october 2009 etwork news - premera blue cross · learn more about the review process ... surgical...

Company Updates

ContentsCompany Updates page 1-3

Claims & Payment Policy Updates page 4-5

BlueCard Updates page 4

Online Services Updates page 6-7

Medical Policy Updates page 8-9

Pharmacy Updates page 9

Administrative Resources page 10-11

An Independent Licensee of the Blue Cross Blue Shield Association

Our partnership

with Starbucks

further reinforces

Premera’s success

serving members.

October 2009

newsnetwork

Premera Wins Starbucks Account

Starbucks has selected Premera Blue Cross as their new health plan administrator. After evaluating many national health

carriers, they determined Premera can best meet the needs of Starbucks’ partners and their families. Effective Oct. 1, 2009, Starbucks will begin relying upon Premera Blue Cross for its nationwide health plan administration, including medical, dental, and pharmacy.

We will serve as Starbucks’ sole PPO health plan. Starbucks had been a client of Aetna for more than 15 years.

Our partnership with Starbucks further reinforces Premera’s success serving members, from individuals to the largest and most complex national accounts. In addition to Starbucks, Premera serves Microsoft, Weyerhaeuser, the Washington Education Association, Alaska Air Group, Paccar, and many others.

Starbucks said they selected Premera for our local presence, strong national reach, extensive network of quality physicians and hospitals, best in class customer service,

technology solutions, and a greater opportunity for health care savings.

Learn more about the review process for maternity ultrasounds for Starbucks members in the Administrative Resources section on page 10. For more information about Starbucks’ membership and how it may impact providers, check the provider portal at premera.com/provider and future issues of Network News.

News from Premera Blue Cross Blue Shield of Alaska

October 2009 Alaska Network News 1

2 October 2009 Alaska Network News

Company Updates

New Payment Policy Supports Patient Safety

Figure 1: CMS List of Serious Adverse Events Premera is adopting Jan. 1, 2010

National Quality ForumEvent Category Summarized Measure Description

Surgical Events Surgery performed on the wrong body part (aka Never Event, Diag code E876.5)

Surgery on wrong patient (aka Never Event, Diag code E876.5)

Wrong surgery on a patient (aka Never Event, Diag code E876.5)

Foreign object left in patient after surgery

Post-operative death in normal health patient

Product or Device Death/disability associated with use of contaminated drugs, Events devices or biologics

Death/disability associated with use of device other than as intended

Death/disability associated with intravascular air embolism

Patient Protection Events Infant discharged to wrong person

Death/disability due to patient elopement

Patient suicide or attempted suicide resulting in disability

Care Management Events Death/disability associated with medication error

Death/disability associated with incompatible blood

Maternal death/disability with low risk delivery

Death/disability associated with hypoglycemia

Death/disability associated with hyperbilirubinemia in neonates

Stage 3 or 4 pressure ulcers after admission

Death/disability due to spinal manipulative therapy

Wrong donor sperm or wrong egg w/artificial insemination

Environment Events Death/disability associated with electric shock

Incident due to wrong oxygen or other gas

Death/disability associated with a burn incurred within facility

Death/disability associated with a fall within facility

Death/disability associated with use of restraints within facility

Criminal Events Impersonating a heath care provider (i.e., physician, nurse)

Abduction of a patient

Sexual assault of a patient within or on facility grounds

Death/disability resulting from physical assault within or on facility grounds

CMS Additional Events Catheter-associated UTI

Surgical Site Infection Following: Coronary Artery Bypass Graft (CABG) - Mediastinitis

Bariatric Surgery for Obesity Laparoscopic Gastric Bypass Gastroenterostomy

Certain Orthopedic Procedures involving Spine, Neck, Shoulder, Elbow Deep Vein Thrombosis /Pulmonary Embolism – in knee or hip replacement

Premera continues to plan for a new Serious Adverse Event (SAE) Payment Policy to be effective no

later than Jan. 1, 2010. This policy is part of a nationwide effort to promote higher quality through reporting of adverse patient safety events. Once this payment policy becomes effective, Premera will not reimburse providers for these events. Below are questions and answers related to the policy.

What is a Serious Adverse Event? What is a Never Event?

A serious adverse event is defined as a hospital injury caused by medical management (rather than the underlying disease) that prolonged the hospitalization, and/or produced a disability at the time of discharge. Serious adverse events are identified by POA (“present on admission”) indicators on claims.

A never event is defined the same way, but is so named as a subset of events that should never occur. These claims are identified by the use of diagnosis code: E876.5. There are three cases of never events: ◗ Surgery on wrong patient ◗ Surgery on wrong body part ◗ Wrong surgery

Premera will follow the list of serious adverse and never events as defined by the Centers for Medicare & Medicaid Services (CMS). See Figure 1 for a summary of measures. For a specific list, refer to cms.hhs.gov.

Who is affected by the SAE Payment Policy?

The SAE Payment Policy will apply to all acute care hospitals and exempt


Company Updates

Code Reason for Code

Y Diagnosis was present at time of inpatient admission.

CMS will pay the CC/MCC DRG for those selected HACs that are coded as “Y” for the POA Indicator.

N Diagnosis was not present at time of inpatient admission.

CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “N” for the POA Indicator.

U Documentation insufficient to determine if the condition was present at the time of inpatient admission.

CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “U” for the POA Indicator.

W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

CMS will pay the CC/MCC DRG for those selected HACs that are coded as “W” for the POA Indicator.

1 Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A.

CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “1” for the POA Indicator. The “1” POA Indicator should not be applied to any codes on the HAC list. For a complete list of codes on the POA exempt list, see page 110 of the Official Coding Guidelines for ICD-9-CM. cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf

Figure 2: Present on Admission (POA) Indicators

hospital units that have signed a Premera Participating Hospital Agreement.

What are the key deliverables?

Beginning Jan. 1, 2010, Premera will require facilities to provide a POA (“present on admission”) indicator on all applicable claims. A POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the “ICD 9-CM Official Guidelines for Coding and Reporting”). See Figure 2 for a list of POA indicators.

Other considerations

Participating hospitals and physicians may not bill members for services associated with treatment of a serious adverse event. Members are held harmless for these events.

Premera recognizes some rural facilities were granted exception status by CMS and currently are not required to submit POAs. However, as a commitment to improve safety at all hospitals for members, all Blues plans are required to obtain POAs from all facilities. In the coming months, Premera will collaborate with those rural facilities that currently do not submit POAs to identify processes for submitting POAs.


Claims & payment poliCy Updates

Privacy Requirements Strengthened

Many providers are already aware that the American Recovery and Reinvestment Act of 2009 (ARRA) includes the Health Information Technology for Economic and Clinical Health (HITECH) Act.

The HITECH Act expands and tightens the security and privacy provisions of HIPAA and has multiple requirements stretching over the next few years. The new notification requirements for breaching unsecured Protected Health Information (PHI) began Sept. 15, 2009. (Note: This work is independent of compliance with HIPAA 5010.)

Just like your organization, Premera is committed to the secure handling of members’ personal information and is busy implementing the system enhancements necessary to comply with the new requirements.

HIPAA 5010 UpdateThe US Department of Health and

Human Services (HHS) has issued the final rule for adoption of both a new HIPAA electronic transaction version and the transition to the ICD-10 coding structure:

HHS has published the final rule to adopt the 5010 version for the related health claim standard transactions in order to resolve issues that exist within the current 4010A1 version that do not currently support the extended field lengths for the ICD-10 coding structure.

Following are key dates for the transition from version 4010A1 to 5010: ◗ Payers must be ready to begin Trading

Partner testing on Jan. 1, 2011 ◗ Compliance testing to be completed by

Dec. 31, 2011 ◗ Full transition compliance for all

parties expected by Jan. 1, 2012Watch for future updates on the

provider portal and in future issues of EDI News and Network News.

BlueCard Updates

Provider Satisfaction Surveys: Improving BlueCard Services

We recognize that serving patients who are members of other Blue Plans through

the BlueCard program presents some unique challenges. BlueCard Provider Satisfaction Surveys are one way we seek to understand and address provider service issues and hear provider feedback.

Provider Satisfaction Surveys are conducted twice per year by an independent research firm to collect feedback and identify improvement

opportunities. Separate survey results are reported for Washington and Alaska providers.

These are some of the recent improvements we have implemented to address your feedback: ◗ Enhancing the provider portal for

BlueExchange ◗ • Fewer required search fields ◗ • More accurate search results ◗ • More benefits information

provided

◗ Enhancing technology that enables us to transmit scanned images of claims and medical records to other Blue Plans through secure, real-time transactions (“BlueSquared”)

If you are contacted to participate in the BlueCard Provider Satisfaction Surveys, we encourage you to complete the survey and help us identify what we are doing well and what we could be doing better.


Claims & payment poliCy Updates

Payment Policy Updates New Patient Edit

In a January 2009 News Brief article we notified providers about updates to our claims editing software, which included an update to the New Patient edit. This is a reminder that we edit for the appropriate use of new patient and established patient codes as defined by American Medical Association’s (AMA) Current Professional Terminology (CPT) guidelines. Claims are denied for established patients if they are billed as new patients. If you have questions regarding the definitions and coding guidelines of new and established patients please refer to the AMA CPT codebook.

Surgical Trays as Medicare Status B

Beginning on or near Jan. 18, 2010, we will begin applying standard editing for Surgical Trays (A4550). This code is considered a Medicare Status B code and will no longer be eligible for separate reimbursement.

If you have any questions or require additional information, please call Physician and Provider Relations at 1-800-722-4714; option 4.

Reduce Audit Risk: Appropriate use of Prolonged Service Codes

Prolonged Service Codes (99354-99357) should be used to report services by a physician that are beyond the usual services of an E&M code, and must represent direct face-to-face patient contact. Per Medlearn Matters MM5972, “Documentation is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill.” Just noting the physician spent an extra 60 minutes with a patient is not adequate documentation to show medical necessity and bill for extra time.

When history, examination, and medical decision-making are the determinants of the appropriate E&M code, Prolonged Service Codes can be used with any E&M code. When time is the key factor in choosing the E&M service level, Prolonged Service Codes can only be used with the highest E&M code level (99205 or 99215). Prolonged service of less than 30 minutes is not separately reported because the work involved is included in the total work for the E&M codes.

For additional information about appropriate Prolonged Service Code billing, please refer to the “Revisions

to Prolonged Services” and “Deletion of Modifier 21” in the CPT Assistant July 2009/Volume 19 Issue 7, and to the Evaluation and Management (E/M) Services Guidelines in the 2009 Current Procedural Coding Expert manual.

If you have any questions or require additional information, please call Physician and Provider Relations at 1-800-722-4714, option 4. Providers can access all current Premera Payment Policies at premera.com/provider, under Reference Info.

Multi Channel Lab Pricing Guidelines

An organ or disease-oriented panel of laboratory tests should be billed using the appropriate panel code rather than billing separate codes for each component of the panel. In the event the components are billed instead, the component tests may not be reimbursed. In order to be reimbursed for those services, the provider should submit each claim with the panel code in place of the individual component codes where appropriate. Any laboratory service not included under the panel code should continue to be billed using its individual code.

Organ or disease-oriented panels and their component tests are defined by the AMA using CPT codes.


Watch our Provider Portal video tours available at the

WorkSMART Institute site located at https://worksmart.onehealthport.com

online serviCes Updates

Helpful Information About Our Real-Time Estimates/Claims Tool

This new tool allows providers to give patients information about their share of cost at the time

of service and submit real-time claims. For your ease of reference, the tool includes a comprehensive help file with common questions and answers. A recent enhancement of the tool allows you to enter up to four diagnosis codes per line item and generate an estimate for patients with dual coverage when Premera is the primary carrier. (Figure 1 shows an example response of a patient estimate from the new tool.)

Providers can access the new Real-Time Estimates/Claims tool at premera.com/provider by selecting ‘Submit Estimate/Claim’ from the left navigation menu under Tools.

As a contracted provider, you already have access to use the tool to generate estimates. If you submit claims on paper, you can request to enable the real-time claims submission feature by completing and returning the Request to Enable Real-Time Claims Submission form. You can find this form at premera.com/provider under Miscellaneous Forms.

To learn more about navigation and functionality of the tool, watch our video tour at worksmart.onehealthport.com. You will need to sign in with your OneHealthPort secure ID. Click on Collaboration Tools select Training and then select Video Tours of Health Plan Sites.

Helpful Tips:

3Use for Premera Dimensions members

3Set your Internet browser to allow pop-ups

3Do not include the decimal in the diagnosis code

3Create templates for common services to save keying time

3Organize your templates by categories for quick retrieval

3Maximize the screen and reduce scrolling by clicking on the small black arrow located on the left navigation menu

3Use the help file for detailed, step-by-step instructions and more tips

Figure 1: Sample Response


online serviCes Updates

OneHealthPort Organization Administration

In addition to updating your demographic information with Premera, providers also should update information with OneHealthPort. This includes:

◗ Contact information for the organization (address and phone number)

◗ Names of persons authorized to serve as OneHealthPort administrators for the organization

◗ Information about any sub-organizations created under the primary organization name

◗ A list of the organization’s Tax ID numbersTo manage your organization’s OneHealthPort

account, go to onehealthport.com. At the top of the page, in the Subscriber Quick Access bar, click on Manage Your Account. From the Manage Your Account page, select the login button under the For Administrators area. (See Figure 1 for screen shot of OHP Organization Administration Menu.)

Important Note: The OneHealthPort administrator is responsible, on behalf of their organization, for maintaining accurate affiliation and role information so that their subscribers receive access only to online information their organization is entitled to view and manage. The administrator should

immediately remove the subscriber’s affiliation when the subscriber’s employment is terminated. Inaccurate affiliation and role information could allow unauthorized access to protected information.

To change a subscriber’s affiliation, click Modify Subscriber’s Affiliations & Roles on the Subscriber Profile Manager main menu.

Temporary Coverage LettersBeginning Oct. 1, 2009, some Premera members may print a temporary coverage letter using the secure member portal

at premera.com. This new tool allows new enrollees or members who have lost their ID cards to print a temporary coverage letter until they receive a replacement ID card.

This feature is currently only available for Starbucks employees, but will expand to large accounts in January 2010 and all members later in 2010. See Figure 1 for an example of the temporary coverage letter.

Figure 1: OHP Organization Administration Menu

Figure 1: Sample temporary coverage letter


mediCal poliCy Updates

Physicians, Providers and Office Staff

Premera Blue Cross Blue Shield of Alaska medical policies are guides in evaluating the medical necessity of a particular service or treatment. We adopt policies after careful review of published, peer-reviewed scientific literature, national guidelines, and local standards of practice. Since medical technology is constantly changing, we reserve the right to review and update our policies

as appropriate. When there are differences between the member’s contract and medical policy, the member’s contract prevails. The existence of a medical policy does not guarantee that the member’s contract allows the service.

Medical policies are now available at premera.com/provider. Click on the Medical Policies link under Reference Info. If you are not able to obtain the policy from that site and you would like a copy of a particular medical policy, email your request to [email protected]. If you do not have Internet access, call Physician and Provider Relations at 1-800-722-4714, option 4.

Note: All policy numbers begin with CP.MP and are listed here in numeric order.

The following policy changes are effective for dates of service of June 9, 2009 and later:

BC.2.01.15 Intravenous or Subcutaneous Histamine Therapy. This policy has been deleted and will no longer be reviewed.

BC.8.01.36 Extracorporeal Photopheresis as a Treatment of Graft-versus-Host Disease, Autoimmune Disease and Cutaneous T-Cell Lymphoma. Three policy statements added. Extracorporeal photopheresis may be considered medically necessary as a technique to treat late-stage (III/IV) cutaneous T-cell lymphoma. Extracorporeal photopheresis may be considered medically necessary as a technique to treat early stage (I/II) cutaneous T-cell lymphoma that is progressive and refractory to established nonsystemic therapies. Extracorporeal photopheresis is considered investigational as a technique to treat early stage (I/II) cutaneous T-cell lymphoma that is either previously untreated or is responding to established nonsystemic therapies.

PR.8.01.503 Intravenous Immune Globulin Therapy. Policy statement updated. Intravenous immunoglobulin therapy may be considered medically necessary for the off-label indication of any B-cell malignancy that is associated with immune deficiency.

BC.8.02.02 Plasma Exchange (Plasmapheresis). Policy statement updated. Plasmapheresis and plasma exchange may be considered medically necessary for progressive renal failure (as a result of Wegener’s granulomatosis) or when due to anti-basement membrane antibodies (i.e., Goodpasture’s syndrome).

BC.8.03.01 Functional Neuromuscular Stimulation to Provide Ambulation. Policy statement updated. Functional neuromuscular stimulation as an aid for ambulation in post-stroke patients is considered investigational.

PR.1.01.515 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders. Policy statement updated. Oscillatory devices (vest airway clearance system and flutter and acapella devices) may be considered medically necessary for chronic diffuse bronchiectasis.

PR.5.01.521 Pharmacologic Treatment of Neuropathy, Fibromyalgia and Seizure Disorders. Policy statements added. Milnacipran (Salvella™) may be considered medically necessary for the labeled indication of fibromyalgia when certain guidelines are met. Use of milnacipran for other indications is considered investigational.

PR.5.01.603 Epidermal Growth Factor Receptor (EGFR) Inhibitors. Policy statements added and revised. Gefitinib is considered investigational for the treatment of cancer patients. Sorafenib maybe considered medically necessary for treatment of patients with disseminated symptomatic thyroid (medullary) carcinoma; and treatment of patients with clinically progressive or symptomatic

metastatic thyroid (Papillary) carcinoma in patients with nonradioiodine-avid tumors at sites other than central nervous system. Sunitinib may be considered medically necessary for treatment of patients with clinically progressive or symptomatic metastatic thyroid (Papillary) carcinoma in patients with nonradioiodine-avid tumors at sites other than central nervous system; and treatment of disseminated symptomatic thyroid (medullary) carcinoma. Cetuximab, as a single agent or in combination with a platinum-based regimen may be considered medically necessary for the treatment of patients with recurrent, second primary, or metastatic squamous cell carcinoma of the head and neck. Cetuximab may be considered medically necessary for the treatment of patients with recurrent or metastatic NSCLC IIIB (pleural effusion)/IV. K-Ras mutation analysis is considered medically necessary for predicting treatment response to Cetuximab, Panitumumab or EGFR inhibitors if policy guidelines are met.

The following policy changes are effective for dates of service of July 14, 2009 and later:


mediCal poliCy Updates

PR.5.01.605 Medically Necessary Criteria for Pharmacy Edits. Policy statement updated. Modafinil (Provigil®) or Armodafinil (Nuvigil®) may be considered medically necessary for the treatment of sleep apnea, narcolepsy or idiopathic hypersomnia when documented by a sleep study, and multiple sclerosis fatigue.

BC.7.01.69 Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction. Policy criteria updated. Sacral nerve neuromodulation may be considered medically necessary in patients for the treatment of urge incontinence, urgency-frequency, and non-obstructive urinary retention when certain criteria are met.

BC.7.01.116 Radiofrequency Facet Joint Denervation. New policy. Radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints is considered medically necessary when the criteria in the policy guideline section are met. Radiofrequency denervation is considered not medically necessary for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed in the policy guidelines, including but not limited to treatment of thoracic facet or sacroiliac (SI) joint pain. Pulsed radiofrequency denervation is considered investigational for the treatment of chronic spinal/back pain.

The following policy changes are effective for dates of service of July 14, 2009 and later:

pharmaCy Updates

Point-of-Sale Edit Program Expansion Premera has added new review criteria based on clinical

best practices and approval by an independent Pharmacy and Therapeutics Committee. The program is designed to promote appropriate drug selection, length of therapy, and utilization of specific drugs while improving the overall quality of care.

Newly added Point-of-Sale (POS) Program drugs are listed to the right. Drugs may be added or deleted from this list without prior notification. If you have questions concerning the POS Edit Program, please call the Pharmacy Services Center at 1-888-261-1756 of fax us at 1-888-260-9836, Monday through Friday, 8 a.m.-5 p.m. Pacific Time.

Which new edits are included in the Point-of Sale Program?

Effective 9/1/09 Savella (Milnacipran)

Coverage Criteria1. Coverage of Savella may be considered medically necessary in

fibromyalgia patients that have failed a reasonable combination consisting of at least 2 of the following: ◗ a. A tricyclic antidepressant (e.g., amitriptyline) ◗ b. Cyclobenzaprine ◗ c. Tramadol

Plus a trial of gabapentin


administrative Resources

As noted on page 1, Premera Blue Cross will provide nationwide benefit administration including medical, dental and pharmacy to Starbucks employees (“partners”) as part of a self-funding arrangement, effective Oct. 1, 2009.

Starbucks provides comprehensive prenatal and pregnancy-related benefits that are designed to give their partners the medical attention needed during pregnancy. Starbucks Your Care PPO plans cover one routine ultrasound per pregnancy with additional ultrasounds covered only when medically necessary. Starbucks Routine Care PPO plans cover ultrasounds for pregnancy only when medically necessary. Here are a few questions and answers about how the review process for maternity ultrasounds:

Helpful Tips for Submitting an Appeal

Physicians and providers have the right to appeal certain Premera actions. Our dispute resolution

process ensures that we address a complaint or an appeal in a fair and timely manner. In the event you need to file an appeal with Premera, Physician and Provider Appeal Submission forms may be found on premera.com/provider at the following location: Library/Forms/Miscellaneous Forms/Appeal Submission Form.

Please note the following inquiries are considered Correspondence/Claim issues and should be submitted to the

address on the back of the member’s identification card: ◗ Corrected claims ◗ Duplicate claims denials ◗ Claims requests for additional

information ◗ Coordination of benefits ◗ Claims status inquires

When submitting an appeal, please ensure that you complete the form in its entirety, providing the following information: ◗ A detailed description of the issue ◗ The physician or provider position on

the disputed issue ◗ If applicable, all evidence in support of

the physician or provider position

◗ A description of the expected resolution or outcome

Completed forms may be submitted to Premera by: ◗ Faxing the appeal form to

1-425-918-5592 ◗ Mailing the appeal form to:

Attn: Physician and Provider Appeals Premera Blue Cross P.O. Box 91102 Seattle, WA 98111-9202

◗ Contacting Customer Service at 1-800-722-4714, option 2

How will ultrasounds be reviewed?

Premera will review maternity ultrasounds retrospectively to determine medical necessity in accordance with Starbucks benefits. This follows our standard process of reviewing certain services for medical necessity prior to reimbursement.

How is retrospective review initiated?

Retrospective review is initiated through review of claims for benefit determination and/or medical necessity. Retrospective review sends potential denials of services to a Premera medical director for medical necessity review, correct assignment of benefits determination, or resolution of experimental/investigative issues. Consult your provider reference manual for more information about how to provide supporting documentation and coding to support retrospective review.

What if I want my services reviewed before service is delivered?

Call the Customer Service number on the back of the member’s health plan ID card to obtain a benefit advisory.

For more information about any of these items, call Physician and Provider Relations at 1-800-722-4714, option 2.

Starbucks Maternity Ultrasounds


administrative Resources

Physician and Provider Demographic Updates in your comments. These changes support our efforts to display accurate information in our online directories so our members can seek care appropriately.

If you have questions, contact Physician and Provider Relations at 1-800-722-4714, option 4.

Premera wants to ensure your mail reaches you without delay and reduce the volume of returned mail each month. Besides reducing the return volume, correct

addresses will help Premera comply with more stringent U.S. Postal Service (USPS) addressing requirements.

Your office may receive a phone call from a Premera representative validating your provider addresses to comply with USPS mailing standard requirements. You can validate your address information by going to zip4.usps.com/zip4/welcome.jsp.

Please help us ensure we have the most up to date information by reporting all demographic updates, such as address or tax identification number (TIN) changes 30 days in advance. Be sure to include the effective date of the change

Provider Network Representatives: Servicing Our Providers

Provider Network Representatives (PNRs) enhance our service by quickly handling provider requests and resolving non-claims issues. Our PNRs can assist you with the following: ◗ Contract status inquiries ◗ Accessing Premera’s provider portal ◗ Demographic changes (address, tax ID number,

telephone number) ◗ Question about physician/provider communications ◗ Fee schedule requests ◗ Clinic opening or closing ◗ Practitioner/dentist retirement, leaving, etc. ◗ Directory copy requests ◗ Document copy requests (e.g., News Briefs, Network News,

manuals, etc.) ◗ Additions to your clinic ◗ OneHealthPort

PNR phone service levels exceeded 95 percent during the second quarter of 2009 (April-June 2009). Service levels are determined by number of calls answered in 30 seconds, divided by the number of calls offered. In addition to efficient call handling, PNRs meet or exceed turnaround goals for other provider requests. On average, fee schedule requests and demographic updates are processed within 48 hours.

To reach a PNR, contact Physician and Provider Relations at 1-800-722-4714, option 4.

Submit demographic updates in writing, by fax, to Physician and Provider Relations at 1-425-918-4937, or mail updates to:

Attn: Physician and Provider Relations Premera Blue Cross PO Box 327, MS 453 Seattle, WA 98111-0327

Providing Stellar Customer Service Did you know that Premera Customer Service

representatives receive three million phone calls a year? We strive to meet high standards and ensure our calls are handled efficiently, while maintaining exceptional quality standards, and meeting specific goals for service levels.

Our service level goal is to answer 75 percent of our calls in 30 seconds. Quality is determined by analyzing call recordings and measuring quality of our service. Customer Service quality metrics show strong and consistent gains since January 2009. As of July 2009, overall quality was 94 percent and our service level was 80 percent.

As a commitment to quality, all Customer Service Representatives are currently participating in a series of training classes, which will be completed this fall. The training focuses on resolving issues, providing stellar service, and identifying the defining moment on each call.

Overall, we raised our internal quality measurements, while average handling time still improved. Our focus on streamlining internal processes (Rapid Process Improvement Workshops) continues to play a significant part in driving down cost and raising quality.


Please post or circulate this newsletter in your office

PRESORTED STANDARD

U.S. POSTAGE PAIDSEATTLE, WA

PERMIT NO. 2944

012335 (10-2009)

Network NewsBack issues of Network News are on our web site at premera.com/provider in the Library under Communications.

Premera Blue Cross Blue Shield of Alaska

P.O. Box 327

Seattle, WA 98111

october 2009 etwork news - premera blue cross · learn more about the review process ... surgical...

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