BlueLink - provider.carefirst.com · Provider Seminars While little is changing other than the platform that we will use to process the claims, ... migration to the Facets claims

Quick SummaryClaims and Billing

Maryland Health Insurance Program 2FEP Requires an Authorization for all NICU Services 3Attention Psychiatrists 3

What’s Happening

CQR Expands to Include General Surgeons 4

Did You Know? 4

Voice Response Unit (VRU) and CareFirst Direct: Your Answer to Reduce Administrative Cost and Increase Productivity 18

Health Care Policy

Claims Adjudication Policies 5New Technology Evaluated 5Medical Policy Updates 6-8

Provider Seminars 9-11

Provider Representatives Institutional Provider Representatives 12

Phone Numbers & Addresses 13-14

Pharmacy Updates 16Quality Improvement

Case Management -- Assistance to Take Charge of Your Patients’ Health Care Needs 15

Supporting Follow Up Treatment after Behavioral Health Hospitalization 16

FAQ Regarding FACETS 17

A News Publication Linking CareFirst and CareFirst BlueChoice with Participating Physicians, Providers and Institutions

BlueLink March/April 2009 • Vol. 11, Issue 2

CareEssentialsBlueLink is part of the Utilization

Management component of

CareEssentials, our care management

program that provides you with

essential tools for patient care.

Facets Migration Effective April 1

Note: All references to “CareFirst” in this publication refer to CareFirst BlueCross BlueShield. All references to “CareFirst BlueChoice” refer to CareFirst BlueChoice, Inc.

On April 1, 2009, CareFirst began member migration to the Facets claims processing platform. Facets is not new to CareFirst; enrollment and billing functions for members whose claims were processed on the FLEXX platform have been processed on Facets for many years. The migration allows us to integrate our enrollment, claims processing and provider service functions onto a single platform, and is part on an ongoing effort to serve providers and members more efficiently.

The first groups to migrate will consist of about 170 members whose employers are located in Montgomery County and Laurel, Md. Between April 1, 2009 and January 1, 2011, all of our small to mid-sized groups and Individual Market business will move to Facets.

While little is changing other than the platform that we will use to process the claims, we wanted to provide some information.

ProductsMembers who move to Facets will be covered by existing CareFirst products, including BlueChoice and BluePreferred. All rules normally associated with these products will still apply after the migration.

PrefixesWhile some accounts may request account specific prefixes, the majority of members will have one of the following, depending upon their product:

IndemnityXIJ DCbasedgroupsandindividualsXWY MDbasedgroupsandindividuals

PPO (BluePreferred)XIL DCbasedgroupsandindividualsXWV MDbasedgroupsandindividuals

HMO (BlueChoice)XIK DCbasedgroupsandindividualsXWR MDbasedgroupsandindividuals

2 bluelink March/April 2009 u Vol. 11, Issue 2 u Visit us at www.carefirst.com

Facets Migration Effective April 1 (continued from cover)

Id CardMembers who migrate to Facets will receive new identification cards and member numbers. While member information will be “cross-walked” from the previous system to the new, ask your patients if they have received a new card and ask them to bring it with them, as this can help ensure claims submission accuracy.

Claims Submission AddressThe address for submitting paper claims has not changed. Paper claims should be submitted to the following address:

MailAdministratorP.O.Box14116Lexington,Ky.40512-4116

Electronic Billing InformationElectronic billing submission requirements have not changed. For complete information related to submitting electronic claims please refer to the EDI Services section of the CareFirst Web site. Electronic claims should be submitted using your Regional Provider Number.

Service Contact InformationThe telephone number for Provider Services has not changed. Provider service can be reached at 202-479-6560 or 800-842-5975.

CareFirst DirectEligibility and claims information will be available for these members effective April 1, 2009. Benefit information will be available May 7. For verification through May 7, use FirstLine or contact Provider Service. Provider Service can be reached at 202-479-6560 or 800-842-5975.

Further InformationAdditional information related to both this and the large account migration to NASCO will be available through a number of sources. You can attend a Basics and Updates seminar or participate in a Webinar. The Basics and Updates seminar is a full three-hour training that describes CareFirst products, processes and procedures. It also includes CareFirst updates such as the NASCO and Facets migrations. The Webinar is a 15 minute presentation that focuses on the migration process. You can register for both through the provider section of the CareFirst Web site.

You can also receive e-mail updates related to the Facets migration and other CareFirst initiatives by registering on-line at http://www.carefirst.com/providers/html/HealthPlanMailingList.html.

For answers to frequently asked questions regarding Facets, please refer to Page 17 or the CareFirst Web site, www.carefirst.com

ClaimsandBilling

CareFirst began to administer the Maryland Health Insurance Program (MHIP) on July 1, 2007. MHIP was previously administered by Maryland Physician Care (MPC).

We have received an influx of claims mailed to the CareFirst mailing address with MPC member identification numbers. Some of the claims are for current MHIP members, yet submitted using the old MPC ID #. The MPC ID # is completely different from ours, therefore the claims may be returned to your office as patient not found.

Please be sure to obtain the most current copy of the member’s ID card.

Maryland Health Insurance Program

March/April 2009 u Vol. 11, Issue 2 bluelink 3

CareFirst and CareFirst BlueChoice have received numerous inquiries from hospitals regarding authorization requirements for Federal Employee Program (FEP) members whose babies receive Neonatal Intensive Care Unit (NICU) services. To eliminate confusion, below is the FEP policy:

Anytime a baby receives NICU services, even if the baby goes home with the mother, a separate authorization must be obtained by the facility.

FEP Policy:Benefits are available for routine nursery care of newborns during the covered portion of the mother’s maternity stay. If the infant requires definitive treatment, including incubation charges by reason of prematurity or evaluation for medical or surgical reasons during or after the mother’s confinement, the newborn is considered a patient in his or her own right. As such, the infant will require an authorization for the hospital stay and medical or surgical benefits apply rather than maternity benefits.

Billing requirements:When billing for NICU services, please use the following codes, as appropriate.n Revenue code 173 – intermediate care; requires six to 12 hours of nursing each dayn Revenue code 174 - intensive care; severely ill neonate needing constant nursing

and continuous cardiopulmonary and other support

All charges related to the baby’s care must be submitted on a separate claim from the mother.

Authorizations:All authorizations for NICU services must be called into the CareFirst Precertification Department. Because these are newborn babies, there is not any enrollment information on file and iExchange cannot be used.

The Precertification department can be reached at 1-866-PRE-AUTH (773-2884).

Eligibility:CareFirst will provide an authorization for the newborn at the time of service. The policyholder has 30 days to add the baby to the policy. If the baby is not added to the FEP policy within 30 days, CareFirst will retract the money paid for the NICU claim. The policyholder will need to provide the hospital with the corrected insurance information and all of the baby’s charges should be billed to the appropriate carrier.

ClaimsandBilling

FEP Requires an Authorization for all NICU Services

Attention PsychiatristsEffective immediately, CPT code 90862 for medication management will not require an authorization for CareFirst products.


What’sHappening

CQR Expands to Include General SurgeonsCareFirst and CareFirst BlueChoice are excited to announce that general surgeons in our regional networks are now invited to join CareFirst Quality Rewards-Surgeons (CQR-S). CQR-S is an expansion of the CareFirst Quality Rewards (CQR) program launched in 2008.

CQR-S was developed through collaboration with the American Board of Surgery (ABS) to make the voluntary pay-for-quality program relevant to general surgeons. There is no penalty for surgeons who choose not to participate.

Like the original program, CQR-S includes effectiveness measures in the areas of quality, access and service-oriented business practices. While some measures are based on CareFirst administrative data, general surgeons are encouraged to choose from a menu of recognition and certification programs offered by leading national clinical quality organizations, such as, the American Board of Medical Specialties (ABS) and the National Committee for Quality Assurance (NCQA). This will allow surgeons to document their own quality, based on national evidence-based quality and patient safety programs.

In addition to the effectiveness measures, CQR-S has a dimension of affordability, based on NCQA’s prescribed methodology. By attaining scores high enough in effectiveness and affordability, a provider can achieve a reimbursement level up to 107 percent of the base fee schedule applicable to all claims in all CareFirst Regional networks.

General surgeons can submit data for this cycle through Dec. 31, 2009. CQR-S assessment reports will be issued in mid 2010 with earned reimbursement levels effective in late 2010.

CQR-S is the nation’s first pay-for-quality program for general surgeons to be endorsed by Bridges to Excellence, a not-for-profit organization that rewards providers who deliver safe and effective patient-centered care. We are working to expand CQR and CQR-S to additional specialties for the future.

For more information about our pay-for-quality programs and how to participate, visit our Web site, www.carefirst.com > Providers & Physicians > Solution Center and select CQR-S or CQR.

Did You Know?Members with PPO and Indemnity products with co-insurance and high deductible plans may realize a lower out-of-pocket expense if their outpatient laboratory services are provided by either of CareFirst’s participating national independent laboratory providers, Laboratory Corporation of America, Inc. (LabCorp) or Quest Diagnostics, Inc. (Quest), compared to other providers, labs and/or facilities.

To obtain a list of Patient Service Centers or for additional information regarding the services they provide you may access their Web sites at www.labcorp.com or www.questdiagnostics.com.

Requirements for CareFirst BlueChoice HMO members have not changed.???


HealthCarePolicy

Claims Adjudication Policies Reporting CPT® and HCPCS Codes

CareFirst and CareFirst BlueChoice should not receive claims with procedure codes specific to Medicare and Medicaid, or “Temporary National Codes (Non-Medicare).” Therefore, unless otherwise directed through BlueLink or other communication means, providers should report services for our members using the standard CPT® codes instead of comparable Level II HCPCS codes. This includes, but is not limited to, Medicare temporary G-codes; H and T codes which are specific to, Medicaid; and non-Medicare “S” codes. PLEASE NOTE: this policy does not apply to: n Crossover claims which are reimbursed by CareFirst as

secondary to Medicare orn Claims for DME, supplies, equipment, or drugs for which there

is no comparable CPT® code

Reporting ICD-9-CM Diagnosis CodesCarefully follow coding guidelines outlined in the most current

ICD-9-CM coding book. Of particular importance are the following: n Code to the highest level of specificity, to include 4th and 5th

digits, as appropriate n List the primary, or most important diagnosis for the service

or procedure, first; n Code chronic complaints only if the patient has received

treatment for the condition n When referring patients for laboratory or radiology services,

code as specifically as possible and list the diagnosis that reflects the reason for requesting these services.

Claims that are not coded properly may be returned to the reporting provider, which will delay adjudication.

Additional information on claims adjudication and related policies is available in the CareFirst General Information Manual at www.carefirst.com > Providers & Physicians > provider manuals > general information manual > policy statements. For any questions, please contact your provider representative.

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:

*Note: Current Procedural Terminology (CPT®) codes and descriptions only are copyright of the 1966 American Medical Association. All rights reserved.

Technology Description CareFirst and CareFirst Blue Choice Determination

Electromagneticnavigationbronchoscopy,e.g.InReach®

Image-guidedfiberopticbronchoscopyallowsfordeeperpenetrationofbron-choscopedevice

Consideredanadvancedformofbronchoscopy

CPT®reportingcodes316XXseries

Cryoablationofrenalcellcarcinoma Useofcryoprobetodestroytumormassbyfreezing

Consideredmedicallynecessary.

CPT®reportingcodes50593

MicrovoltT-wavealternans Identificationofsmall,beat-to-beatfluctuationsintheamplitudeoftheT-waveonthepatient’selectrocardio-gram

Consideredexperimental/investigationalasariskpredictorofventriculararrhythmia

CPT®reportingcode93025

Softtissuefluorescenceandchemilumi-nescenceaidsinscreeningexaminationsfororalmalignantandpremalignantle-sions,e.g.Vizilite®andVELscope™

Devicesdesignedtofacili-tatevisualizationofintraorallesionsforpossiblebiopsy

Consideredexperimental/investigational

HCPCSreportingcodeD0431


HealthCarePolicy

Medical Policy UpdatesOur Health Care Policy department continually reviews medical policies and operating procedures as new, evidence-based information becomes available regarding advances in 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 for 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.

MEDICAl POlICy ACTIOnS, COMMEnTS AnD POlICy STATuS AnD AnD/OR PROCEDuRE REPORTIng guIDElInES EFFECTIvE DATE

1.01.057AWalkers and Accessories

1.01.072ACanes and Accessories

2.01.008Rhinometry and Acoustic Rhinometry

2.01.023Allergy Testing

2.01.045Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

2.02.002Microvolt T-Wave Alternans

Operating Procedure

revision

Effective 2/18/09

Operating Procedure

revision

Effective 2/18/09

Periodic review and

update.

Effective 2/17/09

Periodic review and

update.

Effective 2/17/09

Policy change and

update

Effective 2/23/09

Policy revision.

Effective 7/2/09

Operating procedure changed to read, “Benefits are provided for

walkers, as ambulatory assist devices, when a member needs

assistance with ambulation, including, but not limited to a surgical

procedure, trauma, or neurological condition.”

Operating procedure changed to read, “Benefits are provided

for canes, as ambulatory assist devices, when a member needs

assistance with ambulation, including, but not limited to a surgical

procedure, trauma, or neurological condition.”

Under Policy Guidelines added an updated 2009 rationale

statement. Rhinomanometry and acoustic rhinometry remain

experimental/ investigational.

Under Policy Guidelines added an updated 2009 rationale

statement. Experimental/investigational indications remain the

same.

Title changed from Continuous Glucose Monitoring (Diagnostic

Testing). Description revised to describe both the intermittent

(diagnostic) and the continuous glucose monitoring in interstitial

fluid. Under the Policy statement, for continuous monitoring,

added medically necessary criteria as a technique of diabetes

management for Type I diabetics. Also added,

”intermittent or continuous interstitial fluid glucose monitoring

for Type II diabetes and all other diagnoses is considered

experimental/ investigational.” A 2009 rationale statement was

added. Under Benefit Applications added “Separate benefits are

not provided for rental of the monitor or transmitter, or for single

use sensors when the monitoring is used intermittently as a

diagnostic test, as these are included in the technical component

of the test.”

Policy changed from medically necessary to experimental/

investigational. Under Policy Guidelines added an updated 2009

rationale statement.


HealthCarePolicy

MedicalPolicyUpdates

MEDICAl POlICy ACTIOnS, COMMEnTS AnD POlICy STATuS AnD/OR PROCEDuRE REPORTIng guIDElInES AnD EFFECTIvE DATE

2.03.011AScreening for Colorectal Cancer

2.03.012Adjunctive Diagnostic Aids for Oral Cancer Screening

6.01.028Computed Tomographic Colonography as a Test for Colon Cancer (Virtual Colonoscopy)

7.01.013Keratoprosthesis

7.01.033Total Hip Resurfacing

7.01.036Obesity and Morbid Obesity

7.01.093Total Ankle Arthroplasty/ Replacement

7.01.098Cryosurgical Ablation of Renal Cell Carcinoma

7.01.099Cryotherapy Dilation for Peripheral Arterial Disease

11.01.001Tumor Markers

11.01.004Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer’s Disease

Policy change and

update

Effective 3/13/09

New Policy

Effective 3/30/09

Archived policy

Effective 3/13/09

Periodic review and

update

Effective 3/13/09

Periodic review and

update

Effective 3/13/09

Policy revision

Effective 2/17/09

Periodic review and

update.

Effective 2/17/09

Policy revision

Effective 3/30/09

Periodic review and

update

Effective 3/13/09

Periodic review and

update.

Effective 2/23/09

Periodic review and

update.

Effective 3/30/09

Policy changed from a Policy to an Operating Procedure regarding benefits

for screening of colorectal cancer in accordance with American Cancer Society

recommendations. See Operating Procedure for details.

Fluorescent and chemiluminescent diagnostic aids for oral cancer screening are

considered experimental/ investigational.

Policy has been archived. See Operating Procedure 2.03.011A.

Under Policy Guidelines added an updated 2009 rationale statement. Medically

necessary and experimental/ investigational indications remain the same.



Under Policy clarified sleeve gastrectomy statement to indicate the sleeve

gastrectomy procedure is for those patients with a BMI exceeding 50.

Under Policy Guidelines added an updated 2009 rationale statement.

Total ankle arthroplasty/ total ankle replacement remains experimental/

investigational.

Cryosurgical ablation for renal cell carcinoma changed from experimental/

investigational to medically necessary. Under Policy Guidelines added an

updated rationale statement.


Cryoplasty/ cryotherapy dilation for peripheral arterial disease remains

experimental/ investigational.


necessary indications remain the same.


Experimental/ investigational indications remain the same.



HealthCarePolicy

MedicalPolicyUpdates

11.01.019In Vitro Chemotherapeutic Drug Assays

11.01.032Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in Breast Cancer Patients

11.01.035Genetic Testing for Celiac Disease

Periodic review and

update.

Effective 2/17/09

Periodic review and

update.

Effective 2/23/09

Periodic review and

update.

Effective 3/13/09


Experimental/investigational indications remain the same.

Description revised. Under Policy added, “The use of 21-gene RT-PCR assay (i.e.,

Oncotype DX®) to determine breast cancer recurrence risk for deciding whether

or not to undergo adjuvant chemotherapy is considered medically necessary.”

Added, “The use of other gene expression assays (e.g., MammaPrint®,

Mammostrat ®, the Molecular Grade Index, or the Breast Cancer Gene

Expression Ratio) is considered experimental/ investigational.” Under Policy

Guidelines added an updated 2009 rationale statement.



*Note: Current Procedural Terminology (CPT®) codes and descriptions only are copyright of the 1966 American Medical Association. All rights reserved.

2.01.046A Infant Hearing Screening (MD, VA and DC Mandates)

POlICIES unCHAngED FROM lAST REvIEw



POlICIES unCHAngED FROM lAST REvIEw

ProviderSeminars

Practitioner and Staff Seminars and Training SessionsCareFirst and CareFirst BlueChoice offer half-day seminars, Webinars and hands-on training sessions designed to familiarize professional and institutional providers and office staff with CareFirst and CareFirst BlueChoice policy, provider-oriented procedures and tools. The types of seminars and our training sessions are listed below accompanied by a brief description and its identification code to assist in selecting the presentations that best meet your needs.

Professional SeminarsBasics & Updates –designed as a new provider staff employee training tool or a refresher for a seasoned employee. This seminar will review CareFirst products, refer-rals, authorizations, COB and much more. The seminar will conclude with a CareFirst update and questions and answers.

Mental Health – CareFirst has added a new Professional Provider Mental Health seminar to its line-up. This seminar is designed to educate and update mental health profes-sional providers.

Specific Specialty – designed to inform and update specific specialty providers.

Date and Time location Room

Wednesday,April22,200910a.m.to1p.m.Mental Health

ProvidenceHospital1150VarnumSt.N.E.Washington,D.C.20017

RossAudito-rium

Tuesday,April28,200910a.m.to1p.m.Mental Health

HolidayInnExp.–Hagerstown241RailwayLaneHagerstown,Md.21740

ConferenceRoom

Tuesday,May5,200910a.m.to1p.m.PT/OT/ST/Chiro

HolidayInnExp.–Hagerstown241RailwayLaneHagerstown,Md.21740

ConferenceRoom

Thursday,May14,200910a.m.to1p.m.Basics and updates

SibleyMemorialHospital5255LoughboroRoadWashington,D.C.20016

Renaissance

Thursday,May21,200910a.m.to1p.m.PT/OT/ST/Chiro

CFOwingsMills10455MillRunCircleOwingsMills,Md.21117

MPR-LL03

Wednesday,May27,200910a.m.to1p.m.BasicsandUpdates

ComfortInn–Fairfax11180MainSt.Fairfax,Va.22030

UniversityRoom

Wednesday,June10,200910a.m.to1p.m.OB/gyn

CFColumbiaGateway6731ColumbiaGatewayDriveColumbia,Md.21046

RedwoodRoom

Wednesday,June17,200910a.m.to1p.m.Basics and udates


MPR-LL03

Thursday,June25,200910a.m.to1p.m.OB/gyn

SouthernMarylandHospital7503SurrattsRoadClinton,Md.20735

Library


ProviderSeminarsPractitioner and Staff Seminars and Training Sessions (continued)

Hospital Quarterly – designed for hospital office staff to receive updated CareFirst information.

DRG – Diagnostic Related Grouper (DRG) – designed to update Washington, D.C. and Virginia hospitals.

Hospital Seminars

Ancillary – Regional Ancillary Semi-nars – dialysis, skilled nursing facility (SNF), durable medical equipment (DME), home infusion therapy (HIT), ambulatory surgical center (ASC), hos-pice, home health (HH) and substance abuse and mental health (Sub/Mtl).

Ancillary Seminars


Wednesday,May13,20091p.m.to4p.m.Hospital Quarterly

HamptonInn–Salisbury121EastNaylorMillRoadSalisbury,Md.21804

ChesapeakeRoom

Thursday,May28,20091p.m.to4p.m.DRg


RossAuditorium

Wednesday,June10,20091p.m.to4p.m.Hospital Quarterly

Baltimore/WashingtonMedical305HospitalDriveGlenBurnie,Md.21061

TateCenterCourtneyConference

Wednesday,June24,20091p.m.to4p.m.Hospital Quarterly

MountVernonHospital2501Parker’sLaneAlexandria,Va.22306

EnghConference


Wednesday,April15,200911a.m.to1p.m.Dialysis

CFColumbiaGateway6731ColumbiaGatewayDr.Columbia,Md.21046

RedwoodRoom

Thursday,April16,200911a.m.to1p.m.DME

FranklinSquare9000FranklinSquareDr.Baltimore,Md.21237

ConferenceE

Tuesday,April21,200910a.m.to2p.m.Sub/Mtl


RossAuditorium

Thursday,April23,200911a.m.to1p.m.SnF

ComfortInn–Fairfax11180MainSt.Fairfax,Va.22030

GeorgeMason

Wednesday,May13,200911a.m.to1p.m.Hospice

QualityInn–Frederick999W.PatrickSt.Frederick,Md.21702

CatoctinRoom

Tuesday,May26,200911a.m.to1p.m.HH


MPR-LL03

Tuesday,June9,200910a.m.to1p.m.Basics and updates


MPR-LL03

Tuesday,June23,200911a.m.to1p.m.HIT

SibleyMemorialHospital5255LoughboroRoadWashington,D.C.20016

Renaissance1


ProviderSeminars

Practitioner and Staff Seminars and Training Sessions (continued)

Date Subject Time

May20,2009 Sub/MtlFacility 12:30p.m.

May20,2009 OB/GYN 2p.m.

May27,2009 CDH 10a.m.

May28,2009 CFD 10a.m.

May28,2009 DME 12:30p.m.

June2,2009 ASC 12:30p.m.

June2,2009 MPOS 2p.m.

June9,2009 CDH 2p.m.

June11,2009 PT/OT/ST/Chiro 10a.m.

June11,2009 HIT 12:30p.m.

June18,2009 Dialysis 12:30p.m.

June18,2009 OB/GYN 2p.m.

June23,2009 BlueChoice 10a.m.

June23,2009 SNF 12:30p.m.

June25,2009 CDH 10a.m.

June30,2009 Sub/MtlFacility 12:30p.m.

June30,2009 CFD 2p.m.

May27,2009 CDH 10a.m.

May28,2009 CFD 10a.m.

May28,2009 DME 12:30p.m.

webinars

Toregisterforanyoftheseseminars,Webinarsortrainingsessions,visittheProviders&Physicianssectionofwww.carefirst.comforafulllistof2009’smostrecentlyupdatedseminars,WebinarsandtrainingsessionsandselectRegisterforaSeminarintheSolutionCenter.IfyoudonothaveInternetaccess,calltheProviderSeminarRegistrationLineat877-269-2219.Pleasenote:Signinforseminars15minutespriortothescheduledstarttime.

CDF Training – CareFirst Direct Training is designed to instruct CareFirst professional and institutional providers on the dynamics of CareFirst Direct and easy navigation through the system. This is a hands-on training. Enrollees must bring their CareFirst log-on and patient information (claims) to class. Refreshments will not be served. Covered drinks are permitted. Do not bring food. If you do not have a CareFirst Direct log-on, go to https://www.carefirst.com/signon/welcome.do for additional information. (If in office training by your dedicated CareFirst Provider Representative is your choice of train-ing, this will always be an option. Please call your representative and set up an appointment).

CareFirst Direct Provider TrainingDate and Time location Room

Thursday, April 30, 20099 a.m. to 12 p.m.CFD

GBMC6701 North Charles St.Baltimore, Md. 21204

Computer Training Room

Date Subject Time

April14,2009 HIT 12:30p.m.

April14,2009 BlueChoice 2p.m.

April15,2009 IntroducingFACETS–Prof. 10a.m.

April16,2009 IntroducingFACETS–Inst. 10a.m.

April16,2009 NASCOMigration–Prof. 2p.m.

April21,2009 IntroducingFACETS–Prof. 2p.m.

April22,2009 NASCOMigration–Prof. 12p.m.

April23,2009 CFD 10a.m.

April23,2009 Dialysis 12:30p.m.

April28,2009 NASCOMigration–Prof. 10a.m.

April29,2009 SNF 12:30p.m.

April29,2009 MPOS 2p.m.

April30,2009 CDH 10a.m.

April30,2009 IntroducingFACETS–Prof 12p.m.

April30,2009 DRG 2p.m.

May5,2009 Hospice 12:30p.m.

May5,2009 Anesthesia 2p.m.

May12,2009 CDH 2p.m.

May14,2009 PT/OT/ST/Chiro 10a.m.

May14,2009 HomeHealth 12:30p.m.

Webinar -- A Web-based training designed to present CareFirst and Carefirst BlueChoice policies and procedures to professional and institutional providers. These Webinars will last 30 minutes, but participants should allow for log on and instruction time. After enrolling, you will receive instructions prior to the presentation date via email. Webinars are CareFirst Quality Rewards qualified Web-based office staff training modules.


Not sure who your Institutional provider representative is or what number to call to reach him or her? See the chart below to find out. This information, as well as professional provider information, can be found in the Providers & Physicians section of www.carefirst.com by clicking on Professional or Institutional under Find My Provider Representative.

Find Your Institutional Provider Representatives

Ancillary Provider Assignments

Hospital Assignments

Joanna Clark

Carol Kreigh

Mike Rutkowski

Dena whitener

Dottie Humes

Baltimore, Cecil and Harford counties and Baltimore City Anne Arundel, Caroline, Dorchester, Kent, Queen Anne’s, Somerset, Talbot, Wicomico and Worcester counties

Anne Arundel, Calvert, Charles, Montgomery, Prince George’s and St., Mary’s counties and Washington, D.C. and Virginia

Allegany, Carroll, Frederick, Garrett, Howard, Montgomery and Washington counties and Pennsylvania and West Virginia

Anne Arundel and Baltimore counties and Baltimore City

Representative name Telephone geographic Area

410-872-3572

410-763-6353

410-872-3539

410-872-3816

410-872-3575

Representative name Telephone Hospital name

Donna Brohawn

Amy Meister

Carol Kreigh

Chris Hudnall

Darin Hutchins

410-872-3571

410-872-3573

410-763-6353

410-872-3536

410-872-3537

* AA Medical Center * Frederick Memorial * Harford Memorial Hospital * Johns Hopkins * Kennedy Krieger* Mercy Medical Center

* Mem Hosp, Cumberland* Garrett County Memorial * Howard County General* Hopkins Bayview Medical Center* St. Agnes Hospital

* Upper Chesapeake Medical* Washington County Hospital* WMHS Braddock Hospital* Veteran’s Affairs Med. Center

* Bon Secours Hospital * Civista Medical Center * Calvert Memorial Hospital * Carroll Hospital Center * Franklin Square Hospital* Good Samaritan Hospital

* Greater Baltimore Medical* Harbor Hospital Center * Kernan Hospital * Maryland General Hospital* Mt. Washington Pediatric * North Arundel Hospital

* Northwest Hospital* Sheppard Pratt* Sinai Hospital* St. Joseph Medical Center * Union Memorial * U of MD Medical Center

* Dorchester General Hospital * Chesapeake Rehab * Union Hosp. of Cecil Cty

* Atlantic General * Memorial Hospital at Easton * McCready Memorial

* Peninsula Regional Medical Center * Chester River Hospital

* Inova Alexandria Hospital * Loudoun Hospital Center * Virginia Hospital Center * Mary Washington * Children’s Hosptial * Inova Mt. Vernon * Dominion Hospital

* Potomac Hospital* Inova Fairfax Hospital * Prince William Hospital* Fair Oaks Hospital * Providence Hospital* Faquier Hospital * Psychiatric Institute of Washington

* Ft. Washington Medical Center * Reston Hospital Center* George Washington Hospital * Northern Virginia Community* Greater Southeast Community Hospital * Veteran’s Affairs

* Doctor’s Community Hospital * Sibley Memorial Hospital * Georgetown Hospital * Southern Maryland Hospital Center* Holy Cross Hospital * Suburban Hospital* Hospital for Sick Children

* Washington Adventist* Howard University Hospital * Washington Hospital Center* Laurel Regional Hospital * Walter Reed Hospital * Montgomery General Hospital * National Naval Medical * National Rehabilitation Center

* Malcolm Grow Medical * Potomac Ridge * DeWitt Army Hospital * Prince George’s Hospital Center * St. Elizabeth Hospital* Shady Grove Adventist Hospital

ProviderRepresentatives


January 1, 2009: Here is a list of the CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. service areas that handle Maryland and National Capital Area provider inquiries. Please copy or detach for future reference. Information that has been added or changed since this page last appeared (November/December2008) is printed in blue font.

PROvIDER SERvICES nASCO PROvIDER SERvICES

MD INDEMNITY – XW PREFIX AND BLUECARD® CLAIMS 410-581-3581 / 800-437-2332

Claims (including oral surgery): Mail Administrator, P.O. Box 14115, Lexington, Ky. 40512-4115

Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky. 40512-4114

Mental Health for Level III and Key Groups only 410-581-3581 / 800-437-2332

Claims: Mail Administrator, P.O. Box 14117, Lexington, Ky. 40512-4117

NCA INDEMNITY – XIA PREFIX AND BLUECARD® CLAIMS CAREFIRST BLUECHOICE – XIC PREFIX BLUEPREFERRED – XIP PREFIX BLUECHOICE ADVANTAGE – XIH PREFIX BLUE PRECISION – BLUE PRECISION LOGO ON ID CARD MHIP - MHIP LOGO ON ID CARD 202-479-6560 / 800-842-5975

Claims: Mail Administrator, P.O. Box 14116, Lexington, Ky. 40512-4116

Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky. 40512-4114

State of Maryland - POS and PPO 877-228-7268 PPO Claims & Correspondence: Mail Administrator, P.O. Box 14115, Lexington, Ky. 40512-4115 or P.O. Box 9885, Baltimore, Md. 21284-9885 POS Claims & Correspondence: Mail Administrator, P.O. Box 14115 Lexington, Ky. 40512-4115 or P.O. Box 9885, Baltimore, Md. 21284-9885 State of Maryland - HMO 877-228-7268 HMO Correspondence and Appeals: Mail Administrator, Mailstop RR 230, Owings Mills, Md. 21117-4208

HMO Correspondence and Appeals: Mail Administrator, Mailstop RR 230, Owings Mills, Md. 21117-4208 NASCO – NATIONAL ACCOUNTS SERVICE AND CLAIMS OPERATIONS Northrop Grumman - NRG Prefix 877-228-7268 for claims information 800-972-8088 for benefit information Northrop Grumman - ESS or NGC Prefix 800-516-1269 All Other NASCO Accounts, including Consumer Directed Health (CDH) Plans and BlueChoice (excluding XIC prefix) 877-228-7268 Claims: Mail Administrator, P.O. Box 14115, Lexington, Ky. 40512-4115 Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky. 40512-4114 FEP – FEDERAL EMPLOYEE PROGRAM – R PREFIX Professional and Institutional providers in Montgomery & Prince George’s counties, Washington, DC and Northern Virginia (east of Rt. 123*) 202-488-4900 Claims: Mail Administrator, P.O. Box 14113, Lexington, Ky. 40512-4113 Correspondence: Mail Admnistrator, P.O. Box 14112, Lexington, Ky. 40512-4112 *For providers west of Rt. 123, send all claims and correspondence to local plan.

ALL OTHER MD FEP PROVIDERS Professional 410-581-3568 / 800-854-5256 Institutional 410-581-3567 / 800-321-2580 Claims: Mail Administrator, P.O. Box 14113 , Lexington, Ky. 40512-4113 Correspondence: Mail Administrator, P.O. Box 14111, Lexington, Ky. 40512-4111

FEP PROvIDER SERvICES

STATE OF MARylAnD PROvIDER SERvICES

✃✃

ImportantPhoneNumbersandAddresses


What’sHappening

PROvIDER COnTACTS

BLUECARD® 800-676-BLUE (2583) for eligibility

PROVIDER INFORMATION AND CREDENTIALING 410-872-3500 / 877-269-9593 Fax: 410-872-4107 / 866-452-2304

Correspondence: CareFirst BlueCross BlueShield, 10455 Mill Run Circle, P.O. Box 825, Mailstop CG-41, Owings Mills, Md. 21117-0825

PROVIDER RELATIONS & PROFESSIONAL CONTRACTING 410-872-3500 / 877-269-9593 Fax: 410-505-6900 / 866-452-2306


INSTITUTIONAL AND VENDOR CONTRACTING 410-872-3500 / 877-269-9593 Fax: 410-872-4106 / 866-452-2305


PROVIDER SEMINAR REGISTRATION Professional, hospital and ancillary seminar registration 877-269-2219

CARE MANAGEMENT Authorizations 866-PRE-AUTH (773-2884) Fax for authorization: 410-781-7661

Case Management 888-264-8648

Correspondence: CareFirst BlueCross BlueShield, Care Management, 1501 S. Clinton St., Mailstop CT-0816, Baltimore, Md. 21224

AuTOMATED vOICE RESPOnSE unITS

BLUELINE MD Region – Authorizations, eligibility and claim and benefit inquiry for PPO, MPOS, PPN and MD Indemnity 410-581-3535 / 800-248-8410

FIRSTLINE NCA Region – Eligibility, claim and benefit inquiry for CareFirst BlueChoice, BluePreferred and NCA Indemnity 202-479-6560 / 800-842-5975

FEP – Eligibility, claim and benefit inquiry 202-488-4900

MARYLAND POINT OF SERVICE (MPOS) REFERRAL FAX LINE MPOS Referrals Fax for referrals: 443-738-7695

vEnDOR COnTACTS ARGUS Pharmacy benefits manager 800-314-2872 for prior authorization requests Fax: 800-315-4025

ICORE HEALTHCARE Supplier of injectable drugs 866-522-2470

LABORATORY CORPORATION OF AMERICA (LABCORP) Contracted vendor for CareFirst BlueChoice members 800-322-3629

MAGELLAN HEALTH SERVICES Inpatient & outpatient mental health and substance abuse services 800-245-7013

MCKESSON SPECIALTY Supplier of injectable drugs 888-456-7274

ELECTRONIC CLAIMS Emdeon 800-845-6592 GatewayEdi 804-323-0275 MedAvant (formerly ProxyMed) 800-792-5256, ext. 813 MTrans (Misys) 800-347-3473, ext.2188 Payerpath 877-623-5706, ext. 2 RelayHealth Institutional 800-693-6890 Professional 847-608-7000 ProtoMed 800-648-4836 RealMed 877-927-8000

DISEASE MANAGEMENT To refer patients to a program call: Asthma/COPD 800-323-4472 Diabetes and Heart Disease 800-783-4582 Oncology 888-264-8648 ✃

✃ImportantPhoneNumbersandAddresses

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. 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.


QualityImprovement

Case Management — Assistance to Coordinate Your Patients’ Health Care NeedsCareFirst’s Case Management services can enhance your patients’ overall care by providing an organized, comprehensive and holistic approach to their health care needs. These services will reduce the frustration of fragmented care that those with complex care requirements often face. The Case Manager can help navigate the complex health care maze by coordinating medical care services and help patients better understand what is happening to their health. Our specialty programs include:

Generalist – Our generalist case management team is comprised of registered nurses with diverse clinical backgrounds for patients with acute and chronic disease processes.

Pediatrics - Our pediatric case managers are experienced pediatric clinicians. They manage referrals for children ages 0 to 17 years with simple to complex health care needs. Our pediatric program also includes oncology education and support.

Oncology – Our oncology case management team is comprised of registered nurses with oncology experience and expertise to assist patients with a cancer diagnosis.

Great Beginnings – A case manager will contact the member during each trimester of their pregnancy to provide supplemental support for expectant mothers, family members and physicians to enhance optimal maternal-infant outcomes.

Case Management Program goalsThe patient’s welfare is always our first concern. The Case Manager will always work to:n Contribute to patients’ sense of well-being and dignityn Enhance the quality of life for your patients and their familiesn Positively influence the quality of health caren Improve health, restore function and prevent disabilityn Reduce the negative effects of a serious, chronic or terminal

health conditionn Increase customer satisfactionn Empower patients and their family members through

education and available resources

When your patients enroll in the Case Management program, a Case Manager will contact them to review their medical history and identify important factors that may affect their health.

The Case Manager is available to answer questions from 8 a.m. to 4:30 p.m. Monday through Friday. Members/patients have the added convenience of making a self referral into our Case Management programs by enrolling online at www.carefirst.com > Members and Visitors > Solutions Center > Managing Your Care – Care Essentials. To find out more information about our programs, please call 888-264-8648.

CareFirst and CareFirst BlueChoice offer Great Beginnings, a comprehensive program in which Case Management nurses provide on-going support and valuable health information to women during pregnancy. This coordination of care with the member’s physician helps to reduce the level of stress for expectant mothers.

Case managers work with the physician to coordinate an effective treatment plan based on the individual needs of the member, as well as identify obstacles affecting compliance to care. If the member has complications during pregnancy, the Case Manager will work closely with the doctor to coordinate necessary services.

Practitioners may refer a member to the Great Beginnings program by calling 888-264-8648 or sending the member’s name, ID number and estimated date of delivery to a secure Rightfax # 410-720-5829. Members/patients have the added convenience of making a self referral into our Great Beginnings program by enrolling online at www.carefirst.com > Members & Visitors > Solutions Center > Managing Your Care – Care Essentials. To find out more about our programs, please call 888-264-8648.

Many other Blue Cross and Blue Shield plans offer similar programs to their members and the programs vary by plan. Please let your out-of-area patients know that such a program might be available to them and they should contact their home plan for additional information.


Supporting Follow Up Treatment after Behavioral Health HospitalizationTimely follow-up treatment after discharge from inpatient behavioral health care is crucial in supporting a member’s ongoing recovery. Early aftercare treatment (within seven days of discharge) with a behavioral health provider has proven to be effective in keeping patients in the community and preventing re-hospitalization. By contrast, lack of ongoing follow-up has been identified as a predictor of poor outcomes.

When a member is hospitalized, it is important to begin aftercare planning as soon as possible after admission. Prior to discharge, key activities that support an effective aftercare plan are:

n Schedule the first follow-up appointment to occur within seven days of the member’s discharge

n Explain the benefits of aftercare to the member, so he or she is advised of the importance of keeping ambulatory follow-up appointments

n Verify with the member that the aftercare plan is a good fit (e.g., transportation is not an issue; time of the appointment will work)

n Involve and educate the member’s family to support the aftercare plan

n Explain the importance of staying on medication and notifying their provider of any side-effects

If you have a member who is hospitalized for behavioral health treatment, you can help by encouraging them to comply with their aftercare plan, including keeping follow up appointments, and coordinating care with their behavioral health provider.

PharmacyUpdates

PriorAuthorizations/QuantityLimits The following prescription drugs require prior authorization for new prescriptions covered under the CareFirst and CareFirst BlueChoice prescription drug plan:

NewGenerics The following drug now has generic equivalents. As a result, the brand-name drug has moved to non-preferred (tier 3) and the generic alternative is now available at tier 1.

For the most current preferred drug list, prior authorization forms and pharmaceutical management procedures, visit www.carefirst.com > Providers & Physicians > Prescription Drugs. For a paper copy of the formulary and pharmaceutical management procedures, call 877-800-3086.

The following drugs now have generic equivalents. The generics are available as a tier 1 and the brand-name drugs remains on tier 3 or non-preferred.

Brand name generic

Zerit® Stavudine

Brand name generic

Depakote®ER divalproexER

Depakote®sprinkle divalproex

Diamox®sequels acetazolamide

Miacalcin®nasalspray calcitonin

• Aplenzin used for the treatment of depression• Epiduo™ gel used for the treatment of acne• Omeprazole 40 mg used for the treatment of

GERD

• Prilosec® oral suspension used for the treatment of GERD


AnswerstoFrequentlyAskedQuestionsRegardingFacetsMember Identification And verification How can I tell that a member has been migrated to Facets?While some accounts may have account specific prefixes, the majority of members will have one of the following, depending upon their product.

IndemnityXIJ DC based groups and individualsXWY MD based groups and individuals

PPO (BluePreferred)XIL DC based groups and individualsXWV MD based groups and individuals

HMO (BlueChoice)XIK DC based groups and individualsXWR MD based groups and individuals

What will the identification card look like? The identification cards will follow the standard format required by the BlueCross BlueShield association. Samples will be available in upcoming training materials and on the CareFirst Web site.

Will CareFirst Direct show Facets as the ‘Source System’ in the member eligibility screen? CareFirst Direct will initially show TZF as the Source System. A change is being made to update CareFirst Direct to show Facets as the source system.

Claim SubmissionWhat EDI payer id should be used for electronic claims?Submit electronic claims to the DC payer

What provider number should be submitted?Submit claims using your Regional (aka DC, National Capital Area, GHMSI) provider number.

ReimbursementWhat will the Notice of Payment look like?The Notice of Payment will look the same as the Notice of Payment for FLEXX (the one that is currently generated for claims processed on the FLEXX system).

What is the schedule for the Notice of Payment?The Notice of Payment schedule is the same as the Notice of Payment schedule for claims processed on the FLEXX system.

Will there be a separate 835?Yes. There will be a separate 835 for claims processed on the Facets system.

What will the check look like?The check will look the same as the check that is issued for claims that are processed on the FLEXX system.

Does the provider need to create new A/R ‘buckets?’Providers should evaluate their own business to determine whether or not a new bucket is needed based upon their practice management system and business needs.

Provider ServiceWhat is the correspondence address?Mail AdministratorP.O. Box 14114Lexington, Ky. 40512-4114

What is the Provider Service telephone number?202-479-6560 or 800-842-5975.

Authorizations And ReferralsWhat number should be called for authorizations?Provider should fax their requests to 410-781-7661.

Will iExchange be remediated for authorizations?Yes. A new payer will be added to the payer selection box indicating ‘Facets CareFirst BlueChoice’ which should be used for all members who are on the Facets system.

What will happen with existing out-patient authorizations?The authorizations will be linked to the Facets system.

What will happen with authorizations for therapies(PT/OT/ST)?The authorizations will be linked to the Facets system.

What will happen with Magellan Authorizations and referrals?Magellan authorizations and referrals will be linked to the Facets system.

(Continued from page 2)

Voice Response Unit (VRU) and CareFirst Direct: Your Answer to Reduce Administrative Cost and Increase Productivity

Need to reduce the administrative time spent waiting to speak with a CareFirst representative to check the status of a claim or benefits and eligibility? If so, CareFirst has two remedies:

voice Response unitCareFirst uses state of the art technology in its Voice Response Units with real time information allowing providers to obtain the following:

Claim status, which provides: n Allowed and paid amountsn Date of payment along with check information and claim numbern Any member liability n Denial reason with the narrative

Patient eligibility and benefits provides:n The effective date of coverage and any termination datesn Type of coverage including group numbern Office visit co-paysn Waiting periods

n Deductible & Stoploss including up-to-date accumulationsn Timely filing periods/coordination of benefits (COB) guidelinesn By using the appropriate 3 digit benefits code you may access

specific benefits a specific service (i.e. physical therapy, outpatient surgery, DME, etc)

n Pre-certification requirements and phone number

CareFirst DirectCareFirst Direct is an on-line tool that allows providers to obtain the following: n Claim status n Patient eligibility and benefitsn Submit inquiries related to a claim disputen View authorization and referrals

To get started or learn more about CareFirst Direct, visit www.carefirst.com > Providers & Physicians > Electronic Services > CareFirst Direct

What’sHappening

CHIEF MEDICAL OFFICER AND SR. VICE PRESIDENT OF MEDICAL AFFAIRS EDITOR Jon P. Shematek M.D. Robert Hilson [email protected]

BlueLink is published bimonthly by CareFirst BlueCross BlueShield’s Corporate Communications Department.

10455 Mill Run Circle Mailstop OM1-800Owings Mills, Maryland 21117

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. 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.

PRSRT STDUS POSTAGE

P A I DMANCHESTER, MD

PERMIT No. 15

Documents

BlueLink - provider.carefirst.com · Provider Seminars While little is changing other than the platform that we will use to process the claims, ... migration to the Facets claims