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A U G U S T 2 0 1 1 V O L . 1 3 , I S S U E 5
W H A T ’ S H A P P E N I N G
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®´ Registered trademark of CareFirst of Maryland, Inc.
From the CareFirst BlueCross BlueShieldfamily of health care plans.
PHARMACY UPDATES
WHAT ’S HAPPENING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
1
CLAIMS AND BILLING QUICK LINKS TO:
PROVIDER REPRESENTATIVES AND CONTACTS
PHONE NUMBERS AND CLAIM ADDRESSES
W H A T ’ S H A P P E N I N G
Qualified PCPs and NPs—It’s Not Too Late to Enroll in PCMH . . . . . . . . 2
Ready for HIPAA 5010? . . . . . . . . 2
AMA Develops New CPT Codes for Pediatric Immunizations . . 3
CareFirst Offers Members HRAs . 3
New Technology Evaluated . . . . . 4
Medical Policy Updates . . . . . . . 5
Practitioner and Staff Seminars and Training Sessions . . . . . . 7
Prior Authorization . . 10
Now on the Preferred Drug List . . . . . 10
New Generics . 10
Check back next issue for updates
New Quality and Affordability Resources Available OnlineWe know how important it is to make proper care decisions and recommendations for your patients, our members. It is our goal to provide you with information and resources to help supplement your clinical decision-making and achieve the goals of improving quality and reducing health care costs.
To help do just that, we have added a Quality and Affordability Resources section to our website. This section provides you with information and data on laboratory, radiology and ambulatory surgery centers, as well as information about medication choices. We will continue to add additional resources on an ongoing basis.
Here are some quick tips that you can use to reduce costs and improve care for your patients:
n Did you know that many routine laboratory tests can cost up to six times more when performed in an outpatient hospital lab? You can save up to 83 percent for your patients by referring them to a national freestanding lab. LabCorp and Quest Diagnostics, the national laboratories for CareFirst, are a cost-effective choice when referring patients. (Remember: BlueChoice members must utilize LabCorp.)
n The costs of common radiology procedures vary widely between outpatient hospital and CareFirst-contracted freestanding radiology centers. You can save up to 73 percent for your patients by referring them to a freestanding radiology center.
n Referring patients to an Ambulatory Surgery Center (ASC) instead of an outpatient hospital can save patients up to 55 percent. CareFirst offers a wide range of accredited ASCs that are appropriate in various clinical situations.
n Most generic drugs are bio-equivalent to brand-name drugs. By prescribing appropriate generic drugs, you can reduce out-of-pocket expenses for your patients without sacrificing quality.
For more information, visit the Quality and Affordability Resources page.
1
BLUELINK > > AUGUST 2011
2WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
W H A T ’ S H A P P E N I N G
Qualified PCPs and NPs— It’s Not Too Late to Enroll in PCMH
Join a Virtual Medical Care Panel and earn a 12 percentage point increase
To date, nearly 3,000 of your fellow primary care physicians (PCPs) and nurse practitioners (NPs) have joined our Primary Care Medical Home (PCMH) program and are receiving incentives.
Are you a qualified PCP or NP interested in participating, but thought you missed the opportunity?
Let us help you. Other interested PCPs and NPs have contacted us and we want to help you get connected. By joining an existing Virtual Medical Care Panel you automatically qualify for a 12 percentage point fee increase and have the opportunity to receive future Outcome Incentive Awards.
Contact an Enrollment Coordinator at 888-646-2604 to connect with a Virtual Medical Care panel today.
Don’t Get Left Behind – Stay Connected
Receive health care news via email
To get ahead these days, you’ve got to Stay Connected . New media and technology are reshaping the way we do business, especially when it comes to communicating with you and your office staff .
To provide you with timely, engaging and informative health care news, we’ve created or enhanced our methods for you to receive health care news from us .
You can now receive health care news via email that’s relevant and applicable to your practice .
Not only will you receive health care news, but you’ll get the latest on when updates on training and seminars are held, product information and much more .
Click here to register .
Ready for HIPAA 5010?
HIPAA 5010 is coming. Are you ready?
By Jan. 1, 2012, you will be required by the Health Insurance Portability and Accountability Act (HIPAA) to adopt the new 5010 electronic data interchange standards for all electronic transactions. As a payer, CareFirst must also meet this deadline.
The 5010 changes require that the same National Provider Identifier (NPI) be used for Centers for Medicare & Services and all payers, including CareFirst.
If you need to update or change the NPI already registered with CareFirst, you can do this by completing the NPI Submission form. This form can then be submitted by:
n Faxing to 410-505-2959
n Mailing to: CareFirst BlueCross BlueShield/CareFirst BlueChoice, Inc. Provider Information and Credentialing 10455 Mill Run Circle P.O. Box 825, Mailstop CG-41 Owings Mills, Md. 21117
Please note: If you are already using the same NPI for CMS and CareFirst and there have not been any changes, no action is required.
BLUELINK > > AUGUST 2011
3WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
C L A I M S A N D B I L L I N G
AMA Develops New CPT Codes for Pediatric ImmunizationsThe American Medical Association (AMA) has issued new Current Procedural Terminology (CPT) codes for pediatric immunizations. Effective Jan. 1, 2011, CPT codes 90465–90468 were deleted and replaced by two new CPT codes, 90460 and 90461.
CareFirst encourages you to bill for these immunization services as recommended by the AMA and the American Academy of Pediatrics to help prevent claims from denying in error as duplicate services.
Please include all immunization services provided during each office visit on one claim form or electronic submission and use frequency units for CPT Code 90460 and other codes as necessary to report the services provided.
If you have questions about the new CPT code update, please contact Provider Services at 877-228-7268 or visit the American Academy of Pedatrics website.
CareFirst Offers Members HRAsCareFirst offers members a Health Reimbursement Arrangement (HRA) to help pay for health care expenses that are subject to the health plan’s deductible. To ensure timely and accurate payments, as well as to avoid the possibility of refunds and adjustments, here are a couple of tips to follow for members who have HRAs:
n The member does not have a copay for routine office visits. Routine care, including well child care, is covered 100 percent and is not subject to the deductible. Please submit the claim to CareFirst. Since the member does not have a copay or deductible for routine services, there is no need to collect a payment at the time of service.
n All other services are subject to the member’s deductible. Please submit the claim to CareFirst to determine the allowed benefit and member liability. If you collect a payment at the time of service that does not match the member liability as determined by CareFirst when the claim is processed, you may need to refund an overpayment. The member will also need to provide additional substantiation to the HRA administrator. To avoid this additional administration and inconvenience, you may choose to bill the member after the claim has been processed.
Members may use their HRA Health Care Payment Card for payment when billed.
BLUELINK > > AUGUST 2011
4WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
MOR E ON [ HEALTH C ARE POLICY] > >
H E A LT H C A R E P O L I C Y
New Technology EvaluatedOur Technology Assessment Unit evaluates new and existing technologies to apply to our local indemnity and managed care benefit plans. The unit relies on current scientific evidence published in peer-reviewed medical
literature, local expert consultants and physicians to determine whether those technologies meet CareFirst and CareFirst BlueChoice criteria for coverage. Policies for non-local accounts like NASCO and FEP may differ from
our local determinations. Please verify member eligibility and benefits prior to rendering services via BlueLine, FirstLine or CareFirst Direct. The Technology Assessment Unit recently made the following determinations:
TECHNOLOGY DESCRIPTION CAREFIRST AND CAREFIRST BLUECHOICE DETERMINATION
Saturation biopsy of the prostate A technique for taking multiple (more than 20) core samples when prostate cancer is suspected
Considered experimental / investigational
CPT® reporting code 55706 (for transperineal approach)
PCA3 genetic assay for prostate cancer Identifies and quantifies the presence of PCA3 gene which expresses in prostate cancer
Considered experimental / investigational
CPT® reporting codes 83891-83913
Oncotype DX® genomic assay for colon
A 12-gene array based genetic test to assess risk for colon cancer recurrence
Considered experimental / investigational
CPT® reporting codes 84999 or 88299
Egrifta® (tesamorelin) injection A synthetically produced growth hormone releasing factor for subcutaneous injection
Considered medically necessary ONLY for patients at least 18 years old with HIV infection who have been diagnosed with clinical lipodystrophy
HCPCS reporting code J3490
Intracranial angioplasty with stent placement
A percutaneous procedure for treatment of intracranial artery disease by placement of a stent
Considered medically necessary for treatment of intracranial aneurysm under specified conditions
CPT® reporting code 61635
Provider Representatives and Contact Information
To find your Provider Representative, click here.
Phone Numbers and Claims Addresses
To find other important phone numbers and address information, click here.
BLUELINK > > AUGUST 2011
5WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
H E A LT H C A R E P O L I C Y
Medical Policy UpdatesOur Health Care Policy department continually reviews medical policies and operating procedures as new, evidence-based information becomes available regarding advances on new or emerging technologies, as well as current technologies, procedures and services.
The table below is a guide designed to provide updates on any changes to existing or new local policies and procedures
during our review process. Each local policy or procedure listed includes a brief description of its status, select reporting instructions and effective dates. Policies from non-local accounts, such as NASCO and FEP, may differ from our local determinations. Please verify member eligibility and benefits prior to rendering services via BlueLine, FirstLine or CareFirst Direct.
Note: The effective dates for the policies listed below represent claims processed on and after that date.
MEDICAL POLICY AND/OR PROCEDURE ACTIONS, COMMENTS AND REPORTING GUIDELINES POLICY STATUS
AND EFFECTIVE DATE
1 .01 .011Continuous Passive Motion (CPM) Device
Under Policy Guidelines, added 2011 rationale statement . Policy statements unchanged . Report the use of CPM for treatment of the knee with HCPCS code E0935 . Report use of CPM device for joints other than the knee with HCPCS code E0936 and jaw dysfunction (TMJ) with E1700, E1701, or E1702 .
Periodic review and updateEffective 5/23/11
2 .01 .005Intravenous or Subcutaneous Histamine Therapy
Under Policy Guidelines, added 2011 rationale statement . Policy remains experimental / investigational . Report with Category I CPT® unlisted code 95199 .
Periodic review and updateEffective 5/23/11
2 .01 .017Allergy Immunotherapy
Under Provider Guidelines, statements regarding professional services for allergen immunotherapy revised to read: “When reporting professional services for the supervision of preparation and provision of antigens for allergen immunotherapy for a specific treatment set, the calculated doses should be based on the actual number of doses prospectively planned to be administered on a given dose schedule (report with CPT® code 95165) . A dose is the amount of antigen(s) in a single injection from a single or multiple dose vial (that is, one injection equals one dose) . The professional services for the immunotherapy are reported separately at the time the injection is administered (Report with CPT® codes 95115 or 95117) .”
Policy revisionEffective 5/23/11
4 .01 .008Uterine Artery Embolization for Fibroid Tumors (Leiomyomata)
Under Policy Guidelines added 2011 rationale statement . Report with the appropriate Category I CPT® code .
Policy review and updateEffective 5/23/11
5 .01 .005Botulinum Toxin
Description updated . Under Policy added “chronic migraine headache under specified conditions (See Policy Guidelines)” to the medically necessary indications . Under Policy Guidelines, added medically necessary criteria for chronic migraine headaches and the 2011 Technology Assessment for chronic migraine headache . Refer to Policy for details . Report services with the appropriate Category I CPT® code and the HCPCS code for botulinum toxin .
Policy revisionEffective 5/23/11
6 .01 .025Scintimammography
Description updated . Under Policy, statement updated by adding “molecular breast imaging” to experimental / investigational statement . Under Policy Guidelines, added 2011 rationale statement . Report with appropriate Category I CPT® code or HCPCS code .
Periodic review and updateEffective 5/23/11
MOR E ON [ SECT ION] > > BLUEL INK > > AUGUST 2011
6WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
H E A LT H C A R E P O L I C Y
MEDICAL POLICY AND/OR PROCEDURE ACTIONS, COMMENTS AND REPORTING GUIDELINES POLICY STATUS
AND EFFECTIVE DATE
6 .01 .032Positron Emission Tomography (PET)
Description updated . Under Policy, updated medically necessary statement with the following indications: lung cancer (expanded criteria), pancreatic cancer, ovarian cancer, testicular cancer, myeloma, soft tissue sarcoma . Under Policy Guidelines, updated criteria and added 2011 rationale statement . Expanded experimental / investigational statements to include additional indications, early response to treatment and as a surveillance tool for patients with cancer . Refer to the Policy for details . Report with the appropriate Category I CPT® codes .
Periodic review and updateEffective 5/23/11
6 .01 .037Radioembolization for Primary and Secondary Malignant Hepatic Tumors
Title changed from “Selective Internal Radiation Therapy for Malignant Hepatic Tumors” to “Radioembolization for Primary and Secondary Malignant Hepatic Tumors .” Policy revised . Radioembolization is considered medically necessary to treat primary hepatocellular carcinoma and hepatic metastasis for certain indications . Refer to the Policy for details . Under Policy Guidelines, added 2011 rationale statement . Report with Category I CPT® codes 37204, 75894, 79445 or HCPCS code S2095 .
Periodic review and updateEffective 5/23/11
7 .01 .035Extracorporeal Shock Wave Lithotripsy for Gallstones
Under Policy Guidelines, added 2011 rationale statement . Policy remains experimental / investigational . Report with HCPCS code S9034 .
Periodic review and update
7 .01 .081Photocoagulation of Macular Drusen
Description updated . Under Policy Guidelines, added 2011 rationale statement . Report with Category I CPT® unlisted code 67299 . Policy unchanged .
Periodic review and updateEffective 5/23/11
7 .01 .083Percutaneous Lysis of Epidural Adhesions
Under Policy Guidelines, added 2011 rationale statement . Report with Category I CPT® codes 62263, 62264 or 64999 .
Periodic review and updateEffective 5/23/11
10 .01 .011AEmergency Services: Auto Codes
New ICD-9 diagnosis codes have been added to the CareFirst, Inc . Emergency Services Auto Code List for Maryland-based indemnity and NASCO business, in compliance with COMAR 31 .10 .11 . See the table effective 5/1/2011, attached to the Operating Procedure 10 .01 .011A to view the list of the additional codes .
Operating procedure updateEffective by 5/1/11
BLUELINK > > AUGUST 2011
7WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
MOR E ON [ PROVIDER SEMINARS] > >
P R O V I D E R S E M I N A R S
Practitioner and Staff Seminars and Training SessionsCareFirst and CareFirst BlueChoice offer half-day seminars and webinars designed to familiarize professional and institutional providers and office staff with CareFirst and CareFirst BlueChoice policy, provider-oriented procedures and tools. Upcoming seminars and webinars are listed below so you can select the presentations and that best meet your needs.
HealthyBlue and Professional Basics & Updates Seminar – designed to introduce specific information on our newest product to professional and institutional providers and office staff during the first half of the seminar (duration – 2 hours). The second half will conclude with a professional Basics & Updates Seminar (duration – 3 hours). Institutional providers may leave after our lunch break between the two presentations. Lunch will be served.
Hospital Quarterly – designed for hospital office staff to receive up-to-date CareFirst information.
Professional Seminars
DATE AND TIME LOCATION ROOM
Tuesday, Sept . 13, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
CareFirst Columbia Gateway6731 Columbia Gateway Dr .Columbia, Md . 21046
Redwood Room
Wednesday, Oct . 5, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
Hilton Garden Inn4770 Owings Mills Blvd . Owings Mills, Md . 21117
Conference
Tuesday, Oct . 25, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
Peninsula Regional Med . Ctr . 100 East Carroll St . Salisbury, Md . 21801
Hallowell
Ancillary Seminars
DATE AND TIME LOCATION ROOM
Thursday, Sept . 8, 201110:30 a .m . to 1 p .m .Sub/Mtl
CareFirst Columbia Gateway6731 Columbia Gateway Dr . Columbia, Md . 21046
Redwood Room
Tuesday, Sept . 13, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
CareFirst Columbia Gateway6731 Columbia Gateway Dr .Columbia, Md . 21046
Redwood Room
Wednesday, Sept . 21, 201110:30 a .m . to 1 p .m .DME
CareFirst Columbia Gateway6731 Columbia Gateway Dr . Columbia, Md . 21046
Redwood Room
Wednesday, Oct . 5, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
Hilton Garden Inn4770 Owings Mills Blvd . Owings Mills, Md . 21117
Conference
BLUELINK > > AUGUST 2011
8WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
MOR E ON [ PROVIDER SEMINARS] > >
P R O V I D E R S E M I N A R S
Ancillary Seminars
DATE AND TIME LOCATION ROOM
Thursday, Oct . 20 , 201110:30 a .m . to 1 p .m .Hospice
CareFirst Columbia Gateway6731 Columbia Gateway Dr . Columbia, Md . 21046
Redwood Room
Tuesday, Oct . 25, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
Peninsula Regional Med . Ctr . 100 East Carroll St . Salisbury, Md . 21801
Hallowell
Tuesday, Nov . 8, 201110:30 a .m . to 1 p .m .ASC
CareFirst Columbia Gateway6731 Columbia Gateway Dr . Columbia, Md . 21046
Redwood Room
Hospital Seminars
DATE AND TIME LOCATION ROOM
Tuesday, Sept . 13, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
CareFirst Columbia Gateway6731 Columbia Gateway Dr .Columbia, Md . 21046
Redwood Room
Thursday, Sept . 29, 201110 a .m . to 12 p .m .HealthyBlue
AAMC – Doordan Health Science Inst .2000 Medical ParkwayAnnapolis, Md . 21401
7th Floor
Thursday, Sept . 29, 201110 a .m . to 12 p .m .Hospital Quarterly
Montgomery General Hosp .18101 Prince Phillip DriveOlney, Md . 20832
Ground FloorRooms A&B
Wednesday, Oct . 5, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
Hilton Garden Inn4770 Owings Mills Blvd . Owings Mills, Md . 21117
Conference
Tuesday, Oct . 25, 201110 a .m . to 4 p .m .HealthyBlue/Basics & Updates
Peninsula Regional Med . Ctr . 100 East Carroll St . Salisbury, Md . 21801
Hallowell
Webinars
DATE AND TIME SUBJECT TIME
7/21/2011 Dialysis 12:30 p .m .
7/21/2011 MPOS 4 p .m .
7/26/2011 PT/OT/ST/Chiro 10 a .m .
7/27/2011 HealthyBlue Introduction/HAWEF 8:30 a .m .
7/27/2011 OB/GYN 2 p .m .
7/28/2011 HealthyBlue Benefits and Referrals 8:30 a .m .
BLUELINK > > AUGUST 2011
9WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
P R O V I D E R S E M I N A R S
Webinars
DATE AND TIME SUBJECT TIME
7/28/2011 Home Health 12:30 p .m .
8/2/2011 Anethesia 2 p .m .
8/3/2011 Hospice 12:30 p .m .
8/9/2011 BlueChoice 10 a .m .
8/9/2011 HealthyBlue Introduction/HAWEF 12 p .m .
8/10/2011 SNF 12:30 p .m .
8/11/2011 HealthyBlue Benefits and Referrals 12 p .m .
8/16/2011 VRU 4 p .m .
8/17/2011 MPOS 10 a .m .
8/18/2011 ASC 12:30 p .m .
8/18/2011 CFD 4 p .m .
8/23/2011 OB/GYN 10 a .m .
8/23/2011 HealthyBlue Introduction/HAWEF 3 p .m .
8/24/2011 Home Health 12:30 p .m .
8/24/2011 HealthyBlue Benefits and Referrals 3 p .m .
8/25/2011 CFD 10 a .m .
8/30/2011 DME 12:30 p .m .
8/31/2011 CDH 12 p .m .
9/7/2011 HealthyBlue Introduction/HAWEF 11 a .m .
9/8/2011 HealthyBlue Benefits and Referrals 11 a .m .
9/8/2011 BlueChoice 4 p .m .
9/13/2011 HealthyBlue Introduction/HAWEF 2:30 p .m .
9/14/2011 ASC 12:30 p .m .
9/14/2011 VRU 4 p .m .
9/15/2011 CFD 12:30 p .m .
9/15/2011 HealthyBlue Benefits and Referrals 2:30 p .m .
9/20/2011 MPOS 4 p .m .
9/21/2011 Anesthesia 1:30 p .m .
9/22/2011 Home Health 12:30 p .m .
9/27/2011 HealthyBlue Introduction/HAWEF 9 a .m .
9/27/2011 Substance/Mental -- Ancillary 12:30 p .m .
9/28/2011 PT/OT/ST/Chiro 12:30 p .m .
9/29/2011 HealthyBlue Benefits and Referrals 9 a .m .
9/29/2011 VRU 11 a .m .
10
BLUELINK > > AUGUST 2011More to feel good about.
CHIEF MEDICAL OFFICER AND SR . VICE PRESIDENT OF MEDICAL AFFAIRSJon P. Shematek M.D.
EDITORRobert Hilson
WHAT ’S HAPPENING
CLAIMS AND BILLING
HEALTH CARE POLICY
PROVIDER SEMINARS
QUALITY IMPROVEMENTS
PHARMACY UPDATES
P H A R M A C Y U P D A T E S
Prior AuthorizationThe following prescription drugs require prior authorization for prescriptions covered under the CareFirst and CareFirst BlueChoice prescription drug plan:
n Incivek™ for the treatment of chronic hepatitis C
n Sylatron™ for the treatment of melanoma
n Caprelsa™ for the treatment of medullary thyroid cancer
n Victrelis™ for the treatment of chronic hepatitis C
n Zytiga® for the treatment of prostate cancer
Now on the Preferred Drug ListThe following drugs are now tier 2 or preferred drugs.
BRAND NAME GENERICSylatron™ peginterferon alfa-2b
Caprelsa™ vandetanib
Viramune® XR nevirapine
Zytiga™ abiraterone
How Are We Doing?
How does BlueLink help you do your job? Let us know how BlueLink has made an impact on the way that you do business with CareFirst. Let us know what you think — what we’re doing right and what we could do better.
Our goal is to provide you with the best articles possible and your feedback is vital. Email your comments to [email protected]
New GenericsThe following drugs will be available as generic. The generics will be covered on tier 1 and the brand-name drugs will be on tier 3 or non-preferred.
BRAND NAME GENERICAromasin® exemestane
Bromday™/Xibrom™ bromfenac
Elestat™ epinastine
Femara® letrozole
Sular® nisoldipine
Xalatan® latanoprost
Click here to view the most current preferred drug list, prior authorization forms and pharmaceutical management procedures. For a paper copy of the formulary and pharmaceutical management procedures, call 877-800-3086.
