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Current Procedural Terminology 2012 American Medical Association. All Rights Reserved. Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP excluding Dentists and Pharmacies Contains Public Information
URAC Grants BCBSKS Provisional Health Plan Accreditation Status URAC recently granted the company Provisional Health Plan Accreditation status, meaning Blue Cross and Blue Shield of Kansas (BCBSKS) will be eligible to sell our products on the Marketplace (exchange) when it opens this fall. In addition to earning accreditation for the Marketplace, the company also was recognized for its commercial or “off-exchange” plans.
“I’m very proud of the teamwork of those involved. The decision and time commitment are what makes us different,” says Andy Corbin, president/CEO.
Provisional status will be in effect until URAC’s onsite review in early 2014, at which point URAC reviewers will ensure BCBSKS is meeting the URAC standards, policies and procedures submitted for the desk top review this past April.
To be ready for the onsite visit, it is imperative we remain on target with the credentialing of the CAP network. We appreciate your prompt responses to any requests from either BCBSKS or Credentialing Corporation of America, Inc. (CCA). See Blue Shield Report S-3-13 for details.
JULY 9, 2013 S-4-13
WHAT’S INSIDE ?
The Blue Shield Report is published by the professional relations department of Blue Cross and Blue Shield of Kansas.
OUR WEB ADDRESS: http://www.bcbsks.com
Ann Dunn, Communications Coordinator
Questions: Contact your professional relations representative or provider network services in Topeka at 785-291-4135 or 1-800-432-3587. Acknowledgement: Current Procedural Terminology (CPT®) is copyright 2012 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein. Applicable ARS/DFARS Restrictions Apply to Government Use.
URAC Grants BCBSKS Provisional Health Plan Accreditation Status ......... 1 FEP HEDIS Targeted Measures ............ 2 Best Wishes…Going…and Coming ....... 2 ICD-10 Readiness and Your
Clearinghouse ...................................... 2 Professional Relations Contact
Information / Territorial Map ................ 3 EDI Presentation at BCBSKS
Workshops ........................................... 4 Intra-articular Hyaluronan Injections
for Osteoarthritis ................................. 4 Vitamin D Deficiency Testing
Clarification.......................................... 4 Pharmaceutical Formulary Update ....... 4 Over-the-Counter (OTC) Preventive
Drugs ................................................... 5 Claims Processing – Per Diem “S”
Code Home Infusion Claims ................. 5 Other Party Liability ............................. 5 Duplicate Claims Handling for
Medicare Crossover .......................... 6, 7 Are You Registered?............................. 7 Web Changes – Medical Policy ......... 7, 8 Credentialing Reminder ................... 8, 9 Fraud Awareness and Prevention .. 10-12
July 9, 2013 BLUE SHIELD REPORT S-4-13
Sent To: CAP excluding Dentists and Pharmacies
Contains Public Information Page 2
Best Wishes . . . Going . . . and Coming!
Cheri Iarossi, with 31 years of dedicated service as a professional relations representative, announced her retirement, effective May 31, 2013. We thank Cheri and wish her the very best with this new chapter in her life. The providers in the northeast portion of Kansas, which includes the counties of Washington, Marshall, Nemaha, Brown, Clay, Riley, Pottawatomie, Jackson, Geary, Wabaunsee, Morris and portions of Shawnee, will be assumed by Christie Blenden. Christie comes to the Professional Relations Department with 15 years experience at BCBSKS, most recently as the Contract Consultant for Institutional Relations. We welcome Christie to our Provider Relations (PR) staff and know that she will provide the exceptional PR service to which Cheri’s providers have become accustomed. See professional relations contact information and a map of the territory covered by each provider representative on the next page.
ICD-10 Readiness and Your Clearinghouse
EDI has been providing education on how HIPAA 5010 sets the stage for ICD-10 for over two years. CMS has published several articles advising that the October 1, 2014 implementation date will not change.
Now is the time to ask the question of your software vendor and/or clearinghouse.
• How will my software and/or clearinghouse accommodate ICD-10?
It is important all providers have a complete understanding of the role their software vendor and/or clearinghouse plays to ensure successful submission of ICD-10 to all payers.
FEP HEDIS Targeted Measures The Blue Cross and Blue Shield Association (BCBSA) is required to participate in the annual HEDIS (Healthcare Effectiveness Data and Information Set) project for the Government-wide Service Benefit Plan (commonly referred to as BCBSA’s Federal Employee Program or FEP). The HEDIS project is intended to measure the quality of care that Federal employees receive. The five targeted measure specifications are:
• A1c & LDL cholesterol at least
yearly for diabetic patients
• LDL cholesterol at least yearly for cardiovascular patients
• Breast Cancer Screening (Mammography) at least every 2 years for women age 50 and older
• 7 Day Follow-up after hospitalization for mental illness
Thank you for your excellent service to our members in delivering quality health care, and for assisting BCBSKS in meeting these quality measures. For a full list of the HEDIS measures, please visit NCQA’s Web site at www.ncqa.org.
Cheri Iarossi Christie Blenden
BLUE SHIELD REPORT S-4-13 July 9, 2013
Current Procedural Terminology 2012 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Page 3
PROFESSIONAL RELATIONS
Contact Information
PROFESSIONAL RELATIONS STAFF LOCATION PHONE NUMBERS Doug Scott, DIRECTOR Topeka 800-432-0216, ext. 8831 (785) 291-8831 Robyne Goates, MANAGER Topeka 800-432-0216, ext. 8206 (785) 291-8206 Christie Blenden Topeka 800-432-0216, ext. 8651 (785) 291-8651 Diana Evans Topeka 800-432-0216, ext. 8716 (785) 291-8716 Darin Fieger Topeka 800-432-0216, ext. 8207 (785) 291-8207 Vikki Lindemuth Topeka 800-432-0216, ext. 7724 (785) 291-7724 Provider Network Services Topeka 800-432-3587 (785) 291-4135 Gwen Nelson Dodge City (620) 225-0884 Debra Meisenheimer Hutchinson (620) 663-1313 Kyle Abbott Wichita 800-432-0216, ext. 1674 (316) 269-1674 Velda Fresquez-Gray Wichita 800-432-0216, ext. 1674 (316) 269-1674
Territorial Map
MD, DO, DPM, DC, PA, APRN, CRNA, LSCSW, PhD, OD, OOD, OSAF
Kyle Abbott – Wichita Velda Fresquez-Gray – Wichita Christie Blenden – Topeka Debra Meisenheimer – Hutchinson Diana Evans – Topeka Gwen Nelson – Dodge City Darin Fieger – Topeka
CCC-A (AUD), Hearing Aid Dispensers (HAD), CCC-SLP (Speech), HME, Orthotists, Private Duty Nurses, Prosthetists, Sleep Labs (SLAB), AMB, OTR, LPT
Vikki Lindemuth – Topeka
July 9, 2013 BLUE SHIELD REPORT S-4-13
Sent To: CAP excluding Dentists and Pharmacies
Contains Public Information Page 4
EDI Presentation at BCBSKS Workshops
EDI Marketing Representatives are making every effort to attend provider-related meetings such as BCBSKS New Biller Workshops, Specialty Workshops and Health Department Meetings. EDI will be presenting information on Health Plan ID (HPID), Preparing for ICD-10, and other EDI-related topics.
As a reminder, EDI Marketing Representatives are available to speak to groups on EDI-related matters upon request. Contact EDI Marketing for more information at 1-800-472-6481, option 3.
Intra-articular Hyaluronan Injections for Osteoarthritis The Intra-articular Hyaluronan Injections for Osteoarthritis prior authorization and quantity limits medical policy will be effective for all BCBSKS members on October 1, 2013. Injections will be medically necessary for treatment of painful osteoarthritis of the knee in patients who have insufficient pain relief from conservative nonpharmacologic therapy and simple analgesics. Repeated courses of intra-articular hyaluronan injections of the knee may be considered medically necessary if significant pain relief was achieved with the prior course of injections and at least six months have passed since completion of the prior course. Injections in joints other than the knee are considered experimental/investigational. The preferred agents will be Euflexxa, Synvisc and Synvisc-One. Use of a nonpreferred product will only be allowed if the member meets the criteria above and has evidence of use of the preferred product in pharmacy claims or medical history, or the member has a contraindication or documented intolerance to the preferred agent. The complete medical policy will be available at www.bcbsks.com.
Vitamin D Deficiency Testing Clarification Clarifying the original communication in Blue Shield Report S-4-10, testing for Vitamin D Deficiency is considered not medically necessary except when the recommended Vitamin D supplementation is being taken AND one of the following conditions is present:
• Chronic kidney disease • Granulomatous disorder • Hyperthyroidism • Hyperparathyroidism • Heritable disorders of Vitamin D metabolism • Liver failure • Malabsorption • Medications (anti-convulsants, glucocorticoids, AIDS
medications) • Obesity • Osteomalacia • Osteopenia • Osteoporosis • Phosphaturia • Rickets
Routine screening for Vitamin D deficiency is not medically necessary. Please refer to the medical policy posted on the BCBSKS Web site: Testing for Vitamin D Deficiency.
Pharmaceutical Formulary Update Prime Therapeutics updates the BCBSKS formulary (preferred medication list) on a quarterly basis. Please refer to the link below when prescribing or dispensing medications for your Blue Cross and Blue Shield of Kansas patients. Coverage is subject to the limitations of the member's individual plan.
• https://www.myprime.com/MyRx/MyRxHealth/forms/KS_Alpha_Drug_List.pdf
A searchable version of the formulary is available at:
• https://www.myprime.com/MyRx/MyPrime/Commercial/findDrugs/KSBCBS/SAMST#ViewFindDrugsEvent
BLUE SHIELD REPORT S-4-13 July 9, 2013
Current Procedural Terminology 2012 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Page 5
Over-the-Counter (OTC) Preventive Drugs
Eligible members can receive OTC preventive drugs at $0 copay or be reimbursed for the cost of the OTC drug, depending on the member benefit. To receive this benefit, a written or phoned prescription drug order must be received by the pharmacy. The pharmacy must fill the prescription as a prescription drug.
OTC drugs eligible for the preventive benefit include: Aspirin 81mg and 325mg for members 45-79 years of age Folic Acid 400mcg and 800mcg for women only Iron 15mg tablets and liquid for children 6-12 months Vitamin D 400IU for members 65 years of age and older Smoking cessations products Contraceptives for women only – female condom, sponge, foam,
gel, suppository, film, cream and insert
The preventive OTC benefit allows the following quantities: Aspirin, folic acid, iron and vitamin D – quantity to fulfill a 34-day
supply or 100 units, whichever is greater. Smoking cessation – quantity to fulfill a 34-day supply, with a
maximum of 180 days per year. Women’s contraceptive products – one per day up to a 34-day
supply.
Members with an insurance benefit that includes preventive coverage as defined by the United States Preventive Services Task Force (USPSTF) and Health Resources and Services Administration (HRSA).
Claims Processing – Per Diem “S” Code Home Infusion Claims
The medical claims processing system does not currently allow the per diem “S” code home infusion claims submissions for a span of service dates, i.e., 6/15 – 6/25, to pay properly. Please submit the per diem “S” code home infusion on a separate line for each date of service. The “S” codes affected by this are S9379 and S9490 through S9504. We apologize for this inconvenience and anticipate the date of service span to be a part of the claims system update coming late in 2014.
Other Party Liability
As outlined in Blue Shield Report S-07-06, BCBSKS receives numerous calls from providers asking who is responsible for submitting the additional information noted on their remittance advice (RA). In most instances, other party liability (OPL) information is needed from the member, which is indicated on the RA with OP in the CNTR column and a “17” in the ADJUSTMENT REASON CODE column. If members call their providers about such claim denials, they should be instructed to contact our OPL department direct at 1-800-430-1274 or 785-291-4013 (Topeka).
An OPL Questionnaire is available on our Web site at http://www.bcbsks.com/CustomerService/Forms/pdf/34-704_OPL.pdf. We encourage providers to have patients complete the questionnaire to expedite claims processing. The questionnaire can be faxed or mailed to BCBSKS as indicated on the form.
As reflected by the total charge in the AMOUNT PATIENT OWES field on the RA, providers may bill their members for these services, and are not required to wait for the requested information to be furnished to BCBSKS.
We encourage providers to use the self-service tools available through the Web and IVR when checking on the status of a claim or an update on the return of an OPL form. If our questionnaire has been returned, claims will have been adjusted, which can be found through the self-service tools. By assisting us in this manner, it will allow us to better serve our providers, and our other customers, with those things that require personal attention.
July 9, 2013 BLUE SHIELD REPORT S-4-13
Sent To: CAP excluding Dentists and Pharmacies
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Duplicate Claims Handling for Medicare Crossover
Since January 1, 2006, all Blue Plans have been required to process Medicare crossover claims for services covered under Medigap and Medicare Supplemental products through Centers for Medicare & Medicaid Services (CMS). This has resulted in automatic submission of Medicare claims to the Blue secondary payer to eliminate the need for the provider’s office or billing service to submit an additional claim to the secondary carrier. Additionally, this has also allowed Medicare crossover claims to be processed in the same manner nationwide.
Effective Aug. 19, 2013 when a Medicare claim has crossed over, providers are to wait 30 calendar days from the Medicare remittance date before submitting the claim to Blue Cross and Blue Shield of Kansas (BCBSKS). The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan only after they have been processed by the Medicare intermediary. This process may take approximately 14 business days to occur. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional calendar days for you to receive payment or instructions from the Blue Plan. Providers should continue to submit services that are covered by Medicare directly to Medicare. Even
if Medicare may exhaust or has exhausted, continue to submit claims to Medicare to allow for the crossover process to occur and for the member’s benefit policy to be applied. Medicare primary claims, including those with Medicare exhaust services, that have crossed over and are received within 30 calendar days of the Medicare remittance date or with no Medicare remittance date, will be rejected by BCBSKS.
Commonly Asked Questions
How do I submit Medicare primary / Blue Plan secondary claims? • For members with Medicare
primary coverage and Blue Plan secondary coverage, submit claims to your Medicare intermediary and/or Medicare carrier.
• When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card for additional verification.
• Be certain to include the alpha prefix as part of the member identification number. The member’s ID will include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and coverage, and key to facilitating prompt payments.
When you receive the remittance advice from the Medicare intermediary, look to see if the
claim has been automatically forwarded (crossed over) to the Blue Plan: • If the remittance indicates that
the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. There is no need to resubmit that claim to BCBSKS.
• If the remittance indicates that the claim was not crossed over, submit the claim to BCBSKS with the Medicare remittance advice.
• In some cases, the member identification card may contain a COBA ID number. If so, be certain to include that number on your claim.
• For claim status inquiries, contact Availity at http://availity.com/providers/registration-details/.
When should I expect to receive payment? The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan only after they have been processed by the Medicare intermediary. This process may take approximately 14 business days to occur. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional business days for you to receive payment or instructions from the Blue Plan.
(continued on next page)
BLUE SHIELD REPORT S-4-13 July 9, 2013
Current Procedural Terminology 2012 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
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Duplicate Claims Handling for Medicare Crossover
(continued from previous page) What should I do in the meantime? If you submitted the claim to the Medicare intermediary/carrier, and haven’t received a response to your initial claim submission, do not automatically submit another claim. Rather, you should:
• Review the automated resubmission cycle on your claim system. • Wait 30 calendar days from receipt of the Medicare Remittance
advice. • Check claims status before resubmitting. Sending another claim, or having your billing agency resubmit claims automatically, actually slows down the claim payment process and creates confusion for the member. Who do I contact if I have questions? If you have questions, please call Customer Service at 1-800-432-3990 or (785) 291-4180. Web Changes - Medical Policy
Since the publication of Blue Shield Report S-2-13, the following new or revised medical policies have been posted to our Web site at: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies.htm
• Accelerated Breast Irradiation after Breast-Conserving Surgery for Early Stage Breast Cancer and Breast Brachytherapy as Boost with Whole-Breast Irradiation
• Actigraphy • Alcohol Injection Therapy for Morton’s Neuroma • Ampyra™ (dalfampridine) • Androgens and Anabolic Steroids • Aqueous Shunts and Stents for Glaucoma • Biologic Immunomodulators Therapy • Breast Reconstructive Surgery after Mastectomy • Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of
the Breast • Cryosurgical Ablation of Primary or Metastatic Liver Tumors • Electrical Bone Growth Stimulation of the Appendicular Skeleton • Electromyography (EMG), Nerve Conduction Studies (NCS), and Other
Electrodiagnostic (EDX) Related Services • Enhanced External Counterpulsation (EECP) • Equipment for Cold Therapy • Extracorporeal Shock Wave therapy (ESWT) for Plantar Fasciitis and Other
Musculoskeletal Conditions (continued on page 8)
Are You Registered?
On August 19, 2013, Availity will become the exclusive portal for online access to all secure information on Blue Cross and Blue Shield members in Kansas. This means BCBSKS will require all of its providers to use Availity. After the transition, providers will no longer be able to directly access BlueAccess from www.bcbsks.com; all secure information must be accessed through Availity.
SPECIAL NOTE: As each pharmacy policy is reviewed, it will be updated to include the following:
Indicating whether BCBSKS or
Prime Therapeutics reviews the Prior Authorizations (found below the PA form link on the first page)
Applicable J codes
July 9, 2013 BLUE SHIELD REPORT S-4-13
Sent To: CAP excluding Dentists and Pharmacies
Contains Public Information
Page 8
Web Changes - Medical Policy (continued from page 7)
• Eye Movement Desensitization and Reprocessing (EMDR) for Acute Stress Disorder and Post Traumatic Stress Disorder (PTSD)
• Foot Care Services • Functional Neuromuscular Electrical Stimulation for Home Use • HP Acthar Gel (repository corticotropin) • Interspinous Distraction Devices (Spacers) • Keratoprosthesis • KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin
Therapy • Lumbar Spine Fusion Surgery • Magnetic Resonance Spectroscopy • Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the
Diagnosis and Management of Asthma and Other Respiratory Disorders • Measurement of Serum Antibodies to Infliximab • Multiple Sclerosis Agents (also addresses Tysabri’s use in Crohn’s disease) • Optical Coherence Tomography (OCT) of the Anterior Eye Segment • Oscillatory Devices for the Treatment of Cystic Fibrosis and other Respiratory
Disorders • Outpatient Use of Limb Pneumatic Compression Devices for Venous
Thromboembolism Prophylaxis • Oxycodone • Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers • Radiofrequency Catheter Ablation of the Pulmonary Veins as Treatment for Atrial
Fibrillation • Real-Time Intra-Fraction Target Tracking during Radiation Therapy • Screening for Lung Cancer Using CT Scanning • Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA • Spinal Cord Stimulation • Sublingual Immunotherapy as a Technique of Allergen Specific Therapy • Transcranial Magnetic Stimulation (TMS) as a Treatment of Depression and Other
Psychiatric Disorders • Vagus Nerve Stimulation • Video EEG Monitoring • Xolair® (omalizumab)
The following Dental Policies have published to the secure Availity portal:
• Cone Beam Computed Tomography (CBCT) • Identification of Periodontal Microorganisms
Credentialing Reminder
Blue Cross and Blue Shield of Kansas (BCBSKS) continues to work toward credentialing MD, DO, DPM, PA, APRN, PhD (LP), LSCSW, LCMFT, LCPC, LCP, LPT, DDS, OD and DC providers. This activity pertains to our existing Competitive Allowance Program (CAP) providers as well as brand new providers coming into the network. Those provider types listed above must be credentialed to become a participating network provider and/or to maintain their network status. As stated in previous Blue Shield
(continued on next page)
BLUE SHIELD REPORT S-4-13 July 9, 2013
Current Procedural Terminology 2012 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Page 9
Credentialing Reminder (continued from previous page)
Reports, we ask that providers utilize the CAQH (Council for Affordable Quality Healthcare) on-line application for their credentialing data. The on-line application is secure, and providers can designate who has access to their data. Once a provider has a complete/current application on CAQH, we can begin the credentialing process.
Help with CAQH on-line or the Universal Provider DataSource (UPD)? Please refer to the Quick Reference Guide link – https://upd.caqh.org/oas/UPDQuickReferenceGuide20120820.pdf - or call the CAQH Help Desk at 1-888-599-1771. Be advised, you must have a CAQH provider ID# before you can begin completing an on-line CAQH application. If you need a provider ID#, please complete the request form off of our Web site –
http://www.bcbsks.com/CustomerService/Forms/pdf/provider_CAQH_ID_request_form.pdf - and send it to us. We will then respond back to you with a provider ID# so you can access the UPD through CAQH.
Once you have a current/ complete on-line application in CAQH, e-mail us at [email protected] so we know you are ready to begin the credentialing review process. Include the following in the subject line of the e-mail: “Provider's Name, NPI#, CAQH Provider ID# - Application Ready."
Paper please? The on-line CAQH application is the preferred and most user friendly method, however, a paper version of the CAQH credentialing application can be printed from the Kansas Insurance Commissioner’s Web site – http://www.ksinsurance.org/industry/company/co_docs/CAQH_Provider_Application_v5.pdf. If you decide to complete a paper credentialing application you must also include a current liability insurance certificate either with the provider's name on it, or you can attach a cover letter stating the provider's name as covered. E-mail the completed application and any attachments to [email protected] or fax it to Attn: CVOcred, 785-290-0734. Once your application is submitted to us, you can also contact the CAQH Help Desk to find out how they can assist you in getting your provider data loaded to the on-line application within CAQH. Doing so will eliminate the need to complete another paper application at the time of recredentialing, which is every three years.
You already credentialed my provider? BCBSKS just began credentialing our CAP network in February 2013. You may already be a CAP provider, but not necessarily credentialed. If you were credentialed as outlined in the Blue Shield Report S-3-13, you are most likely credentialed with us. Check with your office credentialing contact; if still unsure of your credentialed status, send an e-mail to [email protected] with the provider's name and NPI#, along with a request to confirm credentialed status.
Our goal is to have the majority of our providers credentialed by August 1, 2013. We appreciate your assistance and patience as we work to meet provider network requirements as a Qualified Health Plan.
ICD-10 is coming… Ready? … or Not!
Oct. 1 – Topeka Oct. 2 – Salina Oct. 3 – Wichita Online registration will be available after Aug. 1 at www.bcbsks.com
$125 8 CEUs
save the date!
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BLUE SHIELD REPORT S-4-13 July 9, 2013
Current Procedural Terminology 2012 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
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