive of $30 per member. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Well Child and Sick Child Visits Billed on the Same Day You are encouraged to combine sick and well-child visits performed on the same day. This will improve quality outcomes and preventive care for our young members. Increased well-child visits will also lead to better health outcome as well as better Healthcare Effectiveness Data and Information Set (HEDIS) scores. Use Modifier 25 on the line with the Well-Child Evaluation and Management Code to bill for a sick visit and a well-child visit performed on the same day. Please use Modifier 25 to document a distinct, separately identifiable reason for the office visit and the well-child visit.
Medical Necessity of Gastric Bypass Procedures We will be featuring a series of articles that deal with the process of submitting clinical documentation for various procedures that require prior authorization. This is an effort to inform providers of the pertinent information needed in order to be properly reviewed for procedures that require specific clinical information. This article addresses surgical and other treatments for clinically severe obesity. Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures and other treatment modalities intended for the treatment of clinically severe obesity. Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band System or the REALIZE Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch and sleeve gastrectomy (open or laparoscopic) are considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria (1, 2 and 3): 1. BMI of 40 or greater, or BMI of 35 or greater with an obesityrelated co-morbid condition, including, but not limited to: diabetes mellitus; or 2. The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least six continuous months in the two years before surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery; AND 3. The physician requesting authorization for the surgery must provide documentation of ALL of the following: The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and The candidate's postoperative expectations have been addressed; and The individual has undergone a preoperative medical consultation and is believed to be an acceptable surgical candidate; and The individual has undergone a preoperative mental health assessment and is believed to be an acceptable candidate; and The individual has received a thorough explanation of the risks, benefits and uncertainties of the procedure; and cardiovascular disease; or hypertension; or life-threatening cardiopulmonary problems (for example, severe obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy); AND The candidate's treatment plan includes pre- and postoperative dietary evaluations and nutritional counseling; and The candidate's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed. 2
Coverage of Drug Testing Codes The South Carolina Department of Health and Human Services (SCDHHS) covers the following presumptive and definitive drug testing codes at the reimbursement rates in the table. Reimbursement is for a maximum of one screening per procedure code per date of service, not to exceed 18 screenings per 12-month period. Providers should bill the most appropriate Healthcare Common Procedure Coding System (HCPCS) code for the service rendered. G0477 - Drug test(s), presumptive, any number of drug classes; any number of devices or procedures (e.g., immunoassay), capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service. G0479 - Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry, includes sample validation when performed, per date of service. G0480 - Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays [e.g., IA, EIA, ELISA, EMIT, FPIA] and enzymatic methods [e.g., alcohol dehydrogenase]); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, one to seven drug class(es), including metabolite(s), if performed. Drug Testing Code Reimbursement Rate Effective Date(s) G0477 $20 1/1/16 8/31/16 G0479 $82.89 1/1/16 8/31/16 G0477 $11.89 9/1/16 and after G0479 $63.40 9/1/16 and after G0480 $63.95 9/1/16 and after Submit a Pregnancy Notification Report Receive $200 BlueChoice HealthPlan Medicaid encourages healthy outcomes for patients by partnering with our providers. We know you care about your patients. That's why we offer an incentive to PCPs and obstetrical and gynecology physicians who see our BlueChoice HealthPlan Medicaid members who are newly pregnant. If you submit a Pregnancy Notification Report (PNR) for each patient you see at their initial prenatal visit, we will pay you $200. Just follow these steps: 1. Complete a PNR at the time of pregnancy diagnosis. 2. Go online to www.bluechoicescmedicaid.com, and click on Providers > Forms > Pregnancy Notification Report. You must verify your patient is a current BlueChoice HealthPlan Medicaid member. 3. Fax the PNR within seven business days from the pregnancy diagnosis date to 800-551-2410. 4. Complete a separate professional claim for each pregnancy diagnosis. Use CPT/HCPCS code 99080, modifier 32. Indicate billed charge is $200; days or units are 1. 5. Send the professional claim to your contracted clearinghouse or BlueChoice HealthPlan Medicaid. 3
HEDIS Measure of the Month: Antidepressant Medication Management This HEDIS measure looks at members ages 18 years or older with a diagnosis of major depression who were newly treated with an antidepressant medication and remained on antidepressant medication treatment. Two timelines are required for this measure: Effective acute phase treatment: patients newly diagnosed and treated who remained on an antidepressant medication for at least 84 days (12 weeks). Effective continuation phase treatment: patients newly diagnosed and treated who remained on an antidepressant medication for at least 180 days (six months). Code your services correctly The National Committee for Quality Assurance (NCQA) recognizes the following diagnosis codes for major depression: Description: ICD-10-CM Diagnosis Major depression: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 Helpful tips Educate your patients and their spouses, caregivers and/or guardians about the importance of: Complying with long-term medications. Consulting with you before abruptly stopping medications. Contacting you immediately if they experience any unwanted/ adverse reactions, so their treatment can be re-evaluated. Scheduling and attending follow-up appointments to review the effectiveness of their medications. Calling your office if they cannot get their medication prescriptions refilled. Discussing the benefits of participating in a behavioral health case management program. Providing you access to their behavioral health records if you are their primary care provider. Other Resources You can find more information and tools online at: qualitymeasures.ahrq.gov ncbi.nlm.nih.gov The codes listed are informational only. This information does not guarantee reimbursement. Your state contract, state Medicaid and other guidelines determine reimbursement for the applicable codes. Proper coding and providing appropriate care decrease the need for high volume of medical record reviews and provider audits. It also helps us meet the HEDIS measure for quality reporting based on the care you provide our members. 4
Claim Submission Formats and Filing Assistance We accept CMS-1500 and CMS 1450 (UB-04) claim submission formats, filed online or via paper. Electronic and Paper Claims You may file both CMS-1500 and CMS UB-04 claims online using a BlueChoice HealthPlan. Medicaid-approved electronic billing system software vendor or clearinghouse. File clean claims, and any amounts due will process in accordance with your provider agreement. Paper claims may be submitted to the following address for processing and reimbursement: Attn: Medicaid Claims BlueChoice HealthPlan Medicaid P.O. Box 100124 Columbia, SC 29202-3124 If you need claim-filing assistance, please contact our Customer Care Center at 866-757-8286. For more information regarding claims, see our online Provider Manual at www.bluechoicescmedicaid.com. Corrected Claims and Secondary Claims may be filed electronically. Claims Overpayment Recovery Procedure If you are notified of an overpayment, or if you discover that you have been overpaid, please return the overpayment. Mail the check and a copy of the overpayment notification to: Attn: Overpayment Recovery BlueChoice HealthPlan Medicaid P.O. Box 92420 Cleveland, OH 44193 The address above cannot accept overnight packages. If you are sending an overnight package, please address your package to the following: Attn: Cash Dept. - AC10I BlueChoice HealthPlan Medicaid 21555 Oxnard Street Woodland Hills, CA 91367 If BlueChoice HealthPlan Medicaid does not hear from the provider or receive payment within 30 days, the overpayment amount is deducted from his or her future claims payments. In cases when it is determined that recovery is not feasible, the overpayment is referred to a collection service. We re In Your Community! Conway was filled with excitement as BlueChoice HealthPlan Medicaid hosted a Back to School Jam Fest at the Conway Huckabee Housing Authority. Two hundred sixty-five children received free backpacks. Community Partners KISS 98.5, featuring DJ Monique, Project Hope, Waccamaw Council of Governments, SC Thrive, Little River Medical Center and Horry Georgetown Technical College, all provided back-toschool supplies for the community. Low Country Food Bank provided large totes of fresh produce filled with squash, sweet potatoes, cucumbers and watermelons, while Brooklyn South Deli served more than 300 hot dogs. Outreach Specialist Allene Glapion-Tellis, Provider Relations Representative Ty Westbrook and Community Relations Representative Channell Webster kept everyone cool with ice-cold water and Gatorade, while sharing important information about our plan, health tips and providing giveaways. 5
AX-400-Co1 P.O. Box 6170 Columbia SC 29260-6170 PRSRT STD US POSTAGE PAID PERMIT NO 1240 COLUMBIA SC BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support BlueChoice HealthPlan Medicaid. Some links in this newsletter lead to third party sites. Those organizations are solely responsible for the content and privacy policies on these sites. In this issue Page 1 BlueBlast Is Going Electronic! Clinic Days Well Child and Sick Child Visits Billed on the Same Day Page 2 Medical Necessity of Gastric Bypass Procedures Page 3 Coverage of Drug Testing Codes Submit a Pregnancy Notification Report Receive $200 Page 4 HEDIS Measure of the Month: Antidepressant Medication Management Page 5 Claim Submission Formats and Filing Assistance We re In Your Community! 19158-8-2016