Effective October 14, 2018, BCBSGa will enforce the requirement to bill the correct modifier and HCPCS for services utilized. Incorrect billing will be rejected and claims will be returned to the provider for correction and resubmittal.

Durable Medical Equipment (DME) may be purchased, rented or rented until the purchase price has been paid. 

Correct billing will allow member benefits to be applied correctly to include benefit accumulations for a member’s DME benefits.

As part of BCBSGa’s role to safeguard our members and provide relevant information to providers we are relaying the following recent Food and Drug Administration (FDA) Warning Letters:  

Estring – On June 19, 2018 the Food and Drug Administration issued a letter of warning to Pfizer for "false or misleading" promotional materials related to ESTRING® (estradiol vaginal ring).  According to the FDA the posted “… video is especially concerning from a public health perspective because it fails to include any risk information about Estring, which is a drug that bears a boxed warning due to several serious, life-threatening risks, including endometrial cancer, breast cancer, and cardiovascular disorders, as well as numerous contraindications and warnings. The video thus creates a misleading impression about the safety and efficacy of Estring”.

Xtampza – On February 9, 2018 the Food and Drug Administration issued a letter of warning to Collegium Pharmaceuticals for publicly providing false or misleading representations regarding Xtampza (oxycodone) ER because it “fails to adequately communicate information about the serious risks associated with Xtampza ER use”.

Further details regarding these Warning Letters from the FDA can be found online for Estring and Xtampza.

Check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session. During this fast paced hour, learn how to:

• Understand Availity’s EDI Gateway and clearinghouse workflow for 837, 270/271, 276/277, and 835 transactions.
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences, manage your FTP account, and more.
• Enroll for and manage 835 ERA delivery with Availity.
• Access and navigate the Availity EDI Guide.

Upcoming Sessions

Currently scheduled upcoming sessions include:

• October 29, 2018, 1:00 p.m. – 2:00 p.m. ET
• November 7, 2018, 11:00 a.m. – 12:00 p.m. ET

Enroll

1. Log in to the Availity Portal.
2. Select Help and Training, then Get Trained.
3. In the Availity Learning Center (ALC) Catalog, select Sessions.
4. Scroll Your Calendar to find and enroll for a live session.

Can’t make it?

We’ve got you covered with a recording of a previous live session. In the ALC, search the Catalog by the keyword “song” and enroll for the on-demand option.

Need Help?

Email training@availity.com if you have issues enrolling for a live webinar.

As communicated in the past, Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (collectively “BCBSGa”) is leveraging the strength and efficiencies of our parent company and continuing to simplify the way we do business by changing our operating systems to those currently used by our sister plans.

Changes to your remittance.

Starting in January 1, 2019, some providers may notice a few slight differences in remittance. They include:

*Only applies to providers contracted with a percentage of fee schedule

If you have any questions regarding this notification, please contact your local network consultant or call BCBSGa provider services at 800-428-4446. Thank you for your continued participation in our network.

What is Availity?

Most of you know Availity as web portal or claims clearinghouse, but they are much more.  Availity is also an intelligent EDI Gateway for multiple vendors and will be the EDI connection for all Anthem Inc. and its affiliates, including BCBSGa.

If you currently use a clearinghouse, billing company or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to BCBSGa.

How are you submitting EDI transactions today?

• If you currently transmit your EDI Submissions using a clearinghouse or Billing Company, you should contact your clearinghouse to confirm your EDI submission path has not changed. If you are notified of any potential impacts with connectivity, workflow or financial, please know there is no cost alternate submission options available with Availity.
• If you currently submit directly to BCBSGa and already have an Availity login for the portal, you can use that same login for your EDI services.
• Please visit the website to learn more.

How can you directly transmit EDI submission to Availity?

Below are the different ways you can submit direct EDI transactions to Availity:

• Submit transaction files through FTP – If you work with a practice management system, health information system, or other automated system that supports an FTP connection, you can securely upload EDI transactions to the Availity FTP site where they are automatically picked up by Availity and submitted to BCBSGa.
• Submit transaction files through the Availity Portal – If you have batch files of EDI transactions that you need to process and you choose not to use the

Availity FTP site, you can manually upload the batch files through the Availity Portal.

• Submit transactions through manual data entry in the Availity Portal – The Availity Portal makes it easy to submit transactions, such as eligibility and benefits inquiries or claims, by entering data into our user-friendly web forms.

What are your next steps?

• We recommend that you register with Availity for your EDI transmissions and begin migrating your volume by the end of 2018.
• Availity will be working directly with your clearinghouse, billing companies, and if you choose to submit directly, your organization.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-Availity (1-800-282-4548) Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time. 

• G0396 /99408 – Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes
• G0397 / 99409 – Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes
• G0442 – Annual alcohol misuse screening, 15 minutes £ G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0444 – Annual depression screening, 15 minutes

BCBSGa also supports behavioral counseling for specific chronic conditions while in the primary care office. These services include:

• G0446 – Annual, face-to-face intensive behavioral therapy for cardiovascular disease, 15 minutes
• G0447 – Face-to-face behavioral counseling for obesity, 15 minutes
• G0473 – Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

In addition, BCBSGa reimburses for the psychiatric collaborative care codes; procedure codes 99492, 99493, 99494 are used to report these services. These codes are reportable by primary care for their collaboration with a qualified behavioral health provider, such as a Psychiatrist, Licensed Clinical Social Worker, etc. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a BH specialist. The American Psychiatric Association (APA) has created a training program for primary care on the collaborative care model and the use of these codes. It can be found at APA Training Module. 

We appreciate your participation in our networks, and thank you in advance for your continued commitment to use only contracted providers, including laboratories for our members.

The Communication & Education section includes two new categories to help make it easier for you to find what you need:  Payer Spaces and Interactive Care Reviewer. 

With an Availity log in you can easily view any new content added to the ERC. There is no additional role assignment needed.  

Find the ERC on the Availity Portal under Payer Spaces > Blue Cross and Blue Shield of Georgia > Applications. If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your Favorites.

Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.

Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.

The CPT® 2018 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”

As a reminder, physicians are required to refer to in-network laboratories. For our HMO, Open Access and Pathways members, this means referring to Laboratory Corporation of America (LabCorp). By doing so, members are assured of having the highest benefit level and minimum out of pocket expense. 

LabCorp is the exclusive national clinical reference laboratory provider for Blue Cross and Blue Shield Healthcare Plan of Georgia Inc. HMO, Open Access POS and Pathways members.

Laboratory specimens can be collected in the office with LabCorp courier pick-up available throughout the state. Members may also bring a LabCorp requisition form completed by their physician, to any of the over one-hundred LabCorp Patient Service Center locations throughout Georgia. To find out about LabCorp Patient Service Center locations, go to bcbsga.com.

If you have questions about LabCorp services, need to set up a LabCorp account, order supplies or schedule a pick-up, please call LabCorp at 800-762-0890.

If you have questions about our provider network or coverage for your patients, please contact your BCBSGa representative.

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

Your contracted HMO or POS reimbursement will be applied to claims for members who receive benefits thorough a HMO or POS plan. PPO reimbursement will be applied to claims for members who receive benefits thorough a PPO plan. And now, PAR reimbursement will only be applied to claims for members who receive benefits thorough a PAR or indemnity plan.  

If you do not participate in a network you will be considered “out-of-network” for members who access benefits through networks in which you do not participate. In the past, the PAR Network, operated as the default network so that if you treated members who accessed benefits through a network in which you did not participate, the PAR Network would drive reimbursement and cost shares.  Beginning January 1, 2019, if you treat a member with benefits through a network in which you do not participate, the following will occur: (a) If the Plan has approved the out-of-network care, you must secure a single case negotiated agreement before treating the member and/or (b) if the member self-refers, a single case negotiated agreement is not required but is suggested to help the member receive the highest level of benefits.     

• Hospital readmissions
• Frequent ER visits
• No engagement with PCP within three months or more
• Readmission risk score >24
• Multiple diagnoses
• Identified social determinants of health

PCHP does not replace BCBSGa Case Management, the care or the care management provided by PCPs and specialists. Instead provides an extra layer of support with Community Health Workers as an extension of care management to help our members navigate the complex health care system.

A PCHP Community Health Worker may reach out to your practice to introduce themselves and establish a relationship with the physician. They may also discuss developing a mechanism by which to share information regarding patients that have been identified for complex care services.

For questions regarding PCHP and complex care services, please contact 800-353-0923. 

People are dying of opioid addiction. With the ECHO opioid addiction treatment, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website.

Benefits of participating include:

• Addiction treatment training.
• Free continuing education credits.
• Opportunity to receive expert input on your (de-identified) patient cases.
• Access to a virtual learning community for treatment guidelines, tools and patient resources.
• Opportunity to ask questions and get a variety of support from specialists.

Quality Medication-Assisted Therapy (MAT)

To help ensure members have access to comprehensive evidence-based care, BCBSGa is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with buprenorphine or, in some plans, methadone maintenance treatment in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

For more information

For more information about best practices for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.

You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.

Please submit genetic testing prior authorization requests to AIM through one of the following ways:

• Access AIM ProviderPortal_SM 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 at 800-714-0040, Monday–Friday, 8:00 a.m.–8:00 p.m.

For further questions regarding prior authorization requirements, please contact the Provider Services number on the back of your patient’s ID card.

The 2013 American College of Cardiology and the American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events. High-intensity statin therapy is recommended if the patient has an estimated 10-year ASCVD risk ≥7.5 percent. For males 21-75 and females 40-75 years of age with clinical ASCVD, high-intensity statin therapy is recommended unless contraindicated. These guidelines recommend statin therapy in these scenarios regardless of what patient LDL values are.  Please evaluate if your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

Formulary agents are listed below:

*Rosuvastatin (Crestor) is a preferred brand medication on the Medicare formulary. 

**Available for a $0 co-pay for most plans in 2018

1. Cumulative Morphine Milligram Equivalent (MME) > 90mg per day
2. Opioid prescribers > than three and opioid dispensing pharmacies > than three
3. Or Opioid prescribers > than five regardless the number of pharmacies

• Cancer, LTC and Hospice are exempt
• Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.
• Plan sponsors will request agreement from the provider selected as the home.
• At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.
• Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.
• Beneficiaries retain the right to request a coverage determination and may choose to change their Home pharmacy or prescriber at any time.

• July Medicare Advantage reimbursement policy  
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  
• Inpatient Readmissions   
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective Sept. 1  
• Introducing the Interactive Care Reviewer