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VOLUME 14 • ISSUE 5 • MAY 2012
Administrative Practice
Guideline Updates
The following Administrative Practice
Guidelines have been reviewed and/or
updated, effective March 20:
1. Accessibility/availability:
non-physician specialists and
behavioral health facilities
2. Facility and environment:
non-physician specialists and
behavioral health facilities
3. Facility and environment: oral
surgeons/dentists
4. Behavioral health medical record
documentation
5. Credentialing criteria for obstetric
nurses in home care
6. Credentialing criteria for newborn/
pediatric nurses in home care
7. Home care/plan of care
8. Home care medical record documentation
Where Can You Find the
Guidelines?
Administrative Practice Guidelines
are available at www.bcnepa.com.
Just click on the “Provider Homepage,” then “Quality Management” and
select “Quality Management Practice
Guidelines.” You can also find them by
logging on to NaviNet®. If you are not
able to access the guidelines online
and would like a hardcopy, please call
Jill Sikorski at 570.200.4376, weekdays,
between 8 a.m. and 5 p.m.
(Policy Update 1405001)
CMS Announces Delay in On April 9, the Department of
ICD-10 Implementation Health and Human Services
(HHS) announced a proposed rule that would delay the compliance date for ICD-10 from
October 1, 2013 to October 1, 2014. This is the date by which covered entities must comply
with International Classification of Diseases (ICD-10).
Please note: The announcement by HHS is a “proposed rule” that must still be approved
by HHS before it becomes final. Therefore, providers who are working on their efforts to
transition to ICD-10 should continue along that path. Please continue to check upcoming
issues of Provider Bulletin for more information on ICD-10 implementation timeframes.
(Policy Update 1405002)
How to Submit Claims
First Priority Health® (FPH) and First
Priority Life Insurance Company®
for Services Provided by (FPLIC) would like to remind you that
Employed Practice Extenders services given to our members are
to be provided personally by the credentialed, contracted practitioner or by a licensed
physician extender employed by the practitioner.
We recognize the following advanced practice professionals as physician extenders:
• Physician Assistant
• Certified Registered Nurse Practitioner
• Certified Registered Nurse Anesthetist
• Certified Nurse Midwife
Please submit claims for the services of an employed physician extender with the
credentialed practitioner information as the performing provider, since we do not
credential employed physician extenders individually.
Please note: We do not provide coverage for services given by unlicensed professionals
or massage therapists.
(Policy Update 1405003)
Table of Contents
2 New Electronic Remittance
Advice (ERA/835) Request
Form
4 Medical Policy
Updates
3 Update: BCNEPA Expands
6 Patient Review of
Physicians to Launch
in July
NaviNet Access to Entire
Provider Network
updates
New Electronic Remittance
Advice (ERA/835) Request Form
Blue Cross of
Northeastern
Pennsylvania (BCNEPA) is pleased to announce that the new Electronic Remittance
Advice Request Form (ERA/835) is now available on our website at www.bcnepa.com/
Providers/. The ERA/835 form allows providers/facilities to receive auto-posting
capability electronically.
If you submit NUCC 1500 paper claim
forms, please follow these steps:
1.Use approved HCFA 08/05
claim forms.
2.Type all information within the
boundaries of the fields you
are reporting.
Select the type of request you are submitting:
•
•
•
Steps to Submit NUCC
1500 Claim Forms
New—Initial request to receive ERA
Discontinue—Request to discontinue receipt of ERA
Change—Request to change method of receipt (clearinghouse) of ERA
Important Notes:
• When selecting the “Change” option, the only information you can elect to change is
the clearinghouse and any associated location.
• If you need to change any other aspect of your remittance, you will need to submit
a “Discontinue” Request Form to stop your current remittance and then submit a
“New” Request Form with your new information. Example: If you currently receive
an ERA and are changing your Tax ID or NPI number, you will need to complete a
“Discontinue” and enter a “New” request.
• For all 3 types of requests (New, Discontinue and Change), before sending/submitting
the request, please print the form for your records.
• Once your ERA/835 request is completed, you will be contacted via the email
3.Ensure all data are reported in
its entirety.
Following these guidelines will help
ensure claims are read correctly
by the scanning systems and processed correctly.
For more information, visit the Highmark
Provider Resource Center at
https://prc.highmark.com/rscprc/hbcbs/pub.
Click on “Administrative Reference
Materials.” There you can find the
Highmark Blue Shield Office Manual
(chapter 5) that contains proper claim submission techniques.
address you provided on the Request Form with the date you will begin receiving
your ERA/835.
Sign Up for EFT, Too!
In conjunction with the ERA/835, all FPLIC providers are encouraged to receive an
electronic funds transfer (EFT). An EFT will allow you to receive your claim payments
promptly. With the acceptance of EFT, you will no longer receive a paper remittance
advice (RA) or an explanation of benefits (EOB) statement. We will eliminate the printing
and mailing of the RA and EOB. If you are interested in receiving EFT, please fax the
following information to 570.200.7707:
• Provider group/facility name
(Policy Update 1405005)
New Alpha Prefix: LPO
Effective April 1, a new FPLIC PPO alpha
prefix, LPO, has been added to our list of
custom groups. This is not a BlueCard
alpha prefix. Therefore, participating
provider claims must be sent to FPLIC,
not Highmark. All benefit and eligibility
• Provider TIN
files have been updated in NaviNet for
this group.
• Contact person name, phone number and email address
(Policy Update 1405006)
(Policy Update 1405004)
2
Reminder: Route
Inquiries Through
NaviNet When
Possible
BCNEPA NaviNet-enabled providers are
reminded that all routine inquiries must
be routed electronically through NaviNet, rather than by calling a BCNEPA
Customer Service Representative.
BCNEPA has worked diligently to
enhance our enrollment & billing,
claims status and claims investigation
transactions to ensure you have all the
information you need through NaviNet.
However, you may continue to call
BCNEPA Customer Service with unusual issues or concerns that require considerable investigation and/or support.
BCNEPA Customer Service Representatives can tell you how to use NaviNet
for enrollment & billing, claims status
and claims investigation inquiries.
They can redirect you to NaviNet to
take advantage of the tools available to
answer the inquiry.
Please note: If you have multiple offices/
locations, you must ensure that NaviNet
access is granted to each office/location
that may need functionality. Only the
provider’s NaviNet security officer has
the capability to grant “user” access
under each provider’s NaviNet account.
More details on granting user access is
available under the “Customer Support” link, once you sign on to NaviNet.
If you are not yet NaviNet enabled,
you may continue to contact BCNEPA’s
Customer Service department when
needed. Please refer to the article
entitled “BCNEPA NaviNet Expansion”
in this edition of the Provider Bulletin
for more information on how to obtain
BCNEPA NaviNet access.
(Policy Update 1405007)
Update: BCNEPA Expands
NaviNet Access to Entire
Provider Network
As we informed you in
previous editions of our
Provider Bulletin, we understand the importance of real-time electronic capabilities
and are excited to announce the expansion of BCNEPA NaviNet access to our entire
provider network.
We continue to work on Phase 2 of our NaviNet expansion and ask you to provide us with
the following information to establish your NaviNet access, if you haven’t already done so:
1. Provider group/facility name
2. Provider TIN
3. Provider (group/facility) Type II NPI
4. Provider FPH/FPLIC legacy number(s)
5. Provider’s NaviNet security officer contact name
6. Provider’s NaviNet security officer phone number
7. Provider’s NaviNet security officer email address
8. For professional groups, please list all physicians employed with the group (include
each individual provider name, NPI, FPH/FPLIC legacy numbers)
Please email the above information to BCNEPANavi@bcnepa.com. Once we receive
the above information, we will establish your BCNEPA NaviNet access as soon as possible.
NaviNet will send you an email at the address you provided to finalize your access.
Please indicate if you would like to participate in a NaviNet training webinar by a
BCNEPA Provider Relations Representative in your email. A BCNEPA Provider Relations
Representative will follow up with you to schedule your NaviNet training webinar.
Please note:
• Once you are enabled with BCNEPA NaviNet, you must use our eligibility and
benefits inquiry, claims status inquiry and claims investigation transactions for
routine enrollment and billing and claims inquiries instead of calling BCNEPA’s
Customer Service. You will be given a 90-day grace period from the date you
receive access before you are required to use NaviNet for routine enrollment and
billing and claims inquiries.
• PCPs who receive their BCNEPA NaviNet access in Phase 2 will no longer receive their
capitation roster via regular mail. Instead, you can access your capitation rosters
via NaviNet.
Please continue to check future issues of Provider Bulletin for additional information on our
NaviNet expansion.
(Policy Update 1405008)
DRG Utilization Management
Process Change
ve
Effecti12
6/04/
Beginning June 4, BCNEPA will no longer automatically
authorize 7 days’ length of stay at acute care facilities.
Instead, we will assign length of stay according to the
recommendations of InterQual® criteria.
This change will allow us to appropriately coordinate care according
to nationally recognized and accepted criteria, and enable us to
better manage overall costs of care and quality outcomes.
(Policy Update 1405009)
3
ve
Effecti12
6/01/
Medical Policy Updates
Durable Medical Equipment (DME) (MPO-490-0006)
Eligibility for coverage criteria of various DME items have been added to this policy.
Dynamic splinting devices and traction equipment are examples of items which will now
require clinical review, and the criteria are as follows:
Dynamic Splinting Devices
• Dynamic Low-load Prolonged-duration Stretch (LLPS) Devices BCNEPA will provide coverage for dynamic low-load prolonged-duration stretch
(LLPS) devices, when medically necessary.
1. Dynamic low-load prolonged-duration stretch devices (LLPS) for the knee, elbow,
wrist or finger (including, but not limited to, Dynasplint Systems, LMB Pro-glide, EMPI
Advance Ultraflex and Advanced Biomedics) may be considered medically necessary
for use on the knee, elbow, wrist or finger in any of the following clinical settings:
a) As an addition to physical therapy in the subacute injury or postoperative
period (≥ 3 weeks but ≤ 4 months after injury or operation) in patients with
signs and symptoms of persistent joint stiffness or contracture:
• For an initial period of up to 4 months; and
• If the patient shows improvement after the initial period, thereafter for as
long as improvement can continue to be demonstrated; OR
b)In the subacute injury or postoperative period (≥ 3 weeks but ≤ 4 months
after injury or operation) in a patient whose limited range of motion poses a
meaningful (as judged by the physician) functional limitation, AND who has not
responded to other therapy (including physical therapy):
• For an initial period of up to 4 months; and • If the patient shows improvement after the initial period, thereafter for as
long as improvement can continue to be demonstrated; OR
c) In the acute postoperative period for patients who have undergone additional
surgery to improve the range of motion of a previously affected joint:
• For an initial period of up to 4 months; and
• If the patient shows improvement after the initial period, thereafter for as
long as improvement can continue to be demonstrated; OR
d)For patients unable to benefit from standard physical therapy modalities
because of an inability to exercise:
• For an initial period of up to 4 months; and
• If the patient shows improvement after the initial period, thereafter for as
long as improvement can continue to be demonstrated.
2. If there is no significant improvement after 4 months of use, dynamic LLPS devices
for the knee, elbow, wrist or finger are considered not medically necessary under
any circumstance, including but not limited to, use in patients unable to benefit
from standard physical therapy modalities because of an inability
to exercise.
4
3. Dynamic LLPS devices used for all other
conditions are considered not medically necessary.
4. Dynamic LLPS devices which are specific to
the ankle, toe and shoulder are considered
investigational for all indications including, but
not limited, to the management of chronic
joint stiffness or chronic or fixed contractures.
•Bi-directional Static Progressive (SP)
Stretch Devices
5. Bi-directional static progressive (SP)
stretch devices (e.g., Joint Active Systems
Static Progressive Stretch) are considered
investigational for all indications.
• Patient-actuated Serial Stretch
(PASS) Devices
6. Patient-actuated serial stretch (PASS) devices
(e.g., ERMI Knee, MPJ, or Elbow Extensionator®,
ERMI Knee/Ankle or Shoulder Flexionator®) are
considered investigational for all indications. Traction Equipment
BCNEPA will provide coverage for traction equipment,
when medically necessary.
1. Traction equipment may be considered
medically necessary when all of the above
DME criteria have been met, and
2. The patient has a musculoskeletal or
neurologic impairment requiring traction
which prevents ambulation during the period
of use.
3. Traction equipment is considered not
medically necessary when the above criteria
have not been met.
4. Traction equipment, including but not
limited to, the following: ambulatory devices,
pneumatic devices, devices attached to
a headboard or a free-standing frame is
considered not medically necessary.
Intravitreal Angiogenesis Inhibitors for Retinal Vascular
Conditions
Policy language has been added as follows:
• Intravitreal injection of ranibizumab or bevacizumab may be considered medically
necessary for the treatment of the following retinal vascular conditions:
Electrical/Neuromuscular
Stimulator (MPO-490-0018)
Vagus Nerve Stimulation
The policy was updated as follows to include 2 new
investigational conditions:
• Vagus nerve stimulation as a treatment of
other conditions including, but not limited to,
heart failure, fibromyalgia, depression, essential
tremor, headaches and obesity is considered
investigational.
Transcatheter Embolization
(MPO-490-0126)
Transcatheter Arterial
Chemoembolization (TACE) to
Treat Primary or Metastatic Liver
Malignancies
a) Diabetic macular edema
b) Proliferative diabetic retinopathy as an adjunctive treatment to vitrectomy
or photocoagulation
c) Macular edema following central retinal vein occlusion*
d) Macular edema following branch retinal vein occlusion*
* FDA-approved indication (Lucentis)
• Intravitreal injection of bevacizumab may be considered medically necessary for the
treatment of stage 3+ retinopathy of prematurity.
• Intravitreal injection of aflibercept may be considered medically necessary for
treatment of diabetic macular edema.
• Intravitreal injection of aflibercept is considered investigational for treatment of other
retinal vascular disorders, including proliferative diabetic retinopathy and central or
branch retinal vein occlusion.
Experimental/Investigative Services— Radiology
(MPO-490-0137)
Screening for Lung Cancer Using CT Scanning
The following new language has been added:
Our policy has been updated as follows:
• Transcatheter hepatic arterial chemoembolization BCNEPA will provide coverage for screening for lung cancer using low-dose computed
is considered investigational to treat unresectable tomography (CT) scanning, when medically necessary.
cholangiocarcinoma.
1. Low-dose computed tomography (CT) scanning, not more frequently than
Experimental/Investigative Services—
Pathology/Laboratory (MPO-490-0134)
Thromboxane Metabolites
The following new language has been added to policy:
• BCNEPA will not provide coverage for
measurement of urine levels of Thromboxane
metabolites (e.g., AspirinWorks®) to determine
aspirin nonresponse or resistance, as this is
considered investigational.
Experimental/Investigative Services—
Ophthalmologic (MPO-490-0136)
Corneal Collagen Cross-linking
annually for 3 consecutive years, may be considered medically necessary as
a screening technique for lung cancer in individuals who meet all of the
following criteria*:
a) Between 55 and 74 years of age
b)History of cigarette smoking of at least 30 pack-years
c) If former smoker, quit within the previous 15 years
* Patient selection criteria are based on the National Lung Screening Trial (NLST).
2. Low-dose CT scanning is considered investigational as a screening technique for
lung cancer in all other situations.
Experimental/Investigative Services—Medicine
(MPO-490-0138)
Chromoendoscopy as an Adjunct to Colonoscopy
The following new statement has been added to policy: The following language has been added to medical policy:
• BCNEPA will not provide coverage for chromoendoscopy or virtual chromoendoscopy
• BCNEPA will not provide coverage for corneal
as they are considered investigational as an adjunct to diagnostic or surveillance
collagen cross-linking, as this is considered
colonoscopy.
investigational for all indications.
Light Therapy for Vitiligo
The following statement has been added to policy:
• Targeted phototherapy is considered investigational for the treatment of vitiligo.
(Policy Update 1405010)
5
Patient
Review of
Physicians
to Launch
in July
Blue Plans are
committed to
providing Blue
members with the
tools they need to
effectively partner
with their doctors
and make more
informed health
care choices.
We are pleased to announce the Patient Review of Physicians Blue Consumer Engagement Initiative that will
launch in July 2012 on the redesigned Blue National Doctor & Hospital Finder website.
Patient Review of Physicians (PRP)
This initiative allows Blue members to view and post reviews of doctors and other professional providers,
based on their patient experiences. Approximately 85–90% of patient reviews are positive, and BCNEPA has
implemented a rigorous process that authenticates reviews before posting on the Blue National Doctor &
Hospital Finder website. Not only do patient reviews help members make more informed decisions when
choosing a doctor, they are also a valuable way for physicians to gain insights into their current patients’
experiences and to attract new patients.
BCNEPA to roll out patient reviews of providers
BCNEPA will also display patient reviews of local providers on its “Doctor/Hospital Finder,” beginning July
2012. You can see reviews when you login to “Self-Service,” on www.bcnepa.com. These reviews will also be
displayed nationally on the Blue National Doctor & Hospital FinderSM at www.bcbs.com in July 2012.
Delivering Blue patient reviews to support real-time decision-making
Blue Patient Review is an online review system that Blue members can use as part of their decision-making
when they are selecting a doctor or other professional provider. BCNEPA delivers information about patients’
actual experiences with their physicians and other professional providers through an easy-to-use, nationally
consistent online survey and aggregated results display. Because only Blue members can write Blue patient
reviews, they can be trusted to accurately reflect members’ opinions, boosting the integrity of the results
beyond popular public review sites.
How it works
BCNEPA has taken a number of steps to ensure that Blue Patient Reviews deliver valid and trustworthy data:
• Use of a national question set
Patients review their doctors using a nationally consistent set of questions that cover various aspects of
their visit.
• Authentication of all Blue members
Only Blue members who login through the BCNEPA member portal can write a review. This ensures that
patient review contributions remain an exclusive benefit to Blue members.
• Validation of all Blue members writing reviews
BCNEPA members must verify they have seen the doctor or professional provider they intend to
review before they are allowed to access the review form. The verification takes place through a
member attestation.
• Moderation of all open text comments
For security and privacy purposes, reviews that contain user-generated content (such as free-form
comments) must undergo both software and human review before the content is displayed.
Benefits of displaying Blue patient reviews
You can trust Blue patient reviews to complement your practice improvement efforts, provide insights into
your patients’ experiences and attract new patients. While patient reviews are just one of many factors patients
consider when choosing a health care provider, research shows that online patient review capabilities are in high
demand. User-generated patient reviews are one of the most sought-after pieces of information for consumers
looking for a new doctor. To assure that your overall score is positive, encourage your patients to contribute to
your reviews.
Engaging and empowering consumers to make more knowledgeable health care decisions is a fundamental
priority for BCNEPA. We are committed to working hand-in-hand with you to deliver information and tools that
can help your patients take a proactive approach to their families’ health.
6
HERE Is AN Example OF the core patient review questions:
Questions 1 and 2 are required for a review to be submitted. The remaining
questions are optional, including member comments. The questions cover
the same topics of care for Blue members nationwide but may vary in the
exact wording.
Here is an example of what PRP
results will look like on the Blue
National Doctor and Hospital Finder:
For illustrative purposes only.
The Blues will continue to collaborate with national medical specialty societies and medical boards to identify programs and
resources that can be leveraged to support additional quality improvement and recognition opportunities. The Blues also provide
ongoing feedback to federal health care improvement and reporting programs to support physicians and group practices and align
our consumer engagement approaches.
BCNEPA welcomes the opportunity to discuss these new initiatives in detail with you. Please contact your Provider Relations
Consultant for more information and to schedule a meeting time.
(Policy Update 1405011)
7
presorted
standard
u.s. postage
paid
wilkes-barre, pa
permit no. 84
19 North Main Street, Wilkes-Barre, Pennsylvania 18711-0302
www.bcnepa.com
Address Service Requested
Editor: Ann Poepperling
Blue Cross of Northeastern Pennsylvania
administers health plans for Blue Cross
of Northeastern Pennsylvania, Highmark
Blue Shield, First Priority Health® and
First Priority Life Insurance Company®.
Independent licensee of the Blue Cross
and Blue Shield Association. ® Registered
mark of the Blue Cross and Blue Shield
Association.
Provider Relations Department: 1.800.451.4447
How You Can Reach Us
For questions about benefits,
eligibility or claims, please call,
weekdays, between 8 a.m. and 5 p.m.:
• BlueCare HMO/HMO Plus—1.800.822.8752
• BlueCare PPO—1.866.262.5635
Important Fax Numbers:
BC Claims Department...........................570.200.6790
(For claims adjustments, BlueCare Senior, FEP)
BC Precertification Department...........570.200.6788
• BlueCare Traditional—1.888.827.7117
BlueCard® ITS Claims.............................570.200.6790
• BlueCare EPO—1.888.345.2353
FPH Claims Department........................570.200.6790
(For Maternity Precertification Forms, adjustments, Claims Research Request Forms, etc.)
Valuable Health Resources:
Refer your BlueCare patients to the following Blue Health
SolutionsSM health and wellness resources:
• Health Management Programs for disease, care and
lifestyle management—1.866.262.4764
• 24/7 Nurse Now health care information—
1.866.442.BLUE and available online at
www.bcnepa.com. Login to “Member Self-Service”
and click on “MyHealth Coach Chat.”
Report Fraud:
Call our Fraud Hotline at 1.800.352.9100, or email our
Special Investigations Unit at siu@bcnepa.com.
BCNEPA Provider
Relations Consultants
Odette Ashby • 570.200.4658
Odette.Ashby@bcnepa.com
Cheryl Hashagen • 570.200.4670
Cheryl.Hashagen@bcnepa.com
Jill Jenkins • 570.200.4647
Jill.Jenkins@bcnepa.com
Louise LoPresto • 570.200.4674
Louise.LoPresto@bcnepa.com
Provider Relations....................................570.200.6880
Manager, Provider Relations
Provider Services Unit.............................570.200.6733
Dave Levenoskie • 570.200.4673
Dave.Levenoskie@bcnepa.com
Provider Services Inquiry......................570.200.6710
FPH Complaint/Grievance
Department................................................570.200.6770
FPH Non-par Referral Requests...........570.200.6840
FPH Pharmacy Department...................570.200.6870
Manager, SPECIAL PROJECTS
Kevin Quaglia • 570.200.4676
Kevin.Quaglia@bcnepa.com
FPH Precertification Department.........570.200.6799
QUESTIONS?
CALL PROVIDER RELATIONS AT
Other Party Liability (OPL)....................570.200.6790
1.800.451.4447
© Blue Cross of Northeastern Pennsylvania. 2012.