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TRANSCRIPT
May 2017
Making the health care system work better, together.
Blue Cross and Blue Shield of Illinois (BCBSIL) is working every day to identify ways we can streamline, simplify and improveprocesses that may affect your practice. That work includes examining how and in what ways we can work together withproviders to favorably impact care quality and affordability. To that end, we are designing new data and reporting capabilitiesthat may help providers gain deeper and broader insights into the health care needs of BCBSIL members.
Throughout this year and the next, BCBSIL will introduce new tools and technologies that we expect will help:
Make it easier for you to do business with usDeliver actionable data to help you make more insightful patient treatment and practice management decisionsEnhance the value and quality of care our members receive
Modernization is essential. By offering more efficient online options, increased network participation opportunities and riskmodels, and greater access to improved data and reporting tools, BCBIL is aiming to go above and beyond where we aretoday so that we may continue to work with you in more innovative ways.
We invite you to join us in helping make the health care system work better, together. Keep reading future issues of the BlueReview to find out what’s new.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Update: Uniform Coding for Habilitative and Rehabilitative Services
Rehabilitative and habilitative services and devices are one of the required Essential Health Benefits (EHBs) required to becovered by health care plans. Recently, federal regulations further clarified how these benefits should be covered by definingrehabilitative and habilitative services, requiring parity in coverage limits and requiring separate visit limits for each.1
Effective Jan. 1, 2017, visit limits for rehabilitative and habilitative services must not be combined. Providers that submitclaims for habilitative services may need to make a change to their billing practices by using the available HealthcareCommon Procedure Coding System (HCPCS) modifier SZ (habilitative services) when billing for habilitative services onclaims for Blue Cross and Blue Shield of Illinois (BCBSIL) and BlueCard® (out-of-area Blue Plan) members.
Rehabilitative and habilitative services need to be tracked separately for all members, including members accessing care inanother Blue Plan’s service area, to ensure visit limits are not combined. This billing requirement applies to both professional(CMS-1500) and outpatient facility (UB-04) claims. For electronic professional claims, the modifier is coded in the SV1segment and for electronic facility claims, the modifier is coded in the SV2 segment. Without the (SZ) modifier, the servicewill be considered rehabilitative. Providers’ use of the code modifier allows BCBSIL to be able to track habilitative andrehabilitative services separately, in order to comply with EHB requirements of the Affordable Care Act (ACA) regulations.
Current Procedural Terminology (CPT®) codes and Centers for Medicare & Medicaid Services (CMS) HCPCS Level II codesare defined for rehabilitative services. Many of the procedure codes used for rehabilitative services are also used forhabilitative services, which do not have a separate set of procedure codes. In 2014, the HCPCS modifier SZ (habilitativeservices) was created for providers to accurately specify when habilitative services are billed. Use of the (SZ) modifier issupported by the situational rule for HIPAA-adopted claim transactions, which requires modifiers for procedure codes whenthey clarify or improve the reporting accuracy of the associated procedure code.
This information is for educational purposes only. Providers are instructed to bill claims in accordance with BCBSIL and industry standards and based upon services rendered asdocumented in the medical record.1See the regulation at 45 CFR § 156.115
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Crossand Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Provider Learning Opportunities
Blue Cross and Blue Shield of Illinois (BCBSIL) offers complimentary educational workshops and webinars with an emphasis on electronic options that can help createadministrative efficiencies for the independently contracted providers who conduct business with us. A snapshot of upcoming training sessions is included below. For additionalinformation, refer to the Workshops/Webinars page in the Education and Reference Center on our website at bcbsil.com/provider.
BCBSIL WEBINARSTo register now for a webinar on the list below, click on your preferred session date.
Descriptions: Dates: Session Times:
BCBSIL Back to Basics: ‘AvailityTM 101’Join us for a review of electronic transactions, provider tools and helpful online resources.
May 9, 2017May 16, 2017 May 23, 2017 May 30, 2017
11 a.m. to noon
Introducing Remittance ViewerHave you heard? This online tool offers providers and billing services a convenient way to retrieve, view, save or printclaim detail information.
May 16, 2017 10 to 11 a.m.
iExchange® Training: New Enrollee Training Learn how to gain access to and begin using our online benefit preauthorization/predetermination of benefits tool.
May 9, 2017 11 a.m. to 12:15 p.m.
BCBSIL PROFESSIONAL PROVIDER WORKSHOPSRegister via the Workshops page in the Education and Reference Center on our Provider website.
Description: Locations: Dates: Questions? Contact:
Our Provider Network Relations team is offering specializedtraining with a question-and-answer session to discuss currentareas of interest pertaining to independently contracted BCBSILproviders.
The session time for each workshop is 9:30 a.m. to noon.Check-in will be held from 9 to 9:30 a.m.
To register online: Visit the Workshops page in the Education andReference Center on our Provider website. Be sure to sign up bythe registration deadline so that we can be prepared toaccommodate all attendees.
Mt. Vernon Drury Inn & Suites 145 North 44th St. Mt. Vernon, IL 62864
May 17, 2017 Registration deadline: May 12, 2017
Teresa [email protected]
New LenoxSilver Cross Hospital 1900 Silver Cross Blvd New Lenox, IL 60451
June 22, 2017 Registration deadline: June 16, 2017
Aaron [email protected]
Aurora Rush-Copley Heart Institute 2088 Ogden Ave. Aurora, IL 60504
June 27, 2017 Registration deadline: June 23, 2017
Kathy [email protected]
Arlington Heights Northwest Community Hospital,Auditorium 800 W. Central Rd. Arlington Hts., IL 60005
July 19, 2017 Registration deadline: July 14, 2017
Gina [email protected]
East Peoria Par-A-Dice Hotel 21 Blackjack Blvd. East Peoria, IL 61611
Sept. 14, 2017 Registration deadline: Sept. 8, 2017
J’ne [email protected]
AVAILITY WEBINARSAvaility also offers free webinars for their registered users. For a current listing of webinar topics, dates and times, registered Availity users may log on to the secure Availityprovider portal – the Live Webinar Schedule is located under the Free Training tab. Not yet registered with Availity? Visit their website at availity.com for details; or call AvailityClient Services at 800-AVAILITY (282-4548) for assistance.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. iExchange is atrademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third partyvendors such as Availity and Medecision.If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Online Enrollment Options in AvailityTM
Blue Cross and Blue Shield of Illinois (BCBSIL) offers providers multiple enrollment opportunities for electronicoptions through the Availity Web Portal, in addition to supporting utilization of standard administrative transactionsthrough Availity or your preferred vendor portal. Instead of faxing or mailing paper enrollment forms, you maycomplete the online enrollment options listed below through Availity, at no cost. In addition, Availity provides singlesign-on access to several online tools, including those highlighted below. This feature offers you greater convenienceand security, without the need for another User ID and password.
Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA) BCBSIL independently contracted providers* may enroll online for EFT and ERA and also make any necessary set-up changes in Availity. The online enrollment process can be completed in near real-time. Providers will receive aconfirmation letter acknowledging the enrollment effective date and related information. Once an organization isenrolled for ERA, providers and billing services also gain access to the Availity Remittance Viewer. This online toolpermits users to search, view, save and print remittance information, even if the ERA is delivered to an appointedreceiver.
*This excludes atypical providers who have not acquired a National Provider Identifier (NPI).
Benefit Preauthorization – iExchange® (Single sign-on access)Once you are registered as an Availity user, you may enroll through the Availity Web portal for iExchange. This toolsupports online submission and electronic approval of benefits for inpatient admissions, as well as select outpatientand clinical pharmacy services.** iExchange also offers you an alternative to calling to request status of most benefitpreauthorization requests. Additionally, iExchange accepts electronic medical record documentation forpredetermination of benefits requests. As a reminder, always check eligibility and benefits first to find out if benefitpreauthorization is required for a particular member. Please note that, for behavioral health services, you shouldcontinue to use the current fax and telephone benefit preauthorization methods. If you have questions, contact thenumber on the member’s ID card.
Electronic Refund Management (eRM) (Single sign-on access)Registered Availity users also have the opportunity to gain access to eRM, an online tool that helps simplify theoverpayment reconciliation process. You will receive electronic notification of overpayments, with the option to deductfrom a future payment or pay by check. When you enroll for eRM, you also gain access to the Claim InquiryResolution (CIR) tool, a method of online assistance that helps save your staff time by reducing the amount of callsand specific written inquiries on finalized claims. Note: The eRM and CIR tools are not available for governmentprograms (Medicare Advantage and BCBSIL Medicaid) claims.
Learn more…To learn more about these and other electronic tools and resources, visit the Education and ReferenceCenter/Provider Tools section of our website at bcbsil.com/provider. Also see the Webinars page for dates, times andregistration for online training sessions on a variety of topics. For assistance or customized training, contact aBCBSIL Provider Education Consultant at [email protected].
Not yet registered with Availity? Visit availity.com and complete the online application today. If you needregistration assistance, contact Availity Client Services at 800-AVAILITY (282-4548).
**Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized is not a guarantee of payment. Benefits will be determined once aclaim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the dateservices were rendered. If you have any questions, please call the number on the back of the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medicalprofessionals. Availity provides administrative services to BCBSIL. iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health caremanagement solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third partyvendors such as Availity or Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independentBlue Cross and Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Benefit Information Accessible in Our Automated Phone System
Starting on Dec. 12, 2016, Customer Advocate assistance was removed for several common benefit categories within the Blue Cross and Blue Shield of Illinois (BCBSIL)Interactive Voice Response (IVR) phone system. The IVR quotes the same level of patient eligibility and benefits information as the information a Customer Advocate provides.Our Customer Advocates will continue to be available for more complex benefit quotes.
BCBSIL is committed to providing efficient and secure access to patient information. To better assist providers with understanding the recent IVR change, a list of the benefitcategories that are currently contained in the IVR is included below. This listing is continually reviewed and may vary across different BCBSIL networks, products and/or grouppolicies. Also included below is a separate category containment list for Federal Employee Program (FEP) members.*
*Note: These listings are not applicable to government programs (Medicare Advantage and BCBSIL Medicaid) member policies. For government programs eligibility and benefitsrequests, please refer to the number on the member’s BCBSIL ID card.
IVR-Contained Benefit Categories
Office Visit Hospital Preventive Care
Colonoscopy Allergy Ultrasound
Coordinated Home Care Laboratory X-ray
Extended Care Facility Mammogram EKG
Physical Exam Inhalation Therapy Consultations
Pap Smear Private Duty Nursing Office Services
FEP IVR-Contained Benefit Categories
Accidental Injury Maternity
Allergy Office Visit
Chiropractic Services Outpatient Physical, Occupational and Speech Therapy
Diagnostic – Lab, X-ray, Outpatient Diagnostic Vision
Inpatient Benefits – Inpatient Hospital, Inpatient Surgery
When navigating the IVR to determine patient coverage or connecting with a Customer Advocate to request predetermination of benefits status, it is imperative that you select theexact benefit category that will be rendered for the patient. This will help ensure that you receive the most accurate benefit information associated with your request.
Checking eligibility and benefits electronically through Availity™ or your preferred Web vendor is the quickest way to access information for BCBSIL members. To learn moreabout online solutions, refer to the Education and Reference Center/Provider Tools section of our website at bcbsil.com/provider. For IVR navigational assistance, an Eligibilityand Benefits Caller Guide is available on the Tutorials/User Guides page of our Provider website.
Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverageapplicable on the date services were rendered. If you have questions, please call the number on the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. eCare is the registeredtrademark of Nebo Systems, a division of Passport Health Communications, Inc., an independent third party vendor. (Passport/Nebo Systems offers the NDAS Online product to independently contracted BCBSIL providers.) BCBSIL makes no endorsement,representations or warranties regarding any products or services offered by third party vendors such as Availity and Passport Health Communications. If you have any questions about the products or services offered by such vendors, you should contact thevendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
iExchange® Adds Blue Cross Community Integrated Care Plan (ICP)SM and Blue CrossCommunity Family Health PlanSM (FHP) Requests
We are pleased to announce that benefit preauthorization requests for ICP and FHP members can now be initiated throughiExchange. This is in addition to benefit preauthorization requests for Blue Cross Medicare Advantage (PPO)SM and BlueCross Community MMAI (Medicare-Medicaid Plan)SM members.
iExchange supports online submission and electronic approval of benefits for inpatient admissions, as well as selectoutpatient and pharmacy services 24 hours a day, 7 days a week.* For behavioral health services, you should use the currentfax and telephone benefit preauthorization methods. iExchange also offers you an alternative to calling to request the statusof your benefit preauthorization requests.
REMEMBER TO CHECK ELIGIBILITY AND BENEFITS – FIRSTTo determine if a benefit preauthorization is needed, confirm member eligibility and benefits first through AvailityTM, or yourpreferred online vendor portal. As always, questions also may be directed to the Customer Service number on the member’sID card.
We have scheduled webinars through June 2017 to provide iExchange users with an overview of this online benefitpreauthorization tool. For upcoming dates and times and to register online, visit the Webinars page in the Education andReference Center on our website at bcbsil.com/provider.
For more information about iExchange, including how to gain access if you are not a current user, visit the Education andReference Center/Provider Tools section of our Provider website.
*With the exception of the third Sunday of the month from 11 a.m. to 2 p.m.
Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, themember’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, please call the number on themember’s ID card.
iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes noendorsement, representations or warranties regarding any products or services offered by third party vendors such as Medecision. If you have any questions about the products orservices offered by such vendors, you should contact the vendor(s) directly.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals.Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendorssuch as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Crossand Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Update: New Medicaid and Medicare Benefit Preauthorization Requirements through eviCore
In February 2017, Blue Cross and Blue Shield of Illinois (BCBSIL) announced new benefit preauthorization requirements, beginning April 3, 2017, for BCBSIL members enrolledin any of the following plans:
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
Blue Cross Community Integrated Care Plan (ICP)SM
Blue Cross Community Family Health PlanSM (FHP)Blue Cross Community Managed Long Term Supports and ServicesSM (MLTSS)Blue Cross Medicare Advantage (PPO)SM
The benefit preauthorization requirements will now be effective beginning June 1, 2017. eviCore healthcare (eviCore) will manage benefit preauthorization requests for thespecialized clinical services listed below. Please note that the list of services requiring benefit preauthorization beginning June 1, 2017, has been updated to excludeCardiac Rhythm Implantable Devices (Crid).
Outpatient Molecular GeneticsOutpatient Radiation TherapyMusculoskeletal services
ChiropracticPhysical and Occupational TherapySpeech TherapySpine Surgery (Outpatient/Inpatient)Spine Lumbar Fusion (Outpatient/Inpatient)Interventional Pain
Outpatient Cardiology & Radiology imaging servicesPediatric Abdomen ImagingPediatric Cardiac ImagingPediatric Chest ImagingPediatric Head ImagingPediatric Musculoskeletal ImagingPediatric Neck ImagingPediatric Oncology ImagingPediatric Pelvis ImagingPediatric Peripheral Nerve Disorders (Pnd) ImagingPediatric Peripheral Vascular Disease (Pvd) ImagingPediatric Spine ImagingAbdomen ImagingCardiac ImagingChest ImagingCardiac Rhythm Implantable Device (Crid)Head ImagingMusculoskeletalNeck ImagingObstetrical Ultrasound ImagingOncology ImagingPelvis ImagingPeripheral Nerve Disorders (Pnd) ImagingPeripheral Vascular Disease (Pvd) ImagingSpine Imaging
Outpatient Medical OncologyOutpatient SleepPost-Acute CareOutpatient Specialty Drug
Services performed without benefit preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seekreimbursement from the member.
Providers may continue to use iExchange® for all other services that require benefit preauthorization.
Watch the News and Updates on our website at bcbsil.com/provider and also the Blue Review for additional information, including training opportunities, in the coming months.
Our goal is to support access to quality, affordable health care for our members. If you have any questions, please contact your assigned BCBSIL Provider Network Consultant(PNC).
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL.
Please note that the fact that a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of themember’s certificate of coverage applicable on the date services were rendered.
iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or servicesoffered by third party vendors such as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
City of Chicago Requires Second Surgical Opinion
Effective May 1, 2017, City of Chicago Blue Cross and Blue Shield of Illinois (BCBSIL) members with the alpha prefix CTY ontheir member ID card and the group numbers 195500, 195501 or 195502 must call Telligen to obtain a second surgicalopinion before having surgery. If the member does not call Telligen before a scheduled surgery, the City will not authorizeBCBSIL to pay for any expenses related to the surgical procedure. This requirement applies to surgeries in the followingareas:
Hip/knee/shoulderNeck/back/spineGall bladderUterine/vagina/cervixGastric bypass
This requirement does not apply to surgical procedures performed if the member was admitted through the emergency roomfor emergency surgery.
There is no charge for the second opinion and the member is not expected to travel or be examined to complete the review.Most members who are affected by this new requirement received a letter from the City of Chicago explaining the secondsurgical opinion.
The benefit of this requirement is that the member will receive a confidential written report of the second opinion related tothe proposed surgery. The member makes the final decision on how to proceed with the proposed treatment plan. Telligenwill not share any information with the City of Chicago, the member’s treating physician or BCBSIL other than to verify thatthe member met the requirement of the second surgical opinion. Members may call Telligen at 800-373-3727.
Always refer to the member’s ID card to verify prior benefit authorization requirements and appropriate contact information.
Telligen is an independent third party vendor that is solely responsible for the products and services they offer. BCBSIL makes no endorsement, representations or warrantiesregarding any products or services offered by independent third party vendors. If you have any questions about the products or services they offer, you should contact the vendor(s)directly.
The fact that a guideline is available for any given treatment, or that a service has been preauthorized, is not a guarantee of payment. Benefits will be determined once a claim isreceived and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. Ifyou have any questions, please call the number on the member’s ID card.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Hospital Affiliations are Required for M.D.s and D.O.s when Joining PPO and BlueChoice PPOSM Networks
New M.D. and D.O. PPO and Blue Choice PPO contracted providers must be affiliated with a network hospital provider to bepart of the Blue Cross and Blue Shield of Illinois (BCBSIL) PPO and Blue Choice PPO networks. Exceptions to this ruleinclude allergists, dermatologists, physiologists, rehabilitation specialists, ophthalmologists and PCPs who are part of ahospitalist group.
Additional information on requirements for new providers seeking to join the BCBSIL PPO professional network is available inthe Network Participation/Contracting section of our website at bcbsil.com/provider.
As a reminder, existing providers can add hospital affiliations and/or make any other changes as needed using our onlinedemographic change form, which has recently been updated to help make your experience quick, efficient and user-friendly.The form can be found in the Network Participation/Update Your Information section of our Provider website.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
National Drug Code (NDC) Billing Update for BCBSIL Medicaid Claims
Blue Cross and Blue Shield of Illinois (BCBSIL) is implementing Medi-Span® as its NDC validation source. Thisimplementation will help ensure that the BCBSIL system is aligned with the system adopted by the Illinois Department ofHealthcare and Family Services (HFS) to validate use of appropriate NDCs on Blue Cross Community OptionsSM, or BCBSILMedicaid, claims.
BCBSIL follows HFS billing guidance for outpatient services that relate to NDCs. A current list of services that require anNDC can be found on the HFS website.
If you are a BCBSIL independently contracted provider who submitted a BCBSIL Medicaid claim that was denied recently forinvalid NDC, please resubmit your claim after validating that any NDC codes billed are appropriate for the services renderedand also active for the date(s) of service. A timely filing waiver has been temporarily granted to allow impacted providers toresubmit the claim(s).
This information is for educational purposes only. Providers are instructed to bill claims in accordance with BCBSIL and industry standards and based upon services rendered asdocumented in the medical record.
Medi-Span is a registered trademark of Wolters Kluwer Clinical Drug Information, Inc., a separate and independent company that provides information and point of care solutions forthe health care industry. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by Wolters Kluwer Clinical Drug Information, Inc.If you have any questions about the products or services they offer, you should contact the company directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Crossand Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Additional Code Auditing Software Implementation Rescheduled for May 21, 2017
On Dec. 21, 2016, Blue Cross and Blue Shield of Illinois (BCBSIL) published a News and Updates notification regardingadditional code auditing software that was originally scheduled for implementation as of April 23, 2017. BCBSIL hasrescheduled this additional code auditing software implementation for May 21, 2017.
As noted in the previous announcement, this software will further enhance the auditing of professional and outpatient facilityclaims for correct coding according to Healthcare Common Procedure Coding System (HCPCS), Current ProceduralTerminology (CPT®) and Centers for Medicare & Medicaid Services (CMS) guidelines. Upon implementation, providers mayuse the Claim Inquiry Resolution tool, available on the AvailityTM Web Portal, to research specific claim edits.
The above notice does not apply to government programs claims.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals.Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendorssuch as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Crossand Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2017, and April 1, 2017
DRUG LIST (FORMULARY) CHANGESBased on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, someadditions, revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions were made to the Blue Cross and Blue Shield of Illinois (BCBSIL)drug lists. Changes that were effective Jan. 1, 2017, and changes that were effective as of April 1, 2017, are outlined below.
Drug List Updates (Coverage Additions) – As of April 1, 2017
Preferred Brand1 Drug Class/Condition Used For
Basic (formerly known as Standard) Drug List
Invokamet XR Diabetes
Soolantra Topical/Rosacea
Enhanced (formerly known as Generics Plus) Drug List
Soolantra Topical/Rosacea
Performance Drug List
Amlodipine Besylate/Atorvastatin Calcium 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
High Blood Pressure
Clindamycin/Benzoyl Peroxide 1-5% gel Acne
Clindamycin Phosphate 1% gel Topical Anti-infective
Enstilar Topical Steroid
Fenofibrate 40 mg, 120 mg tablet High Cholesterol
Fenofibrate Micronized 200 mg capsule High Cholesterol
Gatifloxacin 0.5 % ophthalmic solution Ophthalmic Anti-infective
Hydrocodone Bitartrate/Acetaminophen 10-325 mg/15 mL solution Pain
Invokamet XR Diabetes
Pramipexole Dihydrochloride ER 3.75 mg Parkinson’s Disease
Rayaldee Hyperparathyroidism
Renvela Kidney Disease
Rubraca Oncology
Soolantra Topical/Rosacea
Tretinoin 0.05% cream Acne
Triamcinolone Acetonide 0.5% ointment Topical Steroid
Performance Select Drug List
Acanya Acne
Amlodipine Besylate/Atorvastatin Calcium 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
High Blood Pressure
Belviq XR Weight Loss
BromSite Ophthalmic NSAID
Clindamycin/Benzoyl Peroxide 1-5% gel Acne
Clindamycin Phosphate 1% gel Topical Anti-infective
Edarbi High Blood Pressure
Edarbyclor High Blood Pressure
Enstilar Topical Steroid
Fenofibrate 40 mg, 120 mg tablet High Cholesterol
Fenofibrate Micronized 200 mg capsule High Cholesterol
Gatifloxacin 0.5 % ophthalmic solution Ophthalmic Anti-infective
Hydrocodone Bitartrate/Acetaminophen 10-325 mg/15 mL solution Pain
Invokamet XR Diabetes
Lomaira Weight Loss
Metronidazole topical cream, gel and lotion (0.75%) Topical Anti-infective
Onexton Acne
Pramipexole Dihydrochloride ER 3.75 mg Parkinson’s Disease
Rayaldee Hyperparathyroidism
Rubraca Oncology
Silenor Insomnia
Soolantra Topical/Rosacea
Taclonex Topical Steroid
Tretinoin 0.05% cream Acne
Triamcinolone Acetonide 0.5% ointment Topical Steroid
Drug List Updates (Revisions/Exclusions) – As of April 1, 2017
Non-Preferred Brand1 Drug Class/Condition Used For Generic Preferred Alternative(s)2 Preferred Brand Alternative(s)1,2
Basic (formerly known as Standard) Drug List Revisions
Daklinza Hepatitis C N/A Harvoni, Epclusa, Sovaldi
Performance Drug List Exclusions
Daklinza Hepatitis C N/A N/A
Sitavig Antiviral N/A N/A
Performance Select Drug List Exclusions
Sitavig Antiviral N/A N/A
Drug List Updates (Coverage Additions) – As of Jan. 1, 2017
Preferred Brand1 Drug Class/Condition Used For
Basic (formerly known as Standard) Drug List
Aubagio Multiple Sclerosis
Avonex Multiple Sclerosis
Axiron Low Testosterone
Descovy Antivirals/HIV
Epclusa Hepatitis C
Genvoya Antivirals/HIV
Odefsey Antivirals/HIV
Otezla Psoriasis/Psoriatic Arthritis
Stiolto Respimat COPD, Emphysema
Vonvendi Hemophilia
Enhanced (formerly known as Generics Plus) Drug List
Aubagio Multiple Sclerosis
Avonex Multiple Sclerosis
Axiron Low Testosterone
Descovy Antivirals/HIV
Epclusa Hepatitis C
Genvoya Antivirals/HIV
Odefsey Antivirals/HIV
Otezla Psoriasis/Psoriatic Arthritis
Stiolto Respimat COPD, Emphysema
Vonvendi Hemophilia
Xarelto DVT, Stroke, Embolism Prophylaxis
Drug List Updates (Revisions/Exclusions) – As of Jan. 1, 2017
Non-Preferred Brand1 DrugClass/ConditionUsed For
Generic PreferredAlternative(s)2
Preferred Brand Alternative(s)1,2
Basic (formerly known as Standard) Drug List Revisions
Androderm 2 mg/24hr, 4 mg/24hr Low Testosterone Testosterone Axiron
Enhanced (formerly known as Generics Plus) Drug List Revisions
Androderm 2 mg/24hr, 4 mg/24hr Low Testosterone Testosterone Axiron
Cuprimine Wilson’s Disease,Cystinuria
N/A Depen
Roche Accu-Chek Active, Aviva, Aviva Plus,Compact, Smartview, Roche Accutrend
Diabetic Supplies N/A Bayer Ascensia Autodisc,Breeze2, Contour, ContourNext
DISPENSING LIMIT CHANGESThe BCBSIL prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on U.S. Food and DrugAdministration (FDA) approved dosage regimens and product labeling.
Effective April 1, 2017:
Drug Class and Medication(s)1 Dispensing Limit(s)
Basic (formerly known as Standard) and Performance Drug List Changes
Misc
Diclegis 120 tablets per 30 days
Rayaldee 60 grams per 180 days
PCSK9
Repatha 140 syringe 2 per 28 days
Repatha 140 autoinjector 2 per 28 days
Selective Serotonin Inverse Agonist (SSIA)
Nuplazid 60 tablets per 30 days
Therapeutic Alternatives
Doxepin 5% cream 45 grams per 180 days
levorphanol 120 tablets per 30 days
Vanatol LQ 1000 mLs per 30 days
Vanos 60 grams per 180 days
Enhanced (formerly known as Generics Plus) Drug List Changes
Therapeutic Alternatives
Doxepin 5% cream 45 grams per 180 days
Performance Select Drug List Changes
PCSK9
Repatha 140 syringe 2 per 28 days
Repatha 140 autoinjector 2 per 28 days
Selective Serotonin Inverse Agonist (SSIA)
Nuplazid 60 tablets per 30 days
Effective Jan. 1, 2017:
Drug Class and Medication(s)1 Dispensing Limit(s)
Basic (formerly known as Standard) Drug List and Enhanced (formerly known as Generics Plus) Drug List Changes
Actinic Keratosis (Diclofenac/Fluorouracil/Imiquimod/Ingenol)
Carac/Fluorouracil 30 grams per 180 days
Efudex cream 240 grams per 180 days
Fluoroplex 60 grams per 180 days
Solaraze Gel 300 grams per 180 days
Tolak 40 grams per 180 days
Antifungal (Onychomycosis)
Jublia 4 mLs per 30 days
Kerydin 4 mLs per 30 days
Onmel 30 tablets per 30 days
Penlac 6.6 mLs per 30 days
Sporanox 100 mg 120 capsules per 30 days
Sporanox Oral Solution 1200 mLs per 30 days
Buprenorphine, Buprenorphine-Naloxone
Suboxone 4/1 30 films per 30 days
Zubsolv 2.9/7.1, 5.7/1.4, 11.4/2.9 30 tablets per 30 days
Fluocinonide
Vanos 120 grams per 180 days
Irritable Bowel Syndrome with Diarrhea
Lotronex 0.5 mg, 1 mg 60 tablets per 30 days
Northera
Northera 100 mg 450 tablets per 30 days
Northera 200 mg, 300 mg 180 tablets per 30 days
Opioid Antidote
Evzio 1 box (2 injectors) per 90 days
Pain
Xartemis QL 120 tablets per 30 days
Rayos
Rayos 1 mg, 2 mg, 5 mg 30 tablets per 30 days
Therapeutic Alternatives
Absorica 60 capsules per 30 days
Amrix 30 capsules per 30 days
Ativan 0.5 mg 30 tablets per 30 days
Ativan 1 mg, 2 mg 150 tablets per 30 days
Bupap 180 tablets per 30 days
Cambia 9 packets per 30 days
Cardizem CD 30 capsules per 30 days
Cuprimine 480 capsules per 30 days
Daraprim 73 per 28 days
Dexpak 6 day 21 tablets per 90 days
Dexpak 10 day 35 tablets per 90 days
Dexpak 13 day 51 tablets per 90 days
Durlaza 30 capsules per 30 days
Fortamet 500 mg 150 tablets per 30 days
Fortamet 1000 mg 60 tablets per 30 days
Glumetza 500 mg, 1000 mg 120 tablets per 30 days
Pandel 80 grams per 90 days
Primlev 5/300 360 tablets per 30 days
Primlev 7.5/300 240 tablets per 30 days
Primlev 10/300 180 tablets per 30 days
Sitavig 2 tablets per 180 days
Spritam 250 mg, 500 mg, 1000 mg 60 tablets per 30 days
Spritam 750mg 120 tablets per 30 days
Vivlodex 30 capsules per 30 days
Zyflo 120 tablets per 30 days
Zyflo CR 120 tablets per 30 days
UTILIZATION MANAGEMENT PROGRAM CHANGES
Effective April 1, 2017, the following changes were applied:The Cox-2/NSAID-GI Protectant Step Therapy (ST) program changed its name to: Combination GI Protectant. All targeted medications and program criteria effective Jan.1, 2017, remain the same.Several drug categories and/or targeted medications were added to the current Prior Authorization (PA) and Step Therapy (ST) programs for standard pharmacy benefitplans, upon renewal for most members. As a reminder, please review your patient’s drug list for the indicator listed in the Prior Authorization or Step Therapy column, asnot all programs may apply. Information on prescription drug lists is available on our public website at bcbsil.com under the Member Services tab. You may ask your patientwhat drug list they have, or contact customer service using the number on the member’s ID card. Members may look up their own information on myprime.com.
Drug categories added to current pharmacy PA standard programs, effective April 1, 2017:
Drug Category Targeted Medication(s)1
Basic (Standard), Performance and Performance Select Drug Lists
Regranex Regranex
Selective Serotonin Inverse Agonist (SSIA) Nuplazid
Strensiq Strensiq
Targeted drugs added to current pharmacy PA standard programs, effective April 1, 2017:
Drug Category Targeted Medication(s)1
Basic (Standard) and Performance Drug Lists
Therapeutic Alternatives Doxepin cream, levorphanol, Vanatol LQ, Vanos
Drug categories added to current pharmacy ST standard programs, effective April 1, 20173:
Drug Category Targeted Medication(s)1
Basic (Standard) and Performance Drug Lists
Gabapentin ER Gralise, Horizant
Insulin Combination Agents Soliqua, Xultophy
Methotrexate Injectable Otrexup, Rasuvo
Performance Select Drug List
Gabapentin ER Gralise, Horizant
Insulin Combination Agents Soliqua, Xultophy
Effective Feb. 15, 2017, the Opioid Dependence PA program was discontinued. Drugs to treat opioid dependence, such as Suboxone, no longer require a PA.Effective Jan. 1, 2017, the following changes were applied:
The Cox-2/NSAID-GI Protectant ST program removed the target drug Celebrex from the program. Grandfathering was also removed from the program criteria. Memberson a current drug regimen are included in program participation.
The Biologic Immunomodulators ST program became a standard PA program. Members on a current drug regimen were grandfathered from participation. Additionally, thetarget drug Otezla from the old ST program became an independent standard PA program. Members with a recent prescription history for this medication are alsograndfathered from participation.Several drug categories were removed from the Therapeutic Alternatives standard PA program and separated into independent standard PA programs:
Antifungal-Onychomycosis Agents (2016 drug targets - Onmel, Sporanox)Topical Lidocaine (2016 drug targets – lidocaine ointment, Lidoderm)Northera (2016 drug target – Northera)Opioid Antidote (2016 drug target – Evzio)Rayos (2016 drug target – Rayos)
PA and ST programs for standard pharmacy benefit plans correlate to the member’s drug list and not all standard programs may apply. Be sure to review your patient’s druglist for the indicator listed in the Prior Authorization or Step Therapy column. Several drug categories and/or targeted medications were added to the current PA and ST programs for standard pharmacy benefit plans, upon renewal for most members.
Drug categories added to current pharmacy PA standard programs, effective Jan. 1, 2017:
DrugCategory
Targeted Medication(s)1
Basic (Standard), Enhanced (Generics Plus) and Performance Drug Lists
ActinicKeratosis
Aldara, Carac/Fluorouracil (2016 target in Therapeutic Alternatives PA), Efudex, Fluoroplex, Picato, Solaraze/genericdiclofenac gel (2016 target in Therapeutic Alternatives PA), Tolak, Zyclara
Effective Oct. 1, 2016, the Ocaliva PA program was added for standard pharmacy benefit plans, upon renewal for most members. This program includes the target drugOcaliva.
Targeted mailings were sent to members affected by basic drug list deletions, dispensing limit, prior authorization and the GI Protectant ST program changes per our usualprocess of member notification prior to implementation. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our website atbcbsil.com/provider.
1Third party brand names are the property of their respective owners2These lists are not all inclusive. Other medications may be available in this drug class.3Members on a current drug regimen will be grandfathered from participation in the ST program.
Prime Therapeutics LLC, a separate company, is a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent BlueCross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms setforth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details,including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Reminder: Pharmacy Program Benefit Changes, Effective Jan. 1, 2017
Blue Cross and Blue Shield of Illinois (BCBSIL) implemented pharmacy benefit changes on Jan. 1, 2017, for some members with prescription drug benefits administered throughPrime Therapeutics.*
Based on claims data, letters are being sent from BCBSIL to alert members who may be affected by one, or more, of the 2017 pharmacy benefit changes. A summary of thechanges, as outlined in the member letters, is included below for your reference.
Drug List Changes and Medication Coverage Revisions/Exclusions – Some members’ plans may now be based on a new drug list:
1. New Performance Drug List and Performance Select Drug Lists – Some members may have one of these new drug lists, which are closed drug lists, meaning they will listcovered medications only. As a result, some medications will move to a higher copay/coinsurance payment tier and select drugs/drug classes may be excluded from coverage.Additionally, if your patient had a prior authorization approval for a drug that is now excluded from coverage, you can submit a drug list coverage exception request to BCBSIL.Based on this change, your patient may ask you about therapeutic alternatives.
2. Enhanced Drug List (formerly known as Generics Plus Drug List) – Some members may move to this drug list, and as a result, select medications may move to a highercopay/coinsurance payment tier. Based on this change, your patient may ask you about generics or lower cost alternatives.
3. Some members may also be affected by annual or quarterly drug list changes, such as drugs moving to a higher payment tier or excluded from coverage. Based on thischange, your patient may ask you about therapeutic or lower cost alternatives.
4. The Standard Drug List is now known as the Basic Drug List.5. As a reminder, medications that have not received U.S. Food and Drug Administration (FDA) approval are not covered under the BCBSIL pharmacy benefit.
Utilization Management Program Changes – Some members’ plans may now be subject to new prior authorization and step therapy programs and/or dispensing limits. If yourpatient is taking any of the selected medications included in these programs, your patient may need to meet certain criteria, such as an approval of a prior authorization request,for coverage consideration. Additionally, these programs may correlate to your patient’s drug list. (For example, if a particular drug is not included on the member’s drug list, aformulary exception request would need to be submitted, rather than a PA request, for coverage consideration.)
Medication Coverage Exclusions – Under the pharmacy benefit, some member’s plans may exclude from coverage the following: weight loss drugs, non-sedatingantihistamines, compound medicines, brand-name proton pump inhibitors (PPIs), drugs that have not received FDA approval and prescription drugs with an over the counter(OTC) equivalent available.
Specialty Drug Changes – Starting Jan. 1, 2017, regardless of plan effective date, HMO individual benefit plans offered on/off the Illinois Health Insurance Marketplace nowrequire the member to obtain self-administered specialty medications from a specialty pharmacy included in the BCBSIL HMO specialty pharmacy network for coverageconsideration under the pharmacy benefit. To help your patients receive appropriate benefits, be sure their self-administered specialty medications are filled at a BCBSIL preferredspecialty pharmacy.
Starting Jan. 1, 2017, members with an individual benefit plan offered on/off the Illinois Health Insurance Marketplace who are using a drug manufacturer’s coupon or copay cardcannot have the specialty drug payment apply to their plan deductible or out-of-pocket maximum, unless the coupon is a permitted third-party cost sharing payment. Your patientscan contact BCBSIL if they have questions about this change.
Pharmacy Network Changes – Some members’ plans may experience changes to the pharmacy network:
1. CVS Exclusion – Effective Jan. 1, 2017, CVS pharmacies® and CVS pharmacies in a Target® store were removed from most members’ pharmacy networks.2. New Pharmacy Networks – Some members’ plans may move to a preferred network where prescriptions filled at these preferred tiered independently contracted pharmacies
offer the lowest copay/coinsurance amounts. 90-day supplies can also be filled at either these preferred tiered pharmacies or through mail order for coverage consideration.
Members who continue to fill prescriptions at a pharmacy no longer in their network will pay more. In most cases, no action is required on your part for any of these pharmacynetwork changes as members can easily transfer prescriptions to a nearby in-network pharmacy. If your office stores pharmacy information on your patients’ records, you maywant to ask your patient which pharmacy is their new in-network choice.
Retail and Mail Order Supply Limit Changes – Some members’ plans may include a 90-day supply limit for covered prescriptions filled at a retail pharmacy or through mailorder.
If your patients have questions about their pharmacy benefits, please advise them to contact the Pharmacy Program number on their member ID card. Members also mayvisit bcbsil.com and log in to Blue Access for MembersSM for a variety of online resources.
*Changes to be implemented, as applicable, based on the member’s 2017 plan renewal, or new plan effective date, unless otherwise noted. These changes do not apply to members with Medicare Part D or Medicaid coverage.
Prime Therapeutics LLC, a separate company, is a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. In addition, contracting pharmacies are contractedthrough Prime Therapeutics. The relationship between BCBSIL and contracting pharmacies is that of independent contractors. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
A “preferred” or “participating” pharmacy has a contract with BCBSIL or BCBSIL’s pharmacy benefit manager (Prime Therapeutics) to provide pharmacy services at a negotiated rate. The terms “preferred” and “participating” should not be construed as arecommendation, referral or any other statement as to the ability or quality of such pharmacy. Please note that changes to participating pharmacies may be made in the future.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. The listing of any particular drug or classification of drugsis not a guarantee of benefits. This is only a brief summary of some plan benefits. For more complete details, including benefits, limitations and exclusions, members should refer to their certificate of coverage. Regardless of benefits, the final decision aboutany medication and pharmacy choice is between the member and their health care provider.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Insurers Required by Centers for Medicare & Medicaid Services (CMS) to Conduct Auditfor Affordable Care Act (ACA) Risk Adjustment Program
CMS requires an annual Initial Validation Audit (IVA) to ensure accurate data is used when assessing the payment transfersfor the ACA Risk Adjustment (RA) program. Therefore, to comply with the IVA requirement, BCBSIL is asking for thecooperation and participation of all independently contracted providers in its networks.
Insurers are required to hire an independent auditor to perform the requirements of the IVA. Tactical ManagementIncorporated (TMI) is the auditor selected by BCBSIL to retrieve medical records for the IVA, which is expected to begin inJune 2017. The RA program applies to all ACA-compliant individual and small group plans, including plans that are availableon and off the Exchange, and conducts a calculation based on enrollee risk. As a reminder, enrollee risk is calculated basedon the diagnosis codes submitted on a claim, as well as through supplemental codes captured through medical recordreview. As BCBSIL independently contracted providers, you may be asked to provide medical records directly to TMI in orderto validate all of the diagnosis codes submitted on claims, which are then used in the RA calculation. Please respond to theserequests in a timely manner. It is important to have a successful audit to help improve the health care delivery system.
The IVA will be performed on a sample of members enrolled in ACA-compliant plans. TMI will seek to validate medical claimsof the sampled members from the previous calendar year. For example, this audit will be conducted in 2017, but will reviewclaims with dates of service in 2016. Please be aware some of these claims may have been paid in 2017 and are likely to beincluded in the IVA sample.
We understand this is a very busy time. However, in an effort to comply with the CMS requirements, we appreciate your fullsupport and cooperation as you receive requests from TMI and deliver the requested medical record(s) in a timely manner.
We want to help ensure that the valuable care you provide to your patients every day is accurately reflected in the data youprovide to auditors for CMS records.
If you have any questions, please contact your assigned BCBSIL Provider Network Consultant (PNC).
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
ClaimsXtenTM Announces Software Version Upgrade
Beginning on or after July 17, 2017, Blue Cross and Blue Shield of Illinois (BCBSIL) will perform a system software upgradefrom version 4.4 to version 6.0 for ClaimsXten. Key enhancements related to this upgrade include, but are not limited to:
Version 6.0 uses XML formatting with flexibility at the header and line levels during claim processing.The Clear Claim ConnectionTM (C3) tool will have a new look and feel with new data fields for greater claim specificity,and the ICD code set default will be ICD-10.Clinical edit clarifications and related sources will continue to be available.
An instruction document will be available by July 17, 2017, to assist users with learning the navigation in C3. Watch the Newsand Updates for additional details and announcements.
For more information about ClaimsXten, including answers to frequently asked questions, refer to the Clear ClaimConnection page in the Education and Reference Center/Provider Tools section of our website atbcbsil.com/provider.Information also may be published in upcoming issues of the Blue Review.
ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products andservices.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Crossand Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
ClaimsXtenTM Quarterly Updates
New and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS)codes are periodically added to or deleted from the ClaimsXten code auditing tool software by the software vendor on aquarterly basis and are not considered changes to the software version. Blue Cross and Blue Shield of Illinois (BCBSIL) willnormally load this additional data to the BCBSIL claim processing system after receipt from the software vendor and willconfirm the effective date via the News and Updates section of the BCBSIL Provider website. Advance notification of updatesto the ClaimsXten software version also will be posted on the BCBSIL Provider website.
To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process,you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool. Refer to the Clear ClaimConnection page in the Education and Reference Center/Provider Tools section of our Provider website for additionalinformation on gaining access to C3, as well as answers to frequently asked questions about ClaimsXten. Updates may beincluded in future issues of the Blue Review.
ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products andservices.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Crossand Blue Shield Plans.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue ShieldAssociation
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Has your information changed? Let us know!
When seeking health care services, our members often rely upon the information in our online Provider Finder®. Inparticular, potential patients may use this online tool to confirm if you or your practice is a contracted in-networkprovider for their health care benefit plan. Other providers may use the Provider Finder when referring their patientsto your practice.
We encourage you to check your own information in the Provider Finder – look for the link on our Provider websiteHome page at bcbsil.com/provider. Is your online information accurate? If changes are needed, it’s important that youinform BCBSIL as soon as possible.
USE OUR ONLINE CHANGE REQUEST FORMSYou can request most changes to your information online by using one of our electronic change request forms. Visitthe Network Participation/Update Your Information section of our Provider website to access instructions along withlinks to each type of form. Currently, there are three different change request forms to help you organize yourinformation, as follows:
1. Request Demographic Information Changes
Use this form to request changes to your practice information currently on file with BCBSIL (such as address, emailor NPI). You may specify more than one change within your request as long as all changes relate to the same billing(Type 2) NPI. As a participating provider, your NPI(s) should already be on file with BCBSIL. You may use this onlineform to request changes, such as deactivation of an existing NPI.
2. Request Addition of Provider to Group
Use this form to notify BCBSIL when a new individual provider joins your practice. Please remember that newproviders are subject to credentialing review and will not be effective until the process is completed and the provideris approved.
3. Request Removal of Provider from Group
Use this form to notify BCBSIL when an individual provider is leaving any or all of your practice locations.
Please note that changes are not immediate upon submission of an online change request form. Processing can takea minimum of 30 business days. If you would prefer to mail or fax your changes to BCBSIL, there is a downloadableProvider Information Change Request Form in the Network Participation/Update Your Information section of ourProvider website, under the Related Resources. If you have any questions or need assistance, contact ProviderNetwork Operations at [email protected].
EXCEPTIONS TO THE ONLINE REQUEST PROCESSThe following types of changes are more complex and require special handling:
Multiple changes, especially changes involving more than one billing (Type 2) NPI – These should besubmitted via email to [email protected].
Tax ID changes that may, or may not, involve Legal Business Name changes – This type of change oftenrequires a new contract. To request a contract application, visit the Network Participation/Contracting section ofour Provider website. You may also want to discuss this with your assigned Provider Network Consultant (PNC).
Ancillary provider changes – Skilled nursing facilities, home health agencies, hospice, home infusion therapy,durable medical equipment (DME) suppliers, orthotics and prosthetics, dialysis centers, private duty nursingagencies and other ancillary providers may request changes by sending details to [email protected],or by calling 312-653-4820.
bcbsil.com/providerBlue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross andBlue Shield Association
A newsletter for contracting institutional and professional providers
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.