Partners in Health Update - July 2014July 1, 2014, IBC’s contract with Quest Diagnostics ® laboratories will end, and Quest Diagnostics will be an out-of-network provider at that

updateSM

Change to IBC’s outpatient laboratory network effective July 1 page 3

Upcoming changes to Medicare Advantage policies and clinical relationship logic page 10

Changes to NaviNet®

coming in July and October page 9

July 2014

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2014. www.dreamstime.com. All rights reserved.Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.The Blue Cross and Blue Shield names and symbols, BlueCard, BlueExchange, and Baby BluePrints are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.The third-party websites mentioned in this publication are maintained by organizations over which IBC exercises no control, and accordingly, IBC disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.NaviNet® is a registered trademark of NaviNet, Inc., an independent company.FutureScripts® and FutureScripts® Secure are independent companies that provide pharmacy benefits management services.CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (IBC), created to provide valuable information to the IBC-participating provider community. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with IBC. This publication is the primary method for communicating such general changes. Suggestions are welcome.

Contact information:Provider CommunicationsIndependence Blue Cross1901 Market Street 27th FloorPhiladelphia, PA [email protected]

Keystone 65 HMO has an accreditation status of Excellent from the National Committee for Quality Assurance (NCQA).

Keystone Health Plan East, Personal Choice®, and Personal Choice 65SM PPO have an accreditation status of Commendable from NCQA.

Inside this edition

Administrative ► Change to IBC’s outpatient laboratory network effective

July 1 ● Reminder: Contraceptive coverage update for religious

organizations ► Check member ID cards at every visit ● Request your office supplies online ► Referrals are required for specialty care for HMO/POS members

Billing ► HIPPS codes requirement for certain SNF and HHA

claims/encounters ► Participating providers must submit all claims for IBC

members to IBC ► Ensure successful electronic claims submissions

NaviNet®

► Changes to NaviNet® coming in July and October

Medical ► Cost-effective treatment options for infliximab (Remicade®) ► Upcoming changes to Medicare Advantage policies and clinical

relationship logic ► Revision to draft Medical Policy #02.01.01c: Home Health

Care Services ► Referring members for genetic testing ► Medical and claim payment policy activity posted from

May 26 – June 24, 2014

Quality Management ● Highlighting HEDIS®: Use of spirometry testing in the

assessment and diagnosis of COPD ● IBC’s Medicare utilization remains within or above

national standards

Health and Wellness ● Help your patients to be active so they stay healthy ► Alcohol screening resource now includes pediatric information

Business Transformation ● Stay informed during our transition to the new platform

► Articles designated with a blue arrow include notice of changes or clarifications to administrative policies and procedures.

For articles specific to your area of interest, look for the appropriate icon:

Professional Facility Ancillary

Independence Blue Cross

Sticky Note

Attention! An update has been made to the content of this article.

ADMINISTRATIVE

July 2014 | Partners in Health UpdateSM 3 www.ibx.com/providers

Change to IBC’s outpatient laboratory network effective July 1As previously communicated, IBC has selected Laboratory Corporation of America® Holdings (LabCorp) as our exclusive nationally based provider of outpatient laboratory services effective July 1, 2014. Also effective July 1, 2014, IBC’s contract with Quest Diagnostics® laboratories will end, and Quest Diagnostics will be an out-of-network provider at that time.

This change applies to all Blue-branded product lines and members (i.e., Personal Choice®, Keystone Health Plan East, and Independence Administrators), including individual, group commercial, and Medicare Advantage members, for services rendered in the Philadelphia five-county region and contiguous counties (i.e., the counties that surround the five-county IBC service area).

As a reminder, your Professional Provider Agreement with IBC requires you to direct members and/or their lab specimens to a participating outpatient laboratory provider, except in an emergency, as otherwise described in the applicable Benefit Program Requirements, or as otherwise required by law.

Establish your electronic interfaces with LabCorpLabCorp offers a variety of test ordering and result delivery solutions that provide the flexibility to meet your needs, including several electronic options, like LabCorp Beacon®.

If you haven’t already, we strongly suggest that you contact LabCorp at 1-888-295-5915 as soon as possible to establish your preferred electronic interfaces.

Re-issue of ID cards for affected membersAs a result of this change in outpatient laboratory network, primary care physicians (PCP) who were previously capitated to Quest Diagnostics were assigned a new capitated laboratory provider. As a result, HMO and POS members whose PCP’s capitated laboratory changed have been issued a new member ID card by mail. ID cards for HMO and POS members indicate the member’s capitated laboratory provider through the Lab Indicator.

As they do today, physicians should check the member’s ID card and the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal to verify the capitated laboratory provider for HMO and POS members. Using NaviNet will ensure that practices have the most accurate information.

More information about this changeWe encourage you to review the information posted on the LabCorp-dedicated section of our Provider News Center at www.ibx.com/pnc/lab. This section contains resources specific to our provider network, including:

● frequently asked questions; ● a list of LabCorp’s new patient service centers in the five-county IBC service area;

● a list of other currently contracted laboratories that will remain in our network in addition to LabCorp;

● an archive of communications related to this change.

If you have any questions about this change, please email us at [email protected].

ADMINISTRATIVE


Reminder: Contraceptive coverage update for religious organizationsThe Patient Protection and Affordable Care Act, also known as Health Care Reform, requires non-grandfathered health plans to cover contraceptive services for women with no out-of-pocket costs (i.e., $0 cost-sharing). There are two exceptions to this requirement:

● Religious employer exemption. Religious employers can elect not to provide contraceptive coverage, and their employees are not eligible for contraceptive coverage.

● Non-profit religious organization. Non-profit religious organizations can elect not to cover contraceptives for religious reasons but are not exempt as a “religious employer.”For these non-profit religious organizations, Health Care Reform requires IBC to pay the cost of certain contraceptive services for eligible employees and eligible dependents of non-profit religious organizations that elect not to cover contraceptives.

Eligible members within these organizations will receive a separate ID card that indicates “Contraceptive Coverage.” Using this ID card, contraceptive methods approved by the U.S. Food and Drug Administration will be covered at an in-network level with no cost-sharing under the medical benefit and covered with no cost-sharing for generic products and for those brand products for which we do not have a generic equivalent under the pharmacy benefit at retail and mail order pharmacies.*

For these members, it is important that only contraceptive services be billed using the ID number on the Contraceptive Coverage ID card.*

For a complete listing of medical contraceptive services, please refer to the current version of Medical Policy #00.06.02: Preventive Care Services at www.ibx.com/medpolicy.

Please contact your Network Coordinator if you have any questions about this coverage or billing.

*Contraceptive services are covered under the pharmacy benefit only if the member has an IBC prescription drug plan.

Contraceptive Coverage ID card samples

IBC & KHPEWPHCS Sample ID Card

Medical with Rx

SAMPLEMEMBER

Rx BIN CONTRACEPTIVE COVERAGE600428Rx PCN 03820000

USI1234567800

Pharmacy Benefits Administrator

Visit www.ibxpress.com

Member: Use this card for eligible medical and/or prescription contraceptive services only.

Submit Paper Claims to: PPO ClaimsP.O. Box 69352 Harrisburg, PA 17106-9352

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Customer Service1-800-ASK-BLUE

Independence Blue Cross, QCC Insurance Company and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.

Pharmacy Benefits1-888-678-7012

Medical Contraceptive Coverage Only — No IBC Rx Coverage*

IBC Medical and Rx Contraceptive Coverage

IBC & KHPEWPHCS Sample ID Card

Medical Only

SAMPLEMEMBER

Rx BIN CONTRACEPTIVE COVERAGE600428Rx PCN 03820000

USI1234567800

Visit www.ibxpress.com

Member: Use this card for eligible medical contraceptive services only.

Submit Paper Claims to: PPO ClaimsP.O. Box 69352 Harrisburg, PA 17106-9352

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Customer Service1-800-ASK-BLUE

Independence Blue Cross, QCC Insurance Company and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.

www.ibx.com/medpolicy

ADMINISTRATIVE


Check member ID cards at every visitAs you know, IBC is in the process of transitioning to a new claims processing platform, which will offer greater capabilities, increased flexibility in benefit design, and enhanced functionalities for an improved overall customer experience. As members are migrated to the new platform, they will be issued a new member ID card with a new ID number and, in some cases, a new alpha prefix.

For this reason, it is imperative that provider offices do the following:1. Obtain a copy of the member’s current ID card at every visit to ensure that you submit the

most up-to-date information to IBC.2. Verify eligibility and benefits using the NaviNet® web portal prior to rendering service.

New ID cards for migrated membersFor members who have been migrated to the new platform, IBC will assign a new 12-digit member ID number, called a “unique member ID” (UMI). Each member ID card will include the member’s name and subscriber UMI. The subscriber and all members covered under the subscriber’s policy will share the same ID number. Some plans will also be assigned a new three-character alpha prefix, which will also appear as part of the ID number.

Note: Members with our Medicare Supplement plan – MedigapSecurity – will be assigned a 13-digit ID number, with the last digit being an alpha character.

See below for sample ID cards for migrated members:

For more informationTo assist you in successfully submitting claims for IBC members, be sure to use the most current payer ID grids, available at www.ibx.com/edi. These payer ID grids include alpha prefix information for both migrated and non-migrated members.

For more information about our Business Transformation, please visit our dedicated site at www.ibx.com/pnc/businesstransformation. On this site, you will find a communication archive and frequently asked questions (FAQ) document. If you still have questions after reviewing the FAQ, email us at [email protected].

www.ibx.com/pnc/businesstransformation

ADMINISTRATIVE


Request your office supplies onlineTo replenish office supplies, such as manuals or health and wellness materials, please submit a request using our online order form at www.ibx.com/providersupplyline.

In order to properly fulfill your request, you will need to provide some basic office information, including your National Provider Identifier (NPI), mailing address, and office phone number. Orders are usually shipped within 24 hours and should arrive to you within 3 – 5 business days.

While completing your request, you also have the option to sign up to receive provider email notifications

from IBC. We encourage you to sign up for this option to receive the latest provider information from IBC, including when a new edition of Partners in Health Update is available and news alerts.

Providers without Internet access should call 1-800-858-4728 to place an order. Note: Calls to the Provider Supply Line should be related to supply requests only. Providers must use the NaviNet® web portal for information related to member eligibility or claims status. All other provider inquiries should be directed to Customer Service at 1-800-ASK-BLUE.

Referrals are required for specialty care for HMO/POS membersThis is a reminder that commercial HMO and POS and Medicare Advantage HMO (HMO/POS) members are required to have a referral for specialty care, including for non-emergency and hospital care. The referral must be issued by the member’s primary care physician (PCP) through the NaviNet® web portal. If an HMO/POS claim is received for specialty services and a referral is not on file, the claim will be denied for “no referral.”

Referrals are valid for 90 days and do not guarantee active eligibility on the date of service. PCPs should be as specific as possible when issuing a referral. Members who are not eligible on the date of service will be responsible for payment. All visits must occur within the 90-day period following the date the referral is issued. Non-emergency services (other than Direct Access services, which include OB/GYN, infertility, and maternal fetal medicine) that have not been referred by the PCP will not be covered.

HMO members must be referred to participating providers only. If a participating provider cannot provide care, and a referral to a nonparticipating provider is contemplated, such a referral by a PCP would require IBC’s preapproval.

Please also note the following: ● For HMO/POS members. All radiology, outpatient laboratory, and short-term physical and occupational therapy referrals must be to the PCP’s capitated site. Note: Providers in Berks, Lancaster, Lehigh, and Northampton counties in Pennsylvania are not required to choose capitated radiology or short-term rehabilitation sites.

● For Direct POS members. No referrals are required for Direct POS members to see participating specialists. However, referrals are required for routine radiology (except mammograms), spinal manipulation, and physical/occupational therapy services. To receive the highest level of benefits, members should be referred to the PCP’s capitated site for capitated services (i.e., routine radiology, physical/occupational therapy, and laboratory).

For additional information regarding referral requirements, please review the Administrative Procedures section of the Provider Manual for Participating Professional Providers, which is available on IBC NaviNet Plan Central in the Current Publications section.

BILLING


HIPPS codes requirement for certain SNF and HHA claims/encountersAs a Medicare Advantage Managed Care Organization (MCO), IBC is required to meet the standards set by the Centers for Medicare & Medicaid Services (CMS). Recently, information was received from CMS regarding specific requirements on when Health Insurance Prospective Payment System (HIPPS) codes should be included on Skilled Nursing Facility (SNF) and Home Health Agency (HHA) claims/encounters that are sent to CMS.

Services that require HIPPS codesEffective July 1, 2014, IBC will be required to submit HIPPS codes to CMS for certain SNF and HHA claims/encounters as outlined below:

● SNF. Claims/encounters that come from the initial Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessment (Admission Assessment).

● HHA. Claims/encounters that come from the initial Outcome and Assessment Information Set (Start of Care Assessment) or OASIS.

How this affects providersIn order for IBC to meet this CMS requirement, SNF and HHA providers are required to include the proper HIPPS codes on their 837-Institutional claim forms submitted to IBC for any claims/encounters that meet the criteria above where the “from” date is on or after July 1, 2014. Failure to include the appropriate HIPPS codes will cause your claims to reject.

We appreciate your compliance in this matter. If you have any questions about this requirement, please contact your Network Coordinator. You can also email CMS directly at [email protected] and specify “HPMS memo-HIPPS Codes” in the subject.

Participating providers must submit all claims for IBC members to IBCIf you are a participating provider with IBC submitting claims for IBC commercial HMO, POS, and PPO and Medicare Advantage HMO and PPO members, you must submit the claim directly to IBC. This requirement applies both to providers in the IBC five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia) and providers located in contiguous counties (i.e., counties that surround the IBC five-county service area).

Claims for IBC members may not be submitted to a local plan if the provider is contracted with IBC. For example, an IBC-participating provider located in Camden County, New Jersey (i.e., a contiguous county) should not submit a claim to Horizon Blue Cross Blue Shield of New Jersey for an IBC member. Rather, he or she should submit the claim directly to IBC.

If an IBC-participating provider attempts to submit a claim to their local plan for an IBC member, the claim will be denied. No payment will be issued by IBC until the claim is correctly submitted to IBC.

If you have any questions about this requirement, please contact your Network Coordinator.

BILLING


Ensure successful electronic claims submissionsAs previously communicated, Highmark, Inc. (Highmark), an independent company, handles EDI transactions on behalf of IBC. Therefore, IBC trading partners and/or providers send and receive EDI transactions to and from the Highmark Gateway. IBC is in the process of migrating membership to a new operating platform. Until all of our business is on the new platform, trading partners will be receiving transactions from both the current IBC platform and the new platform via the Highmark Gateway.

For proper claims processing, please ensure that your billing NPI is affiliated with the entity that submits your electronic claims (e.g., your clearinghouse vendor). If your billing NPI is not affiliated with the submitter, claims for migrated members will not be accepted for processing and will reject with both of the following status codes:

● 496: Submitter not approved for claim submissions for this entity; ● 562: Entity’s National Provider Identifier (NPI).

If your claims are rejecting with these status codes, please contact your billing software vendor, clearinghouse vendor, or third-party billing service for instructions on how to submit an EDI enrollment request.

Common reasons why your claims may be rejecting include, but are not limited to, the following: ● You have recently registered a new NPI with IBC, but you and your software vendor did not register your NPI with Highmark EDI.

● You have recently changed your billing software vendor, clearinghouse vendor, or third-party billing service, but your new vendor has not registered the NPI with Highmark EDI.

If you know the trading partner number assigned to the entity that submits your claims, please go to www.highmark.com/edi-ibc/apps/claims/forms/provider.shtml to enroll. Please only enroll the NPI that identifies your billing group, not the individual NPIs for your practitioners.

If you have any questions on how to enroll your NPI, please contact Highmark EDI Operations at 1-800-992-0246.

NAVINET®


Changes to NaviNet® coming in July and OctoberAs previously communicated, IBC is in the process of transitioning our claims processing to a new platform. During this time, we will be working with you in a dual claims-processing environment until all of our business is on the new platform. Providers will likely see a mix of migrated and non-migrated members.

Beginning in July, the Eligibility and Benefits Detail screen for migrated members will display the National Provider Identifier (NPI) of the member’s primary care physician, where applicable.

In addition, as part of our ongoing transition, all NaviNet offices will be converted to the new platform in mid-October. As a result, most providers will see a difference in their provider group drop-down menus within many individual transactions on the NaviNet web portal. Some other significant changes that providers will see on the new platform include the following:

● NaviNet office will move from a location-specific to a group-specific office configuration. ● Because there will no longer be a need for duplicate records to differentiate between HMO and PPO lines of business, we will consolidate drop-down lists.

● Customized provider group name descriptions will be eliminated.

Also coming in October, IBC will introduce a new transaction – called Allowance Inquiry – to replace the retired Fee Schedule Inquiry transaction.

More information about these changes, including the availability of detailed user guides, will be communicated through future articles in Partners in Health Update.

If you have any questions regarding these upcoming NaviNet changes, please call the eBusiness Hotline at 215-640-7410.

Cost-effective treatment options for infliximab (Remicade®) IBC is pleased to announce that infliximab (Remicade®) is now able to be administered at Walgreens infusion suites for IBC members who are approved to receive this drug.

Over the next few months Walgreens will reach out to select network physicians whose patients typically receive Remicade® in an outpatient facility setting. As part of the discussions, they will offer information about the Walgreens Site of Care Optimization Program, highlighting the benefits of administering Remicade® in Walgreens infusion suites.

Another option for physicians whose patients typically receive Remicade® in an outpatient facility setting is to have it administered by an IBC-approved home infusion provider. Home infusion providers are medical professionals who bring drugs and medical supplies to the member’s home, monitor the member during the

infusion, and remove all used supplies after the infusion is complete. Many members choose home infusion therapy because they can coordinate their treatment based on their schedule and receive treatment in the comfort and convenience of their own home.

In most cases, members who choose to receive drug therapy in an infusion suite or through home infusion pay lower cost-sharing amounts (i.e., copayment, deductible, coinsurance) than members who receive drug therapy in an outpatient facility setting.

To learn more about options for the administration of Remicade® in an infusion suite or the member’s home, call 1-800-ASK-BLUE.

Note: Janssen Biologics, Inc. and Walgreens are conducting separate outreach to providers on the use of Remicade®.

MEDICAL Attention! An update has been made to the content of this article.

MEDICAL


Upcoming changes to Medicare Advantage policies and clinical relationship logicEffective January 1, 2015, we are introducing changes related to the application of medical and claim payment policies, as well as clinical relationship logic, for IBC’s Medicare Advantage business.

Policy changesMedical and claim payment policies that currently apply to both commercial and Medicare Advantage business will be separated into two unique policy portfolios: one for Medicare Advantage business and one for commercial business.

The new Medicare Advantage policy portfolio will become effective January 1, 2015; notifications for these policies will be available on the IBC Medical Policy Portal by October 1, 2014. This policy portfolio will be based on Medicare coverage guidance as well as additional IBC medical and claim payment policy determinations.

Note: The existing policy portfolio will continue to apply to commercial business.

Clinical relationship logic (procedure code-to-procedure code edits)Effective January 1, 2015, the following will be applied to claims submitted on the CMS-1500 claim form or through the 837P transaction for Medicare Advantage HMO and PPO members:

● Medicare’s National Correct Coding Initiative (NCCI) editing; ● other clinical relationship logic, which is based on procedure code editing standards.

For more informationAdditional information about these changes will be provided in future editions of Partners in Health Update.

Stay up to date on policy activity by visiting www.ibx.com/medpolicy and selecting Accept and Go to Medical Policy Online. You can also view policy activity using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Be sure to check back often, as the site is updated frequently.

Revision to draft Medical Policy #02.01.01c: Home Health Care ServicesDue to the recent clarification from the Centers for Medicare & Medicaid Services (CMS) regarding face-to-face encounter requirements for home health care services, IBC’s draft policy on home health care services (#02.01.01c), slated to become effective July 22, 2014, has been revised to remove the requirements for a face-to-face encounter by the certifying professional provider prior to certifying an individual's eligibility for home care services.

To view the revised Notification for Medical Policy #02.01.01c: Home Health Care Services in its entirety, visit our Medical Policy page at www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, and click on the Policy Notifications box. You can also view policy notifications using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. After this policy is in effect on July 22, 2014, it will be available by using the Search box on the Medical Policy homepage.

MEDICAL


Referring members for genetic testingGenetic testing can identify alterations in an individual’s genetic makeup that may indicate the possibility of risk or the presence of disease (i.e., inherited or acquired) or carrier status. In addition to its use as a possible clinical tool for diagnostic, predictive, carrier, and pre-symptomatic testing, genetic testing may be part of the clinical work-up during the provision of prenatal or embryo pre-implantation services, as well as newborn screening. Genetics is an extensive and expansive field, and due to its continuously evolving nature, a large number of genetic tests are in the research phase of development at this time.

Referral processIBC’s laboratory network has extensive genetic testing capabilities; therefore, providers should refer members only to participating laboratories for covered services. In the unusual circumstance that a specific test and related services are not available through a participating laboratory, providers must contact IBC to obtain preapproval. Preapproval is required for the use of a non-participating laboratory.

Contractual obligation to use participating providersIn accordance with your IBC Provider Agreement (IBC Agreement), except in an emergency, a participating provider should refer commercial and Medicare Advantage HMO members only to participating providers for covered services. This includes, but is not limited to, ancillary services such as laboratory and radiology, unless the provider has obtained preapproval from IBC for the use of a non-participating laboratory.

Non-compliance may result in financial and other implications When applicable under the terms of your IBC Agreement, if a provider continues the use of a non-participating laboratory (such as Ambry GeneticsTM, Boston Heart Diagnostics®, Counsyl, Inc., Good Start® Genetics, Ascendant MDX, Inc. (now Progenity), and Sequenom® Laboratories) for HMO members and does not obtain preapproval from IBC, the provider is required to hold the member harmless. The provider will be responsible for any and all costs to the member and shall reimburse the member for such costs or be subject to claims offset by IBC for such costs. In addition, further non-compliance may result in immediate termination of your IBC Agreement.

Exception to the use of non-participating providers per the terms of your IBC AgreeementIf a provider refers a member to a non-participating laboratory for non-emergent services without obtaining preapproval from IBC to do so, sends a member’s specimen to a non-participating laboratory without preapproval, or provides or orders non-covered services for a member, the provider must inform the member in advance, in writing, of the following:

● a list of the services to be provided; ● that IBC will not pay for or be liable for the listed services;

● that the member will be financially responsible for such services.

Providers should also be aware of the coverage status of the tests they order and should notify the member in advance if a service is considered experimental, investigational, or non-covered by IBC. To view our coverage position on specific genetic tests, visit www.ibx.com/medpolicy and search for the current version of Medical Policy #06.02.35: Genetic Testing.

Note: Members who have out-of-network benefits may choose to use a non-participating laboratory for a medically necessary service, but they will have greater out-of-pocket costs associated with that service. In addition, the member will be financially responsible for the entire cost of any service that is non-covered (e.g., a service that is considered experimental/investigational).

If you have any questions related to the referral process for genetic testing, please contact your Network Coordinator.

MEDICAL


continued on the next page

Medical and claim payment policy activity posted from May 26 – June 24, 2014 Below is a listing of the policy activity that we have posted to our website from May 26 – June 24, 2014.

New policiesThe following policies have been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with IBC.

Policy # Title Notification date Effective date

00.10.40 Reimbursement for Certified Registered Nurse Practitioners (CRNP) N/A

January, 1 2014 (policy published on June 4, 2014)

08.01.17 Elosulfase alfa (Vimizim™) June 18, 2014 July 18, 2014

Updated policies The following policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with IBC.

Policy # Title Type of policy change Notification date Effective date

00.06.02k Preventive Care Services Medical Necessity Criteria; Medical Coding June 5, 2014 September 3, 2014

02.01.01c Home Health Care Services

Medical Necessity Criteria; Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

April 23, 2014 (revised June 19, 2014)

July 22, 2014

05.00.14g High-Frequency Chest Wall Oscillation Devices Medical Necessity Criteria June 18, 2014 July 18, 2014

05.00.26cProthrombin Time Monitor for Home Anticoagulation Management

Medical Necessity Criteria; Medical Coding; Guidelines May 5, 2014 June 4, 2014

05.00.30i

Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices

Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

May 5, 2014 June 4, 2014

07.03.03f

Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)

General Description, Guidelines, or Informational Update; Coverage and/or Reimbursement Position

N/A June 18, 2014

07.03.15c

Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)

General Description, Guidelines, or Informational Update N/A June 18, 2014

07.07.01h Routine Foot Care For Certain Medical Conditions Informational Update N/A June 18, 2014

07.11.01b Smell and Taste Dysfunction Testing Medical Coding N/A June 4, 2014

MEDICAL


Policy # Title Type of policy change Notification date Effective date

08.00.33j Trastuzumab (Herceptin®)

Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

April 23, 2014 July 22, 2014

08.00.34g Infliximab (Remicade®)

Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

May 22, 2014 June 23, 2014

08.00.50l Rituximab (Rituxan®) Medical Coding March 5, 2014 June 3, 2014

08.00.58c Risperidone (Risperdal® Consta®) Injection

Medical Coding; General Description, Guidelines, or Informational Update N/A June 18, 2014

08.00.62eAbatacept (Orencia®) for Injection for Intravenous Use

Coverage Position; Medical Necessity Criteria; General Description March 5, 2014 June 3, 2014

08.00.85d Tocilizumab (Actemra®) for Intravenous Infusion

Medical Necessity Criteria; General Description March 5, 2014 June 3, 2014

08.00.98b Eribulin Mesylate (Halaven™)

Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

N/A June 18, 2014

11.00.06eTreatment of Obstructive Sleep Apnea (OSA) and Primary Snoring for Adults

Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

April 23, 2014 July 23, 2014

11.02.10j

Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms

General Description; Coverage Position; Medical Necessity Criteria; Medical Coding

March 26, 2014 June 24, 2014

12.01.01x Experimental/ Investigational Services Medical Coding; Coverage Position April 10, 2014 July 9, 2014

Reissued policiesThe following policies have been reviewed, and no substantive changes were made.

Policy # Title Reissue effective date08.00.49c Dofetilide (Tikosyn®) Use In the Inpatient Setting May 28, 2014 (published May 28, 2014)

11.02.02e Treatment of Medical and Surgical Complications May 28, 2014 (published May 29, 2014)

11.08.17d Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Nails June 11, 2014 (published June 12, 2014)

To view policy activity, go to www.ibx.com/medpolicy and select Accept and Go to Medical Policy Online. You can also view policy activity using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Be sure to check back often, as the site is updated frequently.

continued from the previous page

QUALITY MANAGEMENT

Highlighting HEDIS®:


This article series is our monthly tool to help you maximize patient health outcomes in accordance with NCQA’s1 HEDIS®2 measurements for high-quality care on important dimensions of services.

HEDIS definitionUse of spirometry testing in the assessment and diagnosis of COPD: The percentage of commercial and Medicare members ages 40 and older with a new diagnosis of chronic obstructive pulmonary disease (COPD) or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis.

Note: A period of two years with no claims/encounters containing any diagnosis of COPD is needed for a member to be considered newly diagnosed. For these members, HEDIS® is searching for at least one claim/encounter for spirometry testing within the last two years to confirm the diagnosis.

Coding guidelinesUse the following codes for a diagnosis of COPD and spirometry testing:

Plan performanceIn a three-year comparison of national plan performance on the rate of spirometry testing to confirm the diagnosis of COPD, IBC plan performance has trended at or below the 50th percentile of national averages. The following chart shows the 10 percent gap in performance between IBC plans and the 90th percentile national benchmark.

1 The National Committee for Quality Assurance (NCQA) is the most widely recognized accreditation program in the U.S.

2 The Healthcare Effectiveness Data and Information Set (HEDIS) is an NCQA tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care.

3 The Quality Incentive Payment System (QIPS) is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care.

Support from IBCIBC Health Coaches can collaborate with you to support and guide patients through an acute or chronic episode to help achieve the medical treatment goals you establish.

Please encourage your patients to contact an IBC Health Coach. IBC Health Coaches are available 24/7 and can support your patients as they make important decisions about their health. Ask your patients to call 1-800-ASK-BLUE and say “Health Coach” when prompted.

Learn moreVisit www.ibx.com/providers/resources/hedis.html to view previously published Highlighting HEDIS® articles.

If you have feedback about the Highlighting HEDIS® series or you have topic ideas, email us at [email protected].

Description ICD-9-CM diagnosis code

Chronic bronchitis 491

Emphysema 492

COPD 493.2, 496

Description CPT® codeSpirometry 94010, 94014-

90416, 94060, 94070, 94375, 94620

Use of spirometry testing in the assessment and diagnosis of COPD

COPD diagnosis codes Spirometry testing codes

IBC Spirometry Testing Performance vs Average Percentile Benchmarks

The use of spirometry testing in the assessment and diagnosis of COPD is included as a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2014 for participating providers.

QIPS3 Alert!

www.ibx.com/providers/resources/hedis.html

QUALITY MANAGEMENT


IBC’s Medicare utilization remains within or above national standardsAs part of IBC’s annual review process, we obtain data from the Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) to help evaluate utilization for our Medicare Advantage HMO and PPO members. The results showed that utilization remains within or above national standards.

HEDIS® data evaluationIBC used the data from HEDIS® to evaluate hospital discharges and the frequency rates of selected cardiac procedures.

Hospital utilizationHospital utilization comparison acute discharges per 1,000 (Table 1) show that Keystone 65 HMO and Personal Choice 65SM PPO rates continue to improve and remain within the relevant national 10th and 90th percentiles as the appropriate thresholds for over/under utilization.

Table 1: Hospital utilization comparison acute discharges per 1,000

HEDIS® year 2012 HEDIS® year 2013

Product Rate Threshold Threshold status Rate Threshold Threshold

statusKeystone 65 HMO

346.31 193.14 – 355.92

Within 286.89 189.91 – 359.05

Within

Personal Choice 65 PPO

301.65 193.14 – 355.92

Within 277.40 189.91 – 359.05

Within

Use of servicesIBC also measured the frequency of selected procedure rates for cardiac angioplasty, cardiac catheterization, and coronary artery bypass graft (CABG). Based on a comparison of 2013 HEDIS® utilization rates with respect to established thresholds, utilization for use of services for these identified indicators fell within the established threshold for most age/gender cohorts. Three cohorts fell above both national and regional established thresholds. These rates are measured according to age group and gender, and IBC recognizes the probability of unequal variance as an issue with the cardiac procedure rates.

CAHPS data evaluationIBC used CAHPS data to evaluate composite care, including member perception of getting needed care in a timely manner and specialty care.

Keystone 65 HMO membersThe rate for getting needed composite care for Keystone 65 HMO members during 2013 (Table 2) rose significantly above the national threshold. In addition, the rate for members who are referred to a specialist remained significantly better than the national threshold. Both of these rates may be attributed to the emergence of the Patient-Centered Medical Home (PCMH) model as primary care in 2010. The rate for ease of care also increased in 2013 after remaining stagnant for three years, indicating that members feel they are still receiving all of the medically appropriate studies.

continued on the next page

QUALITY MANAGEMENT


Table 2: CAHPS Member Satisfaction Data — Keystone 65 HMO

2012 2013

CriteriaKeystone 65 HMO members

National average

Threshold status

Keystone 65 HMO members

National average

Threshold status

In the last six months, how often was it easy to get care, tests, or treatment you thought you needed?

3.64 3.60 Within 3.67 3.60 Within

In the last six months, how often was it easy to get appointments with a specialist?

3.61 3.54 Above* 3.64 3.56 Above*

Getting needed care composite 3.64 3.57 Within 3.67 3.58 Above*

*Threshold status significantly better/worse than the national average

Personal Choice 65 PPO The rate for Personal Choice 65 PPO members during 2013 (Table 3) remained within the national threshold, including an increase in the rate for ease of care.

PPO members are not required to identify a primary care physician, and many PPO members with chronic conditions use a specialist as their primary physician. However, based on member responses regarding the ease of care and care composite, there are no significant barriers to members receiving appropriate care noted.

Table 3: CAHPS Member Satisfaction Data — Personal Choice 65 PPO

2012 2013

Criteria

Personal Choice 65 HMO members

National average

Threshold status

Personal Choice 65 HMO members

National average

Threshold status

In the last six months, how often was it easy to get care, tests, or treatment you thought you needed?

3.61 3.60 Within 3.64 3.60 Within

In the last six months, how often was it easy to get appointments with a specialist?

3.61 3.54 Within 3.61 3.56 Within

Getting needed care composite 3.61 3.57 Within 3.61 3.58 Within

For more informationTo learn more about HEDIS®, go to www.ibx.com/providers/resources/hedis.html to view Highlighting HEDIS® articles that have been published in Partners in Health Update. These articles are educational resources for understanding HEDIS® measures. If you have feedback about the Highlighting HEDIS® series or topic requests, please email us at [email protected].

continued from the previous page

HEALTH AND WELLNESS


Help your patients to be active so they stay healthyAre your IBC Medicare Advantage patients getting enough physical activity to stay healthy and fit? According to the Centers for Disease Control and Prevention, older adults should get at least two hours and 30 minutes of activity, such as brisk walking, every week, plus activity that works the muscles in the legs, hips, back, abdomen, chest, shoulders, and arms on two or more days per week.1

Your patients may not be that active, and they may have questions about their ability to exercise. Encourage them to talk with you at their annual exam. Your answers to their questions can help them decide how to improve their fitness levels. Here are a few questions you can anticipate:

● How do I start to increase my activity? ● How often should I work out? ● What can I expect at a gym or fitness center? ● Are there any restrictions on what exercises I can do?

To get your patients moving, recommend that they participate in the SilverSneakers® Fitness program. Encourage patients to track their activity and energy level and then provide you with an update at their next visit.

SilverSneakers can help patients get activeAn excellent way for IBC Medicare Advantage members to get the activity they need is to use their fitness benefit – Healthways SilverSneakers Fitness program. With nearly 20 years of performance-based programming experience, SilverSneakers delivers innovative physical activity and social interventions to attract members and keep them engaged in improving their health. The program provides a basic fitness membership that allows participants to:

● access more than 11,000 fitness locations nationwide, including women-only sites;

● use exercise equipment and other amenities such as pools and walking tracks;

● take signature SilverSneakers group fitness classes designed specifically for active older adults and led by certified instructors;

● learn about relevant health topics; ● participate in fun social activities and events; ● receive guidance and assistance from a SilverSneakers Program Advisor™, a dedicated staff member at the fitness location.

SilverSneakers makes it easy for members to enroll and start using the program. Each eligible Keystone 65 Select HMO, Keystone 65 Preferred HMO, and Personal Choice 65SM PPO member receives a mailing from SilverSneakers that includes their personal member ID card and a list of the four fitness locations closest to their home. Members can simply take the ID card to the location of their choice and present it at the front desk. Members who have either not received an ID card or may have misplaced it can call 1-888-423-4632 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. ET, to request that a new ID card be mailed and to obtain their SilverSneakers ID number, which can be used at the location until the new ID card arrives in the mail.

Note: SilverSneakers is a benefit offered to Keystone 65 Select HMO, Keystone 65 Preferred HMO, and Personal Choice 65 PPO members at no additional cost. 1www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html.

SilverSneakers® is a registered mark of Healthways, Inc., an independent company.

www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html

HEALTH AND WELLNESS


Alcohol screening resource now includes pediatric informationOur alcohol screening handout was recently updated with new information and resources on children and adolescents.

The alcohol screening handout is designed to give primary care physicians information and screening techniques, as well as resource links, that can be used when discussing alcohol use with patients. This document, along with documents on depression and smoking cessation, is a result of IBC and Magellan Behavioral Health, Inc. working together to provide resources for physicians to use when assessing and managing behavioral health conditions.

The handouts can be downloaded from our website at www.ibx.com/resources in the Worksheets, Forms, and Guides section or from the NaviNet® web portal under Health and Wellness in the Administrative Tools & Resources section. You can also request a printed copy of these documents by submitting an online request at www.ibx.com/providersupplyline or by calling our Provider Supply Line at 1-800-858-4728.

Magellan Behavioral Health, Inc., an independent company, manages mental health and substance abuse benefits for most IBC members.

BUSINESS TRANSFORMATION

Stay informed during our transition to the new platformAs of November 2013 and continuing through mid-2015, IBC is in the process of transitioning its membership to a new operating platform, generally based on when the customer/member’s contract renews.

During this transition, we will be working with you in a dual claims-processing environment until all of our membership is migrated to the new platform. In other words, as members are migrated, their claims will be processed on the new platform; however, we will continue to process claims on the current IBC platform for members who have not yet been migrated.*

We are committed to working closely with our entire provider network as we complete this Business Transformation. We will continue to provide comprehensive communications and tools to support our members and provider network, both during and after the transition to the new platform.

Be sure to visit our dedicated Business Transformation site at www.ibx.com/pnc/businesstransformation. On this site you will find a communication archive as well as a frequently asked questions (FAQ) document. If you still have questions after reviewing the FAQ, email us at [email protected].

*Behavioral health claims for HMO/POS non-migrated members should continue to be submitted to Magellan Behavioral Health, Inc. Behavioral health claims for all migrated members, including HMO/POS, should be submitted to IBC.

Magellan Behavioral Health, Inc., an independent company, manages mental health and substance abuse benefits for most IBC members.

Visit our Provider News Center: www.ibx.com/pnc

Anti-Fraud and Corporate Compliance

Hotline 1-866-282-2707 or www.ibx.com/antifraud

Care Management and Coordination

Baby BluePrints® 215-241-2198 / 1-800-598-BABY (2229)*

Case Management 1-800-ASK-BLUE

Condition Management Program 1-800-ASK-BLUE

Credentialing

Credentialing Violation Hotline 215-988-1413 or www.ibx.com/credentials

Customer Service/Provider Services

Provider Automated System† (eligibility/claims status/precertification) 1-800-ASK-BLUE

Provider Services user guide www.ibx.com/providerautomatedsystem

eBusiness

Help Desk 215-241-2305

FutureScripts® (commercial pharmacy benefits)

Prescription drug prior authorization 1-888-678-7012

Fax 1-888-671-5285

Blood Glucose Meter Hotline 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.ibx.com/rx

FutureScripts® Secure (Medicare Part D pharmacy benefits)

FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.ibxmedicare.com

Prescription drug prior authorization toll-free fax 1-888-671-5285

Other frequently used phone numbers and websites

IBC Direct Ship Injectables Program (medical benefits) www.ibx.com/directship

Medical Policy www.ibx.com/medpolicy

NaviNet® portal registration www.navinet.net

Provider Supply Line 1-800-858-4728 or www.ibx.com/providersupplyline

*Outside 215 area code†The Provider Automated System will be phased out as members are migrated to the new operating platform. For more information go to www.ibx.com/pnc/businesstransformation.

Important Resources

Documents

Partners in Health Update - July 2014July 1, 2014, IBC’s contract with Quest Diagnostics ® laboratories will end, and Quest Diagnostics will be an out-of-network provider at that