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3rd Quarter 2013 Provider Network News 3A p u b l i c a t i o n t o ke e p o u r n e t wo r k p ro v i d e r s u p t o d a t e o n t h e l a t e s t n e w s a t B l u e C ro s s a n d B l u e S h i e l d o f Lo u i s i a n a
4th Quarter 2011
networknewsprovider
p r o v i d i n g h e a l t h g u i d a n c e a n d a f f o r d a b l e a c c e s s t o q u a l i t y c a r e
1st Quarter 2016
23XX6753 R06/11
www.bcbsla.com/providerswww.bcbsla.com/ilinkblue
23XX6753 R03/16Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.
Provider Relations RepresentativesProvider Relations representatives are your point of contact within Blue Cross and Blue Shield of Louisiana when you need education on policy changes and the tools we offer. You may also contact your representative when you have an issue that cannot be resolved through iLinkBLUE or by Provider Services.
Use our interactive Provider Representative Map available, online at www.bcbsla.com/providers >Provider Tools, to find your area representatives. Simply scroll over your parish to find the desired contact information.
Recently, we made changes to the Provider Relations representative areas of responsibility. Below is a list of each representative and the parishes they serve. Please check the list to see if your representative may have changed.
Anna Granen - [email protected] - Jefferson, Orleans, Plaquemines, St. Bernard and St. Charles
Jami Zachary - [email protected] - Ascension, East Baton Rouge, East Feliciana, Livingston, St. Helena, St. Tammany, Tangipahoa and Washington
Kelly Smith - [email protected] - Acadia, Allen, Beauregard, Calcasieu, Cameron, Jefferson Davis, Sabine and Vernon
Marie Davis - [email protected] - Avoyelles, Evangeline, Iberia, Lafayette, St. Martin, St. Landry and Vermillion
Mary Guy - [email protected] - Assumption, Concordia, Iberville, Lafourche, Pointe Coupee, St. James, St. Mary, St. John the Baptist, Terrebonne, West Baton Rouge and West Feliciana
Patricia O’Gwynn - [email protected] - Bienville, Bossier, Caddo, Caldwell, Catahoula, Claiborne, Desoto, East Carroll, Franklin, Grant, Jackson, La Salle, Lincoln, Madison, Morehouse, Natchitoches, Ouachita, Rapides, Red River, Richland, Tensas, Union, Webster, West Carroll and Winn
INSIDE THIS ISSUEProvider Network 2 Jill Taylor New to Network
Development2 Blue Cross Portal Browser
Requirements2 Requesting W-9s from Our
Providers2 Request for Medical Records
for Risk Adjustment Process3 BCBSLA Authorizations
Application Enhancements
3 Professional Provider Workshops
4 Recredentialing Reminders
Billing & Coding 4 Correct Use of HCPCS Level II
Toe Modifiers4 Specificity of Codes4 Subcontracted Lab Providers4 Claims Dispute Form 7 Drug Screening Assays7 Reporting ICD-10 Qualifiers/
Indicators7 Update Code Ranges8 NDC on Claims8 Child's Benefit from Annual
Wellness Exam
Medical Management9 HEDIS: Avoidance of
Antibiotics for Adults with Acute Bronchitis
10 Medical Policy Update
Member Benefits11 Healthier Generation Benefit11 Diabetes Telemonitoring
Provider Network
2 Provider Network News 1st Quarter 2016
Jill Taylor New to Network Development We are pleased to announce Jill Taylor as the new Blue Cross Network Development representative for the New Orleans area, effective December 2015.
Taylor comes to Blue Cross with 10 plus years of experience in provider relations and network contracting. A recent transplant from Lakeland, Florida, Taylor brings her technical knowledge of how to analyze market trends, proven negotiation skills and a desire to serve the New Orleans community with enthusiasm and attention to detail.
Taylor spent most of her adult life in Lakeland, Florida; however, she was born and raised on the West Bank in St. Charles Parish and has strong family ties to the New Orleans area. She and her husband currently live in Kenner with their two sons.
Provider Network
Request for Medical Records for Risk Adjustment and HEDIS ProcessesBlue Cross, including HMO Louisiana, Inc., has partnered with Altegra* to perform risk adjustment and HEDIS chart reviews on our behalf.
We have a confidentiality agreement with Altegra. Any information shared with Altegra will be kept in the strictest of confidence, in accordance with all applicable state and federal laws as well as HIPAA requirements regarding the confidentiality of patient records.
Reviewing medical chart documentation is a key component of the risk adjustment and HEDIS processes. For example, it enables us to identify conditions that you may have noted in the progress notes, but were:
• Not included on the claim at the time of the visit
• Not coded to the highest degree of specificity at the time of the visit
You are required to provide us with medical records as quickly as you can and without charge as outlined in your Blue Cross network agreement:
Provider shall provide Blue Cross, upon request and without charge to Blue Cross or Member, information including medical records of a Member reasonably required by Blue Cross to determine benefits and verify services related to provider’s attendance, examination, and/or treatment and allow Blue Cross onsite audit of such records.
For questions about your network contract obligations, please contact Provider Relations at [email protected] or 1-800-716-2299, option 4.
*Altegra Health Company is an independent company that serves as a risk adjustment research manager for Blue Cross and HMO Louisiana.
Requesting W-9s from Our ProvidersPlease remember that you must submit a W-9 form along with your letter for network related changes such as TIN updates, address updates, recredentialing, etc. The IRS requires that we maintain updated W-9 forms for our network providers.
Blue Cross Portals Browser RequirementsThe supported browser for all Blue Cross portals is Internet Explorer. For Authorizations Portal users, if your organization is running IE 9 or above, you must run the application in Compatibility View. Other browsers such as Firefox, Chrome, etc., are not supported by Blue Cross. Authorizations Portal users with unsupported browsers may find features of the applications do not function appropriately, or the applications may fail to load.
Get this newsletter emailed to you quarterly. Send an email to [email protected]. Put "newsletter" in the subject line.
1st Quarter 2016 Provider Network News 3
BCBSLA Authorizations Application EnhancementsOn April 4, 2016, we are enhancing our BCBSLA Authorizations application that is available under the Authorizations Portal section of iLinkBLUE. Utilizing your feedback, we have made improvements to the application that will help the authorization process become more efficient. There are six major changes that will be incorporated in this update.
1. One of the major updates will be the implementation of McKesson’s InterQual clinical guidelines for providers to perform their clinical reviews. There will be three new InterQual Criteria icons in place of the Milliman icons. Clinical content criteria will be unavailable April 1-4 as we make the transition from Milliman to InterQual.
2. A new Attestation Page will display before you enter the application. It explains that if you are documenting sensitive information you must mark the note as sensitive, and the information entered does not replace your own Electronic Health Records. To continue to the application select the “Yes” button.
3. A new extension icon will now allow you to perform a concurrent review or extension of service.
4. There are new search criteria for when you are searching for a member. You may now use a member’s Social Security number if the Subscriber ID is unavailable.
5. A confirmation page will display utilization management information, submitted request information and the automated decision after submission.
6. The Provider Supervisor Dashboard is an enhanced feature that will allow supervisors to reassign staff activities in the portal as needed.
More details about these enhancements are available in the Authorizations Portal User Guide, located on iLinkBLUE under the “Manuals” section. An updated guide will be posted mid-April.
April 12, 2016 Baton Rouge Blue Cross 9 a.m. to noon or 1 to 4 p.m.
April 13, 2016 Covington St. Tammany Parish Hospital 9 a.m. to noon
April 19, 2016 Alexandria Pineville Convention Center 9 a.m. to noon
April 20, 2016 West Monroe Hilton Garden Inn 9 a.m. to noon April 21, 2016 Bossier City Homewood Suites 9 a.m. to noon or 1 to 4 p.m.
April 26, 2016 Thibodaux Thibodaux Regional 9 a.m. to noon April 27, 2016 Lake Charles Holiday Inn Suites 9 a.m. to noon April 28, 2016 Lafayette Wyndham Garden 9 a.m. to noon or 1 to 4 p.m.
May 5, 2016 Metairie East Jefferson General Hospital 9 a.m. to noon or 1 to 4 p.m.
To RSVP, please email:[email protected]
• Put “Provider Workshop” in the subject line
• Please include the date and session time you plan to attend
• List all attendees by name and office name
• Please identify if the attendee is representing a billing/practice management company
If unable to send an email, you may contact our Provider Relations department at 1-800-716-2299, option 4.
Professional Provider Workshops
4 Provider Network News 1st Quarter 2016 CPT® only copyright 2016 American Medical Association. All rights reserved.
Billing & Coding
Recredentialing RemindersTo streamline the recredentialing process, the necessary forms are now available online. This allows you to complete them in advance of your recredentialing date. It means we will no longer send providers a pre-printed Recredentialing Application.
Additionally, the Professional Liability Information Form can also be found online should you need to report case details on any professional liability action(s) incurred since your last credentialing approval with us. You will continue to receive a letter advising of your recredentialing deadline date. The recredentialing forms are available online at www.bcbsla.com/providers, then click on "Forms for Providers."
Below are a few reminders to keep in mind when completing the recredentialing application as they will help expedite the recredentialing process.
• Use the most current Recredentialing Application
• Complete all fields that are applicable to you
• Include your Tax ID number
• Include the month and year in the education and work history sections
• The signature and date must be handwritten as Blue Cross does not accept signature stamps or date stamps
Provider Network
Correct Use of HCPCS Level II Toe ModifiersEffective immediately, when billing toe or toenail surgeries, the following modifiers are necessary to ensure services are processed and paid correctly:
• Modifier TA • Modifiers T1-T9
HCPCS Level II toe modifiers are anatomical and describe procedures performed on the right and left foot digits.
Failure to use these modifiers appropriately may result in claims denial.
It is incorrect to additionally append modifiers LT and/or RT. It is also incorrect to use Modifier 59 and/or Modifier 59 subset “X modifiers” (XE, XS, XP, XU).
Additionally, post audits will be performed and will result in recoupments if documentation reviewed supports unbundling by incorrect use of Modifiers 59, XE, XS, XP, XU, LT and RT.
Subcontracted LaboratoriesSubcontracted laboratory services are those services furnished to patients by providers other than the facility while a patient is inpatient or outpatient. These services include the technical components of clinical and anatomical laboratory testing.
The reimbursement outlined in the provider contract is intended to cover all hospital services rendered to a patient, including those services that are performed by subcontracted laboratories.
• Subcontracted laboratories must seek payment solely from the facility.
• Subcontracted laboratories cannot bill Blue Cross or the member for such services. This is a violation of the contract agreement with Blue Cross.
Full information is included in our Member Provider Policy & Procedures Manual available on iLinkBLUE (www.bcbsla.com/ilinkblue) under the "Manuals" section.
CorrectionIn our 4th quarter edition we incorrectly stated that Place of Service 22 for on-campus and off-campus services reimbursement will be based on office (non-facility) fees. This reference is only correct for Place of Service 19. Place of Service 22 is reimbursed based on non-office fees. We apologize for any inconvenience this error may have caused.
Specificity of CodesIt is important to file ALL applicable diagnosis codes (supported by the patient's medical records) on a claim. It is equally important that providers code claims to the highest degree of specificity. Blue Cross discourages providers from filing "not otherwise specified" (NOS) diagnosis codes. Claims with NOS codes may pend for medical record review and more appropriate coding.
Claims Dispute FormOur new Claims Dispute Form has replaced the Reimbursement Review Form. This form is available online now for use for when you have a claims dispute.
Effective June 1, 2016, we will no longer accept the current Reimbursement Review Form.
You may cut out the new form located on the next two pages. The form is available at www.bcbsla.com/providers, then click on "Forms for Providers."
1st Quarter 2016 Provider Network News 5
Page 1
Claims Dispute Form
18N2284 03/16 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association andincorporated as Louisiana Health Service & Indemnity Company.
Last reviewed on March 16, 2016.
Use this form to dispute a claim. This form must be included with your request to ensure that it is routed to the appropriate area of the company, thus avoiding delays in our review process. It is important to return the proper information (based on your reason for review) and that it is sent to the appropriate mailing address.
Please submit only one form per patient, per dispute.
PROVIDER INFORMATION
TYPE OF PROVIDER:
Professional Facility Other:
PROVIDER NAME
NATIONAL PROVIDER IDENTIFIER (NPI) PROVIDER TAX ID
PERSON COMPLETING THIS FORM CONTACT PHONE NUMBER
CONTACT EMAIL ADDRESS
PATIENT INFORMATION
MEMBER ID NUMBER POLICYHOLDER NAME
PATIENT NAME PATIENT DATE OF BIRTH
CLAIM NUMBER DATE(S) OF SERVICE AMOUNT CHARGED
GUIDE FOR SUBMITTING SUPPORTING DOCUMENTATION
SURGERY, ASSISTANT SURGERY or ANESTHESIA
DOCTOR’S HOSPITAL VISITS
DOCTOR’S OFFICE/CLINIC VISITS
OTHER SERVICE X-RAYS, LAB, PHYSICAL THERAPY
1) Operative Report 2) Anesthesia Report 3) Pre-Op History and
Physical 4) Asst. Surgeon
Credentials (If Not M.D.)
1) Discharge Summary 2) Hospital Progressive
Notes 3) History and Physical
Notes 4) Pathology Report
1) Office Notes Pertaining to Date of Service
2) History and Physical Notes
1) Physical Therapy Notes and Radiology/Lab Report
Page two of this form contains the list of reasons for your claims dispute. Please check only one reason per form. In order for us to review your claim dispute, we must receive the entire form.
A printable PDF of this form is available online at www.bcbsla.com/providers, then click on Forms for Providers.
(dispute reasons on next page)
6 Provider Network News 1st Quarter 2016
We help Louisianians protect every day.
CPT® only copyright 2016 American Medical Association. All rights reserved.
Page 2
Claims Dispute Form
18N2284 03/16 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association andincorporated as Louisiana Health Service & Indemnity Company.
Last reviewed on March 16, 2016.
PLEASE REVIEW MY CLAIM FOR THE FOLLOWING REASON
(Check only one reason per form)
REASON FOR REVIEW MUST INCLUDE TIME TO ALLOW
FROM DATE SUBMITTED
WHERE TO SEND
Claim rejected as duplicate Supporting medical documentation
30 days ELECTRONICALLY: Submit an action request through iLinkBLUE: (www.bcbsla.com/ilinkblue)
HARDCOPY: BCBSLAP.O. Box 98029 Baton Rouge, LA 70898-9029
Claim denied for bundling Reason why current bundling logic is incorrect
Supporting medical documentation
14 days
Claim denied for medical records Copy of our letter of request for medical records
Supporting medical documentation
14 days HARDCOPY: BCBSLA Medical Records P.O. Box 98031 Baton Rouge, LA 70898-9031
Claim denied as investigational or not medically necessary
Formal letter of appeal including reason
Supporting medical documentation
30 days HARDCOPY: BCBSLA MEDICAL APPEALS P.O. Box 98022 Baton Rouge, LA 70898-9022 orFAX: 225-298-1837
Claim payment/denial affects the provider’s reimbursement
Timely filing Reimbursement Authorization penalty Other
Formal letter of dispute including reason
Supporting medical documentation
Proof of timely filing (only if denied for timely filing)
60 days HARDCOPY: BCBSLAAppeals and Grievances P.O. Box 98045 Baton Rouge, LA 70898-9045
Claim payment affects the member’s cost share (deductible, coinsurance, copayment)
Formal letter of appeal including reason
Supporting medical documentation (must include authorization from the member)
30 days
1st Quarter 2016 Provider Network News 7
Drug Screening AssaysRecently we made changes to our Drug Screening Assays policy. Effective January 1, 2016, we only accept claims with CPT® drug screen codes.
Presumptive drug screening:Blue Cross will only allow payment for one presumptive drug screen for drugs from Drug Class A and/or B (CPT codes 80300-80304) regardless of the number of services performed.
Definitive drug testing:For dates of service on or after January 1, 2016, Blue Cross requires that claims be filed using CPT codes 80300-80377 rather than the temporary Medicare HCPCS codes G0477-G0483. Claims filed with HCPCS codes G0477-G0483 will be denied and must be refiled with current CPT codes.
Updated Code RangesWe recently completed a review of new 2016 CPT and HCPCS codes. As a result, we made minor updates to the Diagnostic and Therapeutic Services code ranges.
The following HCPCS code(s) have been added to the Outpatient Procedure Services code list effective January 1, 2016:
The following HCPCS codes have been added to the Diagnostic and Therapeutic Services code range and the Outpatient Hospital Drug list effective January 1, 2016.
These changes do not affect existing codes and allowable charges on the Diagnostic and Therapeutic Services schedules. It simply allows our system to accept these codes appropriately for claims adjudication. The above changes also apply to the HMO Louisiana, Inc. Diagnostic and Therapeutic Services schedule.
The complete lists of the Outpatient Procedure Services and Diagnostic and Therapeutic Services are in the Member Provider Policy & Procedures Manual, available on iLinkBLUE (www.bcbsla.com/ilinkblue) under the "Manuals" section.
10035-1003631652-316543347737252-3725339401-3940243210
47531-475444918550430-504355060650693-5069550705-50706
54437-544386164561650-6165164461-644636578569209
0396T0397T0404T0406T-0416T0419T-0436T
72081-7208473501-7350373521-7352373551-7355274712-7471377767-7777278265-7826680081811628117081218-8121981272-8127381276813118131481412
81432-8143481493815258152881535-8153681538815408154581595883509062592537925389305096931-9693699177
0394T-0395T0398T-0402T0417T-0418T0422T-0423TA4337C1822C2645C9458-C9460G0297G0299-G0300G0475-G0483J0202J0596J0695J0714J0875
J1443J1447J1575J1833J2407J2502J2547J2860J3090J3380J7121J7188J7205J7297J7298J7313
J7328J7340J7503J7512J7999J8655J9032J9039J9271J9299J9308P9070-P9072Q4161-Q4165Q9950Q9980
Billing & Coding
Reporting ICD Qualifiers/IndicatorsCovered entities under HIPAA are required to report the ICD qualifier/indicator on all claim submissions. Claims submitted without the qualifier or with an incorrect value will be returned. Follow these important points when submitting claims:
• Report the ICD qualifier/indicator in Form Locator 66 of the UB-04
• Report the ICD qualifier/indicator in Box 21 of the CMS-1500 claim form
• Use ICD qualifier "9"to report ICD-9 coded claims
• Use ICD qualifier "0" to report ICD-10 coded claims
Note: ICD-9 and ICD-10 codes cannot be reported on the same claim.
We help Louisianians protect every day.
CPT® only copyright 2016 American Medical Association. All rights reserved.
8 Provider Network News 1st Quarter 2016
Child's Benefit from Annual Wellness ExamAn annual wellness visit is especially important for children, to check their physical, emotional and social development and make sure they are meeting the right age milestones.
The following codes can be used for children's annual wellness visits:
E&M Codes for Well-Child Visits• 99382 - new patient, preventative visit, age 1 through 4 years• 99383 - new patient, preventative visit, age 5 through 11 years • 99392 - established patient, preventative visit, age 1 through 4 years• 99393 - established patient, preventative
visit, age 5 through 11 years
ICD-10 Codes for Well-Child Visits, as appropriate• Z00.121 - encounter for routine child
health examination with abnormal findings
• Z00.129 - encounter for routine child health examination without abnormal findings
• Z00.8 -encounter for other general examination
Submitting the well-child and sick-child visit on the same claim:You can bill for a preventative evaluation and management (E&M) service (well-child visit) and a problem-oriented E&M service (sick visit) on the same day and be reimbursed for both by filing the well-child CPT® code and the sick-visit CPT code with Modifier 25.
CPT guidelines state, "The abnormality or pre-existing problem found during the preventative exam must be significant enough to require additional work to perform all the components of the problem-oriented E&M service."
The well-child visit must occur with a primary care physician or pediatrician. Medical records must have documentation to justify both services.
In addition, please file all the appropriate diagnosis codes as applicable for all services performed during the well/sick child visit.
If your patients want more information about why a yearly checkup with a primary care doctor is important for their overall health, they can visit www.bcbsla.com/PCP.
NDC on ClaimsEffective July 1, 2016, we require all drugs billed on medical claims to be processed through the member’s medical benefits must include an NDC. Failure to report an NDC on these claims will result in automatic denials.
For Hardcopy Claims• On the CMS-1500 claim form,
report the NDC in the shaded area of Box 24A (the NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code, e.g. N499999999999)
• On the UB-04 claim form, report the NDC in Box 43 (description field)
For Electronic ClaimsReport the NDC in loop 2410, Segment LIN03. The code should consist of the CMS 11-digit NDC derivative with a leading zero resulting in a fixed length 5-4-2 (no hyphens) configuration. The proper format is validated during the processing period. The drug pricing information along with the corresponding unit(s) of measure should be reported in loop 2410 CTP03-05. Available measures of units include the international unit, gram, milliliter and unit.
For iLinkBLUE ClaimsSelect 24K to expand claim line to report NDC, Quantity, and Measurement.
Reporting NDCs on claims improves accuracy, especially for claims filed using the miscellaneous HCPCS code J3490. Having NDCs improves claims adjudication and provides us with better data for our members.
Billing & Coding
CPT® only copyright 2016 American Medical Association. All rights reserved.
1st Quarter 2016 Provider Network News 9
Do I need an antibiotic? How many times have you heard your patients presenting with symptoms of acute bronchitis or the common cold, ask this question? In today’s world, where everyone is looking for instant gratification, and in healthcare, instant relief via a quick cure, the patient’s expectation of receiving antibiotics poses a challenge for physicians.
According to the Centers for Disease Control and Prevention, antibiotic resistance is one of the world’s major public health challenges. Inappropriate use of antibiotics is the single most important factor in antibiotic resistance. An example of antibiotic misuse is the inappropriate prescribing of antibiotics for treating acute bronchitis in adults. Avoidance of antibiotic treatment in adults with acute bronchitis (AAB) is a Healthcare Effectiveness Data Information Set (HEDIS) measure that assesses patient care and services specifically for this issue with the overall goal being to NOT prescribe antibiotics for patients 18-64 years of age with a diagnosis of acute bronchitis without a competing diagnosis or co-morbidity.
A cough is the most common symptom bringing patients in to see their primary care physician with acute bronchitis being the most common diagnosis. About 90 percent of the time, acute bronchitis is caused by a virus and antibiotics are not warranted. Many patients receiving this diagnosis expect medications for symptom relief, and physicians are tasked with convincing patients that an antibiotic is not the right course of treatment. The challenge becomes managing the patient’s expectation of receiving a prescription for an antibiotic.
Educating patients that antibiotics do not significantly reduce the duration of symptoms and may cause more harm than good may be helpful in reducing the expectation of an antibiotic prescription. Careful word selection such as defining the diagnosis as a chest cold or “viral upper respiratory infection” along with offering at home treatments can also be helpful. In addition, setting realistic expectations for symptom duration (cough may last about three weeks) gives the patient a better understanding of the disease process. Education and communication are important in managing patient expectations for medications to treat acute bronchitis symptoms.
Although 90 percent of bronchitis infections are caused by viruses, approximately two thirds of patients in the United States diagnosed are inappropriately treated with antibiotics. Because of the risk of antibiotic resistance and potential adverse effects such as rashes, yeast infections, and Clostridium difficile infections, antibiotics should not be routinely used in the treatment of acute bronchitis. Patient education and effective communication are vital in overcoming the challenge of managing the patient with acute bronchitis thus helping to reduce inappropriate antibiotic prescribing.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Sources: www.ncqa.org www.qualitycompass.com
HEDIS: Avoidance of Antibiotics for Adults with Acute Bronchitis
Medical Management
Please share the information in this newsletter with your billing office and those at your office who work with Blue Cross reimbursement.
10 Provider Network News 1st Quarter 2016
New Medical PoliciesPolicy No. Policy Name
Eff ecti ve December 16, 201500484 Focal Treatments for Prostate Cancer00486 Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia00444 Quanti tati ve Electroencephalography as a Diagnosti c Aid for Att enti on-Defi cit/ Hyperacti vity Disorder00478 Treatment of Hepati ti s C with ombitasvir, paritaprevir, and ritonavir (TechnivieTM)00472 Proprotein Convertase Subti lisin Kexin Type 9 (PCSK9) Inhibitors [alirocumab (Praluent®), evolocumab (Repatha™)]00479 Treatment of Hepati ti s C with daclatasvir (Daklinza™) plus sofosbuvir (Sovaldi®)
Eff ecti ve January 22, 201600489 Mutati on Testi ng for Limb-Girdle Muscular Dystrophies00490 Gene Expression Profi ling and Protein Biomarkers for Prostate Cancer Management00498 Multi spectral Digital Skin Lesion Analysis
Eff ecti ve February 17, 201600487 insulin degludec (Tresiba®)00493 Adipose-derived Stem Cells in Autologous Fat Graft ing to the Breast00494 Transcatheter Mitral Valve Repair00499 asfotase alfa (Strensiq™)00500 aspirin extended release capsules (Durlaza™)00501 mepolizumab (Nucala®)
Provider inquiries for reconsiderati on of medical policy coverage, eligibility guidelines or investi gati onal status determinati ons will be reviewed upon writt en request. Requests for reconsiderati on must be accompanied by peer-reviewed, scienti fi c evidence-based literature that substanti ates why a technology referenced in an established medical policy should be reviewed. Supporti ng data will be reviewed in accordance with medical policy assessment criteria. If you have questi ons about our medical policies or if you would like to receive a copy of a specifi c policy, log on to iLinkBLUE at www.bcbsla.com/ilinkblue or call Provider Services at (800) 922-8866.
Medical Policy Coverage LegendThese symbols are referenced next to medical policies listed on this page and indicate Blue Cross’ coverage indicati ons as follows:
Investi gati onal Eligible for coverage with medical criteria Not medically necessary
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Recently Updated Medical PoliciesPolicy No. Policy Name
Changes Eff ecti ve December 16, 201500006 Autologous Chondrocyte Implantati on for Focal Arti cular Carti lage Lesions00008 Automati c Implantable Cardioverter Defi brillator (AICD)00070 Hyperbaric Oxygen Pressurizati on (HBO)00098 Dermatologic Applicati ons of Photodynamic Therapy00225 adalimumab (Humira®)00260 Spinal Cord Sti mulati on00397 Treatment of Hepati ts C with a sofosbuvir (Sovaldi®) Based Regimen
00455 Treatment of Hepati ti s C with sofosbuvir/ledipasvir (Harvoni®)
Changes Eff ecti ve January 22, 201600034 Treatment of Varicose Veins/Venous Insuffi ciency00170 Immune Globulin Therapy00261 Endoscopic Radiofrequency Ablati on or Cryoablati on for Barrett 's Esophagus00408 Geneti c Testi ng for Cardiac Ion Channelopathies00459 Geneti c Testi ng for FLT3, NPM1, and CEBPA Mutati ons in Acute Myeloid Leukemia
Change Eff ecti ve February 17, 201600012 Botulinum Toxins00045 Stereotacti c Radiosurgery and Stereotacti c Body Radiotherapy00169 Cytochrome p450 Genotyping00228 Intradialyti c Parenteral Nutriti on00243 Iomitapide (Juxtapid®)00248 Adopti ve Immunotherapy00292 Sinus Osti al Dilatati on with Balloon Catheter for Chronic Rhinosinusiti s00344 Tropical Acne Kits00345 Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeleti ons Using Cell-free Fetal DNA00349 mipomersen (Kynamro®)00488 Identi fi cati on of Microorganism Using Nucleic Acid Probes
Change Eff ecti ve February 20, 201600104 Positron Emission Tomography (PET) Miscellaneous (Non- cardiac, Non-oncologic) Applicati ons
Medical Policy Update Blue Cross regularly develops and revises medical policies in response to rapidly changing medical technology. Our commitment is to update the provider community as medical policies are adopted and/or revised. Benefi t determinati ons are made based on the medical policy in eff ect at the ti me of the provision of services. Please view the following updated medical policies, all of which can be found on iLinkBLUE at www.bcbsla.com/ilinkblue.
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Medical Management
1st Quarter 2016 Provider Network News 11
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BlueCard® ProgramMember Benefits
Healthier Generation BenefitIn Louisiana, 39.8% of middle school and high school-aged children are obese, considerably more than the national average of 31.3%. As a provider, you now have more resources for helping some of these children in your care.
Blue Cross has partnered with the Alliance for a Healthier Generation to increase awareness about a benefit for children who are diagnosed overweight or obese.
This benefit is available for:
• Children ages 3 to 18 who are diagnosed as overweight or obese and covered under some policies. They are allowed at least four primary care physician visits and at least four registered dietitian visits as contract benefits.
• Additionally, children ages 6 to 18 diagnosed with obesity and covered under some policies. These kids are fully covered for six months of intensive, comprehensive treatment.
The six-month coverage begins when the child is diagnosed with obesity at his or her annual wellness visit. Treatment such as individual and group health-oriented counseling, eligible weight management classes and health and behavior interventions are included in the benefit.
According to the 2015 State of Obesity report, Louisiana ranks fourth of the 51 states/territories for obesity in children ages 10-17. Louisiana has consistently received an “F” grade for childhood overweight and obesity in the Louisiana Report Card on Physical Activity & Health for Children and Youth. We must work together to fight childhood obesity.
We at Blue Cross urge you to tell your patients with Blue Cross coverage that children diagnosed as obese may be eligible for more help. Blue Cross customers can contact the toll-free customer service phone number on their ID cards for details on what is covered under their plans.
Diabetes TelemonitoringIn November 2015, we partnered with Genesis Health Technology (GHT) to offer Diabetes Telemonitoring to our members. All of our members are eligible to take advantage of this program except Federal Employee Program (FEP), Blue Advantage and Office of Group Benefits (OGB).
Diabetes Telemonitoring involves remotely monitoring diabetic members who are not at the same location as the healthcare provider. This method allows members to track their blood glucose at home and automatically uploads a member’s test results over a cellular network to a secure, online web portal accessed by the healthcare provider. When a member’s glucose readings are out of range, a nurse will contact them. The provider can view their members’ individual glucose readings via secure web portal.
Benefits of Telemonitoring
• Accurate, real-time blood glucose data transmission
• Online access to blood glucose test results with the ability to print reports
• Ability to share test results with healthcare professionals
For more information or to refer your patients to the program:
GHT Customer Service Phone: 1-888-263-0003
GHT Website: www.genesishealthtechnologies.com
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The content in this newsletter is for informational purposes only. Diagnosis, treatment recommendations and the provision of medical care services for Blue Cross members are the responsibilities of healthcare professionals and facility providers.
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PERMIT NO. 458networknewsP. O. BOX 98029 • BATON ROUGE, LA 70898-9029
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BlueCard® Eligibility(800) 676-BLUE (800-676-2583)
EDI Clearinghouse (225) 291-4334 [email protected]
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Fraud & Abuse (800) 392-9249 [email protected]
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Network Administration (800) 716-2299 Fax: (225) [email protected]
Provider Services Call Center(800) 922-8866
Claims Filing AddressP.O. Box 98029 Baton Rouge, LA 70898
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