As announced in the February 2018 edition of the BCBSGa Network Update, we will continue hosting in person Town Hall style provider orientation meetings throughout 2018. There have been a few updates to the schedule and while the schedule is subject to change, at this time we plan to have the following Provider Town Hall meetings:

June 12, 2018 – Athens

St. Mary’s Healthcare System

Flowers Suite

1230 Baxter Street

Athens, GA. 30607

10:00 a.m. – 11:30 a.m.

Breakfast will be provided

Please R.S.V.P. by Tuesday, June 5th to RSVPBlue@bcbsga.com. Include the name of the facility or practice, and the number of attendees 

July 17, 2018 – Gainesville

Gainesville Civic Center

830 Green Street N.E.

Gainesville, GA. 30501

11:30 a.m. – 1:00 p.m.

Lunch will be provided

Please R.S.V.P. by Tuesday, July 9th to RSVPBlue@bcbsga.com. Include the name of the facility or practice, and the number of attendees 

September 6, 2018 – Savannah

Candler Hospital

The Marsh Auditorium

5353 Reynolds Street

Savannah, GA. 31405

1:00 p.m. – 3:00 p.m.

Refreshments will be provided

Please R.S.V.P. by Friday, August 31st to RSVPBlue@bcbsga.com. Include the name of the facility or practice, and the number of attendees 

November 13, 2018 – Atlanta

DeKalb Medical Theatre

(Use the A Elevators to go to the ground floor, turn left and follow the signs for the Theatre/Auditorium)

2701 North Decatur Road

Decatur GA 30030

10:00 a.m. – 12:00 p.m.

Breakfast will be served

BCBSGa continually evaluates coding and billing patterns, and recently identified trends related to the use of code E1399 — DME, miscellaneous. When an appropriate code exists for DME equipment or supply, the more specific code should be used.

Inappropriate use of code E1399 often includes, but is not limited to the following:

• Gait trainers (E8001/E8002)
• Shower chairs (E0240)
• Standing frames (E0641)
• Hospital beds (E0250-E0373)
• Stand assist lifts (E0635)

To ensure proper use of E1399, BCBSGa conduct post-payment reviews of code E1399. If a more appropriate code should have been used, BCBSGa may recoup overpayments accordingly.

BCBSGa continues to require prior authorization for the use of miscellaneous code E1399. If a prior authorization is approved but the claim is submitted with the incorrect code E1399, then the claim may be denied and a corrected claim will need to be resubmitted with the appropriate HCPCS code.

Beginning July 1, 2018, many BCBSGa members will be able to make payments to providers for their out-of-pocket expenses with Healthcare Bill Payments, a new feature via the member portal at bcbsga.com. Now, your patients can quickly and easily pay you online as soon as their claim information is available.

BCBSGa has engaged with InstaMed®, a healthcare payments network, to offer Healthcare Bill Payments. InstaMed is a Payment Card Industry (PCI) Level One Service Provider and certified at the highest levels for both healthcare and payment processing.

Providers registered with InstaMed will conveniently receive patient payments by direct deposit into their bank account without ever mailing a patient bill or making a phone call. Plus, patients enjoy a simple, convenient payment option.

Registration for Healthcare Bill Payments is simple – you can get started today. Here’s what you’ll need:

• Email address
• Tax ID number for your organization
• Bank account information for direct deposit

If you are not registered, these payments are mailed to you as prepaid Mastercard® payments.

For more information about Healthcare Bill Payments:

• Register to attend InstaMed’s upcoming informational webinar on June 14, 2018 at 1:00 pm ET.
• Read more about Healthcare Bill Payments.
• See InstaMed’s Frequently Asked Questions.
• Email questions about Healthcare Bill Payments to connect@instamed.com.

In the April 2018 edition of the Network Update, BCBSGa announced an expansion of hospice benefits for local BCBSGa fully insured plans to begin on June 1, 2018. The newly expanded benefits allow for disease modifying treatments to continue alongside hospice services, as well as member access to hospice services with prognoses of up to 12 months.

Providers should verify whether members have the expanded hospice benefit under their BCBSGa policy.

For some health plans, updated benefit information will return via an electronic eligibility and benefit inquiry on the Availity Portal or using your Electronic Data Interchange (EDI) interface as early as June 1, 2018. We anticipate that all impacted plans will return the updated language by August 1, 2018. Once updated, hospice inquiries (Service Type 45) will confirm access to the expanded hospice benefit by returning: “LIFE EXPECTANCY UP TO 12 MONTHS WITH DISEASE MODIFYING TREATMENT ALLOWED.”

It may be necessary for providers to contact the Provider Service number on the back of the member ID card to confirm if a member’s plan includes the expanded hospice benefits from June 1, 2018 - August 1, 2018, before all systems are updated to report the more detailed benefit language.

As a reminder, the following plans include the expanded hospice benefits beginning June 1, 2018: Commercial fully-insured group and individual plans. The following plans do not include expanded hospice benefits: self-insured plans, Medicare, Medicaid, and FEP.

Publix members who have services performed at an Ambulatory Surgery Center (ASC) will have a significantly lower out-of-pocket cost than having the same services performed at a hospital’s outpatient center. ASC health care facilities can provide surgery as well as certain pain management and diagnostic services, such as colonoscopies, at a much lower member out-of-pocket cost.

Publix members’ cost will be a $100 copay for covered services at an ASC that is a Blue Cross Blue Shield PPO provider. Publix members who have the same service performed at an in-network hospital’s outpatient facility and have not met their out-of-pocket cost for the year must satisfy their calendar year deductible and applicable coinsurance.

BCBSGa has recently moved into a strategic partnership with Availity to serve as our designated EDI Gateway and E-solutions Service Desk.

• Availity and BCBSGa are working together to develop new ways to simplify how you manage claims and other administrative tasks online.
• Beginning June 1st 2018 you will be able to manage all changes and new setup requests for the electronic remittance advice (835) through the Availity Portal.
• To register or manage account changes for electronic funds transfers (EFT) only, please continue to use the EnrollHub at https://solutions.caqh.org
• If you directly submit your electronic transactions to Anthem (Brand) and have your own practice management software, Availity provides trading partner services and access to Portal tools through an easy setup experience.      
• If you use a clearinghouse, they will work with Availity on your behalf.

Next Steps If you are a Direct Submitter:

Key Factors:

• You will be able to manage changes or new registrations for the electronic remittance advice (835) through your Availity Portal account beginning June 1st 2018. We encourage you to register with Availity to initiate the change to the Availity EDI Gateway.
• BCBSGa and Availity are committed to transparency with this change, and will emphasize the continuity of quality service to our trading partners.

We look forward to delivering a smooth transition to Availity for our EDI services.

If you have any questions or concerns please contact the E-Solutions service desk at 1-800-470-9630 or Availity at 1-800-AVAILITY (282-4548)

In response to provider feedback, and as part of our commitment to support and enable providers, we are pleased to provide Availity overview training.  Please plan to attend one of the two upcoming webinars and learn more on the following:

• Eligibility & Benefits
• Claim Inquiry
• Remittances
• Interactive Care Review (ICR)

Webinars are scheduled for June 21st and October 17th from 1:00 p.m. – 2:00 p.m.

June 21, 2018 from 1:00 p.m. - 2:00 p.m.

RSVP here

October 17th from 1:00 p.m. – 2:00 p.m.

RSVP here

Beginning with dates of service on and after July 1, 2018, the following updates will apply to AIM Musculoskeletal Program Clinical Appropriateness Guidelines:

Spine Surgery guideline: 
Cervical decompression with or without fusion:

• Added osteotomy and corpectomy definitions
• Clarified implant/instrumentation failure

Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis):

• Added osteotomy and corpectomy definitions

Spinal stenosis:

• Removed bilateral or wide decompression

Interventional Pain Management guideline: 

Epidural injection procedures and diagnostic selective nerve root blocks:

• Added prior authorization exemption for CPT codes 62320 and 62322 when used for post-procedural pain with certain ICD-10-CM diagnoses

Repeat therapeutic epidural steroid injections, clarified initial injection as therapeutic:

• Clarified injection sessions for procedural requirements

Paravertebral facet injection/nerve block/neurolysis:

• Increased procedural limitation for diagnostic medial branch blocks
• Increased procedural limitation for therapeutic intraarticular facet joint injections and clarified requirement for conservative treatment between injections

 Sacroiliac joint injections:

• Added HCPCS code G0260

Ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways:

• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET

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.

The following details provide important information about this policy:

• All newborn inpatient stays must include sufficient documentation or prior authorization to support
• an admission to a level of care area beyond the newborn nursery, such as the Neonatal Intensive Care Unit (NICU), or for the higher level of care associated with more complex newborn DRG.

• Newborn claims submitted for a higher level of care DRG that do not include the appropriate documentation, or those submitted with only newborn care revenue codes (170 and 171) and no prior authorization will be automatically processed based on the normal newborn rate. 
• Current prior authorization guidelines for normal newborn and higher level of care newborn inpatient stays apply.

BCBSGa has created a new remark code to help provide additional detail in the above mentioned claim scenarios. The explanation, “Claim did not meet criteria for higher DRG payment. Level of care adjustment has been made. Claim paid at Normal Newborn DRG.” will appear on the provider remit when a claim is submitted with a higher level of care newborn DRG code and the required documentation or prior authorization is not on file. Providers may appeal decisions related to the DRG Newborn Inpatient Stays policy by following their normal appeal process and submitting the appropriate supporting clinical documentation.

To view this and other facility reimbursement policies, visit our Reimbursement Policy page on our bcbsga.com provider website.

To view this and other facility reimbursement policies, visit our Reimbursement Policy page on our bcbsga.com provider website.

Certain DME is not routinely purchased up-front; rent-to-purchase durable medical equipment (DME) is eligible for rental reimbursement up to the purchase price or 10 months rental, whichever comes first. We are receiving claims billed with up-front purchases and we are denying those claims because they must be billed as rent-to-purchase. If you receive such a denial, please do not request a medical necessity review, as that was not the reason for the denial. Instead, please bill claims for these services correctly as rent-to-purchase.  

As a reminder, for dates of service on or after July 1, 2016, the following HCPCS codes for sleep apnea equipment are only eligible for reimbursement when reported as rented items and should not be reported with DME purchase modifiers NR (New when rented (use the NR when DME was new at the time of rental is subsequently purchased)), NU (new equipment), or UE (used durable medical equipment).: 

• E0470 (respiratory assist device, bi-level pressure capability, without backup rate feature)
• E0471 (respiratory assist device, bi-level pressure capability, with back-up rate feature)
• E0561 (humidifier, non-heated, used with positive airway pressure device)
• E0562 (humidifier, heated, used with positive airway pressure device)
• E0601 (continuous positive airway pressure (CPAP) device) 

• Documentation Reporting Guidelines for Consultations
• Duplicate Reporting of Diagnostic Services
• Frequency Editing
• Overhead Expense for Office Based Surgery and Diagnostic Testing
• Sleep Studies and Related Bundled Services & Supplies
• Unit Frequency Maximums for Drugs and Biologic Substances

Blue Cross and Blue Shield of Georgia and Blue Cross Blue Shield Healthcare Plan of Georgia

NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a Group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.

Preapproval changes are listed below.  For additional information, you can access the complete GA Standard Preapproval List, GA Standard Preapproval CODE List and the GA Standard Adopted Clinical Guideline List by using the links below.

• Georgia Standard Preapproval List 
• Georgia Standard Preapproval CODE List
• Georgia Standard Adopted Clinical Guideline List

Notification of Preapproval changes chart

Effective with dates of service on and after October 31, 2018, BCBSGa will begin using MCG Care Guidelines 22^nd edition Behavioral Health guidelines for the review of behavioral health services.  This represents a change from the behavioral health medical policies and clinical guidelines currently used. 

Please note that the following behavioral health (BEH) medical policies and clinical guidelines will be retained at this time:

• BEH.00002 Transcranial Magnetic Stimulation
• BEH.00004 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-BEH-01 Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
• CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder
• CG-BEH-14 Intensive In-Home Behavioral Health Services

BCBSGa may continue to use additional medical policies and clinical guidelines to supplement MCG Care Guidelines.

View BCBSGa’s medical policies and clinical guidelines and view Customizations to MCG Care Guidelines 22^nd edition.

This change impacts BCBSGa’s Commercial health plans.

Providers should continue to call the phone number indicated on the back of the member ID card to request prior authorization review or for additional questions regarding behavioral health benefits.

In the October 2017 edition of the Network Update, BCBSGa announced a new coverage guideline, Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing (CG-MED-53) to be effective January 1, 2018. Please be advised that CG-MED-53 was not implemented. 

Beginning June 1, 2018, BCBSGa will offer an Individualized Care Program to our fully insured commercial members to provide palliative care support for members with advanced illness in the last 12 months of life.  

This program does not replace the care of PCPs and specialists, but provides an extra layer of support with an interdisciplinary team that includes palliative care physicians, palliative care nurse practitioners, registered nurses, social workers, chaplains and patient care coordinators.

Specific palliative care services include:

• Comprehensive assessments including symptoms, spiritual and psychosocial needs
• Expert symptom management
• Supporting patients in defining their goals, values and preferences and in advance care planning
• Encouraging patients to execute advance directives
• 24/7 access to urgent clinical support from an palliative care team member
• Securing needed resources
• Education on palliative services and hospice care services

1. Telehealth services and support at routine intervals to patients by palliative trained providers.
2. Home based visits by a palliative care nurse practitioner, supported by an interdisciplinary team of palliative providers for patients with a high symptom burden, increased risk of hospitalization, or other complex issues. The home based visits will be offered through a BCBSGa partnership with Aspire Health (available in certain geographic areas).
3. Clinic based services offered through a BCBSGa partnership with Aspire Health. Aspire’s palliative care team will be embedded within the outpatient clinic/practice of the member’s medical oncologist to provide services to targeted patients (available in certain geographic areas)
   
   

Aspire Health already provides services for members with advanced illness enrolled in our Medicare and Medicaid health plans and has demonstrated improvement in quality and cost of care savings.

If you are a BCBSGa contracted network provider, an Aspire Health palliative physician may reach out to your practice to introduce themselves in order to establish a physician to physician relationship. They may also discuss developing an individualized mechanism by which to share information regarding patients that have been identified for palliative care services. Aspire will provide clinical updates to your practice on a regular basis to facilitate the best possible co-management of your patient.

Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy level of care review process.

BCBSGa’s level of care prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.

View the Clinical Site of Care (Level of Care) drug list and Clinical Site of Care (Level of Care) prior authorization clinical review FAQs for more information.

BCBSGa recently discovered that some claims with services under the following programs are processing without the required prior authorization through AIM Specialty Health® (AIM), a separate company:

• Sleep Management
• Radiology Oncology
• Radiology Benefit Management (RBM)
• Cardiology

• Access AIM ProviderPortal℠ directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

• Updated: Prior authorizations required for new group-sponsored MA membership 
• BCBSGA adopts MCG care guidelines 22nd edition  

• Improve Medicare Advantage members’ medication adherence with 90-day prescriptions 
• Prior authorization requirements for cardiovascular services  
• Medicare Advantage reimbursement policy provider bulletin  
• Medicare risk adjustment and documentation training  
• Dual Eligible Special Needs Plans – provider training required
• Prior authorization requirement for Electrical Stimulation Device
• Prior authorization requirements for part B drugs: Zevalin and Eptacog 
• Prior authorization requirements for Part B drug: Trelstar

71763MUPENMUB 04/18/2018

Please note, this notice is only applicable to Medicare Advantage members: Cologuard, that at-home colorectal cancer screening, is covered at 100 percent for BCBSGa Medicare Advantage individual and group-sponsored members. Members will not incur an out-of-pocket cost for the screening and no prior authorization is required.

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