1. health and fitness
2. disease
3. diabetes

presorted
standard
u.s. postage
Antidepressant Medication Management
paid
wilkes-barre, pa
permit no. 84
According to recent studies, approximately 11% of Americans, aged 12 or older, take antidepressants.
The National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC),
also says that the rate of antidepressant use in the U.S. has increased nearly 400% since 1988. It is very
likely that in your practice you care for patients who are appropriately prescribed antidepressants, either
by their primary care physician or a behavioral health specialist.
The current best practice recommendations for
Non-adherence to antidepressant medication can
managing antidepressant medication include:
be a significant barrier to the successful treatment of
• Monitoring patients carefully to assess their response
to treatment, the emergence of side effects, their
clinical condition, safety and adherence to treatment
• Encouraging patients who have achieved some
improvement during the initial weeks of treatment
to continue for a total of at least 12 weeks (Effective
Acute Phase Treatment HEDIS Measure)
• For continued improvement and control of
depression, it is recommended that the patient
be compliant for at least 6 months (Effective
Continuation Phase Treatment HEDIS Measure)
depression. The Health Effectiveness Data Information
Set (HEDIS) measures seen above have been developed
by the National Committee for Quality Assurance
(NCQA), and are designed to reduce the risk of relapse.
For more information about this and other HEDIS
measures, visit our website at bcnepa.com, and click on
the Providers tab. Select Quality Management, and then
click on the link to the HEDIS Homepage.
For extra support, you can always refer your BCNEPA
patient to one of our Depression Management health
coaches at 1.866.262.4764 or (TTY) 1.877.720.7771,
weekdays, between 8 a.m. and 8 p.m. ET. You will need
• Sufficient ongoing contact of all clinicians involved
to provide your patient’s name, phone number and date
in the patient’s care with both the patient and each
of birth. A Disease Management nurse will then contact
other. This ensures care is coordinated and that
your patient.
bcnepa.com
Address Service Requested
Volume 16 • Issue 11 • November 2014
(Policy Update 1611008)
NUCC 1500 Claim Form
New Version 02/12 Timeline
Renew Your License!
Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan
issuer in the Federally Facilitated Marketplace.
Please remember to renew your
Independent Licensee of the Blue Cross and Blue Shield Association.
®Registered Mark of the Blue Cross and Blue Shield Association.
license with the State Board before
it expires. You may not practice in
Pennsylvania with an expired license.
Provider Relations department:
1.800.451.4447
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
The following practitioners have
Important fax numbers:
BC Claims....................................... 570.200.6790
(For claims adjustments, BlueCare Senior, FEP)
BC Precertification........................ 570.200.6788
• BlueCare Traditional—1.888.827.7117
BlueCard® ITS Claims.................. 570.200.6790
• BlueCare EPO/Custom PPO—1.888.345.2353
FPH Claims..................................... 570.200.6790
(For Maternity Precertification forms, adjustments, Claims Research Request forms, etc.)
Valuable health resources:
Refer your BCNEPA patients to the following Blue
Health Solutions health and wellness resources:
Provider Relations........................ 570.200.6880
SM
All FPH and FPLIC paper claim submissions must be on the 02/12 version of the NUCC 1500 claim form as of
April 1, 2014, to comply with the CMS mandate. Providers will receive notification from BCNEPA when the
decision is made to no longer accept claims submitted on the 08/05 form. We strongly recommend providers
migrate to the new version of the form as soon as possible to ensure your paper claim submissions will
continue to be accepted for processing.
(Policy Update 1611009)
• Personalized health management and
wellness programs, care management
resources and much more—1.866.262.4764
• 24/7 Nurse Now—Call 1.866.442.2583 anytime
or chat online at bcnepa.com. Logon to
Self-Service; click on the Health & Wellness
tab and then select 24/7 Nurse Now
Report fraud:
Call our Fraud Hotline at 1.800.352.9100, or email our
Special Investigations Unit at siu@bcnepa.com.
Provider Customer Service......... 570.200.6868
FPH Complaint/Grievance.......... 570.200.6770
FPH Non-par Referral Requests.... 570.200.6840
FPH Pharmacy................................ 570.200.6870
FPH Precertification...................... 570.200.6799
Other Party Liability (OPL)......... 570.200.6790
BCNEPA Provider
Relations Consultants
licenses expiring this year:
Practitioner
Cheryl Hashagen • 570.200.4670
Cheryl.Hashagen@bcnepa.com
Doctors of
Optometry
11/30/14
Doctors of
Medicine
12/31/14
Jill Jenkins • 570.200.4669
Jill.Jenkins@bcnepa.com
Louise LoPresto • 570.200.4674
Louise.LoPresto@bcnepa.com
Tracie Wyandt • 570.200.4647
Tracie.Wyandt@bcnepa.com
Senior Manager,
Provider Relations
Dave Levenoskie • 570.200.4673
Dave.Levenoskie@bcnepa.com
Senior Manager,
Provider Services
Kevin Quaglia • 570.200.4676
Kevin.Quaglia@bcnepa.com
Questions?
Call Provider Relations at
1.800.451.4447
Doctors of
Podiatric
Medicine
Physical Therapists
Immunizations for
Adolescents (IMA)
Colorectal Cancer
Screening (COL)
Measure Description:
Measure Description:
The percentage of adolescents,
The percentage of members, 50 to 75
13 years of age, who had one dose
years of age, who had the appropriate
of meningococcal vaccine and one
screening for colorectal cancer.
tetanus, diphtheria toxoids
and acellular pertussis
Visit the HEDIS Homepage at bcnepa.com for
(Tdap) or one tetanus,
these and other measures with documentation
diphtheria toxoids vaccine
tips, best practices and information about the
(Td) by their 13th birthday.
importance of these measures to your practice.
The measure calculates a
Click on the Providers tab and select Quality
rate for each vaccine and
Management. Then click on the link to the
HEDIS Homepage.
one combination rate.
Expiration
Date
Odette Ashby • 570.200.4658
Odette.Ashby@bcnepa.com
© Blue Cross of Northeastern Pennsylvania. 2014.
5
The following HEDIS measures will be added to the HEDIS Homepage in November:
Reminder:
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®.
• BlueCare PPO/myBlue® Plans—1.866.262.5635
Reminder:
New HEDIS Measures
Available Online
Editor:
Lily A. Stahley
How You Can Reach Us
relevant information is available to guide
treatment decisions
19 North Main Street
Wilkes-Barre, PA 18711-0302
Self-Service Login / Register | bluecrossnepastore.com
Members
Employers
Providers
Brokers
Health Insurance Plans
Find a Doctor/Hospital
Rx Drug Benefits
Health & Wellness
Health Care Reform
HEDIS Homepage
12/31/14
12/31/14
(Policy Update 1611001)
HEDIS (Healthcare Effectiveness Data and Information Set) is one of the most widely used set of health care performance measures
in the United States. While the measures are used to quantify quality performance among Health Care Organizations (HMOs, PPO's),
the scope of HEDIS includes measures for physicians. BCNEPA is dedicated to the use of Best Practice Clinical Guidelines in
providing its membership quality health care. The information provided on this website will include the Measure Description, Why the
Measure is Important, and Best Practice for meeting the HEDIS measure.
Quality Management
2014
Related Resources
Cervical Cancer Screening (CCS)
Chlamydia Screening in Women (CHL)
Human Papillomavirus Vaccine for Female Adolescents (HPV)
Medication Management for People with Asthma
Pharmacotherapy Management of COPD Exacerbation
Appropriate Testing for Children with Pharyngitis
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Adolescent Well Care Visits
Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
Childhood Immunization Status (CIS)
Well Child Visits for the First 15 Months of Life (W15)
Adult BMI Assessment (ABA)
Antidepressant Medication Management (AMM)
Controlling High Blood Pressure (CBP)
Diabetes - A1c Testing & Control
Diabetes - Diabetic Retinopathy
Diabetes - LDL Screening
Diabetes - Nephropathy
Follow-up After Hospitalization for Mental Illness (FUH)
Persistence of Beta-Blocker Treatment after a Heart Attack (PBH)
Prenatal Care and Post Partum Care
Use of Imaging Studies for Low Back Pain
Use of Spirometry Testing in the Assessment of COPD (SPR)
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
Table of Contents
2 Utilization Management
Updates
Chart Forms
Flow Chart
Practice Guidelines
HEDIS Homepage
Providers
Resources & Tools
Quality Management
Medicare Advantage
Navinet Self-Service
Prefix Finder
(Policy Update 1611002)
Provider Transparency
Autism Mandate Updates
EDI Registration Form
Electronic Remittance Advice Request
Form (835)
Pharmacy Benefits
4 Clinical Quality Measures:
Tests & Screenings
for Diabetic Members
Health & Wellness
3 Change in Medicare
Advantage Freedom Blue PPO 5 Antidepressant
Structure, New NAIC Number Medication Management
Reminder:
NIA to Review All
Radiology Requests
Utilization Management Updates
New Prior Approval Requirements
We will be transitioning certain services that historically required retrospective review to
requiring prior approval (prior authorization/precertification). Once transitioned, you will
know if these services will be considered medically necessary before they are rendered.
This helps to ensure that our members receive high quality and appropriate care.
Beginning December 1, 2014, the following services will require prior approval:
Services
Transcatheter Embolization
Codes
37241, 37242, 37243, 37244,
Q0083, S2095
Beginning January 1, 2015, the following services will require prior approval:
Services
Transcranial Magnetic Stimulation (TMS)
Home Sleep Test (HST)
Fixed Wing Air Ambulance
Codes
90867, 90868, 90869
G0398, G0399, G0400, 95800,
95801, 95806
A0430, A0435
Beginning February 1, 2015, the following services will require prior approval:
Services
Codes
Myoelectric Prosthesis for Upper Limb,
Microprocessor-Controlled Prostheses
for the Lower Limb
L5828, L5845, L5856, L5857, L5858,
L5859, L5920, L5930, L5969, L6025,
L6715, L6882, L6925, L6935, L6945,
L6955, L6965, L6975, L7007, L7008,
L7009, L7045
Genetic Testing for Long QT Syndrome
81280, 81281, 81282
Pneumatic Compression Devices
E0650, E0651, E0652, E0655, E0656,
E0657, E0660, E0665, E0666, E0667,
E0668, E0669, E0670, E0671, E0672,
E0673, E0675, E0676
Prior approval requirements apply to all First Priority Health® (FPH) and First Priority
Life Insurance Company® (FPLIC) products. Please continue to check future issues of
Provider Bulletin for more services which will require prior approval.
Additional Codes Requiring Prior Approval
As noted in previous editions of Provider Bulletin, cochlear implants and implants of
bone conduction and bone-anchored hearing prostheses now require prior approval.
Beginning November 1, 2014, for these services, the following codes will also
require prior approval:
Services
Codes
Cochlear implant, external speech processor, component, replacement
L8627
Cochlear implant, external controller component, replacement
L8628
Transmitting coil and cable, integrated, for use with cochlear implant
device, replacement
L8629
2
Effective October 1, 2014,
National Imaging Associates (NIA)
began reviewing all radiology
requests for prior approval. This
applies to radiology prior approval
requests for all members with
plans that have a Radiology Benefit
Management Program, including all
fully insured members, all members
with individual plans and members
of some self-funded groups.
If a member is part of a self-funded
group without a Radiology Benefit
Management Program, their
radiologic service will not require
prior approval, unless the request
is for a non-participating provider. In
these cases, the service will require a
non-participating referral only if one
does not already exist.
If you have any questions about
the Radiology Benefit Management
Program, please contact your
Provider Relations consultant.
Change in Medicare Advantage Freedom Blue PPO Structure
New NAIC Number
Impacts Medicare Advantage Freedom Blue
PPO Plan Only
When to Bill with the Existing NAIC Code
(54771) for Medicare Advantage Claims
A change is coming to the organizational structure
of Highmark’s subsidiary companies that administer
Medicare Advantage plans. In 2015, administration of
the Freedom Blue PPO product will move from Highmark
Inc. to a new subsidiary called Highmark Senior Health
Company. These affiliates are already covered under your
Medicare Advantage contract.
NAIC code 54771 should continue to be used for Medicare
Advantage claim submissions for Freedom Blue PPO with
2014 dates of service.
This change will require action on behalf of Highmark’s
trading partners because a new NAIC number will be
required on claim submissions with dates of service
beginning January 1, 2015.
In preparation for this change,
Highmark’s Electronic Data Interchange (EDI) Operations
department has begun contacting any trading partner
who submitted Freedom Blue PPO claims within the
past 24 months with instructions regarding issuance
of a new trading partner ID associated with the new
NAIC code, 15460.
When to Bill with the New NAIC Code
(15460) for Freedom Blue PPO
Important:
The following alpha prefixes will be assigned to Highmark
Senior Health Company Freedom Blue PPO members
beginning January 1, 2015: HRF, HRT, TDM and USK.
Lung Cancer CT
Screening Benefit
Claims filed for 2015 dates of service with these alpha
prefixes must be submitted with NAIC code 15460.
As mandated by the Affordable
Care Act, beginning January 1, 2015,
annual lung cancer screenings using
low-dose computed tomography
(CT) will be covered as a preventative
service for high-risk members.
Individuals are defined as “high-risk”
if all of the following apply:
• An adult between 55 to 80 years
of age
• At least a 30-pack-year history of
cigarette smoking
• If a former smoker, had quit
smoking within the previous
15 years
Note: Members whose health
plans have a Radiology Benefit
Management Program, the CT
screening (code S8032) now requires
prior approval by National Imaging
Associates (NIA).
(Policy Update 1611003)
What Else You Need to Know
Highmark’s NaviNet claim submission transactions will be
updated to reflect the addition of the new company name
and corresponding NAIC code.
Payment will be reported separately for claims paid
through Highmark Senior Health Company, whether
issued electronically or by check, according to the normal
reimbursement schedule. Providers enrolled for EFT can
expect to receive a separate transaction for all Freedom
Blue PPO claims associated with NAIC code 15460.
Always
check the member’s ID card prior to each visit or service you
provide to record new or updated information.
Claims submitted with an incorrect NAIC code will be
rejected up front.
Information about this change is included in Issue 5 of
Provider News, which published in late October. Trading
partners with questions about this change can call
Highmark’s EDI Operations at 1.800.992.0246.
(Policy Update 1611004)
Effective
12/01/14
Reminder: FPLIC Claims
Processing/Medical Policies
Medical Policy
Updates
Blue Cross of Northeastern Pennsylvania’s (BCNEPA)
medical policies will be applied for the processing of
Serum Biomarker Panel Testing for Systemic
Lupus Erythematosus (MPO-134-0004)
FPLIC claims. However, if there is a “gap” (no BCNEPA
The following new policy language has been added:
policy in place) for a specific service, BCNEPA will then
BCNEPA will not provide coverage for serum biomarker
revert to Highmark Blue Shield’s (HMBS) medical policies
panel testing with proprietary algorithms and/or
for the processing of FPLIC claims.
index scores (e.g., Avise™ 2.0, Avise SLE 2.0, Avise SLE
To view either BCNEPA or HMBS medical policies, visit:
+ Connective Tissue 2.0™, Avise SLE Prognostic) for the
• BCNEPA medical policies—
bcnepa.com
diagnosis of systemic lupus erythematosus, as this is
considered investigational.
Clinical Quality Measures:
Tests and Screenings for Diabetic Members
As noted in previous editions of Provider Bulletin, we understand the importance of providing high-quality
and cost-effective care for our members. Through our Quality Incentive Program (QIP), we recognize the
achievement of quality goals by rewarding eligible FPH and FPLIC network providers for delivering
high-quality care to our members.
Four of the clinical quality metrics in our PCP QIP are
related to tests and screenings for diabetic members.
Since November is National Diabetes Month, we’d like to
focus on why this measure is so important to the health of
your patients.
Clinical Quality Measures
(From 2014 QIP Primary Care Physician
Quality Incentive Program):
Diabetes HbA1c Test—The percentage of
attributed members, 18 through 75 years of age,
with diabetes (type 1 and type 2) who had an
HbA1C test during the measurement year.
Almost 26 million Americans have diabetes, and these rates
are increasing. Causing nearly 70,000 deaths a year, it is the
7th leading cause of death in the U.S.
Diabetes LDL-C Screening—The percentage
of attributed members, 18 through 75 years
of age, with diabetes (type 1 and type 2)
who had an LDL-C screening during the
measurement year.
Diabetes is a chronic illness that requires ongoing medical
care and patient education to prevent the risk of serious
short- and long-term complications. With support from
their doctors, people with diabetes can reduce their risk
of such complications by controlling their levels of blood
glucose, their blood pressure and their blood lipids and by
receiving appropriate preventive screenings.
Diabetes Eye Exam—The percentage of
attributed members, 18 through 75 years of
age, with diabetes (type 1 and type 2) who had
an eye exam (retinal) performed during the
measurement year.
According to the Centers for Disease Control (CDC), studies
have shown the various benefits of properly managing
diabetes, including the following:
Diabetes Microalbumin Test—The percentage
of attributed members, 18 through 75 years of
age, with diabetes (type 1 and type 2) who had
medical attention for nephropathy during the
measurement year.
• In general, every percentage point drop in A1c blood
test results can reduce the risk of microvascular
complications (eye, kidney and nerve diseases) by 40%
• Improved control of LDL cholesterol can reduce
cardiovascular complications by 20% to 50%
• Detecting and treating diabetic eye disease with
appropriate therapies can reduce the development of
severe vision loss by an estimated 50% to 60%
• Detecting and treating early diabetic kidney disease
through appropriate treatment can reduce the decline
in kidney function by 30% to 70%
By making sure your diabetic patients are receiving these
important tests, you are ensuring they are receiving the care
they need. Additionally, by complying with these important
measures, you will be taking steps to meet your QIP metrics
and improve your overall HEDIS measures.
If you have any questions about quality measures or
the QIP, please contact your Provider Relations consultant.
Sources: National Quality Measures Clearinghouse (NQMC), the Centers for Disease Control and Prevention (CDC) and the American Diabetes Association
• HMBS medical policies—
highmarkblueshield.com
(Policy Update 1611005)
quality corner
(Policy Update 1611006)
3
(Policy Update 1611007)
4
Reminder:
NIA to Review All
Radiology Requests
Utilization Management Updates
New Prior Approval Requirements
We will be transitioning certain services that historically required retrospective review to
requiring prior approval (prior authorization/precertification). Once transitioned, you will
know if these services will be considered medically necessary before they are rendered.
This helps to ensure that our members receive high quality and appropriate care.
Beginning December 1, 2014, the following services will require prior approval:
Services
Transcatheter Embolization
Codes
37241, 37242, 37243, 37244,
Q0083, S2095
Beginning January 1, 2015, the following services will require prior approval:
Services
Transcranial Magnetic Stimulation (TMS)
Home Sleep Test (HST)
Fixed Wing Air Ambulance
Codes
90867, 90868, 90869
G0398, G0399, G0400, 95800,
95801, 95806
A0430, A0435
Beginning February 1, 2015, the following services will require prior approval:
Services
Codes
Myoelectric Prosthesis for Upper Limb,
Microprocessor-Controlled Prostheses
for the Lower Limb
L5828, L5845, L5856, L5857, L5858,
L5859, L5920, L5930, L5969, L6025,
L6715, L6882, L6925, L6935, L6945,
L6955, L6965, L6975, L7007, L7008,
L7009, L7045
Genetic Testing for Long QT Syndrome
81280, 81281, 81282
Pneumatic Compression Devices
E0650, E0651, E0652, E0655, E0656,
E0657, E0660, E0665, E0666, E0667,
E0668, E0669, E0670, E0671, E0672,
E0673, E0675, E0676
Prior approval requirements apply to all First Priority Health® (FPH) and First Priority
Life Insurance Company® (FPLIC) products. Please continue to check future issues of
Provider Bulletin for more services which will require prior approval.
Additional Codes Requiring Prior Approval
As noted in previous editions of Provider Bulletin, cochlear implants and implants of
bone conduction and bone-anchored hearing prostheses now require prior approval.
Beginning November 1, 2014, for these services, the following codes will also
require prior approval:
Services
Codes
Cochlear implant, external speech processor, component, replacement
L8627
Cochlear implant, external controller component, replacement
L8628
Transmitting coil and cable, integrated, for use with cochlear implant
device, replacement
L8629
2
Effective October 1, 2014,
National Imaging Associates (NIA)
began reviewing all radiology
requests for prior approval. This
applies to radiology prior approval
requests for all members with
plans that have a Radiology Benefit
Management Program, including all
fully insured members, all members
with individual plans and members
of some self-funded groups.
If a member is part of a self-funded
group without a Radiology Benefit
Management Program, their
radiologic service will not require
prior approval, unless the request
is for a non-participating provider. In
these cases, the service will require a
non-participating referral only if one
does not already exist.
If you have any questions about
the Radiology Benefit Management
Program, please contact your
Provider Relations consultant.
Change in Medicare Advantage Freedom Blue PPO Structure
New NAIC Number
Impacts Medicare Advantage Freedom Blue
PPO Plan Only
When to Bill with the Existing NAIC Code
(54771) for Medicare Advantage Claims
A change is coming to the organizational structure
of Highmark’s subsidiary companies that administer
Medicare Advantage plans. In 2015, administration of
the Freedom Blue PPO product will move from Highmark
Inc. to a new subsidiary called Highmark Senior Health
Company. These affiliates are already covered under your
Medicare Advantage contract.
NAIC code 54771 should continue to be used for Medicare
Advantage claim submissions for Freedom Blue PPO with
2014 dates of service.
This change will require action on behalf of Highmark’s
trading partners because a new NAIC number will be
required on claim submissions with dates of service
beginning January 1, 2015.
In preparation for this change,
Highmark’s Electronic Data Interchange (EDI) Operations
department has begun contacting any trading partner
who submitted Freedom Blue PPO claims within the
past 24 months with instructions regarding issuance
of a new trading partner ID associated with the new
NAIC code, 15460.
When to Bill with the New NAIC Code
(15460) for Freedom Blue PPO
Important:
The following alpha prefixes will be assigned to Highmark
Senior Health Company Freedom Blue PPO members
beginning January 1, 2015: HRF, HRT, TDM and USK.
Lung Cancer CT
Screening Benefit
Claims filed for 2015 dates of service with these alpha
prefixes must be submitted with NAIC code 15460.
As mandated by the Affordable
Care Act, beginning January 1, 2015,
annual lung cancer screenings using
low-dose computed tomography
(CT) will be covered as a preventative
service for high-risk members.
Individuals are defined as “high-risk”
if all of the following apply:
• An adult between 55 to 80 years
of age
• At least a 30-pack-year history of
cigarette smoking
• If a former smoker, had quit
smoking within the previous
15 years
Note: Members whose health
plans have a Radiology Benefit
Management Program, the CT
screening (code S8032) now requires
prior approval by National Imaging
Associates (NIA).
(Policy Update 1611003)
What Else You Need to Know
Highmark’s NaviNet claim submission transactions will be
updated to reflect the addition of the new company name
and corresponding NAIC code.
Payment will be reported separately for claims paid
through Highmark Senior Health Company, whether
issued electronically or by check, according to the normal
reimbursement schedule. Providers enrolled for EFT can
expect to receive a separate transaction for all Freedom
Blue PPO claims associated with NAIC code 15460.
Always
check the member’s ID card prior to each visit or service you
provide to record new or updated information.
Claims submitted with an incorrect NAIC code will be
rejected up front.
Information about this change is included in Issue 5 of
Provider News, which published in late October. Trading
partners with questions about this change can call
Highmark’s EDI Operations at 1.800.992.0246.
(Policy Update 1611004)
Effective
12/01/14
Reminder: FPLIC Claims
Processing/Medical Policies
Medical Policy
Updates
Blue Cross of Northeastern Pennsylvania’s (BCNEPA)
medical policies will be applied for the processing of
Serum Biomarker Panel Testing for Systemic
Lupus Erythematosus (MPO-134-0004)
FPLIC claims. However, if there is a “gap” (no BCNEPA
The following new policy language has been added:
policy in place) for a specific service, BCNEPA will then
BCNEPA will not provide coverage for serum biomarker
revert to Highmark Blue Shield’s (HMBS) medical policies
panel testing with proprietary algorithms and/or
for the processing of FPLIC claims.
index scores (e.g., Avise™ 2.0, Avise SLE 2.0, Avise SLE
To view either BCNEPA or HMBS medical policies, visit:
+ Connective Tissue 2.0™, Avise SLE Prognostic) for the
• BCNEPA medical policies—
bcnepa.com
diagnosis of systemic lupus erythematosus, as this is
considered investigational.
Clinical Quality Measures:
Tests and Screenings for Diabetic Members
As noted in previous editions of Provider Bulletin, we understand the importance of providing high-quality
and cost-effective care for our members. Through our Quality Incentive Program (QIP), we recognize the
achievement of quality goals by rewarding eligible FPH and FPLIC network providers for delivering
high-quality care to our members.
Four of the clinical quality metrics in our PCP QIP are
related to tests and screenings for diabetic members.
Since November is National Diabetes Month, we’d like to
focus on why this measure is so important to the health of
your patients.
Clinical Quality Measures
(From 2014 QIP Primary Care Physician
Quality Incentive Program):
Diabetes HbA1c Test—The percentage of
attributed members, 18 through 75 years of age,
with diabetes (type 1 and type 2) who had an
HbA1C test during the measurement year.
Almost 26 million Americans have diabetes, and these rates
are increasing. Causing nearly 70,000 deaths a year, it is the
7th leading cause of death in the U.S.
Diabetes LDL-C Screening—The percentage
of attributed members, 18 through 75 years
of age, with diabetes (type 1 and type 2)
who had an LDL-C screening during the
measurement year.
Diabetes is a chronic illness that requires ongoing medical
care and patient education to prevent the risk of serious
short- and long-term complications. With support from
their doctors, people with diabetes can reduce their risk
of such complications by controlling their levels of blood
glucose, their blood pressure and their blood lipids and by
receiving appropriate preventive screenings.
Diabetes Eye Exam—The percentage of
attributed members, 18 through 75 years of
age, with diabetes (type 1 and type 2) who had
an eye exam (retinal) performed during the
measurement year.
According to the Centers for Disease Control (CDC), studies
have shown the various benefits of properly managing
diabetes, including the following:
Diabetes Microalbumin Test—The percentage
of attributed members, 18 through 75 years of
age, with diabetes (type 1 and type 2) who had
medical attention for nephropathy during the
measurement year.
• In general, every percentage point drop in A1c blood
test results can reduce the risk of microvascular
complications (eye, kidney and nerve diseases) by 40%
• Improved control of LDL cholesterol can reduce
cardiovascular complications by 20% to 50%
• Detecting and treating diabetic eye disease with
appropriate therapies can reduce the development of
severe vision loss by an estimated 50% to 60%
• Detecting and treating early diabetic kidney disease
through appropriate treatment can reduce the decline
in kidney function by 30% to 70%
By making sure your diabetic patients are receiving these
important tests, you are ensuring they are receiving the care
they need. Additionally, by complying with these important
measures, you will be taking steps to meet your QIP metrics
and improve your overall HEDIS measures.
If you have any questions about quality measures or
the QIP, please contact your Provider Relations consultant.
Sources: National Quality Measures Clearinghouse (NQMC), the Centers for Disease Control and Prevention (CDC) and the American Diabetes Association
• HMBS medical policies—
highmarkblueshield.com
(Policy Update 1611005)
quality corner
(Policy Update 1611006)
3
(Policy Update 1611007)
4
Reminder:
NIA to Review All
Radiology Requests
Utilization Management Updates
New Prior Approval Requirements
We will be transitioning certain services that historically required retrospective review to
requiring prior approval (prior authorization/precertification). Once transitioned, you will
know if these services will be considered medically necessary before they are rendered.
This helps to ensure that our members receive high quality and appropriate care.
Beginning December 1, 2014, the following services will require prior approval:
Services
Transcatheter Embolization
Codes
37241, 37242, 37243, 37244,
Q0083, S2095
Beginning January 1, 2015, the following services will require prior approval:
Services
Transcranial Magnetic Stimulation (TMS)
Home Sleep Test (HST)
Fixed Wing Air Ambulance
Codes
90867, 90868, 90869
G0398, G0399, G0400, 95800,
95801, 95806
A0430, A0435
Beginning February 1, 2015, the following services will require prior approval:
Services
Codes
Myoelectric Prosthesis for Upper Limb,
Microprocessor-Controlled Prostheses
for the Lower Limb
L5828, L5845, L5856, L5857, L5858,
L5859, L5920, L5930, L5969, L6025,
L6715, L6882, L6925, L6935, L6945,
L6955, L6965, L6975, L7007, L7008,
L7009, L7045
Genetic Testing for Long QT Syndrome
81280, 81281, 81282
Pneumatic Compression Devices
E0650, E0651, E0652, E0655, E0656,
E0657, E0660, E0665, E0666, E0667,
E0668, E0669, E0670, E0671, E0672,
E0673, E0675, E0676
Prior approval requirements apply to all First Priority Health® (FPH) and First Priority
Life Insurance Company® (FPLIC) products. Please continue to check future issues of
Provider Bulletin for more services which will require prior approval.
Additional Codes Requiring Prior Approval
As noted in previous editions of Provider Bulletin, cochlear implants and implants of
bone conduction and bone-anchored hearing prostheses now require prior approval.
Beginning November 1, 2014, for these services, the following codes will also
require prior approval:
Services
Codes
Cochlear implant, external speech processor, component, replacement
L8627
Cochlear implant, external controller component, replacement
L8628
Transmitting coil and cable, integrated, for use with cochlear implant
device, replacement
L8629
2
Effective October 1, 2014,
National Imaging Associates (NIA)
began reviewing all radiology
requests for prior approval. This
applies to radiology prior approval
requests for all members with
plans that have a Radiology Benefit
Management Program, including all
fully insured members, all members
with individual plans and members
of some self-funded groups.
If a member is part of a self-funded
group without a Radiology Benefit
Management Program, their
radiologic service will not require
prior approval, unless the request
is for a non-participating provider. In
these cases, the service will require a
non-participating referral only if one
does not already exist.
If you have any questions about
the Radiology Benefit Management
Program, please contact your
Provider Relations consultant.
Change in Medicare Advantage Freedom Blue PPO Structure
New NAIC Number
Impacts Medicare Advantage Freedom Blue
PPO Plan Only
When to Bill with the Existing NAIC Code
(54771) for Medicare Advantage Claims
A change is coming to the organizational structure
of Highmark’s subsidiary companies that administer
Medicare Advantage plans. In 2015, administration of
the Freedom Blue PPO product will move from Highmark
Inc. to a new subsidiary called Highmark Senior Health
Company. These affiliates are already covered under your
Medicare Advantage contract.
NAIC code 54771 should continue to be used for Medicare
Advantage claim submissions for Freedom Blue PPO with
2014 dates of service.
This change will require action on behalf of Highmark’s
trading partners because a new NAIC number will be
required on claim submissions with dates of service
beginning January 1, 2015.
In preparation for this change,
Highmark’s Electronic Data Interchange (EDI) Operations
department has begun contacting any trading partner
who submitted Freedom Blue PPO claims within the
past 24 months with instructions regarding issuance
of a new trading partner ID associated with the new
NAIC code, 15460.
When to Bill with the New NAIC Code
(15460) for Freedom Blue PPO
Important:
The following alpha prefixes will be assigned to Highmark
Senior Health Company Freedom Blue PPO members
beginning January 1, 2015: HRF, HRT, TDM and USK.
Lung Cancer CT
Screening Benefit
Claims filed for 2015 dates of service with these alpha
prefixes must be submitted with NAIC code 15460.
As mandated by the Affordable
Care Act, beginning January 1, 2015,
annual lung cancer screenings using
low-dose computed tomography
(CT) will be covered as a preventative
service for high-risk members.
Individuals are defined as “high-risk”
if all of the following apply:
• An adult between 55 to 80 years
of age
• At least a 30-pack-year history of
cigarette smoking
• If a former smoker, had quit
smoking within the previous
15 years
Note: Members whose health
plans have a Radiology Benefit
Management Program, the CT
screening (code S8032) now requires
prior approval by National Imaging
Associates (NIA).
(Policy Update 1611003)
What Else You Need to Know
Highmark’s NaviNet claim submission transactions will be
updated to reflect the addition of the new company name
and corresponding NAIC code.
Payment will be reported separately for claims paid
through Highmark Senior Health Company, whether
issued electronically or by check, according to the normal
reimbursement schedule. Providers enrolled for EFT can
expect to receive a separate transaction for all Freedom
Blue PPO claims associated with NAIC code 15460.
Always
check the member’s ID card prior to each visit or service you
provide to record new or updated information.
Claims submitted with an incorrect NAIC code will be
rejected up front.
Information about this change is included in Issue 5 of
Provider News, which published in late October. Trading
partners with questions about this change can call
Highmark’s EDI Operations at 1.800.992.0246.
(Policy Update 1611004)
Effective
12/01/14
Reminder: FPLIC Claims
Processing/Medical Policies
Medical Policy
Updates
Blue Cross of Northeastern Pennsylvania’s (BCNEPA)
medical policies will be applied for the processing of
Serum Biomarker Panel Testing for Systemic
Lupus Erythematosus (MPO-134-0004)
FPLIC claims. However, if there is a “gap” (no BCNEPA
The following new policy language has been added:
policy in place) for a specific service, BCNEPA will then
BCNEPA will not provide coverage for serum biomarker
revert to Highmark Blue Shield’s (HMBS) medical policies
panel testing with proprietary algorithms and/or
for the processing of FPLIC claims.
index scores (e.g., Avise™ 2.0, Avise SLE 2.0, Avise SLE
To view either BCNEPA or HMBS medical policies, visit:
+ Connective Tissue 2.0™, Avise SLE Prognostic) for the
• BCNEPA medical policies—
bcnepa.com
diagnosis of systemic lupus erythematosus, as this is
considered investigational.
Clinical Quality Measures:
Tests and Screenings for Diabetic Members
As noted in previous editions of Provider Bulletin, we understand the importance of providing high-quality
and cost-effective care for our members. Through our Quality Incentive Program (QIP), we recognize the
achievement of quality goals by rewarding eligible FPH and FPLIC network providers for delivering
high-quality care to our members.
Four of the clinical quality metrics in our PCP QIP are
related to tests and screenings for diabetic members.
Since November is National Diabetes Month, we’d like to
focus on why this measure is so important to the health of
your patients.
Clinical Quality Measures
(From 2014 QIP Primary Care Physician
Quality Incentive Program):
Diabetes HbA1c Test—The percentage of
attributed members, 18 through 75 years of age,
with diabetes (type 1 and type 2) who had an
HbA1C test during the measurement year.
Almost 26 million Americans have diabetes, and these rates
are increasing. Causing nearly 70,000 deaths a year, it is the
7th leading cause of death in the U.S.
Diabetes LDL-C Screening—The percentage
of attributed members, 18 through 75 years
of age, with diabetes (type 1 and type 2)
who had an LDL-C screening during the
measurement year.
Diabetes is a chronic illness that requires ongoing medical
care and patient education to prevent the risk of serious
short- and long-term complications. With support from
their doctors, people with diabetes can reduce their risk
of such complications by controlling their levels of blood
glucose, their blood pressure and their blood lipids and by
receiving appropriate preventive screenings.
Diabetes Eye Exam—The percentage of
attributed members, 18 through 75 years of
age, with diabetes (type 1 and type 2) who had
an eye exam (retinal) performed during the
measurement year.
According to the Centers for Disease Control (CDC), studies
have shown the various benefits of properly managing
diabetes, including the following:
Diabetes Microalbumin Test—The percentage
of attributed members, 18 through 75 years of
age, with diabetes (type 1 and type 2) who had
medical attention for nephropathy during the
measurement year.
• In general, every percentage point drop in A1c blood
test results can reduce the risk of microvascular
complications (eye, kidney and nerve diseases) by 40%
• Improved control of LDL cholesterol can reduce
cardiovascular complications by 20% to 50%
• Detecting and treating diabetic eye disease with
appropriate therapies can reduce the development of
severe vision loss by an estimated 50% to 60%
• Detecting and treating early diabetic kidney disease
through appropriate treatment can reduce the decline
in kidney function by 30% to 70%
By making sure your diabetic patients are receiving these
important tests, you are ensuring they are receiving the care
they need. Additionally, by complying with these important
measures, you will be taking steps to meet your QIP metrics
and improve your overall HEDIS measures.
If you have any questions about quality measures or
the QIP, please contact your Provider Relations consultant.
Sources: National Quality Measures Clearinghouse (NQMC), the Centers for Disease Control and Prevention (CDC) and the American Diabetes Association
• HMBS medical policies—
highmarkblueshield.com
(Policy Update 1611005)
quality corner
(Policy Update 1611006)
3
(Policy Update 1611007)
4
presorted
standard
u.s. postage
Antidepressant Medication Management
paid
wilkes-barre, pa
permit no. 84
According to recent studies, approximately 11% of Americans, aged 12 or older, take antidepressants.
The National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC),
also says that the rate of antidepressant use in the U.S. has increased nearly 400% since 1988. It is very
likely that in your practice you care for patients who are appropriately prescribed antidepressants, either
by their primary care physician or a behavioral health specialist.
The current best practice recommendations for
Non-adherence to antidepressant medication can
managing antidepressant medication include:
be a significant barrier to the successful treatment of
• Monitoring patients carefully to assess their response
to treatment, the emergence of side effects, their
clinical condition, safety and adherence to treatment
• Encouraging patients who have achieved some
improvement during the initial weeks of treatment
to continue for a total of at least 12 weeks (Effective
Acute Phase Treatment HEDIS Measure)
• For continued improvement and control of
depression, it is recommended that the patient
be compliant for at least 6 months (Effective
Continuation Phase Treatment HEDIS Measure)
depression. The Health Effectiveness Data Information
Set (HEDIS) measures seen above have been developed
by the National Committee for Quality Assurance
(NCQA), and are designed to reduce the risk of relapse.
For more information about this and other HEDIS
measures, visit our website at bcnepa.com, and click on
the Providers tab. Select Quality Management, and then
click on the link to the HEDIS Homepage.
For extra support, you can always refer your BCNEPA
patient to one of our Depression Management health
coaches at 1.866.262.4764 or (TTY) 1.877.720.7771,
weekdays, between 8 a.m. and 8 p.m. ET. You will need
• Sufficient ongoing contact of all clinicians involved
to provide your patient’s name, phone number and date
in the patient’s care with both the patient and each
of birth. A Disease Management nurse will then contact
other. This ensures care is coordinated and that
your patient.
bcnepa.com
Address Service Requested
Volume 16 • Issue 11 • November 2014
(Policy Update 1611008)
NUCC 1500 Claim Form
New Version 02/12 Timeline
Renew Your License!
Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan
issuer in the Federally Facilitated Marketplace.
Please remember to renew your
Independent Licensee of the Blue Cross and Blue Shield Association.
®Registered Mark of the Blue Cross and Blue Shield Association.
license with the State Board before
it expires. You may not practice in
Pennsylvania with an expired license.
Provider Relations department:
1.800.451.4447
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
The following practitioners have
Important fax numbers:
BC Claims....................................... 570.200.6790
(For claims adjustments, BlueCare Senior, FEP)
BC Precertification........................ 570.200.6788
• BlueCare Traditional—1.888.827.7117
BlueCard® ITS Claims.................. 570.200.6790
• BlueCare EPO/Custom PPO—1.888.345.2353
FPH Claims..................................... 570.200.6790
(For Maternity Precertification forms, adjustments, Claims Research Request forms, etc.)
Valuable health resources:
Refer your BCNEPA patients to the following Blue
Health Solutions health and wellness resources:
Provider Relations........................ 570.200.6880
SM
All FPH and FPLIC paper claim submissions must be on the 02/12 version of the NUCC 1500 claim form as of
April 1, 2014, to comply with the CMS mandate. Providers will receive notification from BCNEPA when the
decision is made to no longer accept claims submitted on the 08/05 form. We strongly recommend providers
migrate to the new version of the form as soon as possible to ensure your paper claim submissions will
continue to be accepted for processing.
(Policy Update 1611009)
• Personalized health management and
wellness programs, care management
resources and much more—1.866.262.4764
• 24/7 Nurse Now—Call 1.866.442.2583 anytime
or chat online at bcnepa.com. Logon to
Self-Service; click on the Health & Wellness
tab and then select 24/7 Nurse Now
Report fraud:
Call our Fraud Hotline at 1.800.352.9100, or email our
Special Investigations Unit at siu@bcnepa.com.
Provider Customer Service......... 570.200.6868
FPH Complaint/Grievance.......... 570.200.6770
FPH Non-par Referral Requests.... 570.200.6840
FPH Pharmacy................................ 570.200.6870
FPH Precertification...................... 570.200.6799
Other Party Liability (OPL)......... 570.200.6790
BCNEPA Provider
Relations Consultants
licenses expiring this year:
Practitioner
Cheryl Hashagen • 570.200.4670
Cheryl.Hashagen@bcnepa.com
Doctors of
Optometry
11/30/14
Doctors of
Medicine
12/31/14
Jill Jenkins • 570.200.4669
Jill.Jenkins@bcnepa.com
Louise LoPresto • 570.200.4674
Louise.LoPresto@bcnepa.com
Tracie Wyandt • 570.200.4647
Tracie.Wyandt@bcnepa.com
Senior Manager,
Provider Relations
Dave Levenoskie • 570.200.4673
Dave.Levenoskie@bcnepa.com
Senior Manager,
Provider Services
Kevin Quaglia • 570.200.4676
Kevin.Quaglia@bcnepa.com
Questions?
Call Provider Relations at
1.800.451.4447
Doctors of
Podiatric
Medicine
Physical Therapists
Immunizations for
Adolescents (IMA)
Colorectal Cancer
Screening (COL)
Measure Description:
Measure Description:
The percentage of adolescents,
The percentage of members, 50 to 75
13 years of age, who had one dose
years of age, who had the appropriate
of meningococcal vaccine and one
screening for colorectal cancer.
tetanus, diphtheria toxoids
and acellular pertussis
Visit the HEDIS Homepage at bcnepa.com for
(Tdap) or one tetanus,
these and other measures with documentation
diphtheria toxoids vaccine
tips, best practices and information about the
(Td) by their 13th birthday.
importance of these measures to your practice.
The measure calculates a
Click on the Providers tab and select Quality
rate for each vaccine and
Management. Then click on the link to the
HEDIS Homepage.
one combination rate.
Expiration
Date
Odette Ashby • 570.200.4658
Odette.Ashby@bcnepa.com
© Blue Cross of Northeastern Pennsylvania. 2014.
5
The following HEDIS measures will be added to the HEDIS Homepage in November:
Reminder:
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®.
• BlueCare PPO/myBlue® Plans—1.866.262.5635
Reminder:
New HEDIS Measures
Available Online
Editor:
Lily A. Stahley
How You Can Reach Us
relevant information is available to guide
treatment decisions
19 North Main Street
Wilkes-Barre, PA 18711-0302
Self-Service Login / Register | bluecrossnepastore.com
Members
Employers
Providers
Brokers
Health Insurance Plans
Find a Doctor/Hospital
Rx Drug Benefits
Health & Wellness
Health Care Reform
HEDIS Homepage
12/31/14
12/31/14
(Policy Update 1611001)
HEDIS (Healthcare Effectiveness Data and Information Set) is one of the most widely used set of health care performance measures
in the United States. While the measures are used to quantify quality performance among Health Care Organizations (HMOs, PPO's),
the scope of HEDIS includes measures for physicians. BCNEPA is dedicated to the use of Best Practice Clinical Guidelines in
providing its membership quality health care. The information provided on this website will include the Measure Description, Why the
Measure is Important, and Best Practice for meeting the HEDIS measure.
Quality Management
2014
Related Resources
Cervical Cancer Screening (CCS)
Chlamydia Screening in Women (CHL)
Human Papillomavirus Vaccine for Female Adolescents (HPV)
Medication Management for People with Asthma
Pharmacotherapy Management of COPD Exacerbation
Appropriate Testing for Children with Pharyngitis
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Adolescent Well Care Visits
Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
Childhood Immunization Status (CIS)
Well Child Visits for the First 15 Months of Life (W15)
Adult BMI Assessment (ABA)
Antidepressant Medication Management (AMM)
Controlling High Blood Pressure (CBP)
Diabetes - A1c Testing & Control
Diabetes - Diabetic Retinopathy
Diabetes - LDL Screening
Diabetes - Nephropathy
Follow-up After Hospitalization for Mental Illness (FUH)
Persistence of Beta-Blocker Treatment after a Heart Attack (PBH)
Prenatal Care and Post Partum Care
Use of Imaging Studies for Low Back Pain
Use of Spirometry Testing in the Assessment of COPD (SPR)
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
Table of Contents
2 Utilization Management
Updates
Chart Forms
Flow Chart
Practice Guidelines
HEDIS Homepage
Providers
Resources & Tools
Quality Management
Medicare Advantage
Navinet Self-Service
Prefix Finder
(Policy Update 1611002)
Provider Transparency
Autism Mandate Updates
EDI Registration Form
Electronic Remittance Advice Request
Form (835)
Pharmacy Benefits
4 Clinical Quality Measures:
Tests & Screenings
for Diabetic Members
Health & Wellness
3 Change in Medicare
Advantage Freedom Blue PPO 5 Antidepressant
Structure, New NAIC Number Medication Management
presorted
standard
u.s. postage
Antidepressant Medication Management
paid
wilkes-barre, pa
permit no. 84
According to recent studies, approximately 11% of Americans, aged 12 or older, take antidepressants.
The National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC),
also says that the rate of antidepressant use in the U.S. has increased nearly 400% since 1988. It is very
likely that in your practice you care for patients who are appropriately prescribed antidepressants, either
by their primary care physician or a behavioral health specialist.
The current best practice recommendations for
Non-adherence to antidepressant medication can
managing antidepressant medication include:
be a significant barrier to the successful treatment of
• Monitoring patients carefully to assess their response
to treatment, the emergence of side effects, their
clinical condition, safety and adherence to treatment
• Encouraging patients who have achieved some
improvement during the initial weeks of treatment
to continue for a total of at least 12 weeks (Effective
Acute Phase Treatment HEDIS Measure)
• For continued improvement and control of
depression, it is recommended that the patient
be compliant for at least 6 months (Effective
Continuation Phase Treatment HEDIS Measure)
depression. The Health Effectiveness Data Information
Set (HEDIS) measures seen above have been developed
by the National Committee for Quality Assurance
(NCQA), and are designed to reduce the risk of relapse.
For more information about this and other HEDIS
measures, visit our website at bcnepa.com, and click on
the Providers tab. Select Quality Management, and then
click on the link to the HEDIS Homepage.
For extra support, you can always refer your BCNEPA
patient to one of our Depression Management health
coaches at 1.866.262.4764 or (TTY) 1.877.720.7771,
weekdays, between 8 a.m. and 8 p.m. ET. You will need
• Sufficient ongoing contact of all clinicians involved
to provide your patient’s name, phone number and date
in the patient’s care with both the patient and each
of birth. A Disease Management nurse will then contact
other. This ensures care is coordinated and that
your patient.
bcnepa.com
Address Service Requested
Volume 16 • Issue 11 • November 2014
(Policy Update 1611008)
NUCC 1500 Claim Form
New Version 02/12 Timeline
Renew Your License!
Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan
issuer in the Federally Facilitated Marketplace.
Please remember to renew your
Independent Licensee of the Blue Cross and Blue Shield Association.
®Registered Mark of the Blue Cross and Blue Shield Association.
license with the State Board before
it expires. You may not practice in
Pennsylvania with an expired license.
Provider Relations department:
1.800.451.4447
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
The following practitioners have
Important fax numbers:
BC Claims....................................... 570.200.6790
(For claims adjustments, BlueCare Senior, FEP)
BC Precertification........................ 570.200.6788
• BlueCare Traditional—1.888.827.7117
BlueCard® ITS Claims.................. 570.200.6790
• BlueCare EPO/Custom PPO—1.888.345.2353
FPH Claims..................................... 570.200.6790
(For Maternity Precertification forms, adjustments, Claims Research Request forms, etc.)
Valuable health resources:
Refer your BCNEPA patients to the following Blue
Health Solutions health and wellness resources:
Provider Relations........................ 570.200.6880
SM
All FPH and FPLIC paper claim submissions must be on the 02/12 version of the NUCC 1500 claim form as of
April 1, 2014, to comply with the CMS mandate. Providers will receive notification from BCNEPA when the
decision is made to no longer accept claims submitted on the 08/05 form. We strongly recommend providers
migrate to the new version of the form as soon as possible to ensure your paper claim submissions will
continue to be accepted for processing.
(Policy Update 1611009)
• Personalized health management and
wellness programs, care management
resources and much more—1.866.262.4764
• 24/7 Nurse Now—Call 1.866.442.2583 anytime
or chat online at bcnepa.com. Logon to
Self-Service; click on the Health & Wellness
tab and then select 24/7 Nurse Now
Report fraud:
Call our Fraud Hotline at 1.800.352.9100, or email our
Special Investigations Unit at siu@bcnepa.com.
Provider Customer Service......... 570.200.6868
FPH Complaint/Grievance.......... 570.200.6770
FPH Non-par Referral Requests.... 570.200.6840
FPH Pharmacy................................ 570.200.6870
FPH Precertification...................... 570.200.6799
Other Party Liability (OPL)......... 570.200.6790
BCNEPA Provider
Relations Consultants
licenses expiring this year:
Practitioner
Cheryl Hashagen • 570.200.4670
Cheryl.Hashagen@bcnepa.com
Doctors of
Optometry
11/30/14
Doctors of
Medicine
12/31/14
Jill Jenkins • 570.200.4669
Jill.Jenkins@bcnepa.com
Louise LoPresto • 570.200.4674
Louise.LoPresto@bcnepa.com
Tracie Wyandt • 570.200.4647
Tracie.Wyandt@bcnepa.com
Senior Manager,
Provider Relations
Dave Levenoskie • 570.200.4673
Dave.Levenoskie@bcnepa.com
Senior Manager,
Provider Services
Kevin Quaglia • 570.200.4676
Kevin.Quaglia@bcnepa.com
Questions?
Call Provider Relations at
1.800.451.4447
Doctors of
Podiatric
Medicine
Physical Therapists
Immunizations for
Adolescents (IMA)
Colorectal Cancer
Screening (COL)
Measure Description:
Measure Description:
The percentage of adolescents,
The percentage of members, 50 to 75
13 years of age, who had one dose
years of age, who had the appropriate
of meningococcal vaccine and one
screening for colorectal cancer.
tetanus, diphtheria toxoids
and acellular pertussis
Visit the HEDIS Homepage at bcnepa.com for
(Tdap) or one tetanus,
these and other measures with documentation
diphtheria toxoids vaccine
tips, best practices and information about the
(Td) by their 13th birthday.
importance of these measures to your practice.
The measure calculates a
Click on the Providers tab and select Quality
rate for each vaccine and
Management. Then click on the link to the
HEDIS Homepage.
one combination rate.
Expiration
Date
Odette Ashby • 570.200.4658
Odette.Ashby@bcnepa.com
© Blue Cross of Northeastern Pennsylvania. 2014.
5
The following HEDIS measures will be added to the HEDIS Homepage in November:
Reminder:
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®.
• BlueCare PPO/myBlue® Plans—1.866.262.5635
Reminder:
New HEDIS Measures
Available Online
Editor:
Lily A. Stahley
How You Can Reach Us
relevant information is available to guide
treatment decisions
19 North Main Street
Wilkes-Barre, PA 18711-0302
Self-Service Login / Register | bluecrossnepastore.com
Members
Employers
Providers
Brokers
Health Insurance Plans
Find a Doctor/Hospital
Rx Drug Benefits
Health & Wellness
Health Care Reform
HEDIS Homepage
12/31/14
12/31/14
(Policy Update 1611001)
HEDIS (Healthcare Effectiveness Data and Information Set) is one of the most widely used set of health care performance measures
in the United States. While the measures are used to quantify quality performance among Health Care Organizations (HMOs, PPO's),
the scope of HEDIS includes measures for physicians. BCNEPA is dedicated to the use of Best Practice Clinical Guidelines in
providing its membership quality health care. The information provided on this website will include the Measure Description, Why the
Measure is Important, and Best Practice for meeting the HEDIS measure.
Quality Management
2014
Related Resources
Cervical Cancer Screening (CCS)
Chlamydia Screening in Women (CHL)
Human Papillomavirus Vaccine for Female Adolescents (HPV)
Medication Management for People with Asthma
Pharmacotherapy Management of COPD Exacerbation
Appropriate Testing for Children with Pharyngitis
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Adolescent Well Care Visits
Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
Childhood Immunization Status (CIS)
Well Child Visits for the First 15 Months of Life (W15)
Adult BMI Assessment (ABA)
Antidepressant Medication Management (AMM)
Controlling High Blood Pressure (CBP)
Diabetes - A1c Testing & Control
Diabetes - Diabetic Retinopathy
Diabetes - LDL Screening
Diabetes - Nephropathy
Follow-up After Hospitalization for Mental Illness (FUH)
Persistence of Beta-Blocker Treatment after a Heart Attack (PBH)
Prenatal Care and Post Partum Care
Use of Imaging Studies for Low Back Pain
Use of Spirometry Testing in the Assessment of COPD (SPR)
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
Table of Contents
2 Utilization Management
Updates
Chart Forms
Flow Chart
Practice Guidelines
HEDIS Homepage
Providers
Resources & Tools
Quality Management
Medicare Advantage
Navinet Self-Service
Prefix Finder
(Policy Update 1611002)
Provider Transparency
Autism Mandate Updates
EDI Registration Form
Electronic Remittance Advice Request
Form (835)
Pharmacy Benefits
4 Clinical Quality Measures:
Tests & Screenings
for Diabetic Members
Health & Wellness
3 Change in Medicare
Advantage Freedom Blue PPO 5 Antidepressant
Structure, New NAIC Number Medication Management