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December 2017
Introducing the Blue Cross Community Health PlansSM
The Illinois Department of Healthcare and Family Services (HFS) has entered into a contract with Blue Cross andBlue Shield of Illinois (BCBSIL) to offer Blue Cross Community Health Plans (BCCHPSM) beginning Jan. 1, 2018.BCCHP will be offered to eligible participants in every county of Illinois.
Blue Cross Community Health Plans replaces three previous Medicaid programs:
Blue Cross Community Family Health PlanSM (FHP)Blue Cross Community Integrated Care Plan (ICP)SM
Blue Cross Community Managed Long Term Supports and ServicesSM (MLTSS)
Enrollment in a managed care organization (MCO) is mandatory for those individuals who are eligible for MedicaidManaged Care. Eligible individuals may enroll in the plan of their choice, or the State of Illinois will automaticallyenroll them. Illinois Client Enrollment Services (ICES) provides individuals with access to unbiased education andinformation on available health plan options and assists members in the enrollment processes.
BCBSIL has a network of independently contracted providers including physicians, hospitals, skilled nursing facilities,ancillary providers, Long Term Supports and Services (LTSS) and other health care providers through whichmembers may obtain covered services.
Required Training for ProvidersThe State of Illinois contract with BCBSIL requires providers servicing BCCHP members to participate in mandatorytraining. This training is also required for providers serving members in the Blue Cross Community MMAI (Medicare-Medicaid Plan)SM. MMAI is offered to eligible participants in six Illinois counties: Cook, DuPage, Kane, Kankakee,Lake and Will. BCBSIL is required by the State of Illinois to offer training to providers on the following topics:
Model of Care/Medical Home (Person Centered Practice)Combating Medicare Parts C and D Fraud, Waste, and AbuseAbuse, Neglect, Exploitation/Critical IncidentsCultural CompetencyAmericans with Disabilities Act (ADA)/Independent LivingMedicare Parts C and D General Compliance Training
For links to our online training modules please refer to the Medicare/Medicaid page in the Network Participationsection of our website at bcbsil.com/provider.
For More InformationThe Blue Cross Community Health Plans Provider Manual includes additional details about the network. The manualcan be viewed in the Standards and Requirements/BCBSIL Provider Manual section of our Provider website.Information contained in the BCBSIL Provider Manual section is password protected. You will need to follow theinstructions given on our Provider website to gain access to this secure information.
If you have any questions related to BCCHP or MMAI, please contact our Provider Network team via email [email protected].
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
New Electronic Option Available for Illinois Medicaid Providers: GuidingCare®
Beginning Jan. 1, 2018, Altruista Health GuidingCare, a web-based health care management tool, will becomeavailable online to providers rendering services for the following Blue Cross and Blue Shield of Illinois (BCBSIL)members:
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
Blue Cross Community Health PlansSM
This tool was developed specifically for use by health care providers, support services organizations and other keypartners to assist in the patient’s care management. Not only will this tool help assigned physicians monitor theirMedicaid members’ rendered services, but it will also help allow for quick access to the following patient information:
Care planActivitiesNew membersCare transitions
GuidingCare is accessible to existing AvailityTM administrators and assigned users. If you are not yet registered, youmay visit availity.com and select “Register.” Once logged into Availity, select the “IL Medicaid Care ManagementPortal” link found under the Applications tab within the BCBSIL-branded Payer Spaces section. For more informationon BCBSIL’s electronic solutions, refer to the Education and Reference Center/Provider Tools page on our website atbcbsil.com/provider.
LEARN MOREBCBSIL will be hosting one-hour training sessions to provide additional information on how to navigate theGuidingCare tool. To register for an upcoming webinar, visit the Education and Reference Center/Webinars section ofour Provider website and select a session date and time.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medicalprofessionals. Availity provides administrative services to BCBSIL. GuidingCare is a trademark of Altruista Health, a separate company that provides collaborative healthcare management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by thirdparty vendors such as Availity and Altruista Health. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s)directly.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Government Programs: 835 Electronic Remittance Advice (835 ERA) Update
This notice applies to government programs providers servicing the following Blue Cross and Blue Shield of Illinois(BCBSIL) members:
Blue Cross Medicare AdvantageSM*Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
Blue Cross Community Integrated Care Plan (ICP)SM
Blue Cross Community Family Health PlanSM (FHP)Blue Cross Community Managed Long Term Supports and ServicesSM (MLTSS)
*Including the product types of HMO, PPO, HMO-POS and HMO-SNP (if applicable)
This an update to a March 2017 announcement, which advised that missing ERA files could not be reloaded forclaims submitted for members enrolled in any of the above-referenced Medicare Advantage and Medicaid plans.Impacted providers were instructed to refer to the paper Provider Claim Summary (PCS) sent by regular mail forremittance information on government programs claims.
Effective Nov. 30, 2017, government programs providers enrolled to receive the 835 ERA from BCBSIL maynow request redelivery of missing ERA files, issued since Jan. 1, 2017, to their designated receivers. Pleasenote that ERA files originally issued prior to Jan. 1, 2017, cannot be reloaded. To request redelivery of ERAs forgovernment programs claims, you may contact Provider Customer Service at the number on the member’s ID card.Paper PCSs will continue to be mailed for providers who are not enrolled for ERA.
Not enrolled for ERA? Providers may enroll online for ERA and also make any necessary set-up changes throughthe AvailityTM web portal at no cost. The online enrollment process can be completed in near real-time. Providers willreceive a confirmation letter acknowledging the enrollment effective date and related information. To register forAvaility, visit their website at availity.com and complete the online application today.
For more information on 835 ERA enrollment and related topics, visit the Claims and Eligibility/Claim Payment andRemittance section of our website at bcbsil.com/provider.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medicalprofessionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or servicesprovided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s)directly.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Help FEP Members Take In-home Colorectal Cancer Screening Test
Some Federal Employee Program® (FEP) members received the Fecal Immunochemical Test (FOBT/FIT) forcolorectal cancer screening and Hemoglobin A1c in-home test kits at their homes in November 2017. Recipientsreceived the kits based on claims data submitted to Blue Cross and Blue Shield of Illinois (BCBSIL). Members wereidentified for possible participation in this program if they had a diagnosis of diabetes and did not have a claim forHemoglobin A1c testing and/or had no claim history of colorectal cancer screening.
FEP members received a letter in November 2017 from BCBSIL about the test kits and an option to opt out of theprogram and decline the test kits. If an FEP member did not opt out of the program, the following two tests were sentto the member:
FIT test for colorectal cancer screeningsA1C test for blood sugar control for diabetes
Once returned, the tests are processed by the Home Access Health Corporation. There is no additional cost tomembers to participate in this program.
Home Access Health Corporation is an independent company that provides laboratory testing and will send resultsvia mail to both the member and the member’s primary care physician (PCP) indicated on the form sent back with thekit. BCBSIL’s goal is to help make the process easier for members to complete these tests in the comfort of their ownhomes.
You can help by doing the following:
Encourage your patients to take these tests if they receive the letter and advise your patients that, after taking thetests, they should return them in the prepaid postage envelope.Reiterate to your patients that they should provide your name and mailing address, along with their sample, soyou will also receive the test results.Be on the lookout for these test results so you can place them into the members’ records and be prepared tofollow up on any alert values received from Home Access Health Corporation.
If you have any questions or if you need additional information, please contact your assigned BCBSIL ProviderNetwork Consultant (PNC). Members may call the Customer Service number listed on their ID card to ask questionsor obtain assistance.
The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and otherhealth care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the bestcourse of treatment.
Home Access Health Corporation, an independent company, provides laboratory services to Blue Cross and Blue Shield of Illinois. Home Access Health is solelyresponsible for the products, services, and test results that they provide.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Choosing Wisely® Helps Spread the Word about Antibiotics
According to the Centers for Disease Control and Prevention (CDC), each year in the U.S., at least two million peoplebecome infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a directresult of these infections.1 The CDC states that antibiotic use is the single most important contributing factor toantibiotic resistance, and from one-third to one-half of antibiotic use in humans is either unnecessary orinappropriate.2
An initiative of the American Board of Internal Medicine (ABIM) finds that improved communication in health care maybe one of the keys to improving appropriate antibiotic use. Choosing Wisely is an ABIM program in partnership withConsumer Reports, designed to foster the appropriate and cost-effective use of health care resources by conveyingto all physicians and their patients key insights from 50 clinical specialty groups. Several of the ChoosingWisely specialty group recommendations on antibiotic use are posted on the Choosing Wisely website – use thekeyword “antibiotics” in the Search Recommendations section. In addition, Choosing Wisely provides a handout –Antibiotics: When you need them – and when you don’t – that you may want to share with your patients.
To read more about recommendations for appropriate antibiotic prescribing, including clinical practice guidelines, visitthe CDC website.
1CDC, Antibiotics/Antimicrobial Resistance, https://www.cdc.gov/drugresistance/index.html 2CDC, About Antimicrobial Resistance, https://www.cdc.gov/drugresistance/about.html
Choosing Wisely is an initiative sponsored by the American Board of Internal Medicine Foundation that is solely responsible for the program and its content. The materialpresented here is for informational purposes only and is not intended to be medical advice. Health care providers are instructed to exercise their own independentmedical judgment based upon their evaluation of their patients’ conditions and all available information. BCBSIL makes no representations or warranties regarding theChoosing Wisely program or any of its components.
References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding thoseorganizations should be addressed to them directly.
The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and otherhealth care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the bestcourse of treatment.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Working Together to Help Stop Antibiotic Resistance
According to a PEW Charitable Trust report regarding antibiotic use in outpatient settings, 30 percent of antibiotics aredetermined to be unnecessary for treating the prescribed condition (e.g., prescribing antibiotics for viral illnesses, asthmaexacerbations, etc.).1 Additionally, the Centers for Disease Control and Prevention (CDC) reports up to 50 percent ofantibiotics are not optimally prescribed in terms of choosing an appropriately focused antibiotic for the condition beingtreated.2 These prescribing behaviors, contribute to increasing bacterial resistance, which in combination with the relativelylesser availability of new antibiotics to combat these resistant organisms, have been associated with at least two millionillnesses and 23,000 deaths nationwide.2
A new report from the Blue Cross and Blue Shield Association (BCBSA) similarly found that 20 percent of nationallyprescribed outpatient setting antibiotics are not indicated. While outpatient antibiotic prescriptions for commercially insuredpeople are moving in the right direction nationwide by decreasing nine percent during 2010 to 2016, individual stateperformance data is more variable.3 Antibiotic prescribing in Illinois, for example, has increased three percent over this sametime frame with some regional areas experiencing increases as high as 36 percent.3
In 2015, the White House released a national action plan for combating antibiotic resistance that included the goal ofreducing inappropriate outpatient antibiotic use by 50 percent by 2020.4 Blue Cross and Blue Shield of Illinois (BCBSIL) isworking to do its part by evaluating the antibiotic prescribing patterns of contracted practitioners. Based on pharmacy claimsdata submitted to BCBSIL, nearly 120 Illinois primary care practitioners were identified as having prescribing patternssignificantly deviated from their same-specialty peers. Further analysis found that the selection of antibiotic may not be inaccordance with recommended practice guidelines. Feedback, in the form of a certified letter, was provided to thesepractitioners in October 2017 highlighting potential areas for improvement.
As a health care provider, there are antibiotic stewardship initiatives you may want to consider:
Evaluate your prescribing habits. The following graph shows unnecessary vs. appropriate use of antibiotics by healthcondition.1
Discuss appropriate antibiotic use and potential risks such as adverse side effects with your patients.Confirm a diagnosis of bacterial infection before prescribing an antibiotic.Re-direct your patient’s expectations if antibiotics are not warranted.Offer your patients advice and specific recommendations for symptom relief and ways to help the rest of their family fromgetting sick.Offer your patients a contingency plan if symptoms do not improve. Leaving the door open for future treatment may helpmaintain patient satisfaction.
For additional information visit the American Academy of Family Practice and the CDC websites.
1Antibiotic use in outpatient settings (2016). Retrieved from http://www.pewtrusts.org/en/research-and-analysis/reports/2016/05/antibiotic-use-in-outpatient-settings 2CDC (2017). About Antimicrobial Resistance. Retrieved from https://www.cdc.gov/drugresistance/about.html3BCBSA (2017). Antibiotic prescription fill rates declining in the U.S. Retrieved from https://www.bcbs.com/the-health-of-america/reports/antibiotic-prescription-rates-declining-in-the-US 4National action plan for combating antibiotic resistant bacteria (2015). Retrieved fromhttps://obamawhitehouse.archives.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf
The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health careproviders are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
BCBSIL to Require Adherence to Vaccine Guidelines
The Centers for Disease Control and Prevention (CDC) website refers to vaccines as one of the safest waysindividuals can help protect their health. The CDC advises that patients talk with their doctors about what vaccinesthey may safely receive based on their individual health history or other conditions.1
To help keep Blue Cross and Blue Shield of Illinois (BCBSIL) members safe, doctors treating them should adhere toguidelines recommended by the U.S. Food and Drug Administration (FDA) and Advisory Committee on ImmunizationPractices (ACIP).
BCBSIL has identified two categories of vaccines that may have been administered in a manner that doesn’t alignwith FDA and ACIP guidelines. For those vaccine categories – one for human papillomavirus (HPV) prevention andone for the prevention of shingles resulting from the herpes zoster virus – BCBSIL will:*
Continue to reimburse for claims that are medically necessary and supported by the FDA guidelines.Consider vaccines administered outside of the FDA and ACIP recommendations to be experimental,investigational or unproven, and will periodically review such claims.Recover reimbursements for these vaccines administered outside of the FDA and ACIP recommendations, perour contracts.
HPV Vaccination GuidelinesGardasil, Gardasil 9 and Cervarix are vaccines for the prevention of HPV infections and associated diseases,including cancers. Administration of these vaccines is recommended for males and females between 9 and 26 yearsold. Vaccination at age 11 or 12 is optimal. Since 2006, these vaccines have been administered in three doses, withthe second dose at one or two months after the first and the third dose six months after the first. In October 2016, forpatients between 9 and 14 years old, the ACIP recommendation was updated to two doses, with the second dose sixto 12 months after the first. For patients between 15 and 26 years old, the three-dose regimen is still recommended.
Shingles Vaccination GuidelinesZostavax is a vaccine that helps prevent shingles and its complications. Zostavax is recommended as a single doseby the FDA at age 50 or older and by the ACIP at age 60 or older.
BCBSIL considers the vaccine medically necessary for anyone age 50 or older in recognition of the FDA guidance.
Details on the approved immunization schedule can be found in the Standards and Requirements/Clinical Paymentand Coding Policies section of our website at bcbsil.com/provider – select the Preventive Services link to view theapplicable policy.
*This information does not apply to HMO member claims.
1CDC website (2016), Accessed Nov. 17, 2017, at https://www.cdc.gov/vaccines/adults/reasons-to-vaccinate.html.
Third party brand names are the property of their respective owners.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer totheir certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between themember and their health care provider.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Long Term Care Claims: System Issues and Resolution Updates
Blue Cross and Blue Shield of Illinois (BCBSIL) has identified system issues that are causing long term care (LTC)claim rejections and denials. A summary of these issues is included below to provide notification, with expectedresolution dates and any action that may be needed on the part of the impacted providers.
Electronic Claims Submitted via AvailityTM Rejected for Admission Date/Hour and AdmittingDiagnosisThe release of new LTC claim system guidelines, as issued by the Illinois Department of Health and Family Services(HFS), made it necessary for all managed care organizations to adjust claim system edits to prevent claims fromrejecting for noncompliance. BCBSIL worked with clearinghouses to make the necessary system updates.
BCBSIL identified an issue with LTC claims (21X, 22X and 65X bill types) that were submitted through Availityfrom Sept. 19, 2017, through Nov. 1, 2017. The issue was related to the following Health Insurance Portability andAccountability Act of 1996 (HIPAA) edits, which were unintentionally activated during a system release:
0x3938b7f – Segment DTP (Admission Date/Hour) is used. It may only be used on inpatient claims and someoutpatient claims as defined by the National Uniform Billing Committee (NUBC).0x3938b80 – Segment HI (Admitting Diagnosis) is used. It may be used on most of inpatient claims and someoutpatient claims as defined by the NUBC.
Availity relaxed the above edits in their Nov. 1, 2017, off-cycle release. This issue has been resolved andproviders should now resubmit claims rejected for these edits.
Claims Incorrectly Routed and Denied for AuthorizationPer the HFS guidance, 21X, 22X and 65X are appropriate bill types for LTC claims. Due to an update in authorizationlogic at BCBSIL, however, all LTC claims submitted with 21X or 22X bill types began routing for authorizationvalidation. Claims may have been incorrectly denied for authorization when an authorization was notrequired.
BCBSIL will accept all LTC claims that are submitted per the HFS billing requirements. A workaround is currentlyin place to help prevent additional claims with 21X/22X bill types from routing for authorization.BCBSIL is actively working to isolate all impacted claims and reprocess them according to the patient credit file.No provider action is required; all claims will be reprocessed by BCBSIL.A long-term system fix and all reprocessing of claims impacted by the above issue are targeted for completion byDec. 31, 2017.
We apologize for any inconvenience the issues referenced above may have caused. Please watch the News andUpdates on our website at bcbsil.com/provider for additional announcements. Information also may be published inour Blue Review.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medicalprofessionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or servicesprovided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s)directly.
This material is for informational purposes only and is not intended to be a definitive source for what codes should be used for any particular health care claim. Providersare instructed to submit claims using the most appropriate code based upon medical record documentation, coding guidelines and reference materials.
Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among otherthings, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, pleasecall the number on the back of the member’s ID card.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
National Drug Code (NDC) Rejections for Flu Vaccine on Medicaid Claims
Blue Cross and Blue Shield of Illinois (BCBSIL) has identified an issue that has impacted the processing and payment ofclaims submitted for Blue Cross Community MMAI (Medicare-Medicaid Plan)SM, Blue Cross Community Integrated Care Plan(ICP)SM, Blue Cross Community Family Health PlanSM (FHP) and Blue Cross Community Managed Long Term Supports andServicesSM (MLTSS) members.
Beginning in August 2017, Medicaid claims submitted with Current Procedural Terminology (CPT®) code 90686, containingFluarix Quad 2017-2018 Syringe: NDC 58160090741 may have been rejected for invalid NDC. BCBSIL has rectified theissue by adding this flu vaccine NDC as a valid code available for use.
As of Nov. 1, 2017, providers who received rejections for the above issue can now resubmit as new claims.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Third party brand names are the property of their respective owners.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Provider Learning Opportunities
Blue Cross and Blue Shield of Illinois (BCBSIL) provides complimentary educational workshops and webinars with anemphasis on electronic options that can help create administrative efficiencies for the independently contractedproviders who conduct business with us. A snapshot of upcoming training sessions is included below. For additionalinformation, refer to the Workshops/Webinars page in the Education and Reference Center on our website atbcbsil.com/provider.
BCBSIL WEBINARSTo register now for a webinar on the list below, click on your preferred session date.
Descriptions: Dates: SessionTimes:
BCBSIL Back to Basics: ‘AvailityTM 101’Join us for a review of electronic transactions, provider tools and helpful onlineresources.
Dec. 5, 2017
Dec. 19,2017
11 a.m. tonoon
Introducing Remittance ViewerHave you heard? This online tool gives providers and billing services aconvenient way to retrieve, view, save or print claim detail information.
Dec. 7, 2017 10 to 11 a.m.
iExchange®: New Enrollee TrainingLearn how to gain access to and begin using our online benefitpreauthorization/predetermination of benefits tool.
Dec. 14,2017
11 a.m. to12:15 p.m.
AVAILITY WEBINARSAvaility also offers free webinars for their registered users. For a current listing of webinar topics, dates and times,registered Availity users may log on to the secure Availity provider portal – the Live Webinar Schedule is locatedunder the Free Training tab. Not yet registered with Availity? Visit their website at availity.com for details; or callAvaility Client Services at 800-AVAILITY (282-4548) for assistance.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medicalprofessionals. Availity provides administrative services to BCBSIL. iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health caremanagement solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third partyvendors such as Availity and Medecision.If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
2017 Annual HMO and PPO HEDIS® Reports
Each year, Blue Cross and Blue Shield of Illinois (BCBSIL) reports audited Health Care Effectiveness Data and InformationSet (HEDIS) results. HEDIS is a nationally standardized set of measures related to important areas of care and service.Developed by the National Committee for Quality Assurance (NCQA), it is one of the most widely used set of health careperformance measures in the U.S.
The 2017 BCBSIL HMO and PPO HEDIS Reports, which are based on 2016 data using HEDIS 2017 specifications, includemeasures across domains of care that reflect: effectiveness of care, access/availability of care and utilization. The 2017Quality Compass National Averages are provided to compare the commercial HMO and PPO’s performance to theperformance of other health care organizations submitting data to NCQA. Audited HMO HEDIS results are reported for HMOIllinois®, Blue Advantage HMOSM, Blue Precision HMOSM and BlueCare DirectSM combined. The complete HMO and PPOHEDIS Reports are available in the Clinical Resources/Quality Improvement/HEDIS section of our website atbcbsil.com/provider.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
CMS Notifications for Medicare Providers
The Centers for Medicare & Medicaid Services (CMS) routinely publishes notifications that provide guidance to all Medicarephysicians, providers and suppliers, including those serving beneficiaries enrolled in Original Medicare and privateMedicare Plans. These CMS notifications are located in the Medicare Learning Network (MLN Matters) on the cms.govwebsite and may include informational regulatory updates and reminders as well as required actions or changes by theprovider rendering services. As such, it is important for providers to review these notifications and ensure their staffs areaware of these notifications.
We are including the following link for your information:
CMS notifications regarding the Jimmo Settlement
Continue to check the News and Updates on our website at bcbsil.com/provider, as well as the Blue Review for future CMSupdates. If you need assistance, contact your assigned BCBSIL Provider Network Consultant (PNC).
The information above is not intended to be an exhaustive listing of all CMS notifications or changes. Please refer to the CMS website for details.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Medicare Advantage Organization Coverage of Supervised Exercise Therapy forSymptomatic Peripheral Artery Disease
The Centers for Medicare & Medicaid Services (CMS) has determined the cost and reimbursement for supervised exercisetherapy (SET) for symptomatic peripheral artery disease (PAD) will be covered, for calendar years 2017 and 2018 only, byoriginal fee-for-service Medicare. Providers should bill necessary SET items and services obtained by beneficiaries enrolledin Medicare Advantage plans to original fee-for-service Medicare. For 2019 and subsequent years, providers should plan tobill SET items and services to the beneficiaries’ Medicare Advantage plan unless notified otherwise.
Consistent with §1862(a)(1)(A) of the Social Security Act, Medicare Administrative Contractors will consider whether SET forPAD services are reasonable and necessary and reimbursable by original Medicare for Medicare beneficiaries enrolled inMedicare Advantage plans in calendar years 2017 and 2018.
For more information, refer to the article on the CMS website.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
ClaimsXtenTM Quarterly Updates
New and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS)codes are periodically added to, or deleted, from the ClaimsXten code auditing tool software by the software vendor on aquarterly basis and are not considered changes to the software version. Blue Cross and Blue Shield of Illinois (BCBSIL) willnormally load this additional data to the BCBSIL claim processing system after receipt from the software vendor and willconfirm the effective date via the News and Updates section of the BCBSIL Provider website at bcbsil.com/provider. Advancenotification of updates to the ClaimsXten software version also will be posted on the BCBSIL Provider website.
To help determine how some coding combinations on a particular claim may be evaluated during the claim adjudicationprocess, you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool. Refer to the ClearClaim Connection page in the Education and Reference Center/Provider Tools section of our Provider website for additionalinformation on gaining access to C3, as well as answers to frequently asked questions about ClaimsXten. Updates may beincluded in future issues of the Blue Review. It is important to note that C3 does not contain all of the claim edits andprocesses used by BCBSIL in adjudicating claims, and the results from use of the C3 tool are not a guarantee of the finalclaim determination.
ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products andservices.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
December 2017
Has your information changed? Let us know!
When seeking health care services, our members often rely upon the information in our online Provider Finder®. Inparticular, potential patients may use this online tool to confirm if you or your practice is a contracted in-networkprovider for their health care benefit plan. Other providers may use the Provider Finder when referring their patientsto your practice.
We encourage you to check your own information in the Provider Finder – look for the link on our Provider websitehomepage at bcbsil.com/provider. Is your online information accurate? If changes are needed, it’s important that youinform Blue Cross and Blue Shield of Illinois (BCBSIL) as soon as possible.
USE OUR ONLINE CHANGE REQUEST FORMSYou may request most changes to your information online by using one of our electronic change request forms. Visitthe Network Participation/Update Your Information section of our Provider website to access instructions along withlinks to each type of form. Currently, there are three different change request forms to help you organize yourinformation, as follows:
1. Request Demographic Information ChangesUse this form to request changes to your practice information currently on file with BCBSIL (such as address,email or NPI). You may specify more than one change within your request as long as all changes relate to thesame billing (Type 2) NPI. As a participating provider, your NPI(s) should already be on file with BCBSIL. You mayuse this online form to request changes, such as deactivation of an existing NPI.
2. Request Addition of Provider to GroupUse this form to notify BCBSIL when a new individual provider joins your practice. Please remember that newproviders are subject to credentialing review and will not be effective until the process is completed and theprovider is approved.
3. Request Removal of Provider from GroupUse this form to notify BCBSIL when an individual provider is leaving any or all of your practice locations.
Please note that changes are not immediate upon submission of an online change request form. Processing can takea minimum of 30 business days. If you would prefer to mail or fax your changes to BCBSIL, there is a downloadableProvider Information Change Request Form in the Network Participation/Update Your Information section of ourProvider website, under the Related Resources. If you have any questions or need assistance, contact ProviderNetwork Operations at [email protected].
EXCEPTIONS TO THE ONLINE REQUEST PROCESSThe following types of changes are more complex and require special handling:
Multiple changes, especially changes involving more than one billing (Type 2) NPI – These should besubmitted via email to [email protected].
Tax ID changes that may, or may not, involve Legal Business Name changes – This type of change oftenrequires a new contract. To request a contract application, visit the Network Participation/Contracting section ofour Provider website. You may also want to discuss this change with your assigned Provider Network Consultant(PNC).
Ancillary provider changes – Skilled nursing facilities, home health agencies, hospice, home infusion therapy,durable medical equipment (DME) suppliers, orthotics and prosthetics, dialysis centers, private duty nursingagencies and other ancillary providers may request changes by sending details to [email protected],or by calling 312-653-4820.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
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A newsletter for contracting institutional and professional providers
