1. health and fitness

December 2014
In this issue
Page
Administration















Final notice…start using Interactive Care Reviewer immediately
REMINDER: User profiles and HIPAA compliance
Claim filing tips
Misrouted protected health information (PHI)
Reminder to refer members to in-network laboratories
Solstas Lab Partners leaving BCBSGa December 31, 2014
Global Component billing
Clarification of CoramRx/CVS Caremark change
Clinical practice and preventive health guidelines available on the web
Coordination of care
Important information about utilization management
Members’ rights and responsibilities
Important postpartum visit reminder for OB/GYNs
Survey says…Patients see room for improvement with physician care
Improving your patients’ health care experience
2
3
4
5
5
6
6
6
6
7
7
8
8
9
10
Health care reform updates (including Health Insurance Exchange)

3 new articles have been posted to bcbsga.com
11
Products and programs







New Pathways added to WellPoint Cancer Care Quality Program
Pre-payment review program starting this month
Updates to Blue Physician Recognition Program
2015 FEP Benefit information available online
HEDIS® 2014 Results are in
We believe in continuous improvement
Case Management Program
11
11
12
12
13
16
16
E-business

Creating an LGBT friendly practice – online experience available
17
State Health Benefit Plan

State Health Benefit Plan – 2015 at a Glance
17
Senior business and Medicare Advantage


Prior authorization required for members
Encourage exercise to prevent falls
1 of 37
18
19
bcbsga.com
Important phone numbers
Senior business and Medicare Advantage…continued












Individual Medicare Advantage membership moves to new claims
processing system Jan. 1, 2015
20
New for 2015: BCBSGa introduces new benefits, plans for Medicare Advantage members
22
Advanced notices of non-coverage for Medicare Advantage members
24
OrthoNet to conduct medical necessity reviews, professional service coding reviews
24
Prior authorizations required for CMS-designated high-risk medications
26
Clearinghouse helps ensure timely and accurate claims payment for vaccines covered by Medicare Part D 26
New Federally Qualified Health Center billing guidelines in effect for original Medicare
26
Speaking the language of ICD-10
27
CMS mandated opioid overutilization program
28
Hyaluronate agents require prior authorization
28
CuraScript moved to Accredo brand effective November 24, 2014
29
2015 Georgia Medicare Advantage plan changes
30
Pharmacy

Pharmacy information available on bcbsga.com
35
Policy updates




Ancillary precertification requirements: Ground Ambulance, Non-emergent
Professional Reimbursement policy updates
Professional coding update: Modifiers XE, XP, XS and XU effective Jan. 1, 2015
Precertification change notification
35
35
37
37
Administration
Final Notice…start using Interactive Care Reviewer immediately
The December 12, 2014 deadline is just days away!
Discontinue using ProviderAccess for your Medical Referral Request and Referral and Pre-authorization Inquiries
and begin using the Interactive Care Reviewer (ICR) on the Availity Web Portal immediately!
On December 12, 2014, BCBSGa is transitioning Medical Referral Request and Referral and Pre-authorization Inquiry from
ProviderAccess to the Interactive Care Reviewer Tool (ICR) on the Availity Web Portal.
Whether you are the ordering or servicing provider you can make an inquiry to view information on ANY referral or
precertification previously submitted via phone, fax, ICR or other online tool.
Avoid Business Disruption!
Users must discontinue submitting medical referrals and making referral and pre-authorization inquiries on ProviderAccess
and start using the ICR now.
It’s not too late! Take the steps below to get started.
Not sure if your organization is registered?
December 2014
2 of 37

Call Availity Client Services at 800-AVAILITY (800-282-4548) for registration status of your Tax ID.
If your organization is NOT currently registered for Availity:

The designated Administrator for your organization should go to availity.com to register or click here.

Click on "Get Started" under “Register now for the Availity Web Portal”, and then complete the online registration
wizard.

The Administrator will receive an e-mail from Availity with a temporary password and next steps.
Do you have access to the Availity Web Portal but don’t know who your Availity Primary Access Administrator (PAA) is?

Click on “Who Controls My Access?” on the top left next to the Availity logo.
If your organization is registered for Availity and needs access to ICR Inquiries and/or Referral Submissions:

Your Primary Access Administrator can grant you access to Authorization and Referral Inquiry for inquiries.

Your Primary Access Administrator can grant you access to Authorization and Referral Request for referral
submission and you can start using our tool right away.
You can also submit inpatient and outpatient pre-certifications* including behavioral health requests online.
Use the ICR to determine right away if a precertification is required for a patient. Enter the patient, service and provider
details and receive a message indicating whether you need to proceed with the precertification.
ICR now offers you the ability to view a copy of the imaged letter within the case. This is one of the most recent
enhancements to our online precertification tool but not the last.
Need training?
Free webinars showing you how to navigate the ICR are being offered weekly.
To learn more about how you can take advantage of ICR’s many features, register today by clicking here. For questions
regarding our ICR, please contact your local Network Consultant. For questions on accessing our tool, call Availity Client
Services at 800-AVAILITY (800-282-4548) or email questions to [email protected]. Availity Client Services is available
Monday-Friday, 8:00 a.m. to 7:00 p.m. ET (excluding holidays) to answer your registration questions.
*Note: ICR is not currently available for Medicare Advantage, Medicaid, FEP®, BlueCard®, and some National Account
members; requests involving transplant services; or services administered by AIM Specialty Health®. For these requests,
follow the same precertification process that you use today.
IBM, the IBM logo, ibm.com, and Watson are trademarks of International Business Machines Corp., registered in many jurisdictions worldwide. Other product and service
names might be trademarks of IBM or other companies. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at
www.ibm.com/legal/copytrade.shtml
REMINDER: User Profiles and HIPAA Compliance
If you are the Availity Primary Access Administrator (PAA) and/or BCBSGa ProviderAccess Administrator, please
keep your USER lists up-to-date.
In order to remain compliant with your contractual portal usage agreements, please review your USER lists, at least
quarterly, to disable User IDs of any individuals who are no longer employed by your organization and ensure all current
employees have the access they need to perform their day-to-day responsibilities.
December 2014
3 of 37
All users must have their own individual USER ID and password for each system, registered under their own name and
individual contact information. Also, if you, the site Administrator, are changing roles or leaving your organization, be sure to
assign a new Administrator to replace you.
We would like to remind all Blue Cross and Blue Shield of Georgia users of the following:

The sharing of USER ID and Password information on our secure portals is not compliant with BCBSGa’s
Information Security Policy.
Please take a few moments to review and make updates to your USER list now.
Claim filing tips
Providers should submit claims to their local plan for processing.

Blue Cross and Blue Shield Association guidelines permit virtually ALL claims to be filed to the provider’s local plan
for processing

Those that cannot be processed by the local plan will be referred to the correct plan for handling

Ensure to select the correct Payer ID when sending claims to your Clearinghouses.

Ensure that the billing address requested during the Provider setup is the billing address used when submitting
claims.

Ensure that the Billing, Rendering, Service Facility loops are entered correctly.

Submit the Taxonomy Codes associated with the type of service being performed.

Ensure to indicate the billing location of where the Services were rendered.
Member Identification Number

Providers should check the patient’s identification card with each visit to the office to ensure the most current
insurance information is being submitted.

The identification number must be in the proper location on the paper claim form in Block 1a on the CMS -1500 form

Always include the alpha prefix as listed on the member identification card
Helpful hints for sending corrected claims

If the denial indicates “resubmit a new claim” or the claim was denied by your EDI vendor, the claim never made it
into our claims systems. Please submit a new claim either electronically or on paper. This will expedite processing.

If the claim truly needs adjustment due to additional charges, late charges, etc:
– If you are an electronic submitter, simply resubmit the claim with the appropriate type of bill. Include the
additional charges, late charges, etc.
– If you are a paper submitter, attach a copy of the claim to an adjustment request and indicate specifically what
needs to be changed. For example: ‘Please increase the units of service from 1 to 2 on line 3. No other changes
on the claim.’ The clearer the request, the better.

If you are sending requested medical records, please include the specific medical records cover letter included in
our request. This will help ensure that our expedited medical records processes are followed. In some states, this
letter includes a bar code. Please be sure that the bar-coded letter is on top to help ensure the medical records are
routed correctly.

Be careful when writing “corrected claim” if you are only rebilling one line or code because it may be interpreted as
a refund request if the original claim had more lines. Our claim adjustment areas will adjust the original claim
whenever possible. Therefore, it’s best to file the claim as it was first sent and clearly indicate exactly what changes
need to be made.
December 2014
4 of 37



If you are asking for reconsideration of denied charges, please indicate that clearly in your reque st. Otherwise, you
could get a response that the claim was processed correctly and that may not have been what you needed us to do.
An example of a clear request might be: “Please re-process the claim. Member has confirmed that the coverage was
active through this date of service”.
Please do not address letters to specific individuals unless you are working directly with them to resolve your issue
and they specifically ask you to send the documents directly to them. Why? Correspondence addressed to an
individual will be sent to that person directly rather than flowing through our normal correspondence flows. This
could create delays as the mail is sent to the individual and then re-routed to our imaging area to be put into
correspondence.
In the end, the fastest way to help ensure your request is processed accurately and timely the first time is to be as clear as
possible. Take a moment and ask yourself – is my request clear? Have I stated what I need? Have I provided enough
information? If the answers to all these questions are yes, then we all win.
Ancillary claim filing tips
Ancillary providers include Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies and Specialty
Pharmacy providers. File claims for these providers as follows:

Independent Clinical Laboratory (Lab): The Plan in whose state* the specimen was drawn based on the location
of the referring provider.

Durable/Home Medical Equipment and Supplies (D/HME): The Plan in whose state* the equipment was shipped
to or purchased at a retail store.

Specialty Pharmacy: The Plan in whose state* the Ordering Physician is located.
*If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim
with either Plan.
Misrouted protected health information (PHI)
As a reminder, providers and facilities are required to review all member information received from Blue Cross and Blue
Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (collectively “BCBSGa”) to help ensure
no misrouted PHI is included. Misrouted PHI includes information about members that a provider or facility is not currently
treating. PHI can be misrouted to providers and facilities by mail, fax or e-mail. Providers and facilities are required to
immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or
facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted
PHI, providers and facilities must contact BCBSGa provider services area to report receipt of misrouted PHI. You can call
Provider Customer Service at 800-428-4446 or your local Network Consultant.
Reminder to refer members to in-network laboratories
As a reminder, for all the networks in which you participate, physicians are required to refer to in-network laboratories. By
doing so, patients are assured of having the highest benefit level and minimum out-of-pocket expense.
We are conducting outreach to physicians that are referring members to out-of-network laboratories. If you have been
referring patients to out-of-network laboratories, we will be contacting you very soon. As a part of our outreach effort, we
would like to understand some of the reasons for out-of-network referrals, and work with the in-network laboratories to meet
your clinical needs.
December 2014
5 of 37
To find laboratories that are in-network, go to bcbsga.com.
If you have questions about our provider network or coverage for your patients, please contact your local BCBSGa Network
Consultant.
Solstas Lab Partners leaving BCBSGa December 31, 2014
As previously communicated in the October edition of Network Update, effective December 31, 2014 Solstas Lab Partners
will no longer be a participating BCBSGa laboratory provider. Please ensure you are referring BCBSGa members exclusively
to participating in-network labs per your provider agreement. Referring members to in-network providers allows them to
maximize healthcare benefits and reduce out-of-pocket expenses. For a full list of BCBSGa participating providers, including
laboratories, use the “Find a doctor” tool at bcbsga.com.
Global Component billing
A reminder that we screen for multiple components billing (Global vs. Technical) and duplicate claims received for the same
procedure will not be allowed.
The Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule Relative Value file directs that a
global procedure includes reimbursement for both the professional and technical components of certain procedures. A single
provider can bill for both components (global procedure), or different providers can each bill for different components. Claims
for these types of procedures should only be paid up to the total of the global procedure (both technical and professional
components combined). Any submission of the same procedure will be evaluated against previous submissions to determine
if any or all components of the procedure have already been paid. If so, the current claim will be adjusted accordingly.
Clarification of CoramRx/CVS Caremark change
In the August 2014 issue of Network Update, the article, “CoramRx/CVS Caremark change for specialty drugs,” announced
CVS Caremark’s purchase of CoramRx. This is to clarify that information in that article only applies to CVS
Caremark/Coram’s internal processes when triaging medications for health plan members.
CVS Caremark’s purchase of Coram does not impact contracted home infusion/ambulatory infusion suite providers who
supply specialty medications and home infusion services for health plan members through the medical benefit
Clinical practice and preventive health guidelines available on the web
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted
nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our
website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are
reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research,.
All guidelines are reviewed annually, and updated as needed. The current guidelines can be found on the Health & Wellness
page of our provider website, bcbsga.com.
December 2014
6 of 37
Coordination of care
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment
and referral. BCBGa would like to take this opportunity to stress the importance of communicating with your patient’s other
health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health
practitioners.
Coordination of care is especially important for patients with high utilization of general medical services and those referred to
a behavioral health specialist by another health care practitioner. BCBGa urges all of its practitioners to obtain the
appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners
at the time treatment begins.
We expect all health care practitioners to:
1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate
information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
– Diagnosis
– Treatment plan
– Referrals
– Psychopharmacological medication (as applicable)
In an effort to facilitate coordination of care, BCBSGa has several tools available on Answers@BCBSGa page of the provider
website including a Coordination of Care template and cover letters for both Behavioral Health and other Healthcare
Practitioners. In addition, there is a Provider Toolkit on the Health and Wellness page of the provider website with
information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.
Important information about utilization management
Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the
member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of
coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the
idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to
encourage decisions resulting in under-utilization. BCBSGa’s medical policies are available on our website at bcbsga.com.
You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a
UM denial decision with a physician reviewer by calling us toll-free at the numbers listed below. UM criteria are also available
on our website by clicking on “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” on the left side of the
provider home page.
We work with providers to answer questions about the utilization management process and the authorization of care. Here’s
how the process works:

Call us toll free from 8:00 a.m. – 5:00 p.m. Monday through Friday (except on holidays) for routine calls. For urgent
issues, the phone line is available 24/7. For Medicare, Monday through Friday from 8:00 a.m. – 8:00 p.m. Eastern.
December 2014
7 of 37


After business hours, you can leave a confidential voicemail message. Please leave your contact information so one
of our associates can return your call the next business day.
Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.
The following phone lines are for physicians and their staffs. Members should call the customer service number on their
health plan ID card.
To discuss UM Process
and Authorizations
To Discuss Peer-toPeer UM Denials
w/Physicians
To Request
UM Criteria
1-800 662-9023 or
1-800 722-6614
1-800 662-9023 or
1-800 722-6614
1-800 662-9023 or
1-800 722-6614
TTY/TDD
711
or
TTY: 800-255-0056(T)
Voice: 800-255-0135(V)
Behavioral Health:
Behavioral Health:
Behavioral Health:
1-800-292-2879
1-800-292-2879
1-800-292-2879
For Medicare:
1-866-797-9884 opt 1
1-866-959-1537 – Fax
1-888-449-4642 - Fax (for providers who previously used 1-800-266-3504 or 1-877-236-5173)
For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a
representative will be able to assist them.
Our utilization management associates identify themselves to all callers by first name, title and our company name when
making or returning calls. They can inform you about specific utilization management requirements, operational review
procedures, and discuss utilization management decisions with you.
Members’ rights and responsibilities
The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans.
One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our
commitment to involve the health plan, participating practitioners and members in our system, BCBSGa has adopted a
Members’ Rights and Responsibilities statement which can be found on the Quality Improvement and Standards page of the
Health & Wellness page of our provider website.
Important postpartum visit reminder for OB/GYNs
As you may know, the National Committee for Quality Assurance (NCQA) specifies that the postpartum visit should be
completed 21 to 56 days (3 to 8 weeks) after delivery. This visit is distinct from the c-section visit or incision check your
patient may have had before that time.
The most current data shows that postpartum visits occur in a timely manner, overall. When a random sample of 2013
medical charts was reviewed, we found postpartum visits between 21 and 56 days in Georgia occurred 88% of the time
among HMO plan members. The top 10% of health plans nationally have a compliance rate of least 91% among HMO
members.
December 2014
8 of 37
2013 Medical Chart Review Findings from a Sample of the Non-Compliant Women with an HMO plan in the Eastern Region:

49% of patients had insufficient evidence of postpartum care, with a majority (67% of HMO members) not
documenting the date of the postpartum visit.

34% of women with a documented date were not seen in the appropriate timeframe:
•
14% were seen before 21 days
•
10% were seen between 56 and 63 days
•
13% were seen one or more months after the 56th day

3% of the women had a caesarian section check only, without a postpartum visit.
What can you do?

Make sure that every woman who delivers has a postpartum visit scheduled between 21 and 56 days after delivery.
If possible, schedule the mother’s postpartum visit upon or prior to hospital discharge. You may even be able to
schedule it at the “last” prenatal visit, or two weeks prior to the expected delivery date. A study published in March
2011 found that postpartum follow-up rates were significantly higher (86.1% compared with 71.7%, P=.012) when a
visit was scheduled prior to discharge (Tsai, Pai-Jong, et. Al. “Postpartum Follow-Up Rates Before and After the
Post-Partum Follow-up Initiative at Queen Emma Clinic.” Hawaii Medical Journal. March 2011; 70(3): p 56-59).
When you see a woman for their postpartum visit, remember to clearly indicate the date, complete physical findings,
and counseling/discussion points in the patient’s chart. For your convenience, the Association of Reproductive
Health Professionals has created a “Quick Reference Guide for Clinicians” for Postpartum visits/counseling.
Please take less than 30 seconds to give us your feedback by taking this survey.
Survey says… Patients see room for improvement with physician care
Every year BCBSGa sends out the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey to our
HMO/POS members. The survey gives BCBS Georgia members an opportunity to share their perceptions of the quality of
care and services provided by our HMO/POS network physicians. This same survey is used by all HMO/POS plans that
undergo accreditation review by the National Committee for Quality Assurance (NCQA).
The following charts compare our results from 2013 with those in 2014. Each column contains the score achieved for each
measure along with the box color coded to reflect the NCQA Quality Compass National Percentile achieved by BCBS
Georgia. These Quality Compass percentiles are derived from the scores of all other HMO plans across the country that
perform the CAHPS survey. Our goal is to achieve the 75th Percentile. This is the level we encourage our network
physicians to strive to achieve.
When you’re reviewing these results, we encourage you to focus on and address those performance areas of your own
practice that may have room for improvement. Addressing those areas will help ensure our members, your patients, have a
positive experience that meets their medical needs and their satisfaction with the quality of services provided.
2014 BCBS Georgia HMO/POS
CAHPS ® Adult Member Satisfaction Survey Results and NCQA Quality Compass Percentile Achieved
5
NCQA Quality Compass Percentile Legend
10th 25th
50th
75th 90th
Survey Question
Rating of Physician
December 2014
2013
2014
Trend 2013
vs. 2014
1
9 of 37
Rating of Personal Doctor
Rating of Specialist Seen Most Often
Rating of All Health Care Provided in Past 12 Months
87%
81%
83%
85%


79%
77%

Got appointment for urgent care as soon as needed
88%
NA

Got appointment for check-up or routine care as soon as needed
85%
82%

Got help or advice needed when calling doctor after regular office hours
40%
83%

How often personal doctor explained things understandably to you
99%
97%

How often personal doctor listened carefully to you
97%
96%

How often personal doctor showed respect for what you had to say
97%
97%
=
How often personal doctor spent enough time with you
96%
93%

91%
42%

65%
21%

77%
71%

74%
72%

75%
NA
--
Getting Care Quickly
2
Doctor’s Communication with Patients
2
Shared Decision Making
Doctor discussed reasons to take a medicine?
3
Doctor discussed reasons not to take a medicine?
3
Doctor asked what you thought was best for you?
4
Did you and your doctor discuss ways to prevent illness? 4
Continuity of Care
How often did your personal doctor seem informed about care you received from
other health providers? 2
1 = Percent responding 8, 9 or 10 (0-10, where 0 is the worst and 10 is the best).
2 = Percent responding “Usually” or “Always.”
3 =% responding “A lot” or “Some”
4 = % responding "Yes"
5 = Percentile Definition - A score equal to or greater than 75 percent of all those attained on a survey question is said to be in the 75th percentile.
DNA = Data Not Available
NA = Number of survey respondents too low to be valid.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
*The source of data contained in this report is Quality Compass ® 2014 and is used with the permission of the National Committee for Quality Assurance (NCQA). Any
analysis, interpretation or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation or
conclusion. Quality Compass is a registered trademark of NCQA.
Improving your patients’ health care experience
BCBSGa is committed to working with our network physicians to make our members’ health care experience a positive one.
Towards this end we wanted to share with you a document we discovered that was developed by the California Quality
Cooperative. This resource outlines some helpful tips you can use to improve your relationship with your patients and provide
better care at the same time. You can find this document on the Health & Wellness page of our provide website, bcbsga.com.
December 2014
10 of 37
Health care reform updates (including Health Insurance
Exchange)
Health care reform updates and notifications and Health Insurance Exchange information are posted as they become
available on the communications page of bcbsga.com.
Newly posted articles include:

Provider Quick Reference Guide for 2015

Member ID card update for 2015 ACA-compliant health plans

2015 Frequently Asked Questions
Products and programs
New Pathways Added to WellPoint Cancer Care Quality Program
Effective November 1, 2014, BCBSGa will add Cancer Treatment Pathways to the existing WellPoint Cancer Care Quality
Program, a quality initiative which allows physicians to compare planned cancer treatment regimens against evidence-based
clinical criteria.
The additional Pathways will include treatment regimens for the following malignancies:

Melanoma

Central Nervous System (CNS)
In addition, WellPoint Breast Cancer Pathways have been updated to include:

Breast Endocrine (Hormonal) Therapy
For more information, including details on what you need to participate in this quality initiative, go online
to CancerCareQualityProgram.com, our dedicated provider website.

Get detailed information about all Cancer Treatment Pathways.

Download worksheets and other tools to help your practice participate.

Learn about enhanced reimbursement opportunities for participating network providers.
To access, go to: cancercarequalityprogram.com.
If you have questions, please contact your local Network Consultant or AIM Specialty Health®, a separate company, directly
at 800-554-0580.
Pre-payment review program starting this month
BCBSGa recognizes the importance of preventing, detecting, and investigating fraud, waste, and abuse, and is committed to
protecting and preserving the integrity and availability of health care resources for our members, clients and business
partners. BCBSGa has processes to review claims before and after the claim is processed to detect fraud, waste and abuse.
December 2014
11 of 37
Beginning in December 2014, BCBSGa will include the following language in all Clinical Utilization Management (UM)
Guidelines on the provider website about use of Clinical UM Guidelines for a variety of purposes. For example, Clinical UM
Guidelines may be generally adopted for reviewing the medical necessity of services; used for provider education; and used
for reviewing the medical necessity of services by a provider who has received notice about certain billing practices or
claims, even if a guideline is not used for all providers delivering that service to BCBSGa members. The language states the
following:
Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general
adoption by plans or lines of business for consistent review of the medical necessity of services related to the
clinical guideline. Alternatively, commercial or FEP plans or lines of business which determine there is not a need to
adopt the guideline to review services generally across all providers delivering services to Plan’s or line of
business’s members may instead use the clinical guideline for provider education and/or to review the medical
necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical
necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in
some other manner.
Please refer to your Provider Manual for further details on a new program to deter fraud, waste and abuse that is scheduled
to be rolled out for commercial business and FEP plans throughout 2015.
Updates to Blue Physician Recognition Program
BCBSGa is committed to providing members with the tools they need to effectively partner with their doctors and make more
informed health care choices. As part of that effort, BCBSGa is pleased to participate in the Blue Cross Blue Shield
Association’s consumer engagement initiative.
The Blue Physician Recognition (BPR) Program is designed to reinforce Blue Plans’ commitment to quality by providing more
meaningful and consistent information on physician quality improvement and recognition on the Blue National Doctor &
Hospital Finder site and on BCBSGa’s online provider directories. A BPR indicator is used to identify physicians, groups
and/or practices who have demonstrated their commitment to delivering quality and patient-centered care by participating in
local, national, and/or regional quality improvement programs as determined by the local Blue Plan.
BCBSGa recognizes primary care physicians practicing in the specialties of Family Practice, Internal Medicine and General
Practice with a BPR designation if they have achieved recognition from either the National Committee for Quality Assurance
(NCQA) or Bridges to Excellence (BTE) based on their successful completion of a care recognition program. Information
regarding these recognition programs can be found at on the NCQA website or on the Health Care Incentives Improvement
Institute website.
At a minimum, we will update these recognitions annually to reflect the current status as identified by the Blue Cross Blue
Shield Association’s Quality Recognition Extract.
If you have questions regarding the update, please call Provider Customer Service at 800-428-4446 or contact your local
Network Consultant.
2015 FEP Benefit information available online
To view the 2015 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal
Employee Program® (FEP), go to bcbsga.com/fep and click on “Coverage Options” at the top of the page. There you will find
December 2014
12 of 37
the Service Benefit Plan Brochure and Plan Benefit Summary information for year 2015. If you have questions please
contact FEP Customer Service at 800-282-2473.
HEDIS® 2014 results are in
Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) data collection for
2014. You play a central role in promoting the health of our members. By documenting services in a consistent manner, it is
easy for you to track care that was provided and identify any additional care that is needed to meet the recommended
guidelines. Consistent documentation and responding to our medical record requests in a timely manner, eliminates follow up
calls to your office and also helps improve HEDIS scores, both by improving care itself and by improving our ability to report
validated data regarding the care you provided.
Further information regarding HEDIS documentation guidelines can be found on the Health & Wellness page of our provider
website, bcbsga.com. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Documentation
Guidelines”.
The table below shows a comparison of some of our key measure rates to the NCQA Quality Compass® National Averages.
The rates in bold in the HEDIS 2014 column show an increase from 2013 rates.
Commercial HMO/POS Measures
Effectiveness of
Adult BMI Assessment
Breast Cancer Screening
Childhood Immunization Status – DTAP
Childhood Immunization Status - IPV
Childhood Immunization Status - MMR
Childhood Immunization Status – HEP B
Childhood Immunization Status - VZV
Childhood Immunization Status - PCV
Childhood Immunization Status – HEP A
HEDIS 2014 Rate
(Percent)
Care – Prevention and Screening
79.38
70.14
88.08
93.43
90.02
92.70
93.19
89.05
92.70
81.75
Childhood Immunization Status - ROTAVIRUS
Childhood Immunization Status - INFLUENZA
57.91
Colorectal Cancer Screening
61.48
Immunizations for Adolescents – TDAP/TD
79.51
Weight Assessment and Counseling – BMI TOTAL
61.80
Weight Assessment and Counseling – Nutritional
61.56
Counseling - TOTAL
Access / Availability of Care
Children & Adolescents’ Access to PCP (12-19 yrs)
84.67
Effectiveness of Care – Respiratory Conditions
Antibiotic Treatment Adults w/ Acute Bronchitis
23.53
Appropriate Testing for Children w/ Pharyngitis
77.60
December 2014
Comparison to
National Average
=
↓
↑
↓
↑
↑
↑
↑
↑
↓
↓
↓
↓
↑
↑
↓
↓
↓
13 of 37
Treatment Children w/ URI
81.63
Spirometry Testing for COPD
44.56
Utilization & Relative Resource Use - Utilization
Well-Child Visits in the first 15 Months of Life (6+ visits)
77.08
Adolescents Well-Care Visits
34.67
Effectiveness of Care - Cardiovascular
Persistence of Beta-Blocker Treatment after AMI
75.00
Effectiveness of Care - Diabetes
↓
↑
Comprehensive Diabetes
Comprehensive Diabetes
(>9)*
Comprehensive Diabetes
Comprehensive Diabetes
Comprehensive Diabetes
(LDL-C<100 mg/dL)
Comprehensive Diabetes
nephropathy
Comprehensive Diabetes
Control <140/80
Comprehensive Diabetes
Control <140/90
↓
Care – HbA1c Testing
Care – Poor HbA1c Control
88.32
28.71
↓
↓
Care – Eye Exams
Care – LDL-C Screening
Care – LDL-C Controlled
42.58
82.97
43.31
↓
↓
↓
Care – Medical attention for
81.75
↓
Care – Blood Pressure
38.44
↓
Care – Blood Pressure
59.61
↓
Effectiveness of Care - Musculoskeletal
Use of Imaging Studies for Low Back Pain
69.32
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Acute
59.85
Antidepressant Medication Mgmt – Continuation
42.06
Follow Up Care Children’s ADHD Medication – Initiation
36.33
Follow Up Care Children’s ADHD Medication 47.83
Continuation
*lower rate is better
Commercial PPO Measures
Effectiveness of Care –
Adult BMI Assessment
Childhood Immunization Status – DTAP
Childhood Immunization Status – IPV
Childhood Immunization Status – MMR
Childhood Immunization Status – HIB
Childhood Immunization Status – HEP B
Childhood Immunization Status – VZV
Childhood Immunization Status – PCV
Childhood Immunization Status – ROTAVIRUS
Childhood Immunization Status – INFLUENZA
Colorectal Cancer Screening
Immunizations for Adolescents – MENINGITIS
December 2014
↓
↓
HEDIS 2014 Rate
(Percent)
Prevention and Screening
5.58
64.76
71.04
82.66
74.77
48.84
83.41
66.39
60.98
53.96
44.56
53.81
↓
↓
↓
↓
↓
Comparison to
National Average
↓
↓
↓
↓
↓
↓
↑
↓
↓
↓
↑
↑
14 of 37
Immunizations for Adolescents – TDAP/TD
63.13
Weight Assessment and Counseling – BMI TOTAL
5.56
Weight Assessment and Counseling – Nutrition
2.71
Counseling TOTAL
Weight Assessment and Counseling – Physical Activity
2.24
TOTAL
Access / Availability of Care
Children’s & Adolescents’ Access to PCP (25 mos-6
88.99
yrs)
Children’s & Adolescents’ Access to PCP (12-19 yrs)
84.03
Effectiveness of Care – Respiratory Conditions
Appropriate Testing for Children w/ Pharyngitis
75.47
Appropriate Treatment Children w/ URI
78.28
Spirometry Testing for COPD
39.76
Utilization & Relative Resource Use - Utilization
Well-Child Visits in the first 15 Months of Life (6+ visits)
74.86
Adolescent Well-Care Visits
33.48
Effectiveness of Care - Cardiovascular
Cholesterol Management – LDL-C Control <100
13.51
Persistence of Beta-Blocker Treatment after AMI
75.34
Effectiveness of Care - Diabetes
Comprehensive Diabetes Care – HbA1c Testing
84.17
Comprehensive Diabetes Care – Poor HbA1c Control
83.48
(>9)*
Comprehensive Diabetes Care – Eye Exams
33.30
Comprehensive Diabetes Care – LDL-C Screening
78.04
Comprehensive Diabetes Care – LDL-C Controlled
11.82
(LDL-C<100 mg/dL)
Comprehensive Diabetes Care – Medical attention for
71.54
nephropathy
Effectiveness of Care - Musculoskeletal
Use of Imaging Studies for Low Back Pain
70.45
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Continuation
46.19
Follow Up Care Children’s ADHD Medication – Initiation
33.57
Follow Up Care Children’s ADHD Medication 38.12
Continuation
↑
↓
↓
↓
↓
↓
↓
↓
↓
↓
↓
↓
↓
↓
↑
↓
↓
↓
↓
↓
↓
↓
↓
*lower rate is better
In Georgia many scores for Commercial HMO line of business improved and exceeded the national average especially those
in Childhood Immunization: Pneumococcal Conjugate Vaccine, Childhood Immunization DTAP and Weight Assessment and
Counseling – Body Mass Index Total, with the largest rate increases noted in Childhood Immunization: Varicella Zoster Virus,
Hepatitis B Vaccine. In the PPO line of business there were also many improved scores that exceeded the national average,
especially those in Colorectal Cancer and Immunization for Adolescent Meningitis, with the greatest improvement noted in
Comprehensive Diabetes care.
December 2014
15 of 37
Although many rates were above the national average, this year there were Commercial HMO/PPO plans that had the
greatest number of decrease rates. There are opportunities for improvement for the measures with the most significant
decreases in rates including Childhood Immunization Status –Influenza, Breast Cancer Screening in HMO plan and
Persistence of Beta-Blocker Treatment after AMI in the PPO plan.
Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS project, and to
demonstrate the exceptional care that you have provided to our members.
In an effort to improve our scores, you and your office staff can help facilitate the HEDIS process improvement by:

Responding to our requests for medical records within five days

Providing the appropriate care within the designated timeframes

Accurately coding all claims

Documenting all care in the patient’s medical record
Again, we thank you and your staff for demonstrating teamwork and partnership as we work together to improve the health of
our members and your patients. We look forward to working with you next HEDIS season.
The source for data contained in this publication is Quality Compass® 2014 and is used with the permission of the National
Committee for Quality Assurance (NCQA).Quality Compass 2014 includes certain CAHPS data. Any data display, analysis,
interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility
for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. CAHPS® is
a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
We believe in continuous improvement
Commitment to our members’ health and their satisfaction with the care and services they receive is the basis for the
BCBSGa Quality Improvement Program. Annually, we prepare a quality program description that outlines the plan’s clinical
quality and service initiatives. We strive to support the patient-physician relationship, which ultimately drives all quality
improvement. The goal is to maintain a well-integrated system that continuously identifies and acts upon opportunities for
improved quality. An annual evaluation is also developed highlighting the outcomes of these initiatives. To see a summary of
our quality program and most current outcomes, visit the Quality Improvement and Standards page on our provider website
bcbsga.com.
Case Management Program
Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get
needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.
BCBSGa is available to offer assistance in these difficult moments with our Case Management Program. Our case
managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support
members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise
of the care coordination team whose goal is to educate and empower our members to increase self-management skills,
understand their illness, and learn about care choices in order to access quality, efficient health care.
Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be
transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or
December 2014
16 of 37
through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients
and caregivers are better prepared and informed about healthcare decisions and goals.
How do you contact us?
CM Telephone Number
CM Email Address
CM Business Hours
1-800-353-0923
Georgia Local CM email
Medicare
1-866-797-9884
National
1-866-202-8727
Medicare CM email
Monday - Friday
8:00 a.m. – 5:00 p.m.
Monday - Friday
8:00 a.m. – 5:00 p.m. EST
Monday - Friday
8:00 a.m. – 8:00 p.m
National CM email
E-business
Creating an LGBT friendly practice – online experience available
What you may not know about your Lesbian, Gay, Bisexual, or Transgender (LGBT) patients may be putting their health at
risk. Studies have shown that many LGBT patients fear they will be treated differently in health care settings and that this
fear of discrimination prevents them from seeking primary care. BCBSGa joins you in striving for the best clinical outcomes
for everyone, including LGBT populations. That’s why BCBSGa has created an online experience that provides strategies,
tools, and resources to providers interested in attracting or maintaining an LGBT patient panel. Hopefully, as a result of
increasing LGBT-friendly practices, BCBSGa, along with the entire health care industry, will see an increase in primary care
and prevention among LGBT patients. Like you, BCBSGa strives to meet the needs of our diverse membership and upholds
access to consistently high quality standards across our networks. We believe that by offering our providers these types of
experiences, we can help keep all our members healthy. In addition, this online experience reinforces our commitment to
equality for our LGBT members as referenced in our provider contractual non-discrimination provisions.
Visit our provider website at bcbsga.com for free 24/7 access to the experience – either via your computer, tablet or
smartphone. You will gain an increased understanding of how to create an LGBT-friendly practice, which may improve the
health of your patients.
State Health Benefit Plan
State Health Benefit Plan information is posted as it becomes available on the State Health Benefit Plan information page of
bcbsga.com.
State Health Benefit Plan – 2015 at a Glance
The State Health Benefit Plan will be offering four plans through BCBSGa in 2015

Newly added Open Access HMO with copayments (no out-of-network benefits)
– Member ID card will have three letter pre-fix of STH
– Copayments will be $35 for PCPs and $45 for specialists

The HRA plan is available in three different options: Gold, Silver & Bronze
December 2014
17 of 37
–
–
–
No copayments
Member ID card will have three letter pre-fix of SJN
Coinsurance for 2015:
•
Gold HRA: 85% is paid by Plan for approved in-network services; 60% is paid by Plan for approved out-ofnetwork services.
•
Silver HRA: 80% is paid by Plan for approved in-network services; 60% is paid by Plan for approved out of-network services.
•
Bronze HRA: 75% is paid by Plan for approved in-network services; 60% is paid by Plan for approved outof-network services.
For all plans, covered in-network preventive care services will be paid at 100%. The plans offer the same Custom State
Health Network based on the Blue Open Access network in Georgia and the BlueCard PPO outside of the State of Georgia.
There are also no specialist referrals required for any of the SHBP plans. Although members are encouraged to have a
primary care provider, one does not have to be selected.
The State Health Network and pricing will be utilized for all plans = the Blue Open Access Network in Georgia and the
BlueCard® PPO for members who are residing or traveling outside the state of Georgia.
State Health Benefit Plan Medicare Advantage Update
After mutual agreement with the State Health Benefit Plan, BCBSGa made a strategic, yet difficult decision to no longer offer
Medicare Advantage products to SHBP members for 2015. Retired SHBP members over the age of 65 will have Medicare
Advantage plan options in 2015 with another carrier. Please note there is no change to SHBP Medicare Advantage coverage
through BCBSGa for the rest of 2014. All 2014 dates of services claims may be submitted through 12/31/2015.
Precertification
SHBP requires precertification for some services that are not required for non-SHBP members. The precertification list is
posted to the Precertification page and the SHBP page on our provider website, bcbsga.com. Providers must obtain
precertification for the services listed in order to receive reimbursement. On December 12, 2014, Medical Referral Request
and Referral and Pre-authorization Inquiry is moving from ProviderAccess to the Interactive Care Reviewer (ICR) on the
Availity Web Portal. You can submit inpatient and outpatient pre-certifications requests online. Use the ICR to determine right
away if a precertification is required for a patient. Enter the patient, service and provider details and receive a message
indicating whether you need to proceed with the precertification.
Please visit the SHBP page of our provider website or the SHBP microsite for more SHBP benefit information. Should you
have any questions specific to this information, please contact BCBSGa SHBP Customer Service at 855-322-7062.
Senior business and Medicare Advantage
Prior authorization required for members
BCBSGa wants to remind providers that they are required to request a prior authorization for Medicare Advantage members
for services that require prior authorization. Failure to obtain a prior authorization will result in an administrative denial. The
2015 prior authorization requirements were posted to the Provider Forms section of the BCBSGA Medicare Advantage Public
Provider Portal October 4, 2014.
Members cannot be balance billed for an administrative denial.
December 2014
18 of 37
To obtain prior authorization or to verify member eligibility, benefits or account information, please call the telephone number
listed on the member’s plan membership card.
Please visit the Provider Forms section of the BCBSGa Medicare Advantage Public Provider Portal at
bcbsga.com/medicareprovider to see the prior authorization list that is effective for 2015 as well as prior authorization
requirements for 2014.
Y0071_14_22046_I 10/14/2014
49480MUPENMUB
Encourage exercise to prevent falls
Falls are the leading cause of injury in older adults. Each year, more than one-third of U.S. adults 65 and older experience a
fall and, in more than 20 percent of those cases, the falls lead to injuries like joint problems, bone fractures and brain
trauma. 1 Recovery can be difficult and, in many cases, falls lead to a decline in independence and in overall health. 2
Poor eyesight, dizziness caused by medication and tripping hazards in the home are common reasons for falls. Many times,
however, falls are simply caused by imbalance or a lack of strength. Some people who fall, even if they are not injured,
develop a fear of falling, causing them to limit their activities, which in turn increases their actual risk of falling. It’s just one
more reason to emphasize the benefits of leading an active, healthy lifestyle at any age.
Exercise can help reduce the risk of falling by:

improving balance and strength

decreasing the need for medication that affects balance

increasing the confidence needed to live an active lifestyle, which reduces the risk of falling
As well, regular physical activity makes bones stronger so they’re less likely to break in the event of a fall, or heal faster if
they do break.
Prescribe an exercise program to build strength, improve balance and increase confidence
The facts are decisive, but convincing older patients to adopt an exercise program can be challenging. Healthways
SilverSneakers® Fitness program, included as a benefit for your BCBSGa patients at no extra cost, makes it easier to turn
a medical recommendation into a reality. As you advise patients to “eat right and exercise,” you can direct them to a
comprehensive program that provides encouragement, direction and support every step of the way. With more than 2 million
members, SilverSneakers is the nation’s leading physical activity program designed exclusively for Medicare members.



SilverSneakers members have access to more than 11,000 fitness locations nationwide (including Alaska, Hawaii
and Puerto Rico), where they can use all basic amenities and take SilverSneakers group fitness classes led by
certified instructors specially trained in older-adult fitness. They can use any location any time they want, so even
when traveling they can still work out.
In addition, SilverSneakers FLEX™ offers classes such as Latin dance, tai chi, walking groups and yoga in
members’ neighborhoods – local parks, recreation centers, medical campuses and adult-living communities. FLEX
participants can attend their favorite SilverSneakers fitness location concurrently.
For members who can’t get to a SilverSneakers location or FLEX class, SilverSneakers Steps® offers a choice of
four fitness kits for at-home use – general fitness, strength, walking or yoga.
December 2014
19 of 37

The SilverSneakers member website offers members tools to assess their health and track their activity, fitness
advice, meal plans and downloadable health recipes, and connection with the SilverSneakers online community for
additional support.
SilverSneakers members have the tools and support they need to improve strength, balance and coordination, and the
confidence to continue being active. In fact, SilverSneakers members report experiencing fewer falls than older adults
nationally. Among BCBSGa members, 15 percent reported having a fall in 2013, compared to 26 percent of older adults
nationally. And only 11 percent of members reported having to be hospitalized compared to 17 percent of national older
adults. 3
Please encourage your patients to take advantage of this valuable benefit. To learn more, visit silversneakers.com or contact
Stephanie Williams by phone at 678-458-6371 or via email . Staff trainings and SilverSneakers marketing materials are
available for your office.
1.
http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
2.
http://stopfalls.org/what-is-fall-prevention/fp-basics/
3.
SilverSneakers Annual Member Survey, 2013.
SilverSneakers® is a registered trademark of Healthways, Inc. © 2014 Healthways, Inc.
Y0071_14_21645_I_003_09/17/2014
Individual Medicare Advantage membership moves to new claims processing system Jan. 1, 2015
Starting Jan. 1, 2015 BCBSGa will move Individual (non-group) Medicare Advantage members to a new claims processing
system. Please review the following information so that you and your staff have the information you need to help ensure
your claims are processed accurately and efficiently.
Group sponsored Medicare Advantage plan members are not affected by these changes: In most cases, this
information will not apply to BCBSGa group sponsored Medicare Advantage members unless separately noted.
As of Jan. 1, 2015, members with the following prefixes on their member card will represent group sponsored Business only
and will remain on the current claims processing platform:
JQF
WSP
XVJ
YLR
XGK


JWM
XDK
XVL
YLV
VZM
XDT
YCG
YRA
VZP
XGH
YGJ
YRE
WGK
XKJ
YGS
YRU
Pricing differences between individual and group sponsored Medicare Advantage members: Beginning Jan.
1, 2015, providers may see differences in pricing between Medicare Advantage Individual and group sponsored
member claims. The reasons for the potential differences are based on the following:
– Claims for Medicare Advantage individual and group sponsored members will be processed on different
platforms
– Timing of Original Medicare pricing software updates may vary by platform.
– Administration of claims edits and sequestration.
Code editing enhancements: As reported in the previous Network Update, effective Jan. 1, 2015, we are updating
our individual Medicare Advantage claims editing by enhancing our code-editing technology to better align to
existing payment guidelines. Individual Medicare Advantage claims will be reviewed to:
– Reinforce compliance with standard code edits and rules
December 2014
20 of 37
–
–
–
–





Ensure correct coding and billing practices are being followed
Ensure all CMS required informational and reimbursement modifiers are billed
Determine the appropriate relationship between thousands of medical, surgical, radiology, laboratory, pathology
and anesthesia codes
Ensure compliance with industry standards
Reimbursement policy changes: A complete overview of code editing enhancements and reimbursement policy
changes can be found here.
On-demand patient records: Patient 360 is a read-only dashboard available through Availty to give you instant
access to detailed information about BCBSGa individual Medicare Advantage members. By clicking on each tab in
the dashboard, you can drill down to specific items in a patient’s medical record:
– Demographic information – member eligibility, other health insurance, assigned PCP and assigned case
managers
– Care summaries – emergency department visit history, lab results, immunization history, and due or overdue
preventive care screenings
– Claims details – status, assigned diagnoses and services rendered
– Authorization details – status, assigned diagnoses and assigned services
– Pharmacy information – prescription history, prescriber, pharmacy and quantity
– Care management-related activities – assessment, care plans and care goals
– Patient 360 will be available Jan. 1, 2015. For more information call 1-866-805-4589.
Changes to sequestration reduction: Beginning Jan.1, 2015, we will change how we administer the sequestration
reduction for Medicare Advantage claims processed on the new system.
– Claims for individual members
•
We will continue the existing reduction for contracted providers paid according to Medicare reimbursement
methodologies.
•
We will begin reducing payments to non-contracted providers.
•
For both contracted and non-contracted providers, we will subtract the sequestration reduction from the
final amount to be paid to the provider after the Medicare Advantage member cost share has been applied.
So, the final amount to be paid to the provider is the plan allowance, minus any member cost-sharing,
minus the sequestration reduction.
– Claims for group members
•
We will continue the existing reduction for contracted providers paid according to Medicare reimbursement
methodologies.
•
Since group member claims are not migrating to the new claims processing system at this time, we will
continue our current methodology for applying the sequestration reduction to the plan allowance.
Please file two separate claims for members who have both a BCBSGa Medicare Advantage plan and other
BCBSGa health benefits: If you treat a BCBSGa Medicare Advantage member who has BCBSGa Medicare
Advantage coverage in addition to health benefits with another BCBSGa plan, you will have to file the claim with
both plans separately. Please use the same electronic claims submission or address and P.O. Box you use today for
BCBSGa claims filing.
New Requirements effective 1/1/2015 For Individual Medicare Advantage Ambulance Anesthesia, Clinical
Laboratory and Mammography Claims: Effective Jan. 1, 2015, BCBSGa individual Medicare Advantage front-end
claims editing will return claims billed without CMS required criteria to the provider who submitted the claim. These
new front-end edits will include:
– Ambulance Claims billed without the Ambulance Pickup Location – Reference Medicare Claims Processing
Manual, Chapter 15, Section 10.3 Point of Pickup
December 2014
21 of 37
Anesthesia Claims billed without an appropriate modifier – Reference Medicare Claims Processing Manual,
Chapter 12, Section 50 K Anesthesia Claims Modifiers
– Anesthesia Claims billed with a unit-of-measure of “units”
– Clinical Laboratory claims billed without a Clinical Laboratory Improvement Amendment (CLIA) certification
number in Box 23 on the CMS 1500
– Mammography claims billed without a mammography certification number in Box 23 on the CMS 1500
Please ensure your billing staff is aware of this change. If you have any questions, please contact the Provider Services
number on the back of the member’s ID card.

Continue to use current phone number for 2015 precertifications: Individual Medicare Advantage members will
be issued new ID cards effective Jan. 1, 2015. The new cards will have a new Provider Service phone number. The
new number on the ID cards will be used for all provider inquiries except precertification. For precertification,
please continue to call the same numbers currently in place – as listed below. If you call the number on the back of
the member’s card for Precertification, you will be directed back to the number below. To avoid this inconvenience,
please note that the numbers below should be used for precertification requests throughout 2015.
–
Phone
Fax
866-797-9884
800-959-1537
Submit all required clinical information at least three business days before the requested procedure to allow a thorough
clinical analysis. For Institutional Admissions, all facilities must notify us within 24 hours or the next business day (whichever
is earlier) after admission. In an urgent or emergent situation, the above time frames will be waived. Please provide notice to
the plan as soon as possible.

Continue to reach provider customer service by calling the number on the back of the member’s ID card.

Continue to use Availty: Availity can be accessed in the same manner as before and will continue to have
information about both individual Medicare Advantage and group sponsored Medicare Advantage members.

Continue to use the same mailing address, Electronic Data Interchange gateway as you do today: Claims and
correspondence should continue to be submitted to same EDI gateway and the same Post Office Box address that
you use today.
New for 2015: BCBSGa introduces new benefits, plans for Medicare Advantage members
BCBSGa also will introduce new benefits for our Medicare Advantage members and new types of Medicare Advantage plans.
The information below highlights what’s new for 2015. For more details now and throughout 2015, please refer to Important
Medicare Advantage Updates on your provider portal.
For a more detailed overview of 2015 changes in plan benefits, co-pays, service areas and more please see the 2015
Product Update for your state under Important Medicare Advantage Updates.
Dual Eligible Special Needs Plans New For 2015
BCBSGa will introduce Dual Eligible Special Needs Plans effective Jan. 1, 2015. D-SNPs provide enhanced benefits
to people eligible for both Medicare and Medicaid. These plans are $0 premium plans. Many feature some
transportation to doctor’s appointments and some include over-the-counter drug costs.
Providers should understand that D-SNP members are protected from balance billing. BCBSGa D-SNPs are “zero
cost share” plans, meaning we only enroll dual-eligible beneficiaries (people eligible for both Medicare and
December 2014
22 of 37
Medicaid) who have Medicare cost sharing protection under their Medicaid benefits. The provider may not seek
payments for cost sharing from dual-eligible members for health care service rendered to dual-eligible members. For
any questions regarding how claims are paid, please or contact Customer Service at 1-855-690-7797.
Dual Eligible Special Needs Plans, also known as D-SNPs, coordinate Medicaid and Medicare programs and provide
enhanced member benefits. BCBSGa will begin offering D-SNPs in 2015. Providers who treat BCBSGa DSNP
members in will have to file the claim twice to help ensure accurate reimbursement. Please use the same
electronic claims submission or address and P.O. Box you use today for BCBSGa claims filing.
Providers who see BCBSGa Medicare Advantage HMO members in Georgia also are considered contractually
eligible to see BCBSGa D-SNP members effective Jan. 1, 2015.
BCBSGa will offer an introduction to D-SNP plans, including claims submission, coding procedures and model of
care information. Upcoming training opportunities will be posted to Important Medicare Advantage Updates as soon
as they are available.
Y0071_14_21954_I 10/08/2014
Referrals
A referral may be required for Individual Medicare Advantage HMO members to see a specialist. In most situations,
our individual Medicare Advantage HMO members may need to receive a referral from their Primary Care Physician
before they can use specialists in the plan’s network. However, referrals from a PCP are not required for emergency
care or urgently needed care. Certain routine care can be obtained without having an approval in advance from their
PCP, such as routine women’s health care (breast exams, screening mammograms, Pap tests and pelvic exams)
and routine dental and vision care. Providers are required to periodically review and comply with the latest Medicare
Advantage Referral requirements found on the Medicare Advantage page of our provider website, on the document
named: Medicare Advantage Referral Requirements.
Please visit our website for more detailed product information or contact Provider Services at the number on the
back of the member’s ID card. You can find Important Medicare Advantage Updates here. Contact your provider
representative for participation details for our contracted plans.
Precertification requirements updated for 2015
Please refer to your provider agreement, provider manual and the Medicare Advantage Precertification Guidelines
found at the Medical Policy, UM Guidelines and Precertification Requirements link on the BCBSGa provider home
page at bcbsga.com for further information on existing precertification requirements and new precertification
requirements for 2015.
Submit all required clinical information at least three business days before the requested procedure to allow a
thorough clinical analysis. For Institutional Admissions, all facilities must notify us within 24 hours or the next
business day (whichever is earlier) after admission. In an urgent or emergent situation, the above time frames will
be waived. Please provide notice to the plan as soon as possible.
Precertifications can be obtained at the following phone or fax numbers for individual and group-sponsored
Medicare Advantage plans:
Type of membership
December 2014
Phone
Fax
23 of 37
GA Medicare Advantage individual members
866-797-9884
800-959-1537
Georgia State Health Benefit Plan
855-747-1131
855-747-1132
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of
the member’s identification card.
For individual Medicare Advantage members who can’t get to the doctor’s office, an online alternative
Live Health Online allows individual Medicare Advantage members in Georgia D-SNP and local PPO plans to visit a
board certified doctor of their choice, from a selected group of independent doctors, on a secure connection over
the Internet via a smart phone, tablet or computer. Members can see doctors on their own schedule in nonemergency situations without having to leave their homes. If medically appropriate, doctors using LiveHealth Online
can send prescriptions directly to a nearby pharmacy. A summary of each visit is created and can be forwarded to
the patient’s primary care doctor with their permission, supporting continuity of care and collaboration among
providers.
Advanced illness planning
The Vital Decisions program provides counseling by telephone to help individual Medicare Advantage members with
advanced illness identify their goals, share them with loved ones and take steps toward meeting them.
Advanced notices of non-coverage for Medicare Advantage members
The Centers for Medicare & Medicaid Services (CMS) issued recent guidance concerning Advance Notices of Non-Coverage.
CMS advised Medicare Advantage plans that contracted providers are required to provide a coverage determination for
services that are not covered by the member’s Medicare Advantage plan. This will ensure that the member will receive a
denial of payment and accompanying appeal rights. Please note that this guidance is not entirely consistent with BCBSGa’s
provider agreements. The provider agreements only require that you notify the member in writing in advance of providing non
covered services and that you provide an estimate of the member’s financial liability. BCBSGa asks that you follow the CMS
requirements immediately. BCBSGa will amend your provider agreement to reflect this change in guidance through a future
communication. If you have any doubt about whether a service is not covered, please seek a coverage determination from
the plan.
A written coverage determination will help ensure that a claim for non-covered care from a contracted provider is paid
accurately. According to CMS, if the appropriate written notice of denial of payment is not given to the Medicare Advantage
member regarding a non-covered service, the claim may be denied and the member cannot be held financially responsible.
Therefore, your failure to provide an appropriate coverage determination could result in a denial of payment for the noncovered service.
Contracted providers seeking a coverage determination for BCBSGa Medicare Advantage members should call the telephone
number listed on the back of the member’s identification card for assistance.
Y0071_14_22176_I_001_10/22/14
OrthoNet to conduct medical necessity reviews, professional service coding reviews
BCBSGa is collaborating with OrthoNet, LLC to conduct medical necessity reviews for physical therapy, occupational therapy
and spine and back pain management for our individual Medicare Advantage members.
December 2014
24 of 37
What does this mean to you?
Effective Jan. 1, 2015, the following services/treatment requests must be reviewed by OrthoNet for precertification:

Physical therapy

Occupational therapy

Spine and Back Pain Management procedures:
– Epidurals
– Facet Blocks
– Pain Pumps
– Neurostimulators
– Spinal Fusion
– Spinal Decompression
– Vertebro/Kyphoplasty
In addition, OrthoNet will conduct post service prepayment coding review of professional services, including:

Orthopedic Surgery

Plastic Surgery

Neurosurgery

Sports Medicine

Podiatry

Hand Surgery

Neurology

Pain Management

Psychiatry/ Physical Medicine and Rehabilitation (PM&R)

ENT

General Surgery

Dermatology

Cardiology

Urology

Percutaneous Coronary Intervention (PCI)
Please submit all required clinical information at least three business days before the requested procedure to allow a
thorough clinical analysis. For Institutional Admissions, all facilities must notify us within 24 hours or the next business day
(whichever is earlier) after admission. In an urgent or emergent situation, the above time frames will be waived. Please
provide notice to the plan as soon as possible.
Precertifications can be obtained at the following phone or fax numbers:
Phone
Fax
866-797-9884
800-959-1537
A complete list of precertification requirements can be found at the Provider Forms section of the BCBSGa Medicare
Advantage page of our provider website.
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of the
member’s identification card. That number also may be used to obtain precertification.
December 2014
25 of 37
Prior authorizations required for CMS-designated high-risk medications
The Centers for Medicare and Medicaid Services (CMS)/Medicare regulations require Medicare Prescription Drug plans to
monitor the use of drugs which pose a higher risk to individuals more than 64 years old. To help ensure patient safety,
BCBSGa requires prior authorization for certain high-risk medications. Please refer to your Medicare Advantage members’
List of Covered Medicare Prescription Drugs (formulary) to see which drugs need prior approval.
To ensure providers are aware of any high-risk medications prescribed for our individual and group-sponsored Medicare
Advantage members, we also send a fax to providers when their patients fill a prescription for a high-risk medication.
BCBSGa also distributes a monthly report to prescribers detailing the number of members on high-risk medications and the
number of high-risk medications prescribed year-to-date. We also contact members who have filled prescriptions for high-risk
medications and suggest that they discuss the prescription with their physician and ask if there is a safer alternate drug.
If you receive a high-risk medication fax or report from us, please review it and help us support safe medication choices.
Alternatives to these high-risk medications are listed here.
Clearinghouse helps ensure timely and accurate claims payment for vaccines covered by Medicare
Part D
Providers who have administered a shingles or tetanus vaccine to our individual and group-sponsored Medicare Advantage
plan members with pharmacy benefits may encounter a denial because the claim is covered under Medicare Part D only.
To streamline your claim processing and payment (as applicable) for these and other preventive vaccines covered under Part
D, providers may use TransactRX, a clearinghouse for claims submission.
To use TransactRX please contact the clearinghouse through their web site or call Customer Service at 866-522-3386.
Physicians, facilities, health clinics and pharmacies may use this clearinghouse to process Part D claims. There is no charge
to providers who use electronic funds deposit to receive payment. There is a service fee of $2.50 for check payments on
claims.
CMS provides more information on Part D vaccines here.
New Federally Qualified Health Center billing guidelines in effect for original Medicare
Medicare introduced a new Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) began Oct. 1,
2014. FQHCs that are non-contracted and those contracted to Medicare rates will be reimbursed the lesser of actual
charges or the PPS rate, less any cost sharing amounts. This will apply to BCBSGa individual and group-sponsored Medicare
Advantage plans.

Federally Qualified Health Centers (FQHC) will be transitioned to the FQHC Prospective Payment System (PPS)
based on their cost reporting periods.
– FQHCs whose cost reporting period began on or after October 1, 2014 will be reimbursed using the new PPS
system.
– FQHCs whose cost reporting period began before October 1, 2014 will be reimbursed using the current allinclusive rate until their new cost reporting period beings.
December 2014
26 of 37
PPS and non-PPS dates of service cannot be billed on the same claim. This means two separate claims must be
billed.
We would like to remind providers that CMS established five new HCPCS which are required for FQHC PPS billing.
– G0466 – FQHC visit, new patient (Revenue code 0519 or 052X)
– G0467 – FQHC visit, established patient (Revenue code 0519 or 052X)
– G0468 – FQHC visit, IPPE or AWV (Revenue code 0519 or 052X)
– G0469 – FQHC visit, mental health, new patient (Revenue code 0900 or 0519X)
– G0470 – FQHC visit, mental health, established patient (Revenue code 0900 or 0519X)
–

For more information, please refer to Medicare Learning Network (MLN) SE1039.
Speaking the language of ICD-10
The Department of Health and Human Services has formally changed the compliance date for conversion to ICD-10
diagnostic and procedure codes from Oct. 1, 2014 to Oct. 1, 2015. The delay provides us with an opportunity to continue our
readiness efforts for the transition to come. We encourage you to continue your ICD-10 readiness activities.
In our previous articles we shared with you some basic information and recommendations to help you begin your journey of
learning to speak the language of ICD-10. We realize that this journey will not be an easy one as the ICD-10 code sets
include greater detail, changes in terminology, and expanded concepts for injuries, laterality, and other related factors. As
you make this journey, please be reminded that complete and accurate medical record documentation and diagnosis coding
plays a critical role in managing our Medicare Advantage membership. Because your coding and record documentation
efforts have a direct impact on accurate risk adjusted payment, we want to share with you specific ICD-10 coding tips related
to risk adjustment-related diagnosis codes (also referred to as hierarchical condition categories, or HCCs).
For this article we will use diabetes mellitus as an example:
Type 2 Diabetes
Diabetes, no complication,
controlled
Diabetic Retinopathy with
Macular Edema
Diabetic Neuropathy
ICD-9 Code(s)
250.00- DM without complications, not
stated as uncontrolled
ICD-10 Code(s)
E11.9- DM without complications
*ICD-10 does not reference controlled vs
uncontrolled DM
250.50- DM with ophthalmic
manifestations
362.01- Diabetic neuropathy NOS
362.07- Diabetic macular edema
250.60- DM with neurological
complications
357.2- Polyneuropathy in DM
E11.311- DM with unspecified diabetic
retinopathy with macular edema
E11.40- DM with diabetic neuropathy,
unspecified
250.70- DM with peripheral circulatory
E11.51- DM with diabetic peripheral
disorders
angiopathy without gangrene
Diabetic Peripheral Angiopathy 443.81- Peripheral angiopathy in
diseases classified elsewhere
In future articles, we will continue to bring your helpful coding tips to assist you and your coding staff transition from ICD-9 to
ICD-10.
December 2014
27 of 37
Please note that CMS will not accept ICD-9 codes beginning Oct. 1, 2015. This will be critical, as all encounters/claims
submitted with ICD-9 codes will reject beginning Oct. 1, 2015 resulting in delay or denial of payment. We must all be
prepared to meet CMS guidelines. To further assist you in your preparation we are providing the following references, helpful
links, and additional resources:

The one-page reference sheet produced by AAPC shows how the code sets are organized, with easy color coding to
help you find what you're looking for. It also has mnemonic tips (such as "C is for cancer" and "T is for toxicity") to
help you remember where the new codes are located.

American Medical Association physician resource page

Centers for Medicare & Medicaid Services (CMS) Provider Resources

AAPC ICD-10 Implementation and Training Opportunities
CMS mandated Opioid Overutilization program
CMS expects Part D sponsors to have effective programs to address opioid overutilization to protect beneficiaries and to
reduce fraud, waste and abuse in the Part D program. CMS expects plans to continue to improve retrospective DUR
programs and case management as related to medication overutilization. As of March 12, 2012, the Food and Drug
Administration (FDA) placed fentanyl-containing products under a new Risk Evaluation and Mitigation Strategy (REMS),
which is now called TIRF REMS. The TIRF drugs include Abstral, Actiq, Fentanyl Citrate, Fentanyl Oralet, Fentora, Lazanda,
Onsolis and Subsys. They are approved for the management of breakthrough cancer pain in patients who are already
receiving and who are tolerant to around-the-clock opioid therapy for their underlying persistent cancer pain.
BCBSGa will mail and/or call providers upon identification of members with suspected patterns of opioid overutilization due to
multiple prescribers and multiple pharmacies. During the phone call, our pharmacists attempt to facilitate a conversation with
providers about the appropriate use, medical necessity and safety of the high opioid dosage for their patient.
Our goal is to work with providers to prevent overutilization and to determine the appropriate amount of opioids for our
members.
For more information, please reference:
1. GAO-11-699, http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/GAOInstancesofQuestionableAccesstoPrescriptionDrugs.pdf
2. CMS Supplemental Guidance, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf
3. HPMS Memo, Medication Part D Overutilization Monitoring System, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSmemo_MedicarePartDOverutilizationMonitoringSystem0117
14.pdf
Hyaluronate agents require prior authorization
Effective immediately, the following drugs should not be billed under the members Part D benefit. Ordering physicians should
call the Specialty Pharmacy Part B department at 866-797-9884 option 5 to obtain precertification for these drugs:

J7323 – Euflexxa, Monovisc

J7326 – Gel-One

J7324 – Orthovisc, Hyaluronan

J7325 – Synvisc, Synvisc One

J7321 – Supartz, Hyalgan
December 2014
28 of 37
If these drugs are taken to a retail pharmacy and attempted to be billed to Part D benefits, the pharmacist will see a message
that rejects the claim and asks to have the prescribing physician call their Part B carrier for prior authorization.
CuraScript moved to Accredo brand effective November 24, 2014
Express Scripts’ acquisition of Medco Health Solutions in 2012 resulted in the merger of ESI’s CuraScript Specialty
Pharmacy and Medco’s Accredo Specialty Pharmacy. Starting in 2014, unified pharmacy operations will be under the
Accredo name and license. Members of our Medicare Advantage Prescription Drug plans transitioned to the Accredo
brand on November 24, 2014.
Some of the limited changes members will experience:

They will see the Accredo name and label on their medication shipments and pharmacy letters

Expanded pharmacy hours: Monday–Friday, 8 a.m.–11 p.m. ET, Saturday, 8 a.m.–5 p.m., ET.

Upgraded assessments to include therapy-specific questions for improved adherence
How providers will be impacted – frequently asked questions
Q. What changes will impact providers as a result of the brand transition to Accredo?
A. Referral forms will be updated to reflect the change to Accredo and will be available on the Accredo website. However, if
providers continue to use CuraScript-branded referral forms, Accredo can accept them and there will be no disruption in
service.
Q. Will the fax number remain the same?
A. Yes, providers will continue to use the same fax number, 1-800-824-2642.
Q. Will the provider contact number remain the same?
A. Yes, providers will continue to use the same phone number, 1-800-870-6419.
Q. Will the pharmacy hours remain the same?
A. The Accredo Specialty Pharmacy will have expanded hours, Monday-Friday, 8 a.m.–11 p.m. ET, Saturday, 8 a.m.–5 p.m.
Q. Will prior authorization phone numbers change?
A. No. Prior authorization phone numbers will stay the same.
Q. Will the process for ordering office-administered drugs change?
A. No, the process for ordering office-administered drugs will not change.
Q. If providers or their staffs have questions about the brand change to Accredo, who should they contact?
A. Providers and their staffs should contact the CuraScript provider help desk, just as they would today.
Q. How will providers be notified about the change?
A. In addition to this article, a letter will be faxed by CuraScript to prescribing providers prior to member notification, alerting
providers to the change.
Pharmacy information available on online
Visit our website for more information on our Medicare Advantage Prescription Drug plans, including formularies, Part D
conditions and limitations and forms.
December 2014
29 of 37
Y0071_14_21910_I 10/06/14
2015 Georgia Medicare Advantage plan changes
Annual benefits changes for Medicare Advantage plan members will be effective January 1, 2015. Each year, we renew our
contract with the Centers for Medicare and Medicaid Services (CMS) and CMS re-evaluates and approves the benefits we’ll
offer to our Medicare Advantage members for the upcoming year.
The below changes apply to members enrolled in BlueValue Basic (HMO), Medicare Preferred Core (PPO), or BCBSHP Dual
Advantage (HMO SNP). You can help members manage their health care costs by being aware of these changes. In
addition, remember to check the Member identification card at the beginning of each calendar year, as the member may have
changed plans.
Notable 2015 benefits changes and highlights by plan type.
Medicare Preferred Core (PPO) Highlighted Plan Changes

2015 Plans may include changes to Medical and Part D benefits, copayments and/or coinsurance, deductibles,
formulary coverage, pharmacy network, premium and out-of-pocket maximums. Please check the member’s benefits
for the new Plan year changes, by visiting our website at or calling provider services at the number on the back of
the member’s ID card.

If members receive two or more services from the same provider during the same visit and/or on the same day,
members will be responsible to pay the copay for each applicable service. This includes but is not limited to lab
services, diagnostic procedures and test, X-rays, Radiology, Part B drugs.

Our plan will no longer cover unlimited inpatient days for acute care illness or injury.

These plans will offer a new benefit called LiveHealth Online. LiveHealth Online provides convenient access for
members to interact with a doctor via live, two-way video on a computer or mobile device.

These plans will offer one routine physical exam in addition to the Medicare-Covered “Welcome to Medicare” exam
or Annual Wellness Exam. The examination for this visit is multi-system, and the exact content and extent of the
exam is based on the patient’s age, gender, and identified risk factors; face-to-face visit. The comprehensive history
obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief
complaint or present illness. It does, however, include a comprehensive system review and comprehensive or
interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors. It
also includes clinical laboratory tests. Providers should bill 99381-99397 (Preventive Medicine Services) for the
routine physical exam. When the routine physical is completed by an in-network provider, there are no out-ofpocket costs for the member. Physicals completed by out-of-network providers will be subject to member co-pay as
applicable by the member’s plan.

Preventive dental consisting of 1 exam and 1 cleaning and preventive vision consisting of 1 eye exam are new
covered benefits in 2015. Members have the option of purchasing an optional supplemental benefit package beyond
this coverage.

Please check the member ID card for any identification and/or group number changes that may affect claim
submissions.
New Plans and Service Area Changes:

Members in DeKalb County will no longer have the Medicare Preferred Core (PPO) available to them in 2015. An
HMO plan is available to these members.
December 2014
30 of 37
Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the service area changes described
above for PPO plans.
BlueValue Basic (HMO) Highlighted Plan Changes

2015 Plans may include changes to Medical and Part D benefits, copayments and/or coinsurance, deductibles,
formulary coverage, pharmacy network, premium and out-of-pocket maximums. Please check the member’s benefits
for the new Plan year changes, by visiting our website at or calling provider services at the number on the back of
the member’s ID card.

If members receive two or more services from the same provider during the same visit and/or on the same day,
members will be responsible to pay the copay for each applicable service.

Our plan will no longer cover unlimited inpatient days for acute care illness or injury.

These plans will offer a new benefit called LiveHealth Online. LiveHealth Online provides convenient access for
members to interact with a doctor via live, two-way video on a computer or mobile device.

These plans will offer one routine physical exam in addition to the Medicare-Covered “Welcome to Medicare” exam
or Annual Wellness Exam. The examination for this visit is multi-system, and the exact content and extent of the
exam is based on the patient’s age, gender, and identified risk factors; face-to-face visit. The comprehensive history
obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief
complaint or present illness. It does, however, include a comprehensive system review and comprehensive or
interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors. It
also includes clinical laboratory tests. Providers should bill 99381-99397 (Preventive Medicine Services) for the
routine physical exam. When the routine physical is completed by an in-network provider, there are no out-ofpocket costs for the member. Physicals completed by out-of-network providers will be subject to member co-pay as
applicable by the member’s plan.

Preventive dental consisting of 1 exam and 1 cleaning and preventive vision consisting of 1 eye exam are new
covered benefits in 2015. Members have the option of purchasing an optional supplemental benefit package beyond
this coverage.

Please check the member ID card for any identification and/or group number changes that may affect claim
submissions.
New Plans and Service Area Changes:

Members in Henry County will no longer have the BlueValue Basic (HMO) available to them in 2015.
New for 2015: BCBSHP Dual Advantage (HMO SNP):

A Dual Eligible Special Needs Plan for beneficiaries with Medicare and Medicaid serving select counties

Preventive dental exam, cleaning and x-rays

Hearing exam and hearing aids

Vision exam with glasses/contact benefit

Transportation benefits
Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the service area changes described
above for HMO plans.
Optional Supplemental Benefits (OSB)
For 2015, many of our Medicare Advantage plans will offer three Optional Supplemental Benefit (OSB) packages for an
additional premium. OSB packages allow the Medicare Advantage plan to be tailored for additional dental and vision
coverage.
December 2014
31 of 37
We will offer the below Optional Supplemental Benefit (OSB) packages on select plans. Members will have up to 90 days
from their plan effective date to enroll in one of the below packages:
1.
2.
3.
Preventive Dental Package
Dental and Vision Package
Enhanced Dental and Vision Package
Diabetic Supplies:
Effective January 1, 2015, all of our individual Medicare Advantage plans will only cover certain diabetic supplies if they are
purchased at one of our network pharmacies or through our mail-order service. Durable Medical Equipment (DME) providers
as well as physicians will no longer be able to bill for these supplies.
HCPC codes that will no longer be covered when purchased through a DME provider or other physicians:

A4253 blood glucose test strips

E0607 home blood glucose monitor

E2100 blood glucose monitor with integrated voice synthesizer

E2101 blood glucose monitor with integrated lancing/blood sample
Members impacted by this change will be notified in October through their Annual Notice of Change and Evidence of
Coverage plan benefit materials.
To be covered for a $0 copay, the members must purchase these supplies at an in-network retail or mail-order pharmacy
supplier.
Covered blood glucometers and blood glucose test strips in 2015:

LifeScan, Inc., OneTouch®

Roche Diagnostics, ACCU-CHEK®

A limit of 100 blood glucose test strips per month
Other blood glucometer or blood glucose test strip brands or quantities of more than 100 test strips per month are not
covered unless you as the doctor or provider tell us another brand or a larger quantity is medically necessary for the
member’s treatment, no other brand or larger quantity limit will be covered.

If our member is currently using LifeScan, Inc, OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips or
glucometer products and using an in-network retail or mail-order pharmacy supplier, you don’t need to do anything!

If our member is not using LifeScan, Inc, OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips or
glucometer products or using an in-network retail or mail-order pharmacy supplier, then our member will need to get
new prescriptions for the supplies by January 1 st for these claims to be covered by us.

You should discuss these coverage changes and possible new prescriptions with our member/your patient. If it is
medically necessary for them to continue using a different brand of blood test strips or glucometer and/or more than
100 blood test strips per month, you will need to communicate this to us by requesting an exception. If your patient
purchases their supplies through the pharmacy or the ESI mail-order service exceptions may be requested by
calling 800-338-6180.
The benefit and brand limitations described above generally do not apply to our Group Sponsored Medicare
Advantage Health Benefit Plans. Please contact provider services for benefit information.
December 2014
32 of 37
Insulin Exclusivity:
As a reminder for 2015 Individual MAPD plans have an insulin exclusivity contract with Eli Lilly, the
manufacturer of Humulin and Humalog human insulins. Other insulin’s are considered non-formulary and are not
eligible for coverage.
New Year! New Formulary Changes!
Each year we evaluate our benefits and formulary and may make changes to update them. Formulary changes
in the upcoming year include: tier changes, drug removals, and new Prior Authorization and Quantity Limit
requirements.
Your patients will have formulary changes and will need your help to ensure they get their needed treatments at
the most affordable cost.
Please, encourage your patients to review the 2015 formulary information within their Annual Notice of Change
(ANOC) mailing, or to view the information online when it is available, beginning October 1. Ask them if the
coverage for any of their prescriptions has been changed, and consider alternative medications in a lower costsharing tier that may meet their needs.
Pharmacy Benefit Changes for 2015:

Tier 6 has select care drugs at a $0 for the following conditions: high blood pressure, high cholesterol
and diabetes and will have the following drugs on it: GLIPIZIDE, LISINOPRIL, LOSARTAN
POTASSIUM, METFORMIN HCL, and SIMVASTATIN.

The pharmacy network includes preferred and other network retail pharmacies. Member’s save more
by paying a lower cost-sharing amount at preferred cost-sharing pharmacies. Our preferred costsharing pharmacies include CVS/Pharmacy (participating pharmacies include CVS and Longs Drugs),
Giant Eagle Pharmacy, Hannaford Brothers (participating pharmacies include Hannaford and Food
Lion), Harris Teeter Supermarkets, Kroger (Kroger Co. participating preferred pharmacies include
Kroger, FredMeyer, King Soopers, City Market, Fry’s, Smith’s, Dillons, Ralphs, QFC, Baker’s, Scott’s,
Owen’s, Pay Less, Gerbes and JayC), Target and Wal-Mart (Walmart participating preferred
pharmacies include Walmart, Neighborhood Market and Sam’s Club. Members can fill a prescription at
a network retail pharmacy, but their cost-sharing amount may be higher.) Please note: Ride Aid will no
longer offered preferred cost sharing for member, but will continue as part of the standard retail
network.
Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the changes described
above for Pharmacy plans.
Balance Billing Reminder:
The Centers for Medicare and Medicaid Services and our plan does not allow you to “balance bill” Medicare Advantage HMO
and PPO members for Medicare covered services. CMS provides for an important protection for Medicare beneficiaries and
our members such that, after our members have met any plan deductibles, they only have to pay the plan’s cost-sharing
amount for services covered by our plan. As a Medicare provider and/or a plan provider, you are not allowed to balance bill
members for an amount greater than their cost share amount. This includes situations where we pay you less than the
charges you bill for a service. This also includes charges that are in dispute.
December 2014
33 of 37
Claim payment guidelines for BCBSHP Dual Advantage (HMO SNP):
To fulfill state and federal contractual requirements, this plan applies the Medicare statutory amounts to Medicare covered
services. The remaining Medicare Advantage deductible, coinsurance or copayment amounts are then applied to the
members’ Medicaid benefits; those claims are processed subject to Medicaid processing guidelines.
Under Medicaid, additional payment may be available dependent upon the Medicaid rate of reimbursement. If the Medicaid
rate of reimbursement is more than the filed Medicare benefit, the difference will be paid to the provider. If the Medicaid rate
is less than what the filed Medicare benefit has already paid on that claim, no additional payment will be made. Providers
are prohibited from balance billing members for any portion of that Medicare cost share that is deemed not covered under
their Medicaid benefit.
Employer or Union Group Retiree Changes:
Group Sponsored Medicare Advantage Benefit Plan benefits vary from the Medicare Preferred Core (PPO), BlueValue
Basic (HMO), and BCBSHP Dual Advantage (HMO SNP) mentioned here. Employer or Union Group Plan names and
benefit changes may be different than what is described above. For Group Sponsored Medicare Advantage Health
Benefit Plan members, please refer to the member’s Evidence of Coverage or call Provider Services at the number on the
member ID card for more benefit detail. Medicare Advantage member ID cards contain a CMS identifier in the lower right
corner of the card. The number will be five characters (XXXXX) followed by three characters (XXX). The member is in a
Group Sponsored Medicare Advantage Health Benefit Plan when the last three digits start with an eight (8XX).
Providers should reference the member’s ID card for changes at every visit to help ensure proper billing. You can also assist
your patients by passing on any ID card prefix or benefit change information to any ancillary providers who will be asked to
serve your patient.
What Does the Annual Wellness Visit Cover?
All of our Medicare Advantage plans cover the AWV. Members are encouraged to use this annual benefit as one way to help
assess current health status and future needs.
For the first visit, providers should bill G0438 for the AWV which includes the Personalized Prevention Plan Service.
Thereafter, providers should bill G0439 for the AWV and Personalized Prevention Plan Service, subsequent visit.
Annual Wellness Visit:
All Medicare Advantage plans cover the AWV. Members are encouraged to use this annual benefit as one way to help assess
current health status and future needs.
What if Additional Services Are Provided at the Same Time As the AWV?
If other evaluation and management services are provided in conjunction with the AWV, use CPT Modifier 25 (Significant,
separately identifiable evaluation and management service by the same physician on the same day of the procedure or other
service) as appropriate.
Prior Authorization Updates for Medicare Advantage Plans:
Providers are required to periodically review and comply with the latest Medicare Advantage Prior Authorization requirements
found on the Medicare Advantage page of our provider website on the document named: Medicare Advantage Precertification
Requirements (updated 10/01/2014).
December 2014
34 of 37
Referral Process Updates for Individual Medicare Advantage Plans:
In most situations, our members may need to receive a referral from their PCP before they can use specialists in the Plan’s
network. Examples of specialists include Cardiologists, Dermatologists, Orthopedic surgeons, Oncologists and Urologists.
However, referrals from a PCP are not required for emergency care or urgently needed care. There are also other kinds of
care members can obtain without having approval in advance from their PCP.
Please visit the Medicare Advantage page of our provider website for more detailed product information or contact Provider
Services at the number on the back of the member’s ID card. You can find important Medicare Advantage updates in the
Plan & Administrative Changes/Update section. Contact your provider representative for participation details for our
contracted plans.
Y0071_14_22298_I_10/31/14
Pharmacy
Pharmacy information available on bcbsga.com
For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes,
prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management
methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain
drugs, visit anthem.com/pharmacyinformation. The commercial drug list is reviewed and updates are posted to the website
quarterly (the first of the month for January, April, July and October).
To locate the “Marketplace Select Formulary” and pharmacy information for Health Plans offered on the Exchange
Marketplace, click on “about us” at the bottom of the page, then go to Customer Support, select your state, Download Forms
and choose “Select Drug List”.
Policy updates
Ancillary precertification requirements: Ground Ambulance, Non-emergent
BCBSGa announced in the August 2014 edition of Network Update that effective December 1, 2014 a new and revised
coverage guideline for Ground, Non-Emergent Ambulance/Transportation Services will be implemented. The services
addressed in this coverage guideline will require precertification and medical necessity review for all HMO, PPO, POS and
Indemnity products, with the exception of the Federal Employee Program® (FEP®). The Ambulance/Transportation Services:
Ground; Non-Emergent (CG-ANC-06) guideline can be found by visiting our provider website, bcbsga.com.
Professional Reimbursement policy updates
On December 1, 2014, we will update our BCBSGa provider website with the following revised professional reimbursement
policies.
December 2014
35 of 37
Bundled Services and Supplies
The Health Plan considers the scraping or smoothing of vertebral endplates in preparation of spinal fusion to be incidental to
the spinal arthrodesis. Therefore, for dates of service on or after March 16, 2015, vertebral corpectomies performed at the
same time as spinal arthrodesis will not be eligible for separate reimbursement unless there is a diagnosis of spinal fracture,
infection, or tumor. There will be no modifier override unless diagnosis criteria described above is met; therefore, this
information is also included in our Modifier 59 policy.
As we advised in our August 2014 Network Update, we are reviewing and adding Healthcare Common Procedure Coding
System (HCPCS Level II) “S” codes to our always bundled services edit. According to the Health Plan, unless there are
specific, specialized contracts or criteria for a provider to report their services using a temporary HCPCS “S” code, the Health
Plan will consider “S” codes to be always bundled codes. Therefore, effective with dates of service on or after November 17,
2014, codes S0250, S1002, S3630, S4020, S4021, S4023, S5160, S5190, S9335, S9349, S9437, and S9474 are included
in the always bundled edit.
In addition, for claims processed on or after March 1, 2015, codes S0201, S0209, S0215, S0265, S0320, S0390,
S0618, S3650, S4026, S8185, S9001, S9025, S9447, S9982, and S9991 will not be eligible for reimbursement.
Modifier 59 (Distinct Procedural Services)
Effective for claims processed November 17, 2014, fluoroscopic guidance codes 77002 and 77003 and CT guidance code
77012 that are indicated as not reportable “with” specific other codes per Current Procedural Terminology (CPT®)
parenthetical statements (e.g., “do not report 77002 in conjunction with …”) will not be eligible for separate reimbursement
when reported with modifier 59.
In April 2014, CMS updated the 2014 relative value units for CPT code 63650 (percutaneous implantation of neurostimulator
electrode array, epidural) to include HCPCS code L8680 (implantable neurostimulator electrode, each). Therefore, beginning
with dates of service on or after November 17, 2014, L8680 when reported with 63650 will not be allowed for separate
reimbursement even when reported with modifier 59.
The following professional reimbursement policies received an annual review and may have word changes or clarifications,
but do not have significant changes to the policy position or criteria:

Documentation and Reporting Guidelines for Consultations

Documentation and Reporting Guidelines for Evaluation and Management

Durable Medical Equipment

Injectable Substances with Related Injection Services

Multiple Diagnostic Imaging Procedures

Physical and Manipulative Maintenance Services

Qualitative Drug Screen Testing

Urgent Care (Coding and Bundled Supplies)
Documentation Guidelines for Central Nervous System Assessments/Tests
We are posting a new policy effective December 1, 2014 outlining our documentation guidelines for reporting Central
Nervous System (CNS) Assessments/Tests.
System Updates for 2015
As a reminder, our ClaimsXten editing software package will be updated quarterly in February, May, August and November of
2015. These upgrades will:

reflect the addition of new and revised CPT/HCPCS codes and their associated edits
December 2014
36 of 37




include updates to National Correct Coding Initiative (NCCI) edits
include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
include assistant surgeon eligibility in accordance with the policy
include edits associated with reimbursement policies including, but not limited to, preoperative and post-operative
periods assigned by The Centers for Medicare & Medicaid Services (CMS)
View BCBSGa Professional Reimbursement policies at bcbsga.com by clicking on the “Reimbursement policies” link on the
lower left side of the page.
Professional coding update: Modifiers XE, XP, XS, and XU effective 01/01/2015
Effective January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) has created four new HCPCS modifiers
that will selectively identify subsets of modifier 59 for Distinct Procedural Services as follows:

XE Separate Encounter: a service that is distinct because it occurred during a separate encounter

XP Separate Practitioner: a service that is distinct because it was performed by a different practitioner

XS Separate Structure: a service that is distinct because it was performed on a separate organ/structure

XU Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual
components of the main service
Beginning with claims for dates of service on or after January 1, 2015, BCBSGa will accept these new modifiers, collectively
referred to as -X {EPSU} modifiers. We will apply edits to the -X {EPSU} modifiers equivalent to our modifier 59 edits with
our February quarterly update for claims processed on or after February 16, 2015. Prior to the February 16, 2015 update,
these modifiers will be considered informational and will not be used to override an edit.
Precertification change notification
The following Medical Policies will be added to the GA Standard Precertification List effective 03/01/15:

DRUG.00064 Levodopa/Carbidopa Intestinal Infusion - J3490

DRUG.00065 Recombinant Coagulation Factor IX, Fc Fusion Protein (rFIXFc)- C9135 and J7199
The policies and guideline below are already on the GA Standard Precertification List but the codes listed will now also
require precertification effective 03/01/15:

DRUG.00058 Pharmacotherapy for Hereditary Angioedema (HAE) - J3590

SURG.00007 Vagus Nerve Stimulation - E1399

SURG.00020 Bone-Anchored Hearing Aids - V5298

CG-DRUG-05 Recombinant Erythropoietin Products - Q9972 and Q9973
For additional information, you can access the complete GA Standard Precertification CODE List and the GA Adopted
Clinical Guideline List by using the links below.

Standard Precertification CODE List

Standard Adopted Clinical Guideline List
December 2014
37 of 37