January 2013www.ibx.com/providers

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

Inside this edition ANNOUNCEMENTS

► Updated QIPS Program Manual now available

● 2012 Cumulative Index now available

BLUECARD®

► Winter 2012 edition of Inside IPP now available

ICD-10 ► Putting ICD-10 into Practice: Coding exercises and scenarios

MEDICAL ► Policy notifications posted as of December 21, 2012

► New policy for athletic pubalgia effective March 5, 2013

● New report available for primary care practices

HEALTH AND WELLNESS ● Discuss routine preventive immunizations with

your patients at their wellness visits

● ConnectionsSM Health Management Program: Supporting your patients, our members

Discuss routine preventive immunizations with your patients at their wellness visits page 8

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2013 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, 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 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. The AMA assumes no liability for data contained or not contained herein.

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 19103

provider_communications@ibx.com

John Shermer Managing Editor

Charleen BaseliceProduction Coordinator

Personal Choice®, Keystone 65 HMO, and Personal Choice 65SM PPO have an accreditation status of Excellent from the National Committee for Quality Assurance (NCQA).

Keystone Health Plan East has an accreditation status of Commendable from NCQA.

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

Professional

Facility

Ancillary

To replenish office supplies such as provider manuals and directories and maternity questionnaires, please submit your request through 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 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 filling out your request, you also have the option to sign up to receive provider email notifications from IBC. These notifications provide you with the latest information, including when a new edition of Partners in Health Update is available, and news alerts.

For providers without Internet access, call 1-800-858-4728 to place your order. Note: Calls to the Provider Supply Line should be related to supply requests only. All other provider inquiries, such as member eligibility or claims status, should be directed to Customer Service at 1-800-ASK-BLUE.

Request your office supplies through the Provider Supply Line

Reminder...

January 2013 | Partners in Health UpdateSM 3 www.ibx.com/providers

Announcements

Updated QIPS Program Manual now availableWe recently made changes to the Quality Incentive Payment System (QIPS) program for measurement year 2013 for participating primary care physicians in Pennsylvania. Changes include, but are not limited to, updates to the following:

● Medical Cost Management incentive program

● Patient-Centered Medical Home incentive program

● Appeals timeline

The QIPS Program Manual – Measurement year 2013 is now available on the NaviNet® web portal and provides additional information about these changes. Printed copies of the QIPS Program Manual can be ordered by submitting an online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

For additional information regarding the QIPS program, please contact your Network Coordinator.

BluecArd®

The Winter 2012 edition of Inside IPP, an inter-plan programs publication, is now available and features the following articles:

● Precertifying additional days for inpatient hospital stays

● Ask out-of-area members to complete the COB Questionnaire with other registration forms

● Submit initial claim and late charges together for out-of-area members

● Reminder: Check member ID cards

● Use the Medical Policy Router for out-of-area members

● Expediting medical record requests from the Host Plan

Go to www.ibx.com/insideipp to read this edition. You can also find a complete archive of past editions there. Printed copies of Inside IPP are available by submitting an online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

Inside IPP is a newsletter intended to increase awareness of and satisfaction with the BlueCard Program. It highlights BlueCard-specific initiatives and plans for improvement.

Winter 2012 edition of Inside IPP now available

Ask out-of-area members to complete the COB Questionnaire with other registration formsUnderstand how this form can streamline claims processing and prevent denials related to COB

Submit initial claim and late charges together for out-of-area membersEnsure quick claims processing by submitting initial claim and late charges together

Reminder: Check member ID cardsRemind office staff to check member ID cards for up-to-date informationUse the Medical Policy Router for out-of-area membersFind coverage requirements for out-of-area members using the NaviNet® web portal

Expediting medical record requests from the Host Plan Learn ways to expedite Host Plan medical record requests for prompt reimbursement and appropriate member coverage

I N S I D E T H I S E D I T I O N

2W I N T E R 2 0 1 2

www.ibx.com/providers

3

Please remind your BlueCard® patients that they are responsible for obtaining precertification/preauthorization for inpatient and outpatient services as required under their Home Blue Plan. In diagnosis related group (DRG)/case rate situations when the length of an inpatient hospital stay extends past the previously approved length of stay, any additional days must be approved prior to or by the last day of the original approved days. Failure to obtain approval for the additional days may result in potential payment denials and application of a precertification penalty on the member. To avoid precertification penalties for members, it is important to check that additional days were precertified before a patient is discharged, as some national accounts may require concurrent review for out-of-area members, regardless of DRG status. Providers may also contact the member’s Home Blue Plan for approval on his or her behalf. To do so, call the BlueCard Eligibility® line at 1-800-676-BLUE and ask to be transferred to the utilization review area. The member’s Home Blue Plan may contact providers directly for clinical

information and medical records prior to treatment or for concurrent review or disease management for a specific member. v

Precertifying additional days for inpatient hospital stays

4

Program ManualMeasurement year 2013Payment period beginning January 2014

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.

Quality Incentive Payment System for Keystone Health Plan East

QIPS

The 2012 Provider Publication Cumulative Index (Cumulative Index) is included with this edition of Partners in Health Update. This index lists all of the 2012 articles that were published in Partners in Health Update and Inside IPP, the edition in which they can be found, and the provider audience type for which the article was intended.

A complete archive of all cumulative indexes is also available.

Printed copies of the 2012 Cumulative Index can be ordered by submitting an online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

2012 Cumulative Index now available

January 2013 | Partners in Health UpdateSM 4 www.ibx.com/providers

The ICD-10 Spotlight: Know the codes feature that appeared in Partners in Health Update throughout 2012 was designed to communicate various coding conventions, general guidelines, and chapter-specific guidelines in ICD-10. These conventions and guidelines are rules and instructions that must be followed to classify and assign the most appropriate code. As with ICD-9, adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).

This year, we are introducing a new feature called Putting ICD-10 into Practice: Coding exercises and scenarios. Each month this feature will help you put the new guidelines and conventions you learned about last year into practice. If needed, use the ICD-10 Spotlight: Know the codes booklet for assistance with these exercises. An answer key is provided below so you can verify if your answers are correct. In addition, a list of code narratives is included to describe each ICD-10 code.

Coding exercises Code the following conditions according to ICD-10 coding conventions and guidelines:

1. Varicose vein of heel and mid-foot with presence of ulceration and swelling

2. Premature menopause with headache

3. Acute myocardial infarction of the anterolateral wall

4. Subsequent encounter for obesity resulting from the prescription drug Tryptanol®

5. Crohn’s disease of ileum with rectal bleeding and abscess

6. Bilateral central corneal ulcer

7. Severe generalized abdominal pain with abdominal rigidity

8. Female with bilateral breast cancer of lower outer quadrant

9. Acute nonsuppurative otitis media of the right ear

10. Initial encounter for concussion and edema of the thoracic spine

11. Initial encounter for third degree burn of the right thigh by gasoline to fifteen percent of the total body surface area

Coding scenarioCode the following scenario according to ICD-10 coding conventions and guidelines:

While chopping vegetables in the kitchen of his mobile home for the local food bank’s Thanksgiving dinner, John Doe lacerated his right thumb causing injury to the nail.

January 2013 | Partners in Health UpdateSM 4 www.ibx.com/providers

Putting ICD-10 into Practice: Coding exercises and scenarios

continued on the next page

Answers to coding exercises:

1) I83.224 2) E28.310 3) I21.09 4) E66.1, T43.015D 5) K50.011, K50.014 6) H16.013 7) R10.0 8) C50.511, C50.512 9) H65.191

10) S24.0xxA 11) T24.711A, T32.10, T52.0x1A

Answer to coding scenario:

S61.111A, W26.0xxA, Y92.020, Y93.G1, Y99.2,

January 2013 | Partners in Health UpdateSM 5 www.ibx.com/providersJanuary 2013 | Partners in Health UpdateSM 5 www.ibx.com/providers

NarrativesThe following are the corresponding code narratives for each of the ICD-10 codes in the answer key:

I83.224: Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation

E28.310: Symptomatic premature menopause

I21.09: ST elevation myocardial infarction (STEMI) involving other coronary artery of anterior wall

E66.1: Drug-induced obesity

T43.015D: Adverse effect of tricyclic antidepressants, subsequent encounter

K50.011: Crohn’s disease of small intestine with rectal bleeding

K50.014: Crohn’s disease of small intestine with abscess

H16.013: Central corneal ulcer, bilateral

R10.0: Acute abdomen

C50.511: Malignant neoplasm of lower-outer quadrant of right female breast

C50.512: Malignant neoplasm of lower-outer quadrant of left female breast

H65.191: Other acute nonsuppurative otitis media, right ear

S24.0xxA: Concussion and edema of thoracic spinal cord, initial encounter

T24.711A: Corrosion of third degree of right thigh, initial encounter

T52.0x1A: Toxic effect of petroleum products, accidental (unintentional), initial encounter

T32.10: Corrosions involving 10%–19% of body surface with 0%–9% third degree corrosion

Y93.G1: Activity, food preparation and clean up

W26.0xxA: Contact with knife, initial encounter

S61.111A: Laceration without foreign body of right thumb with damage to nail, initial encounter

Y92.020: Kitchen in mobile home as the place of occurrence of the external cause

Y99.2: Volunteer activity

For additional information related to IBC’s transition to ICD-10, please visit www.ibx.com/icd10. On this site you will find examples of how ICD-9 codes will translate to ICD-10 codes in the ICD-10 Spotlight: Know the codes booklet.

Putting ICD-10 into Practice: Coding exercises and scenarios

January 2013 | Partners in Health UpdateSM 6 www.ibx.com/providers

medicAl

Policy notifications posted as of December 21, 2012All policies are posted prior to their effective date. Below is a listing of the policy notifications that we have posted to our website as of December 21, 2012.

Policy effective date Policy No. Notification titleNotification issue date

December 21, 2012 05.00.62e Injectable Dermal Fillers November 21, 2012

December 21, 2012 11.15.24 Migraine Deactivation Surgery November 21, 2012

December 31, 2012 06.02.39 Measurement of Serum Antibodies to Infliximab November 30, 2012

January 1, 2013 00.03.01j

Podiatry Services Included in Capitation for Pennsylvania Based Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products

October 3, 2012

January 1, 2013 11.05.16Aqueous Shunts, Canaloplasty, and Viscocanalostomy for the Treatment of Glaucoma

December 3, 2012

January 2, 2013 11.06.07aOvarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome

December 3, 2012

January 4, 2013 07.10.06Intracytoplasmic Sperm Injection and Assisted Embryo Hatching

December 5, 2012

January 9, 2013 11.01.01g Otoplasty October 10, 2012

January 16, 2013 11.08.20j Wound Care: Bioengineered Skin Substitutes December 17, 2012

February 5, 2013 00.01.44e Never Events and Preventable Adverse Events November 7, 2012

February 25, 2013 07.08.03Medical and Surgical Treatment of Temporomandibular Joint Disorder

November 27, 2012

March 5, 2013 11.14.26 Surgical Treatments of Athletic Pubalgia December 5, 2012

To view the policy notifications, go to 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. Once these policies are in effect, they will be available by using the Search box on the Medical Policy homepage. Be sure to check back often, as the site is updated frequently.

January 2013 | Partners in Health UpdateSM 7 www.ibx.com/providers

medicAl

In an effort to assist you in staying informed of the care your patients are receiving, a new hospital census report for your HMO patients is now available daily for all primary care practices. This report contains information such as hospital name, patient name, diagnosis, and date of admission. You can have this report faxed to your practice daily, Monday through Friday. Each patient will remain on the list until a discharge date is entered into our system.

If you are interested in receiving this report, please email your practice name and contact information to pcmh@ibx.com. You will be contacted by an IBC representative to enroll and begin receiving this new report.

New report available for primary care practices

New policy for athletic pubalgia effective March 5, 2013A new policy for the surgical treatments of athletic pubalgia (AP) will be effective for dates of service on or after March 5, 2013.

AP is a condition associated with chronic groin pain and primarily affects professionally trained athletes. AP is most prevalent among athletes who participate in sports that require running, changes in direction, and repetitive kicking such as ice hockey, soccer, rugby, or football. AP has also been called athletic hernia, sports hernia, sportsman’s hernia, sportsman’s groin, soft groin, and Gilmore’s groin, among other names.

There are limited studies that compare the effectiveness of any particular surgical approach to conservative treatment of AP. Although some studies have suggested that an open or laparoscopic surgical approach to treat AP may provide successful outcomes, these studies are of low quality and do not appropriately compare the effectiveness of AP surgery to conservative treatment.

A lack of consensus regarding the etiology, diagnosis, and treatment of AP warrants the need for further research. Therefore, at this time, we must categorize surgical treatment for AP as experimental and investigational.

Please visit www.ibx.com/medpolicy to review the Notification for Medical Policy #11.14.26: Surgical Treatments of Athletic Pubalgia. If you have any questions, please contact your Network Coordinator.

January 2013 | Partners in Health UpdateSM 8 www.ibx.com/providers

HeAltH And Wellness

Discuss routine preventive immunizations with your patients at their wellness visitsRoutine immunizations are considered preventive and therefore are covered in full for commercial IBC members under the medical benefit. We encourage you to discuss the following immunizations — as recommended by the Advisory Committee on Immunization Practices (ACIP) — with your patients during their wellness visits.

Immunization Coverage

Hepatitis B virus (HBV) ● Nonimmune individuals requesting protection from HBV infection

Diphtheria, tetanus, and pertussis (Dtap)/Tetanus, diphtheria, and pertussis (Tdap)

● One-time dose for adults ages 19 through 64 who have not received Tdap previously or who lack evidence of immunity

● Booster vaccination covered for adults and adolescents (any age) who have, or anticipate having, close contact with an infant younger than 12 months, who previously have not received Tdap†

● Booster vaccination for pregnant women after 20 weeks gestation who previously have not received Tdap; if not vaccinated during pregnancy, Tdap should be administered immediately postpartum

● One-time dose of Tdap for adults ages 65 and older without a risk indicator

Tetanus, Diphtheria (Td) ● Booster vaccination once every ten years for adults ages 19 and older

Pneumococcal (PPSV23)*

● One dose of PPSV23 vaccination for nonimmune adults ages 65 years and older

● A second dose of PPSV23 for adults ages 65 and older if it has been five or more years since their first dose, or if received before turning 65

● PPSV23 vaccination (first and second dose) for individuals ages 19 through 64 who have underlying medical conditions (e.g., chronic lung disease, chronic cardiovascular diseases, diabetes mellitus, cirrhosis, alcoholism, functional or anatomic asplenia, cochlear implants, cerebrospinal fluid leaks, chronic renal failure, nephrotic syndrome, HIV/AIDS, lymphoma, leukemia, Hodgkin’s disease, organ or bone marrow transplant, taking immunosuppressive drugs)†

● PPSV23 vaccination for adults ages 19 through 64 who smoke

● PPSV23 vaccination for adults ages 19 through 64 who have asthma

● PPSV23 vaccination for American Indians, Alaska Natives, and individuals ages 50 through 64 who live in areas where the risk for invasive pneumococcal disease is increased

● PPSV23 vaccination for American Indians, Alaska Natives, and individuals younger than 65 who have underlying medical conditions

Note: The recent change in ACIP recommendations regarding PCV13 for individuals ages 19 and older who have risk factors and have not received PCV13 or PPSV23, and for individuals ages 19 years and older with specified risk factors who have previously received one or more doses of PPSV23, is currently under review.

continued on the next page

*Denotes coverage for at-risk population†ACIP recommendations for this immunization overlap the pediatric and adult populations

January 2013 | Partners in Health UpdateSM 9 www.ibx.com/providers

Discuss routine preventive immunizations with your patients at their wellness visits (continued)

HeAltH And Wellness

Immunization Coverage

Influenza

● Annual influenza vaccination for individuals ages 6 months and older (two-dose regimen for first-time influenza vaccination recipients ages 6 months through 8 years)†

● Annual influenza vaccination with trivalent inactivated influenza vaccine (TIV) for adults ages 50 and older

● Annual influenza vaccination with live attenuated influenza vaccine (LAIV) for healthy, non-pregnant individuals ages 2 through 49 years†

Varicella

● A two-dose regimen of single-antigen varicella vaccination for unvaccinated adults who lack evidence of varicella immunity

● A second dose of single-antigen varicella vaccination for nonimmune adults with incomplete varicella vaccination

Zoster ● Nonimmune individuals ages 60 and older who have not received the varicella vaccine

Human papillomavirus (HPV4 or HPV2)*

● Three-dose regimen of quadrivalent human papillomavirus (HPV4 [types 6, 11, 16, and18]) vaccination for individuals ages 9 through 26†

● Three-dose regimen of bivalent human papillomavirus (HPV2 [types 16 and 18]) vaccination for females ages 9 through 26†

● Catch-up vaccination for females ages 13 through 26 who have not been vaccinated previously or who have not completed the three-dose series. If a female reaches age 26 before the vaccination series is complete, remaining doses can be administered after age 26.†

● Routine three-dose regimen of HPV4 for males ages 9 through 12†

● Catch-up vaccination for males ages 13 through 21 who have not been vaccinated previously or who have not completed the three-dose series†

● Males in a defined risk group for human papillomavirus (i.e., immunocompromised, HIV infection, MSM); the remaining doses can be administered from ages 22 through 26

Haemophilus influenza type B (Hib)

● Adults with specific health conditions that may affect immune system

Polio* ● Three-dose primary vaccination series for unvaccinated adults who are at increased risk

● Catch-up for under-vaccinated adults who are at risk

Measles, mumps, rubella (MMR)*

● A two-dose regimen of MMR vaccination for nonimmune adults at risk for measles and mumps infection

● One dose of MMR vaccination for individuals who lack evidence of rubella immunity

continued on the next page

*Denotes coverage for at-risk population†ACIP recommendations for this immunization overlap the pediatric and adult populations

January 2013 | Partners in Health UpdateSM 10 www.ibx.com/providers

Discuss routine preventive immunizations with your patients at their wellness visits (continued)

HeAltH And Wellness

Immunization Coverage

Hepatitis A virus (HAV)* ● Nonimmune individuals at risk for HAV infection

Meningococcal (MCV4, MCV4-CRM, MPSV4)*

● One-dose regimen of meningococcal conjugate vaccine (MCV4, MCV4-CRM) for unvaccinated individuals ages 16 through 21; no booster dose needed†

● Booster vaccination five years after the initial dose for individuals with an increased risk for meningococcal disease, then every five years if individual remains at increased risk

● Individuals ages 19 through 55 who are at increased risk may elect to receive the two-dose regimen for vaccination. In this case, the initial booster is covered three years after completion of the vaccination regimen, then a booster every five years if individual remains at increased risk.

● One-dose meningococcal polysaccharide vaccine (MPSV4) for nonimmune individuals ages 56 and older with an increased risk of meningococcal disease, with a booster dose every five years if individual remains at risk

*Denotes coverage for at-risk population†ACIP recommendations for this immunization overlap the pediatric and adult populations

The coverage information included in this table applies to commercial IBC members. For more information about immunization coverage for Medicare Advantage HMO and PPO members, please refer to the article in the November 2012 edition of Partners in Health Update: Vaccination coverage for Medicare Advantage HMO and PPO members.

Note: IBC continually reviews coverage for immunizations benefits. Coverage may change according to ACIP recommendations.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 Customer Service for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number listed on their ID card.

ConnectionsSM Health Management Program: Supporting your patients, our members

Health Coaches also provide decision support for numerous health-related issues, including back pain, fall prevention, depression, cardiometabolic risk, weight loss surgery, breast or prostate cancer, and chronic pain.

Call the Provider Support Line at 1-866-866-4694 to refer a member to a Health Coach if the member has any of the following conditions:

● asthma

● coronary heart disease (CHD)

● chronic obstructive pulmonary disease (COPD)

● diabetes

● heart failure

Information about our Connections Health Management Program is available at www.ibx.com/providerconnections.

I m p o r t a n t r e s o u r c e s

Visit our website: www.ibx.com/pnc

* Outside 215 area code

Anti-Fraud and Corporate Compliance Hotline 1-866-282-2707

www.ibx.com/antifraud

Care Management and Coordination Case Management 1-800-313-8628

Baby BluePrints® 215-241-21981-800-598-BABY (2229)*

ConnectionsSM Health Management Programs ConnectionsSM Health Management Program Provider Support Line 1-866-866-4694

ConnectionsSM Complex Care Management Program 1-800-313-8628

ConnectionsSM Provider Portal www.hdproviderportal.com/ibc

Credentialing Credentialing Violation Hotline

215-988-1413www.ibx.com/credentials

Customer Service/Provider Services Provider Automated System (eligibility/claims status/referrals) Connections Health Management Programs Precertification/maternity requests — Imaging services (CT, MRI/MRA, PET, and nuclear cardiology) — Authorizations

1-800-ASK-BLUE(275-2583)

Provider Services user guide www.ibx.com/providerautomatedsystem

eBusiness Help Desk 215-241-2305

FutureScripts® (pharmacy benefits) Prescription drug prior authorization Fax

1-888-678-70121-888-671-5285

Direct Ship Specialty Pharmacy Program Fax

1-888-678-70121-888-671-5285

Mail order program toll-free fax 1-877-228-6162

Blood Glucose Meter Hotline 1-888-678-7012

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

FutureScripts® Secure (Medicare Part D) 1-888-678-7015

Formulary updates www.ibxmedicare.com

Mail order program toll-free fax 1-877-344-1318

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

www.ibx.com/providersupplyline

ProviderPublicationCumulativeIndex

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.

March 2012www.ibx.com/providers

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

Inside this edition Announcements

Blue Distinction ● ®: New value-based designation IBC study shows that integrating medical and ●pharmacy benefits offers advantages to members

IcD-10ICD-10 Spotlight: Know the codes ► IBC invited to present during the Pennsylvania ●Medical Society’s ICD-10 webinar

BILLInG Professional Injectable and Vaccine Fee Schedule ►updates effective April 1, 2012

ADmInIstrAtIveIBC to introduce new urgent care benefit ►CFID continues to keep down health care costs ● Reminder: Medicare Advantage PPO network sharing ●billing procedures Reminder: Provider self-service requirements ●

HIPAA 5010HIPAA 5010 troubleshooting tips ►

nAvInet®

Reminder: Authorization submission requirements ●through NaviNet

meDIcALPolicy notifications posted as of February 21, 2012 ►Clarification on the use of Modifier 52 ►

PHArmAcYSelect Drug Program ► ® Formulary updatesPrescription drug updates ►

HeALtH AnD WeLLness Strong bones, improved quality of life for women: ●Controlling osteoporosis after a fracture Connections ● SM Health Management Program: Supporting your patients, our members

Prescription drug updates page 11

July 2012www.ibx.com/providers

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

Inside this edition AdministrAtive

The process of requesting retrospective reviews ●for inpatient stays

ClaimCheck ► ® upgrade and edit clarification

Enhanced outreach program for Medicare Advantage ●HMO and PPO members

Member cost-sharing for urgent care benefit ►

Updated payer ID grids now available ►

iCd-10

ICD-10 Spotlight: Know the codes ►

mediCAL

Health care reform: Expansion of 100 percent ►coverage for women’s preventive health services

Choosing a safe, cost-effective setting for injectable ►and infusion therapy drugs

Policy notifications posted as of June 22, 2012 ►

HeALtH And WeLLness

Choosing Wisely ● ®: A new initiative that promotes smart and effective care choices

Connections ● SM Health Management Program: Supporting your patients, our members

Exercise: A key to fall prevention ●

Health care reform: expansion of 100 percent coverage for women’s preventive health services page 8

December 2012www.ibx.com/providers

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

Inside this edition ICD-10

► ICD-10 Spotlight: Know the codes (Coding Convention/Guideline: Mental and Behavioral Disorders)

CONSUMERISM ● Look for the new Find a Doctor tool this month

ADMINISTRATIVE ● Reminder: Provider self-service requirements

BILLING ► Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2013

► Nutrition counseling not eligible for payment in group setting

► Significant changes in 2013 to CPT® codes for behavioral health services

MEDICAL ► Policy notifications posted as of November 30, 2012

► Health care reform: Expansion of 100 percent coverage for women’s preventive health services

► Updated policy for Never Events and Preventable Adverse Events

● Reminder: Coverage change for Plan B One-Step® (Levonorgestrel, Next Choice®)

PHARMACY ► Changes to growth hormone prescribing procedures

► Prescription drug updates

► Select Drug Program® Formulary updates

NAVINET®

● Reminder: Authorization submission requirements through NaviNet

QUALITY MANAGEMENT ● Our Quality Management Program promotes quality

of care and service

HEALTH AND WELLNESS ● The importance of lead screening and lead safety

● Resolution solution: The SilverSneakers® Fitness Program

● 2012-2013 Clinical Practice Guideline Summary now available

● Case management: Help for your patients when they need it

Health care reform: Expansion of 100 percent coverage for women’s preventive health services page 10

Clarification of billing guidelines for BlueCard claims for DME, independent clinical laboratory, and specialty pharmacy providersLearn about standardized claims filing for DME, independent clinical labotory, and specialty pharmacy providers.

HHS announces new ICD-10 compliance date of October 1, 2014Find a link to the final ruling.

I n s I d e t h I s e d I t I o n

2

F A L L 2 0 1 2www.ibx.com/providers

4

BlueCard® host claims not only involve claims for members of Blue Plans in the United States (50 states) and the District of Columbia, they also include claims for Blue Plan members of international Licensees such as:

• Triple-S Salud* (Blue Cross Blue Shield of Puerto Rico) • Blue Cross Blue Shield of the U.S. Virgin Islands* • Blue Cross Blue Shield of Panama* • Blue Cross Blue Shield of Uruguay* • GeoBlueSM* – the Blue International Solutions Licensee located in

Malvern, PA. Provides coverage for students and expatriates of other nations while they are in the United States.

Members enrolled with a foreign Licensee can access provider networks of Blue Licensees in the United States, as well as the networks of other foreign Licensees. These members carry a Blue ID card with an alpha prefix that has been assigned to the specific international Licensee.

The claims submission process is the same as with any other BlueCard claim. Host claims for these service areas should be sent to IBC for processing. Please treat these members the same as domestic Blue Plan members and do not collect any payment from them beyond their cost-sharing amounts such as deductible, coinsurance, and copayment. v

Identifying members of foreign Licensees and submitting their claims

*Independent licensee of the Blue Cross and Blue Shield Association.

PPAARRTTNNEERRSS IINN HHEEAALLTTHH UUPPDDAATTEESSMM

ADMINISTRATIVE .................................................................................................................................................... 1 ANNOUNCEMENTS ................................................................................................................................................. 3 BILLING ................................................................................................................................................................. 3 BLUECARD

® .......................................................................................................................................................... 4

BUSINESS TRANSFORMATION ................................................................................................................................. 5 CONSUMERISM ...................................................................................................................................................... 5 HEALTH AND WELLNESS ........................................................................................................................................ 5 HIPAA 5010 ......................................................................................................................................................... 7 ICD-10 ................................................................................................................................................................. 7 MEDICAL ............................................................................................................................................................... 8 NAVINET

® ........................................................................................................................................................... 10

PHARMACY ......................................................................................................................................................... 11 PRODUCTS .......................................................................................................................................................... 11 QUALITY MANAGEMENT ....................................................................................................................................... 12 REIMBURSEMENT ................................................................................................................................................ 12

IINNSSIIDDEE IIPPPP .............................................................................................................................................................................................................................................................. 1133

Partners In Health Update

_________

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.

FutureScripts® and FutureScripts Secure® are independent companies that provide benefits management services.

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

SMART® is a registered trademark of Health Dialog Services Corporation, an independent company.

CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. The AMA assumes no liability for data contained or not contained herein.

The Blue Cross and Blue Shield names and symbols, BlueCard, Blue365, and Baby BluePrints are registered marks of the Blue Cross and Blue Shield

Association, an association of independent Blue Cross and Blue Shield plans.

Note: Partners in Health Update articles are specific to a provider type. The audience is identified by the following indicators:

P – Professional F – Facility A – Ancillary

Partners in Health UpdateSM

1

ADMINISTRATIVE Ambulance transport for Medicare Advantage HMO and PPO members receiving custodial and skilled nursing care A April 2012 An updated Provider Manual now available P September 2012 Attention: Changes to the Provider Automated System postponed P, F, A January 2012 CFID continues to keep down health care costs P, F, A March 2012 ClaimCheck® upgrade and edit clarification P, A July 2012 Cost-sharing for preventive and nonpreventive services P, F, A April 2012 Cost-sharing for sleep disorder testing (sleep studies) F November 2012 Elimination of capitated podiatry program P October 2012 Reminder article was posted in: November 2012 Emergency hospital admission notification submission changes for Independence Administrators beginning June 1, 2012 P, F, A May 2012 Emergency room follow-up care reminder P, F, A June 2012 Enhanced outreach program for Medicare Advantage HMO and PPO members P July 2012 IBC to introduce new urgent care benefit P, F, A March 2012 Independence Administrators offers free electronic claims payments and remittances with Integrated ERA/EFTTM P, F May 2012 Long-term care billing and referral requirements P, F, A April 2012

Partners in Health UpdateSM

2

ADMINISTRATIVE (CONTINUED) Medicare Part D prescriber prescription verification requests P, F, A October 2012 Member cost-sharing for urgent care benefit P, F, A July 2012 New hospitals join Keystone 65 Select HMO network P, F, A February 2012 New Provider Automated System is now live P, F, A February 2012 Physician refresher/re-entry courses P January 2012 Register pregnant IBC members for Baby BluePrints® to ensure early outreach P May 2012 Reminder: Medicare Advantage PPO network sharing billing procedures P, F, A March 2012 Reminder: Provider self-service requirements P, F, A March 2012 June 2012 September 2012 December 2012 Request your office supplies through the Provider Supply Line P, F, A June 2012 October 2012 Sign up to receive IBC news and announcements via email P, F, A January 2012 February 2012 March 2012 April 2012 June 2012 September 2012 December 2012 The process of requesting retrospective reviews for inpatient stays F July 2012 Upcoming CFID provider audits P, F, A August 2012

Partners in Health UpdateSM

3

ADMINISTRATIVE (CONTINUED) Update your provider information with us P, F, A May 2012 August 2012

November 2012

ANNOUNCEMENTS 2011 Cumulative Index now available P, F, A January 2012 AIM changes its company name P, F, A May 2012 A new look for ibx.com P, F, A May 2012 Blue Distinction®: New value-based designation F March 2012 Blue plans and Lumeris complete acquisition of nation’s largest real-time health care communication network P, F, A April 2012 Changing the way we do business P, F, A July 2012 Get involved this year and help us stop diabetes P, F, A September 2012 IBC study shows that integrating medical and pharmacy benefits offers advantages to members P, F, A March 2012 Updated QIPS Program Manual now available P January 2012

BILLING Billing ambulance services for Medicare Advantage PPO members A September 2012

Partners in Health UpdateSM

4

BILLING (CONTINUED) Clarification of billing guidelines for BlueCard® claims for DME, independent A clinical laboratory, and specialty pharmacy providers September 2012 Nutrition counseling not eligible for payment in group setting P December 2012 Professional fee schedule changes effective July 1, 2012 P May 2012 Professional Injectable and Vaccine Fee Schedule updates effective April 1, 2012 P, F, A March 2012 Professional Injectable and Vaccine Fee Schedule updates effective July 1, 2012 P, F, A June 2012 Professional Injectable and Vaccine Fee Schedule updates effective October 1, 2012 P, F, A September 2012 Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2013 P, F, A December 2012 Significant changes in 2013 to CPT® codes for behavioral health services P December 2012 Updated payer ID grids now available P, F January 2012

July 2012

BLUECARD®

Winter 2011 edition of Inside IPP now available F, A January 2012 Spring 2012 edition of Inside IPP now available F, A May 2012 Summer 2012 edition of Inside IPP now available F, A August 2012 Fall 2012 edition of Inside IPP now available F, A November 2012

Partners in Health UpdateSM

5

BUSINESS TRANSFORMATION Changing the way we do business with you P, F, A November 2012

CONSUMERISM Coming soon: New tool for members to provide online reviews for their network physicians P April 2012 Introducing new cost and quality transparency tools and features P, F, A November 2012 Look for the new Find a Doctor tool this month P, F, A December 2012 Reminder: IBX Mobile, our free smartphone application P, F, A November 2012

HEALTH AND WELLNESS

2012-2013 Clinical Practice Guideline Summary now available P December 2012 Case management: Help for your patients when they need it P

February 2012 April 2012 June 2012 August 2012 October 2012 December 2012

Celiac disease: Information and resources for you and your patients P January 2012 Choosing Wisely®: A new initiative that promotes smart and effective care choices P July 2012

Partners in Health UpdateSM

6

HEALTH AND WELLNESS (CONTINUED) ConnectionsSM Health Management Program: Supporting your patients, our members P

January 2012 March 2012

May 2012 July 2012 September 2012 November 2012

ConnectionsSM Program Provider Satisfaction Survey now available P September 2012 Counseling older adult patients about fall prevention P June 2012 Encourage your older adult patients to get moving P August 2012 Encourage your older adult patients to take a walk P May 2012 Exercise: A key to fall prevention P July 2012 Highlights of the June 2012 release of the SMART® Registry from the ConnectionsSM Program P June 2012 Introducing the ConnectionsSM Provider Portal P August 2012 Members can help prevent heart disease with SilverSneakers® P February 2012 Members encouraged to get whooping cough vaccine to combat rising rates P October 2012 New screening and vaccination recommendations for children P, F, A February 2012 Prescribing medications for your older adult patients P June 2012 Resolution Solution: The SilverSneakers® Fitness Program P December 2012

Partners in Health UpdateSM

7

HEALTH AND WELLNESS (CONTINUED) Safe use of acetaminophen in infants and children P April 2012 Seasonal flu vaccine recommendations P October 2012 Strong bones, improved quality of life for women: Controlling osteoporosis after a fracture P March 2012 The ConnectionsSM Health Management Program 2012 Annual Update is now available P September 2012 The importance of lead screening and lead safety P December 2012 Updated meningococcal vaccine/booster dose guidelines from the AAP P April 2012

HIPAA 5010 HIPAA 5010 troubleshooting information P, F, A April 2012 HIPAA 5010 troubleshooting tips P, F, A March 2012 IBC follows CMS lead with second HIPAA 5010 90-day enforcement grace period P, F, A April 2012 Reminder: IBC follows CMS lead with HIPAA 5010 90-day enforcement grace period P, F, A January 2012

ICD-10 HHS announces new ICD-10 compliance date of October 1, 2012 P, F, A October 2012 IBC invited to present during the Pennsylvania Medical Society’s ICD-10 webinar P, F, A March 2012

Partners in Health UpdateSM

8

ICD-10 (CONTINUED) ICD-10 implementation update: IBC continues to move forward P, F, A May 2012 ICD-10 Spotlight: Know the codes P, F, A February 2012

March 2012 April 2012

May 2012 June 2012 July 2012 August 2012

September 2012 October 2012 November 2012 December 2012

MEDICAL Annual Synagis® (palivizumab) distribution program P, F, A October 2012 Note: Original article ran under Pharmacy category in September 2012 Assessing the needs of high-risk Medicare Advantage HMO and PPO members P, F April 2012 Changes to approved drug dose, frequency, or regimen must be resubmitted for precertification P, F, A June 2012 Choosing a safe, cost-effective setting for injectable and infusion therapy drugs P July 2012 Clarification on the use of Modifier 52 P, F, A March 2012 Coverage change for Plan B One-Step® (Levonorgestrel, Next Choice®) P, A October 2012 Reminder article was posted in: December 2012 Health care reform: Expansion of 100 percent coverage for women’s preventive health services P July 2012 December 2012

Partners in Health UpdateSM

9

MEDICAL (CONTINUED) Low-dose chest CT screening for individuals at high risk for lung cancer P, F, A April 2012 Performing EGD and colonoscopy procedures on the same day P August 2012 Policy notifications posted as of December 21, 2011 P, F, A January 2012 Policy notifications posted as of January 20, 2012 P, F, A February 2012 Policy notifications posted as of February 21, 2012 P, F, A March 2012 Policy notifications posted as of March 26, 2012 P, F, A April 2012 Policy notifications posted as of April 23, 2012 P, F, A May 2012 Policy notifications posted as of May 21, 2012 P, F, A June 2012 Policy notifications posted as of June 22, 2012 P, F, A July 2012 Policy notifications posted as of July 25, 2012 P, F, A August 2012 Policy notifications posted as of August 31, 2012 P, F, A September 2012 Policy notifications posted as of September 21, 2012 P, F, A October 2012 Policy notifications posted as of October 26, 2012 P, F, A November 2012 Policy notifications posted as of November 30, 2012 P, F, A December 2012 Policy reminder regarding utilization review decisions P November 2012

Partners in Health UpdateSM

10

MEDICAL (CONTINUED) Preferred providers for insulin pumps and continuous glucose monitoring related supplies P, F January 2012 Reminder: New precertification requirements now in effect for Medicare Advantage HMO and PPO members P, F, A January 2012 Reminder: Use of modifier -25 when reporting E&M services with spinal/extraspinal manipulation codes P January 2012 Retrospective chart review program P August 2012 Updated AIM clinical guidelines P September 2012 Updated InterQual® guidelines for 2012 P, F, A June 2012 Updated policy for Never Events and Preventable Adverse Events P, F December 2012 Vaccination coverage for Medicare Advantage HMO and PPO members P November 2012

NAVINET®

NaviNet enhancement features new urgent care copayment P, F, A April 2012 Reminder: Authorization submission requirements through NaviNet P, F, A March 2012

June 2012 September 2012 December 2012

Updated Clinical Alerts Overview is available P April 2012 Use the Clinical Care Report to improve coordination of care P, F April 2012

Partners in Health UpdateSM

11

PHARMACY Annual Synagis® (palivizumab) distribution program P September 2012 Note: Article also ran under Medical category in October 2012 Changes to growth hormone prescribing procedures P December 2012 Change to our specialty pharmacy network for commercial members P January 2012 Closed formulary options for Medicare Part D members P February 2012 CMS patient safety measures and how you can help P April 2012 Important change for the coverage of Adderall XR® P October 2012 New initiative promotes the use of generic drugs P August 2012 Prescription drug updates P, F, A March 2012 June 2012 September 2012 December 2012 Program for brand Lipitor® ends as of June 1, 2012 P May 2012 Select Drug Program® Formulary updates P, F, A March 2012 June 2012 September 2012 December 2012

PRODUCTS Benefits changes and clarifications for commercial members P, F, A November 2012 Information and resources for your Medicare-eligible patients P, F, A May 2012

Partners in Health UpdateSM

12

PRODUCTS (CONTINUED) New arrangement for self-funded national account customers P, F, A October 2012 Reminder: Medicare Advantage HMO and PPO benefits changes P, F, A January 2012 Upcoming changes for Keystone 65 Select HMO P, F, A October 2012 Reminder article was posted in: November 2012 Upcoming Medicare Advantage HMO and PPO benefits changes P, F, A November 2012

QUALITY MANAGEMENT Our Quality Management Program promotes quality of care and service P, F, A December 2012 Quality ranking for primary care physician offices P October 2012

REIMBURSEMENT Upcoming professional fee schedule changes for 2012 P February 2012

Inside IPP

13

Ask out-of-area members to complete the COB Questionnaire with other registration forms Winter 2012 Blue Distinction®: New value-based designation Spring 2012 Blue plans and Lumeris complete acquisition of nation’s largest real-time health care communication network

Spring 2012 Claim INFO Adjustment transactions reminder Spring 2012 Clarification of billing guidelines for BlueCard® claims for DME, independent clinical laboratory, and specialty pharmacy providers Fall 2012 Coming soon: New tool for members to provide online reviews for their network physicians Spring 2012 Expediting medical record requests from the Host Plan Summer 2012 Winter 2012 HHS announces new ICD-10 compliance date of October 1, 2014 Fall 2012 Identifying members of foreign Licensees and submitting their claims Fall 2012 Out-of-area members should complete the Coordination of Benefits Questionnaire Summer 2012 Quick tips for a smooth out-of-area claims experience Summer 2012 Reminder: Check member ID cards Winter 2012 Roles and responsibilities related to the BlueCard® Program Spring 2012 Submit initial claim and late charges together for out-of-area members Summer 2012 Winter 2012 Updated BlueCard® FAQ available Summer 2012

Inside IPP (continued)

14

Updated payer ID grids now available

Summer 2012

Use the Medical Policy Router for out-of-area members Winter 2012