Questions: Contact your professional relations representative or provider network services in Topeka at (785) 291-4135 or (800) 432-3587.

Acknowledgement: Current Procedural Terminology (CPT®) is copyright 2014 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.

Current Procedural Terminology © 2014 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 PharmaciesContains Public Information

Updating billing records key to avoiding denialsAre you receiving claim denials indicating the provider’s National

Provider Identifier (NPI) number is not registered with Blue Cross and Blue Shield of Kansas (BCBSKS)? The reason could be an outdated record with BCBSKS.

BCBSKS recently upgraded its claims processing system to better match billing NPI numbers with rendering provider NPI numbers. As a result, we are noticing several providers who have not informed us of changes made to their provider data with other payors, primarily the Center of Medicare and Medicaid Services (CMS).

Any change you make to your provider data (Taxpayer Identification Number or TIN, NPI, legal name, address, adding a provider, etc.) with CMS or another payor must be separately communicated to BCBSKS. This communication should occur before you begin filing claims using the new information in order to prevent denials and/or delays in claim payments.

If you are receiving denials or have made changes to your provider billing record and have not notified BCBSKS, please contact provider network services in Topeka at (785) 291-4135 or (800) 432-3587, option 3. You can also refer to the Provider Change of Information Form and/or the Provider Network Enrollment Request form on the BCBSKS website, www.bcbsks.com, to submit changes or add new providers to your billing record.

JUNE 27, 2014S-2-14

A Newsletter forProfessional Providers and their Staff Members

WHAT’S INSIDE ?

• Updating records ..........................1• Pharmaceutical

Formulary Update .........................2• Labs, DME and specialty

pharmacy providers filing Blue claims .......................2, 3

• Prior authorization for Blue KC members ...................4

• Billing reminder .............................4• ICD-10 readiness survey ..............4• ICD-10 workshops set ..................4• Influenza virus

diagnostic testing and treatment in an outpatient setting .................5

• Date of birth edit ...........................6• A look

at Case Management ...................6• Web changes:

Medical Policies ............................6

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

Dustin Kimmel, Communications Coordinator

An Independent Licensee of the Blue Cross and Blue Shield Association

Page 2 Sent To: CAP excluding Dentists and PharmaciesContains Public Information

June 27, 2014 BLUE SHIELD REPORT S-2-14

Pharmaceutical Formulary

UpdatePrime Therapeutics

updates the Blue Cross and Blue Shield of Kansas formulary (preferred medication list) on a quarterly basis. Please refer to the link below when prescribing or dispensing medications for your BCBSKS 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#ViewFindDrugs Event

Pharmacy, Labs, DME, filing Blue claims

Filing certain claims with the proper Blue Plan will help ensure correct processing

Generally, as a health care provider, you should file claims for your Blue Cross and Blue Shield patients to the local Blue Plan. However, there are unique circumstances when claims filing directions will differ based on the type of provider and service.

Ancillary providers are Independent Clinical Laboratory, Durable/Home Medical Equipment (DME) and Supplies and Specialty Pharmacy providers. The local Blue Plan as defined for ancillary services is as follows:

Independent Clinical Laboratory (Lab) — The Plan in whose state* the specimen was drawn.

Durable/Home Medical Equipment and Supplies (DME) — The Plan in whose state* the equipment was shipped to or purchased at a retail store.

Specialty Pharmacy — The Plan in whose state* the Ordering Physician is located.

*If you contract with more than one Plan in a state for the same product type, i.e. PPO or Traditional, you may file the claim with either Plan.

1. The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue Plan where the claim is filed.

2. Providers are encouraged to verify Member Eligibility and Benefits by contacting the phone number on the back of the Member ID card or log on to Availity.com, before providing any ancillary service.

3. Providers that utilize outside vendors to provide services (example:

Sending blood specimen for special

analysis that cannot be done by the Lab

where the specimen was drawn) should

utilize in-network participating Ancillary Providers to reduce the

possibility of additional member liability for

covered benefits. A list of in-network participating providers may be

obtained by contacting http://www.bcbsks.com/

ProviderDirectory/index.htm4. Members are financially liable

for ancillary services not covered under their benefit plan. It is the provider’s responsibility to request payment directly from the member for non-covered services.

5. If you have any questions about where to file your claim, please contact Customer Service, (800) 432-3990 or (785) 291-4180, or email csc@bcbsks.com at Blue Cross and Blue Shield of Kansas.

Page 3Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.Note: Codes published herein are current on the publication/effective date and are subject to change.

June 27, 2014BLUE SHIELD REPORT S-2-14

Provider Type How to file (required fields)

Where to file Example

Independent Clinical Laboratory (any type of non hospital based laboratory)

Types of Service include, but are not limited to: Blood, urine, samples, analysis, etc.

Referring Provider: • Field 17B on CMS 1500

Health Insurance Claim Form or

• Loop 2310A (claim level) on the 837 Professional Electronic Submission or

• Loop 2420F (line level) on the 837 Professional Electronic Submission

File the claim to the Plan in whose state the specimen was drawn*

*Where the specimen was drawn will be determined by which state the referring provider is located.

Blood is drawn* in lab or office setting located in Kansas. Blood analysis is done in Oklahoma.File to: Blue Cross and Blue Shield of Kansas.

*Claims for the analysis of a lab must be filed to the Plan in whose state the specimen was drawn.

Durable/Home Medical Equipment and Supplies (D/HME)

Types of Service include but are not limited to: Hospital beds, oxygen tanks, crutches, etc.

Patient’s Address:• Field 5 on CMS 1500 Health

Insurance Claim Form or • Loop 2010CA on the 837

Professional Electronic Submission

Ordering Provider: • Field 17B on CMS 1500

Health Insurance Claim Form or

• Loop 2420E (line level) on the 837 Professional Electronic Submission

Place of Service: • Field 24B on the CMS 1500

Health Insurance Claim Form or

• Loop 2300, CLM05-1 (claim level) on the 837 Professional Electronic Submissions or

• Loop 2400 SV105 (line level) on the Professional Electronic Submission

Service Facility Location Information: • Field 32 on CMS 1500

Health Insurance Form or • Loop 2310C (claim level)

on the 837 Professional Electronic Submission

File the claim to the Plan in whose state the equipment was shipped to or purchased in a retail store.

• Wheelchair is purchased at a retail store in Kansas. File to: Blue Cross and Blue Shield of Kansas.

• Wheelchair is purchased on the internet from an online retail supplier in Florida and shipped to Kansas.File to: Blue Cross and Blue Shield of Kansas.

• Wheelchair is purchased at a retail store in Florida and shipped to Kansas.File to: Blue Cross and Blue Shield of Florida.

Specialty PharmacyTypes of Service: Non-routine, biological therapeutics ordered by a health care professional as a covered medical benefit as defined by the member’s Plan’s Specialty Pharmacy formulary. Include but are not limited to: injectable, infusion therapies, etc.

Referring Provider:• Field 17B on CMS 1500

Health Insurance Claim Form or

• Loop 2310A (claim level) on the 837 Professional Electronic Submission

File the claim to the Plan whose state the Ordering Physician is located.

Patient is seen by a physician in Kansas who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Oklahoma where the member lives for six months of the year. File to: Blue Cross and Blue Shield of Kansas.

Labs, DME and Specialty Pharmacy Providers Filing Blue Claims

June 27, 2014 BLUE SHIELD REPORT S-2-14

Page 4 Sent To: CAP excluding Dentists and PharmaciesContains Public Information

Billing reminder

When Physical Therapy Assistants (PTA) and Occupational Therapy Assistants (OTA) provide service, it is required that they bill under their own NPI and not the Physical/Occupational Therapist’s NPI.

Blue Cross and Blue Shield of Kansas City (Blue KC) has implemented a prior authorization program and is now using MedSolutions to provide authorization services for all of their members receiving outpatient high tech radiology and lumbar spinal fusions. This is an effort to improve the quality of care for Blue KC members, both in their service area and across the country.

Outpatient and elective MRI, MRA, CT, CTA, PET, echocardiogram, nuclear cardiology studies and lumbar spinal fusions require prior authorization from MedSolutions for Blue KC members. Imaging performed in conjunction with an inpatient stay, 23-hour observation, or testing done in the emergency room is not subject to authorization requirements.

When imaging is required in less

than 48 hours because of an urgent condition, providers should call for authorization and tell MedSolutions that the imaging is urgent and ask for an expedited review.

MedSolutions is a utilization management services organization specializing in the management of quality, cost-effective diagnostic services. To request an authorization, you may access the company’s web portal 24 hours a day, seven days a week at www.medsolutionsonline.com, call (888) 693-3211 or fax a MedSolutions request form (download from www.medsolutionsonline.com) to (888) 693-3210.

MedSolutions is ready to offer any implementation support you may find necessary. Please contact MedSolutions at (888) 693-3211 with any additional questions about the program.

Prior authorizations for Blue KC members

Blue Cross and Blue Shield of Kansas will be hosting ICD-10 workshops June 2-4, 2015.

The June 2 workshop will take place at Newman University in Wichita, the June 3 workshop will be at Fort Hays State University in Hays, and the June 4 workshop will take place at BCBSKS in Topeka.

These will be advanced coding workshops recommended for staff

members of any provider that contracts with BCBSKS. Participants will work through specific cases and coding exercises.

Rebekah S. Gatti (CCS-P, CPC, CPC-1, CEDC, CPMA) will be the speaker. Gatti has 30 years experience in the health care industry, both inpatient and outpatient, with specialty in emergency medicine, general surgery, OB/GYN, cardiology, oral surgery, pain medicine, mental health, and occupational medicine.

ICD-10 workshops set for June 2015

Rebekah Gatti

ICD-10 readiness

surveyBCBSKS is taking a

survey about ICD-10 readiness to better prepare to meet contracting providers’ needs. To take the survey, go to: https://bcbsks.az1.qualtrics.com/ SE/?SID=SV_3Ph6y WE9VZO4is5

The survey will close July 7.

June 27, 2014BLUE SHIELD REPORT S-2-14

Page 5Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.Note: Codes published herein are current on the publication/effective date and are subject to change.

The clinical presentation of patients with uncomplicated influenza virus infection includes: abrupt onset of fever, cough, sore throat, myalgias, arthralgias, chills, headache, and fatigue. Most patients with a clinical illness consistent with uncomplicated influenza, do not require influenza diagnostic testing or treatment with antiviral drugs.

Rapid influenza diagnostic tests have limited sensitivity and false negative results are common. Thus, negative results from rapid influenza diagnostic tests should not be used to guide decisions regarding treatment with influenza antiviral medications. In addition, false positive tests can occur and are more likely when influenza is rare in the community. When laboratory confirmation is desired, testing by RT-PCR and/or viral culture is recommended. If most circulating influenza viruses have similar antiviral susceptibilities, information on influenza A subtypes may not be needed to inform clinical care.

Influenza Virus Diagnostic Testing and Treatment in Outpatient Setting

POLICY1. Testing and treatment for influenza may be considered medically

necessary for persons at high risk of influenza complications which include:a. progressive, severe, or complicated illness regardless of

previous health statusb. age 65 years and olderc. young childrend. children less than 19 years old receiving long term aspirin

therapye. morbidly obese patients (BMI greater than 39)f. persons of American Indian / Alaska Native heritageg. pregnant women or those less than two weeks post partumh. health conditions such as asthma, diabetes, neurologic and

neurodevelopmental disorders, heart diseasei. immunosuppressive conditions or medicationsj. residents of chronic care facilities

2. Chemoprophylaxis with antiviral drugs is not recommended for healthy persons exposed to influenza. It may be considered medically necessary for:a. unvaccinated persons at high risk of complications of the

diseaseb. unvaccinated healthcare workers who come into close

contact with a person with influenza during the infectious period (24 hours before onset of fever to 24 hours after its resolution)

c. to help control outbreaks in nursing homes When indicated, chemoprophylaxis should be started within 48

hours of exposure to the disease.

The term “young children” is not defined by the CDC, but may be considered for children 6 months through 8 years old, according to the CDC’s web page on “Children, the Flu, and the Flu Vaccine” (http://www.cdc.gov/flu/protect/children.htm).

For more information on this medical policy, please see the BCBSKS website: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies/policies/InfluenzaVirusDiagnosticTesting_Treatment_OutpatientSetting_2012-07-17.pdf

June 27, 2014 BLUE SHIELD REPORT S-2-14

Page 6 Sent To: CAP excluding Dentists and PharmaciesContains Public Information

A look at BCBSKS Case ManagementThe Blue Cross and Blue Shield of

Kansas Case Management Program provides coordinated services to meet the member’s needs in a cost efficient manner. The needs and resources of the member and family are used to determine the most appropriate balance of care.

A case manager, who is a registered nurse, works with the doctor and other members of the treatment team to develop a care plan. The case manager also may share information regarding community resources and alternative sources of funding that could be explored.

Participation in case management is voluntary and does not alter the benefits normally offered by the

member’s health care plan. This service may be terminated at any time.

Situations that may benefit from the case management program:• High-risk pregnancies• Premature/high-risk infants• Progressive neuromuscular deterioration diseases• Complex wound management• Head injuries and strokes• End of life care• Severe burns• Spinal cord injuries• Multiple trauma• Ventilator dependency

For more information, please call (800) 432-0216 ext. 6628. Federal Employee Plan (FEP) members should call (800) 432-0216 ext. 6611.

Web changes: Medical Policy

Since the publication of Blue Shield Report S-1-14, the following new or revised medical policies have been posted to our website at: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies.htm• Ambulatory Event

Monitors and Mobile Outpatient Cardiac Telemetry

• Biologic Immunomodulators Therapy

• Botulinum Toxin (BT) • Cardiovascular

Magnetic Resonance (CMR)

• Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions

• Hepatitis B / Oncology and Hepatitis C Agents (Pegasys®/Pegasys Proclick®/peginterferon alfa-2a, PegIntron®/peginterferon alfa-2b, Incivek™/telaprevir, Olysio™ (simeprevir), Sovaldi™/sofosbuvir, and Victrelis™/boceprevir)

• Hereditary Angioedema (Berinert, Cinryze, Firazyr, Kalbitor)

A new edit regarding patient date of birth was implemented June 22 by Blue Cross and Blue Shield of Kansas.

The purpose is to ensure the patient’s date of birth (2010CA DMG02) is accurate. We encourage the use of eligibility inquiry to

confirm the patient’s date of birth.Claims with a patient’s date of

birth less than 60 days from the claim submission date will not be subject to this edit.

Edit Logic will be published in the edit documents.

The Edit Code is A7:158:QC.

New edit regarding patient date of birth being implemented

WHAT IS CASE MANAGEMENT?►A cooperative program that assists our members and their health care

providers with complex medical issues.►A way to assist our members with serious, long-term or high-cost medical

conditions to help preserve their available health care benefits. ►A way to identify situations that involve unusual use of services and assist

in evaluating alternative choices.