CommercialNovember 30, 2018
Coordination of Benefits for an FEP® member
To view this article online:
Visit https://providernews.anthem.com/georgia/articles/coordination-of-benefits-for-an-fep-member-1-1022
Or scan this QR code with your phone
December 2018 BCBSGa Provider NewsletterContentsCommercialNovember 30, 2018 Coordination of Benefits for an FEP® memberCommercialNovember 30, 2018 2019 BCBSGa provider Town Hall meeting scheduleCommercialNovember 30, 2018 Availity to serve as EDI entry point for electronic submissionsCommercialNovember 30, 2018 Company works to simplify payment recovery process for National Accounts membershipCommercialNovember 30, 2018 Request an appeal using Interactive Care Reviewer (ICR)CommercialNovember 30, 2018 Integrated Care Model for plans purchased on the Health Insurance Marketplace benefits patients and physiciansCommercialNovember 30, 2018 Coordination of careCommercialNovember 30, 2018 Important information about utilization managementCommercialNovember 30, 2018 Members’ rights and responsibilitiesCommercialNovember 30, 2018 Vaginal Birth after Cesarean (VBAC) certified shared decision making aid available on the webCommercialNovember 30, 2018 Clinical practice and preventive health guidelines available on anthem.comCommercialNovember 30, 2018 About our Network eUPDATE email toolCommercialNovember 30, 2018 2019 FEP Benefit information available onlineCommercialNovember 30, 2018 HEDIS® 2018 commercial results are inCommercialNovember 30, 2018 Use the Provider Maintenance Form to update your practice informationCommercialNovember 30, 2018 Clinical Practice and Preventive Health guidelines available on the webCommercialNovember 30, 2018 Notification of preapproval list changes (December 2018)CommercialNovember 30, 2018 System updates for 2019 (Professional)CommercialNovember 30, 2018 Coding tip: Claims processed with modifier 79 should be reported by the same health care professionalCommercialNovember 30, 2018 “Rule of Eight” Reporting Guidelines for Physical Medicine and Rehabilitation Services (Professional)CommercialNovember 30, 2018 Updates to AIM musculoskeletal surgery clinical appropriateness guidelinesCommercialNovember 30, 2018 Update to AIM clinical appropriateness guidelinesCommercialNovember 30, 2018 Restructure of AIM advanced imaging clinical appropriateness guidelinesCommercialNovember 30, 2018 Anthem Blue Cross and Blue Shield Georgia Medical Policy and Clinical Guideline Updates 12/1/2018CommercialNovember 30, 2018 Bundled services and supplies (Professional)CommercialNovember 30, 2018 Reimbursement for convenience surgical supply kits (Professional)CommercialNovember 30, 2018 Scope of License reimbursement policy update (Professional)CommercialNovember 30, 2018 Introducing SmartShopper, the consumer shopping and savings program for medical careCommercialNovember 30, 2018 Case Management ProgramCommercialNovember 30, 2018 ConditionCare Program benefits patients and physiciansCommercialNovember 30, 2018 Pharmacy information available on anthem.comCommercialNovember 30, 2018 BCBSGa accepts electronic prior authorization requests for prescription medications onlineCommercialNovember 30, 2018 Benefit change for Infliximab for Federal Employee ProgramCommercialNovember 30, 2018 Introducing the new Clinical Criteria page for injectable, infused or implanted drugsMedicare AdvantageNovember 30, 2018 New Medicare Advantage provider service phone number beginning January 1, 2019Medicare AdvantageNovember 30, 2018 2019 Medicare Advantage individual benefits and formulariesMedicare AdvantageNovember 30, 2018 CMS Medicare Preclusion List effective April 1, 2019Medicare AdvantageNovember 30, 2018 When and how to initiate Medicare Advantage reopeningsMedicare AdvantageNovember 30, 2018 Individual Medicare plans move compound drugs off formulary beginning January 1, 2019Medicare AdvantageNovember 30, 2018 Medicare Part B drugs may include Step Therapy beginning January 1, 2019Medicare AdvantageNovember 30, 2018 Medical Policies updatedMedicare AdvantageNovember 30, 2018 Keep up with Medicare newsTo view this publication online:Visit https://providernews.anthem.com/georgia/publications/december-2018-bcbsga-provider-newsletter-91 Or scan this QR code with your phone CommercialNovember 30, 2018 Coordination of Benefits for an FEP® memberAnthem Blue Cross and Blue Shield values the relationship we have with our providers, and always look for opportunities to help expedite the claim processing. When a Federal Employee visits the provider office, obtaining the most current medical insurance information will help to establish the primary carrier, and will alleviate claim denials and support accurate billing. For questions please contact the Federal Employee Customer Service at: 800-282-2473. To view this article online:Visit https://providernews.anthem.com/georgia/articles/coordination-of-benefits-for-an-fep-member-1-1022 Or scan this QR code with your phone CommercialNovember 30, 2018 2019 BCBSGa provider Town Hall meeting scheduleBCBSGa is pleased to announce that we will continue hosting in person Town Hall style provider meeting throughout 2019.
Topics will include:
February 12, 2019 – Gainesville The Northeast Georgia History Center 322 Academy Street NE Gainesville, GA. 30501. 11:30 a.m.–1:00 p.m., lunch will be provided. Please R.S.V.P by Wednesday, February 6th to RSVPBlue@bcbsga.com
April 9, 2019 – Atlanta Emory North Decatur 2701 North Decatur Road Decatur, GA. 30030 9:30 a.m.–11:00 a.m., breakfast will be provided Please R.S.V.P by Wednesday, April 3rd to RSVPBlue@bcbsga.com. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Availity to serve as EDI entry point for electronic submissionsBCBSGa has designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway. The EDI Gateway is a no-cost option to our direct trading partners. With this change, BCBSGa continues our efforts to ensure consistency between your provider portal and the EDI Gateway.
As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway. Availity is well known as a Web portal and claims clearinghouse. In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.
Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:
If you wish to become a direct a trading partner with Availity, the setup is easy. Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your BCBSGa EDI transmissions.
If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.
Need Assistance? The Availity Quick Start Guide will assist you with any EDI connection questions you may have.
835 Electronic Remittance Advice (ERA) Effective June 1, 2018, please use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes.
Electronic Funds Transfer (EFT) To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time. If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.
Contacting Availity If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Company works to simplify payment recovery process for National Accounts membershipIn our company’s ongoing efforts to streamline and simplify our payment recovery process, we continue to consolidate our internal systems and will begin transitioning our National Accounts membership to a central system in 2019. While this is not a new process, we are transitioning the National Accounts membership to align with the payment recovery process across our other lines of business.
Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835). This segment will show the negative balance associated with the member account number. Monetary amounts are displayed at the time of the recovery adjustment.
As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections.
After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments.
If you have any questions or concerns, please contact the E- Solutions Service Desk toll free at (800) 470-9630. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Request an appeal using Interactive Care Reviewer (ICR)Interactive Care Reviewer (ICR), BCBSGa’s online authorization tool is adding a new feature to further increase the efficiency of your authorization process. In mid-December, you can begin using ICR to request a clinical appeal for denied authorizations and check the status of a clinical appeal. This feature is available for authorization requests submitted through ICR, phone or fax.
Requesting a clinical appeal is easy: Logon to ICR from the Availity Portal and locate the case using one of the search options, or from your ICR dashboard.
Logon to ICR from the Availity Portal
The appeal status and detail of the decision will open on the bottom of the screen.
Need more information on how to navigate the new ICR Appeals feature? Download the ICR Clinical Appeals Reference Guide located on the Availity Portal. Select: Payer Spaces | Applications | Education and Reference Center | Communication and Education. Find the link to the reference guide below the ICR menu.
Additional Training If you are new to ICR or want to get a refresher please attend our monthly ICR webinar. The next event is taking place on December 6 at 1:00 p.m. Register Here To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Integrated Care Model for plans purchased on the Health Insurance Marketplace benefits patients and physiciansAn Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the exchange) the ability to have continuity of care with each care management case. A single Primary Care Nurse provides case and disease assessment and management. This continuity provides opportunity for the member to get assistance working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as an excellent adjunct to physician care.
The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. Our nurse care 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.
Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan.
Members or caregivers can refer themselves or family members by calling the number located in the grid below. How do you contact Case Management?
Georgia
To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Coordination of careCoordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem Blue Cross 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. Anthem Blue Cross 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:
-Diagnosis
-Treatment plan
-Referrals
-Psychopharmacological medication (as applicable)
In an effort to facilitate coordination of care, Blue Cross Blue Shield of Georgia has several tools available on 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 website with information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.**
*Access to the forms and cover letters are available at anthem.com>Providers> Provider Home>Answers@Anthem **Access to the Toolkit is available at anthem.com>Providers>Provider Home> Health and Wellness To view this article online:Visit https://providernews.anthem.com/georgia/articles/coordination-of-care-2-1014 Or scan this QR code with your phone CommercialNovember 30, 2018 Important information about utilization managementOur utilization management (UM) decisions are based on written criteria, 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 provider website at bcbsga.com/provider.
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 at the toll-free numbers listed below. UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the bcbsga.com/provider website.
We work with providers to answer questions about the utilization management process and the authorization of care. Here’s how the process works:
The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.
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. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Members’ rights and responsibilitiesThe 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, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.
Our member rights and responsibilities statement can be found through the Quality Improvement Standards page of our bcbsga.com/provider website. Practitioners may access the FEP member portal at fepblue.org/memberrights to view the FEPDO Member Rights Statement. To view this article online:Visit https://providernews.anthem.com/georgia/articles/members-rights-and-responsibilities-2-1019 Or scan this QR code with your phone CommercialNovember 30, 2018 Vaginal Birth after Cesarean (VBAC) certified shared decision making aid available on the webAs part of our commitment to provide you with the latest clinical information, we have posted a VBAC shared decision making aid to our provider portal. This is a tool for you to discuss with your patients to aid in making a decision regarding their treatment options. This has been reviewed and certified by the Washington Health Care Authority (HCA) and is available on our website. The shared decision making aid on the Practice Guidelines page under the Health & Wellness tab at the top of the screen. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Clinical practice and preventive health guidelines available on anthem.comAs 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 are available on the Practice Guidelines page at bcbsga.com/provider. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 About our Network eUPDATE email toolWe encourage you to continue subscribing to our Network eUPDATE tool. We also ask that you urge your staff and co-workers to register to receive our Network eUPDATE if they have not already done so. This way, you and your staff continue to receive important information and other late breaking or time-sensitive news that you'll need when providing services and filing claims for Anthem members. It's easy to register for the Network eUPDATE; just a few clicks, and the registration process is complete.
To view this article online:Visit https://providernews.anthem.com/georgia/articles/about-our-network-eupdate-email-tool-1006 Or scan this QR code with your phone CommercialNovember 30, 2018 2019 FEP Benefit information available onlineTo view the 2019 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to fepblue.org>select Benefit Plans>Brochure & Forms. Here you will find the Service Benefit Plan Brochure and Benefit Plan Summary information for year 2019. For questions please contact FEP Customer Service at 800-282-2473. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 HEDIS® 2018 commercial results are inThank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) commercial data collection project for 2018. 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. The records that you provide to us directly affect the HEDIS results that are listed below.
Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS project. In order to demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and your office staff can help facilitate the HEDIS process improvement by:
Further information regarding documentation guidelines and administrative codes can be found on the HEDIS page of our Provider Portal. In addition more information on HEDIS can be found on the Quality Improvements and Standards page of our bcbsga.com/provider website. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Physician Documentation Guidelines and Administrative Codes”.
The attached PDF includes a table that shows some of our key measure rates across Georgia.
See attached PDF titled GA HEDIS 2018 results. In Georgia, Commercial HMO rates improved and/or exceeded the national average.
In Georgia, Commercial PPO rates improved and/or exceeded the national average. Measures with rate increases include:
Measures where there are opportunities for improvement include:
Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.
Again, we thank you and your staff for demonstrating teamwork as we work together to improve the health of our members and your patients. We look forward to working with you again next HEDIS season.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) ATTACHMENTS (available on web): GA HEDIS 2018 results.pdf (pdf - 0.09mb) To view this article online:Visit https://providernews.anthem.com/georgia/articles/hedis-2018-commercial-results-are-in-1-1025 Or scan this QR code with your phone CommercialNovember 30, 2018 Use the Provider Maintenance Form to update your practice informationWe continually update our provider directories to help ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice – updating address and/or phone number, adding or deleting a physician from your practice, etc. – please notify us by completing the BCBSGa Provider Maintenance Form located on the Provider Forms page of our provider website, bcbsga.com. Thank you for your help and continued efforts to keep our records up to date. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Clinical Practice and Preventive Health guidelines available on the webAs 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 are available on the Health & Wellness page of our provider website. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Notification of preapproval list changes (December 2018)Preapproval changes are listed in the attached PDF. For additional information, you can access the complete Georgia Standard Preapproval List, Georgia Standard Preapproval CODE List and Georgia Standard Adopted Clinical Guideline List using the following links:
See attached PDF titled GA Standard Preapproval Provider CHANGE Notification 12.1.2018. ATTACHMENTS (available on web): GA Standard Preapproval Provider CHANGE Notification 12.1.2018.pdf (pdf - 0.4mb) To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 System updates for 2019 (Professional)As a reminder, our claim editing software will be updated monthly throughout 2019 with the most common updates occurring in quarterly in February, May, August and November of 2019. These updates will:
To view this article online:Visit https://providernews.anthem.com/georgia/articles/system-updates-for-2019-professional-1037 Or scan this QR code with your phone CommercialNovember 30, 2018 Coding tip: Claims processed with modifier 79 should be reported by the same health care professionalCurrent Procedural Terminology (CPT®) specifically states modifier 79 should be reported by the same individual when reporting unrelated procedures or services during the postoperative period. For example, this modifier is used when a patient presents with a problem that is unrelated to a previous surgery (yet within the postoperative period) and requires additional services by the same provider/individual. When modifier 79 is appended for a different provider (e.g. Nurse Practitioner or Physician Assistant) during the postoperative period the claim line will deny.
To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 “Rule of Eight” Reporting Guidelines for Physical Medicine and Rehabilitation Services (Professional)Please note: We have updated the title of our “Rule of Eight” Reporting Guidelines for Physical Medicine and Rehabilitation Services reimbursement policy to Guidelines for Reporting Timed Units for Physical Medicine and Rehabilitation Services. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Updates to AIM musculoskeletal surgery clinical appropriateness guidelinesBeginning with dates of review on and after January 1, 2019, the following updates will apply to AIM Musculoskeletal Spine Surgery Clinical Appropriateness Guidelines as indicated by section below:
These services or procedures were previously reviewed by Anthem, but will now be reviewed by AIM as part of the Musculoskeletal program. To view the CPT codes, you may access and download a copy of the current guidelines here.
Ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways:
To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Update to AIM clinical appropriateness guidelinesEffective for dates of service on and after March 9, 2019, the following updates will apply to all of AIM’s Clinical Appropriateness Guidelines, including Advanced Imaging, Cardiac, Sleep, Radiation Oncology and Musculoskeletal guidelines.
Clinical Appropriateness Framework Replacing pretest requirements, this section will more accurately describe the guideline’s purpose, which is to provide a summary of the fundamental components of a decision to pursue diagnostic testing. In order to support the full spectrum of AIM solutions, the terms “imaging request” or “diagnostic imaging” are replaced with “diagnostic or therapeutic intervention”.
Ordering of Multiple Diagnostic or Therapeutic Interventions Replacing ordering of multiple studies, this section expands its applicability to AIM solutions outside of diagnostic imaging. Terminology specific to imaging studies is replaced with the term “diagnostic or therapeutic intervention” to reflect a broader application of the principles included here.
Repeat Diagnostic Testing and Repeat Therapeutic Intervention Replacing repeated imaging, these sections establish conditions in which duplication of the initial test or intervention may be warranted, and where such requests will require peer-to-peer discussion.
To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Restructure of AIM advanced imaging clinical appropriateness guidelinesAIM advanced imaging clinical appropriateness guidelines have been restructured to improve usability and to further link clinical criteria with supporting evidence. These structural enhancements resulted in no changes to existing clinical criteria or content.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Anthem Blue Cross and Blue Shield Georgia Medical Policy and Clinical Guideline Updates 12/1/2018The Medical Policy and Technology Assessment Committee adopted the attached (see PDF) new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Anthem Blue Cross and Blue Shield and all the Medical Policies are available at the Anthem Blue Cross and Blue Shield website (Choose Providers > Medical Policies). Please note our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you don’t have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday-Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying medical policy or guideline of interest, your name and address to where information should be sent) to:
Anthem Blue Cross and Blue Shield Attention: Prior Approval, Mail Code GAG009-0002 3350 Peachtree Road NE Atlanta, GA 30326
See the attached PDF titled GA Medical Policy and Clinical Guideline Updates 12.1.2018. ATTACHMENTS (available on web): GA Medical Policy and Clinical Guideline Updates 12.1.2018.pdf (pdf - 0.45mb) To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Bundled services and supplies (Professional)Beginning with dates of service on or after March 1, 2019, BCBSGa will apply our always bundled edit to HCPCS code G0453 (Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)). For more information, review Section 1 of the policy dated March 1, 2019, along with the Bundled Services and Supplies Section 1 Coding list, by visiting the Policy Reimbursement page at bcbsga.com/provider website. To view this article online:Visit https://providernews.anthem.com/georgia/articles/bundled-services-and-supplies-professional-3-1039 Or scan this QR code with your phone CommercialNovember 30, 2018 Reimbursement for convenience surgical supply kits (Professional)BCBSGa periodically reviews claims submitted by providers to help ensure that benefits provided are for services that are included in our members’ benefit plans. Some providers are submitting claims for point-of-use convenience kits that are used in the administration of injectable medicines or other office procedures. These prepackaged kits contain not only the injectable medicine, but also non-drug components including, but not limited to, alcohol prep pads, cotton balls, band aids, disposable sterile medical gloves, povidone-iodine swabs, adhesive bandages and gauze.
Typically, the cost of a convenience kit exceeds the cost of its components when purchased individually. As a reminder, non-drug components included in the kits are inclusive of the practice expense for the procedure performed for which no additional compensation is available to the provider. Please refer to BCBSGa’s Global Surgery and/or Bundled Services and Supplies Reimbursement Policies located at bcbsga.com/provider for additional information. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Scope of License reimbursement policy update (Professional)The December 2017 edition of the Network Update announced BCBSGa will not reimburse services to a provider that is outside of their state requirements through BCBSGa’s Scope of License policy. BCBSGa is updating its editing systems to deny services deemed to be outside of a specific specialty’s scope of license.
For more information about this policy, visit the Policy Reimbursement page at bcbsga.com/provider website. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Introducing SmartShopper, the consumer shopping and savings program for medical careAs of January 1, Anthem’s offering SmartShopper, a new program that lets our members shop for cost-efficient health care.
SmartShopper is a full-service incentive and engagement program that encourages members to shop for health care like an expert. Our members can earn a cash reward* when they shop online or by phone for better-value medical services.
How SmartShopper works:
*Reward payments may be taxable. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Case Management ProgramManaging 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.
Anthem 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 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?
To view this article online:Visit https://providernews.anthem.com/georgia/articles/case-management-program-6-1030 Or scan this QR code with your phone CommercialNovember 30, 2018 ConditionCare Program benefits patients and physiciansBCBSGa members have additional resources available to help them better manage chronic conditions.
The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their doctor’s orders and how to become a better self-manager of their condition.
Engagement methods vary by the individual’s risk level but can include:
Physician benefits:
Please visit the bcbsga.com/provider website to find more information about the program such as program guidelines, educational materials and other resources. Go to bcbsga.com/provider. Also on our website is the Patient Referral Form, which you can use to refer other patients you feel may benefit from our program.
If you have any questions or comments about the program, call 877-681-6694. Our nurses are available Monday–Friday, 8:00 a.m.–9:00 p.m., and Saturday, 9:00 a.m.–5:30 p.m. To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Pharmacy information available on anthem.comFor 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 and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, go to Customer Support, select your state, Download Forms and choose “Select Drug List.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.
AllianceRX Walgreens Prime is the specialty pharmacy program for the Federal Employee Program. You can view the Specialty Drug List or call us at 1-888-346-3731 for more information To view this article online:Visit https://providernews.anthem.com/georgia/articles/pharmacy-information-available-on-anthemcom-16-1035 Or scan this QR code with your phone CommercialNovember 30, 2018 BCBSGa accepts electronic prior authorization requests for prescription medications onlineBCBSGa accepts electronic medication prior authorization (ePA) requests for commercial health plans through covermymeds.com. This feature reduces processing time and helps determine coverage quicker. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay. For example, medications such as celecoxib (Celebrex®), ezetimibe (Zetia®), fluocinolone acetonide (Synalar®), Victoza®, and long acting opioids are automatically approved when a member meets step therapy and/or clinical criteria (as applicable).
Electronic ePA offers many benefits:
Providers can submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.
For questions, please contact the provider service number on the member ID card.
To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Benefit change for Infliximab for Federal Employee ProgramBeginning January 1, 2019, Blue Cross and Blue Shield Federal Employee Program® (FEP) benefit procedures will change for the autoimmune infusion drug infliximab (brand names Remicade, Inflectra, and Renflexis). Members currently receiving the drug may be covered under either pharmacy or medical benefits. However, members who receive a first infusion on or after January 1, 2019 can only receive the drug under medical benefits. Members who receive it under pharmacy benefits prior to January 1, 2019 will continue receiving it under pharmacy benefits.
If you have any questions please contact FEP Customer Service at 800-282-2473.
To view this article online:Or scan this QR code with your phone CommercialNovember 30, 2018 Introducing the new Clinical Criteria page for injectable, infused or implanted drugsBeginning January 2019, providers will be able to visit the Clinical Criteria tab of the Pharmacy Information page to review clinical criteria for all injectable, infused or implanted prescription drugs.
Injectable oncology medical specialty drug clinical criteria will be located on the new site at a later date in 2019. To view this article online:Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 New Medicare Advantage provider service phone number beginning January 1, 2019Effective January 1, 2019, Medicare providers will have toll free phone numbers specifically designated for their service inquiries. These new provider numbers will be listed separately on the back of the member ID cards and should be used beginning January 1, 2019. The associates answering your provider service calls are trained to answer your questions and resolve your issues as quickly as possible. To ensure you receive the most efficient service, please refrain from using the member services line and use only 844-421-5662 or the provider services phone number listed on the back of the member ID card for individual Medicare Advantage calls beginning January 1, 2019. To view this article online:Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 2019 Medicare Advantage individual benefits and formulariesSummary of benefits, evidence of coverage and formularies for 2019 individual Medicare Advantage plans will be available at bcbsga.com/medicareprovider. An overview of notable 2019 benefit changes also is available at Important Medicare Advantage Updates at bcbsga.com/medicareprovider. Please continue to check Important Medicare Advantage Updates at bcbsga.com/medicareprovider for the latest Medicare Advantage information. To view this article online:Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 CMS Medicare Preclusion List effective April 1, 2019The U.S. Centers for Medicare and Medicaid Services (CMS) and Medicare Advantage and Part D organizations, including BCBSGa, will implement a new initiative, the Preclusion List, to protect the integrity of the Medicare Trust Funds. Beginning April 1, 2019, Medicare Advantage and Part D organizations will deny payment for items and services furnished by providers that CMS has placed on the Preclusion List. For more information, visit cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/PreclusionList.html. To view this article online:Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 When and how to initiate Medicare Advantage reopeningsWhen a claim must be corrected beyond the initial claim timely filing limit of one year from the date of service, a normal adjustment bill is not allowed. Providers must use the reopening process to correct the error. To learn when and how to initiate reopenings and adjustments, check Important Medicare Advantage Updates at bcbsga.com/medicareprovider. To view this article online:Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 Individual Medicare plans move compound drugs off formulary beginning January 1, 2019Beginning January 1, 2019, Individual Medicare Advantage plans will move compounded drugs to non-formulary with the exception of home infusion drugs. Group-sponsored Medicare Advantage members will continue to have compounded drug coverage; these drugs will require prior authorization. Compounded home infusion drugs will continue to be covered for both Individual Medicare and group-sponsored members without prior authorizations. Members and/or providers can request a non-formulary exception for compounded drugs. To view this article online:Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 Medicare Part B drugs may include Step Therapy beginning January 1, 2019CMS updated its guidance to allow Medicare Advantage plans the option of implementing step therapy for Part B drugs as part of a patient-centered care coordination program beginning January 1, 2019. The goal is to lower drug prices while maintaining access to covered services and drugs for beneficiaries. BCBSGa will implement step therapy edits to promote clinically appropriate and cost effective drug options for our members. A patient-centered care coordination program will be created to ensure member access to necessary drugs, provide medication reviews and reconciliations, educate members regarding their medications, encourage medication adherence, and provide incentives to members who complete care coordination programs. To view this article online:Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 Medical Policies updatedThe Medical Policy and Technology Assessment Committee (MPTAC) recently approved a number of Medical Policies. Details are available at Important Medicare Advantage Updates at bcbsga.com/medicareprovider
To view this article online:Visit https://providernews.anthem.com/georgia/articles/medical-policies-updated-1061 Or scan this QR code with your phone Medicare AdvantageNovember 30, 2018 Keep up with Medicare newsPlease continue to check Important Medicare Advantage Updates at bcbsga.com/medicareprovider for the latest Medicare Advantage information, including:
To view this article online:Visit https://providernews.anthem.com/georgia/articles/keep-up-with-medicare-news-18-1062 Or scan this QR code with your phone | |||||||||||||||||||||||