Providing Culturally CompetentServices to Diverse PopulationsA recent study conducted by the Agency for Healthcare Research andQuality (AHRQ), demonstrated disparities in patient care exist. Followingare some findings from the study:

• Heart disease: African Americans are 13 percent less likely to undergocoronary angioplasty and one-third less likely to undergo bypass surgerythan are Caucasians.

• Asthma: Among preschool children hospitalized for asthma, only 7percent of black and 2 percent of Hispanic children, compared with21 percent of white children, are prescribed routine medications toprevent future asthma-related hospitalizations.

• Breast cancer: The length of time between an abnormal screeningmammogram and the follow-up diagnostic test to determine whether awoman has breast cancer is more than twice as long in Asian American,African American and Hispanic women as in Caucasian women.

Health care providers have a direct impact on services their patientsreceive. Providing culturally and linguistically appropriate services todiverse populations can improve access and quality of care, and reducehealthcare disparities such as those listed above.

Free CME/CEU available — a Family Physicians Guide to CulturallyCompetent CareThe United States Department of Health and Human Services, Officeof Minority Health, offers an e-learning program in which physicianscan earn up to nine free CME credits and nurses up to 10.8 CEU creditsthrough review of cases and learning regarding cultural competence inhealth care. Scenarios include:

• A young Hispanic doctor wants her office staff to treat her patients better• A native American patient with diabetes and amputation refuses treatment• A nine-year old Vietnamese girl is mortified to translate a doctor’s

personal questions to her elderly grandmother• A Hispanic teenage boy overdoses on his prescription anti-depressant • Members of the immigrant Ethiopian community feel unwelcome

at the local clinic• A four-year old African American girl has been to the emergency

room with asthma three times in a month

To take advantage of the free CME/CEU credits and increase your awarenessof cultural competence in the provision of care, log on to the United StatesDepartment of Health and Human Services, Office of Minority Health athttps://cccm.thinkculturalhealth.org/default.asp?curcase=6.

Second Quarter 2006 Blue Review

Now available online:

• Register Online for Workshops

• Product Reference GuidesUpdated

• Home Infusion TherapyDrug Schedule

www.bcbstx.com/provider

2006 WellnessGuidelinesNow AvailableThe 2006 Adult Wellness Guidelinesand the Childhood and AdolescentWellness Guidelines were recentlycompleted.

The 2005 Suggested Prenatal CareGuidelines remain unchanged. Pleasesee the Blue Cross and Blue Shieldof Texas (BCBSTX) Web site atwww.bcbstx.com/provider (WellnessGuidelines) or contact the QualityImprovement Programs Department at(800) 863-9798 for a copy of eitherof the guidelines.

Provider Workshop Schedule/RegistrationAvailable Online

The BCBSTX Provider Access and Servicing Strategy Group (PASS) is proud to continue thetradition of offering complimentary workshops and education sessions to our contracting physicians

and providers. We will continue to provide workshops and education sessions designed to maximizeyour effectiveness and satisfaction in the many BCBSTX networks.

We invite you to go online at www.bcbstx.com/provider to view the schedule and register for ourworkshops offered at a location near you.

If you don’t see a workshop in your area or if you need specific training, send an e-mail toPASSWorkshops@bcbstx.com and include the following information: contact name, e-mail address,

telephone number and your specific request. We will make every effort to accommodate your needs.

Free Electronic Health Record Implementation AssistanceIn 2004, President Bush announced his goal to have widespread adoption of electronic healthrecords (EHRs) within 10 years. According to a 2005 study by the Medical Group ManagementAssociation, only 14.1 percent of all medical group practices use EHRs and only 11.5 percenthave fully implemented EHRs for all physician practices.

Why is implementation lagging?Purchasing an EHR system can seem overwhelming, especially for small to mid-size practiceswithout existing information technology support. Practices may have limited resources andmay be worried about choosing a vendor, the cost, new technology and/or training.

The solution:Texas Medical Foundation (TMF) Health Quality Institute is available to help you before,during and after EHR implementation, so your investment is optimized.

What is TMF Health Quality Institute?The BCBSTX Physician Office Review team has partnered with TMF to help physicianoffices select an EHR system that meets their needs. TMF, a nonprofit organization under acontract with the Centers for Medicare & Medicaid Services, provides small to mid-sizeprimary care practices free consultations to help them successfully implement an EHR. Thisnational initiative is called Doctor’s Office Quality-Information Technology (DOQ-IT).

TMF is vendor-neutral and is capable of assisting practices with workflow assessment andprocess redesign. TMF can also help identify care management opportunities to maximizeyour use of the system’s features. TMF will only be working with 286 practices statewide.If you plan to implement an electronic health record in the next 18 months, you will want toenroll in DOQ-IT before July 31, 2006.

To participate in DOQ-IT, please call the Physician Office Quality Improvement team at(866) 439-8863, or visit www.doqit-tx.org.

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TMF

Health

Quality

Institute

is here

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you

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Blue Review

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Electronic Remittance Advice (ERA) — Recipients of OlderNoncompliant ERA FormatsEffective August 1, 2006, only the ANSI ASC X12N 835 Version 4010A1 ERA will be delivered via The HealthInformation Network (THIN). Providers not currently receiving their ERA in this format are urged to begin moving toproduction with this format as soon as possible.

If you currently receive ERA’s in older formats and you are ready to begin receiving the 835 Version 4010A1 or if you donot currently receive this money saving transaction and would like to begin, the necessary enrollment forms can be foundat www.thinedi.com. Click on the Enrollment tab and scroll down to the Electronic Remittance Notices section.

In addition to HIPAA compliance, a major benefit of switching from the older ERA format is the receipt of the ElectronicPayment Summary (EPS). The EPS replaces the paper Provider Claim Summary that you currently receive via US mail.This EPS is an electronic image of the paper summaries you receive. These will be loaded into the same mailbox as theERA file and may be downloaded to your computer for viewing and searching using any text editing program — such asNote Pad, which is included in all windows applications. EPS is not available to those receiving older ERA formats.

If you have questions about the THIN enrollment processes, please contact the THIN EDI Help Lineat (877) EDI-THIN, or (877) 334-8446.

Enhancements to Processing Professional ClaimsBCBSTX will be regularly communicating enhancements made to the processing of professional claims and associatedpayment-auditing logic within this quarterly newsletter. Below are highlights of enhancements with their effective dates thathave been made since our last notice. This action is not retroactive to claims processed prior to the effective dates listed.

DENIED ALLOWED BUNDLING BLUECHIP DATE HMO DATEPROCEDURE CODE PROCEDURE CODE APPLIED TO PRODUCTION TO PRODUCTION

31000 31239 Remove Edit 03/27/06 03/27/06

33820 33750 Remove Edit 03/27/06 03/27/06

43415 38100 Remove Edit 03/27/06 03/27/06

31255, 31267 30462 Remove Edit 03/27/06 03/27/06

62310, 62311, All ASA codes Remove Edit 03/27/06 03/27/0662318, 62319

64704, 64708 28035 Remove Edit 03/27/06 03/27/06

01905 76005 Remove Edit 05/01/06 05/01/06

29888 Assistant Surgeon Remove Edit 05/01/06 05/01/06

51702 78740 Remove Edit 05/01/06 05/01/06

57280 58152 Remove Edit 05/01/06 05/01/06

77315 77778 Remove Edit 05/01/06 05/01/06

31255, 31256, 31276 30160 Remove Edit 05/01/06 05/01/06

76770, 76856 76942 Remove Edit 05/01/06 05/01/06

The five character codes included in this article were obtained from the Physician’s Current Procedural Terminology (CPT®), copyright 2006 by the American Medical Association (AMA). CPT is developed by theAMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. CPT is a registered trademark of the AMA.

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Advantages of AIM’s Preauthorization/RQI Provider PortalAmerican Imaging Management’s (AIM) Provider Portal makes it easy for your office staff to enter an order for ahigh-tech diagnostic imaging exam via the Web. The Web-based Provider Portal gives you 24/7/365 access tothe RQI (Radiology Quality Initiative), preauthorization, and claims and eligibility information. Best of all, not onlycan you enter an order for an exam, but you can receive a preauthorization or RQI number online in real time(as long as additional clinical information is not needed).

To obtain an HMO Blue® Texas preauthorization or a BlueChoice®/BlueChoice® Solutions RQI number, just log ontoAIM’s Provider Portal at www.americanimaging.net and complete the online questionnaire that identifies the reasonsfor requesting the exam. When criteria are met, you will be given a preauthorization or RQI number. If criteria are notmet or additional information is needed, the case will be automatically transferred for further clinical evaluation, andan AIM nurse will follow up with your office.

Other great features include:• Convenient access — no waiting —

available 24/7/365

• Location of radiology providers, inyour patient’s area, that are contractedwith BCBSTX

• Reduction of phone time by allowinginformation to be retrieved via the Web

• Confirmation that a preauthorizationor RQI number has been issued throughthe Preauthorization/RQI feature

• Online CPT Groupers & ClinicalGuidelines are available

Reminders:BlueChoice/BlueChoice Solutions physicians/professional providers must contact AIM first to obtain a RQInumber when ordering or scheduling the following outpatient diagnostic imaging services when performed in aphysician’s/professional provider’s office, or the outpatient department of a hospital, or a freestanding imaging center:CT, MRI, MRA, Nuclear Cardiology studies or PET scans. Please note that facilities cannot obtain a RQInumber from AIM on behalf of the ordering physician. Also, the RQI program does not apply to BlueCard subscribers.

HMO Blue Texas physicians/professional providers located in Collin, Dallas, Denton, Ellis, Grayson, Johnson, Kaufman,Parker, Rockwall, Tarrant or Wise counties must contact AIM first to obtain a preauthorization when ordering or scheduling thefollowing outpatient diagnostic imaging services when performed in a physician’s/professional provider’s office, or the outpatientdepartment of a hospital, or a freestanding imaging center: CT, MRI, MRA, Nuclear Cardiology studies or PET scans.

Note: HMO Blue Texas physicians/professional providers located outside of the following counties: Collin, Dallas,Denton, Ellis, Grayson, Johnson, Kaufman, Parker, Rockwall, Tarrant or Wise are not required to get preauthorizationfor outpatient, non-emergency diagnostic imaging services when ordering or scheduling the following outpatientdiagnostic imaging services when performed in a physician’s/professional provider’s office, or the outpatient departmentof a hospital, or a freestanding imaging center: CT, MRI, MRA, Nuclear Cardiology studies or PET scans.

Medical Policy Disclosure StatementNew or revised medical policies, when approved, will be posted on the BCBSTX Web site on the first or the fifteenth dayof each month. Those policies requiring disclosure will become effective 90 days from the posting date. Policies thatdo not require disclosure will become effective 15 days after the posting date. The specific effective date will be noted foreach policy that is posted.

To view pending policies, go to the General Reimbursement section at www.bcbstx.com/provider and click on MedicalPolicies. After reading the policies disclaimer, click on “I Agree” to advance to the Medical Policy page. The policies canbe accessed by clicking on the View Pending Policies tab.

NUBC Announces Approvalof UB-04 Following the close of a public comment period in February2005, and careful review of comments received, the NationalUniform Billing Committee approved the UB-04 as thereplacement for the UB-92. Receivers (health plans andclearinghouses) need to be ready to receive the new UB-04by March 1, 2007. Submitters (health care providers suchas hospitals, skilled nursing facilities, hospice and otherinstitutional claim filers) can use the UB-04 beginningMarch 1, 2007, however, they will have a transitional periodbetween March 1, 2007 and May 22, 2007 where they canuse the UB-04 or the UB-92. Starting May 23, 2007 allinstitutional paper claims must use the UB-04; the UB-92will no longer be accepted after this date.

The final image of the UB-04 form, a summary of the public comments/NUBC responses, and information on how to obtaina beta version of the UB-04 Data Specifications Manual has been posted on the NUBC website — www.nubc.org.

Providers should contact their software vendors to ensure they are aware of these changes and can meet the designatedtimelines. These new forms may require an update to your practice management software.

Medical Policy ReviewIn an effort to streamline the medical document review process, wewill begin posting draft medical policies on the BCBSTX Web site.After logging onto the Web site you can review the documentsand provide your feedback online. The documents will be madeavailable for your review on the first and the fifteenth of eachmonth with a review period of approximately two weeks.

To view draft policies, go to www.bcbstx.com/provider, referto the General Reimbursement Information section (within thebody of the main provider page) and click on Draft MedicalPolicies. After reading the policies disclaimer, click on “I Agree”to advance to the Medical Policy page.

www.bcbstx.com/provider

Blue Review

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Fee Schedule UpdatesNew or updated reimbursement informationfor BlueChoice and HMO Blue Texaspractitioners (Independent Provider Networkonly) will be posted under “PendingChanges” in the Professional ReimbursementSchedules section on the BCBSTX Web siteat www.bcbstx.com/provider on the first dayof every month.

Those changes requiring disclosure will notbecome effective until at least 90 days fromthe posting date. The specific effective datewill be noted for each change that is posted.To view this information, visit the GeneralReimbursement Information section on theBCBSTX Web site. The required passwordis “manual”.

The Drug/Injectable Fee Schedule willbe updated on the following dates:7/1/2006, 9/1/2006, 12/1/2006,3/1/2007 and 6/1/2007.

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Implementation of the Consolidated Coordinationof Benefits Agreement (COBA) ProgramIn 2004, Centers for Medicare & Medicaid Services (CMS) began implementing the consolidation of theMedicare cross-over process under one Coordination of Benefits Contractor (COBC) by means of a nationalCoordination of Benefits Agreement (COBA). Under this agreement, supplemental claims used forcalculating secondary payment liability will cross-over from the COBC to BCBSTX. This will affect all claimsprocessed on April 3, 2006 and thereafter.

Below are a few highlights as they pertain to the COBA program:Enhancements:

Effective April 3, 2006, under the new process, supplemental claims will continue to cross-over for members found inthe BCBSTX eligibility files. The main difference under this arrangement is that claims will now cross-over to thesupplemental insurer from one party, the COBC contractor, rather than the multiple individual Medicare contractors.This method provides consistency and improves accuracy.

Production Date:Effective April 3, 2006, BCBSTX will be in production with the COBC. Medicare Part A and Medicare Part Bclaims processed on April 3, 2006 and thereafter will cross-over to BCBSTX after the claims have left the Medicarepayment floors. Please do not submit your supplemental claims prior to the release of the Medicare payment floors.Below are examples of the electronic and paper payment floors:

• Electronic claims processed beginning April 3, 2006 will bereleased to the supplemental insurer after a 14-day paymentfloor (i.e. April 17, 2006).

• Paper claims processed on April 3, 2006 will be released afterthe 29-day payment floor (i.e. May 2, 2006).

Medicare Physician Fee Schedule (MPFS) Adjustments:On February 10, 2006, CMS announced that the Deficit ReductionAct (DRA) prevents payments for physicians’ services delivered on orafter January 1 from being reduced by a negative update of 4.4 percent.January claims that have already been paid and have crossed over to thesupplemental insurers are being adjusted by Medicare. All mass adjustments are expected to be completed by July 1, 2006.However, supplemental claims adjusted prior to April 3, 2006, for service date January 1, 2006 through February 1, 2006, mustbe submitted to BCBSTX on paper for the subsequent supplemental adjustment. Mass adjustments processed April 3, 2006and after will not have to be submitted to BCBSTX on paper, as these will automatically cross-over from the COBC.

Medicare Claims with No Liability:Medicare claims paid at 100 percent with no additional beneficiary liability will not cross-over. Example: laboratoryclaims subject to the fee schedule with no coinsurance and/or deductible due will not cross-over. Also, Medicare claimsdenied at 100 percent with no additional beneficiary liability will not cross-over. In instances where there is no liability,we ask that you not submit the claim to BCBSTX.

Although most claims will continue to seamlessly cross-over, CMS has notified Trading Partners that instances will occurwhereby a claim intended for cross-over would have failed to cross-over due to data errors originating at the Medicarecontractor site. In these instances, the Medicare contractors will send notification to the providers advising them thatthe claim did not cross-over to the patient’s supplemental insurer due to claim data errors. Should you receive this typeof Medicare notification, please take the opportunity to submit the supplemental claim electronically to BCBSTX.

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Blue Review

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National Provider Identifier (NPI) Questions & AnswersMay 23, 2007, is the compliance date set for the National Provider Identifier (NPI) as the standardidentifier on all HIPAA transactions. BCBSTX is working through the corporate implementation of NPIand wants to continue addressing physician’s issues and concerns. Below are answers to some of thefrequently asked questions:

Q: What is BCBSTX doing to comply with the adoption of NPIas mandated under HIPAA regulations?

A: Our goal is to execute a seamless transition to HIPAA compliance.As a multi-state corporation, we are using an enterprise-wideapproach that coordinates the business and system impacts of NPIacross all four of our health plans in Illinois, New Mexico, Texasand Oklahoma. Currently, we are in the planning and analysis stage.Throughout the next several months we will establish and informyou about more specific timetables regarding when, where and howwe intend to receive and communicate NPI in all covered standardelectronic transactions. In addition, we are developing a detailedcommunication strategy predicated on conveying consistent andaccurate information to our provider community.

Q: How do I obtain an NPI?A: There are three ways that a health provider can apply for an NPI:

1) Apply through a web-based application process. The Web addressis https://nppes.cms.hhs.gov.

2) Prepare and send a paper application form to the Enumerator (FoxSystems). A copy of the application form, which includes the Enumerator’smailing address, can be found at https://nppes.cms.hhs.gov.A health care provider may also call the Enumerator and request ablank application form. The Enumerator’s telephone number is(800) 465-3203 or TTY (800) 692-2326.

3) With the permission of the health care provider, an organizationmay submit a health care provider’s application in an electronic file.

Q: When should I start submitting my NPI to BCBSTX?A: We will notify all providers when they can begin submitting their NPI on standard electronic transactions

prior to the May 23, 2007, compliance date. In the meantime, providers should not begin using their NPIon electronic transactions until BCBSTX has communicated an effective date and has issued instructionson its use. BCBSTX will be communicating with providers throughout this transition process.

Q: Where can I find more information on NPI?A: The Centers for Medicare & Medicaid Services (CMS) has an NPI Resource online at

http://www.cms.hhs.gov/NationalProvStand/. You can also check for updates on the BCBSTXWeb site at www.bcbstx.com.

BCBSTX’s goal is to continue to use the Blue Review newsletter, the provider Web site and other communicationmediums as the primary means to inform you of BCSBTX’s efforts during the implementation of NPI.

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At BCBSTX we strive to process your claims quickly andaccurately. To ensure your claims are processed timelyand accurately, please follow these steps:

1) Submit all Blue claims to BCBSTX.

2) Include the member’s complete identification number,including the three-character alpha prefix, when you submitthe claim. Submit claims with only valid alpha-prefixes;claims with incorrect or missing alpha prefixes and/ormember identification numbers cannot be filed correctly.

3) When BCBSTX is secondary to any commercial carrier,you can submit your claim electronically. We do notrequire the submission of the primary payer’s explanationof benefits. There are only a few additional data elementsneeded. You can refer to the 1st Quarter 2006 Blue Reviewarticle located on pages 4-5 for additional information.

4) Do not send duplicate claims. Sending another claim, orhaving your billing agency resubmit claims automatically,actually slows down the claims payment process and createsconfusion for the member.

5) Check claim status by contacting BCBSTX at(800) 451-0287 or submit an electronic HIPAA 276transaction (claim status request) to BCBSTX.

If you do encounter an issue with a claim, we arehere to help you. Contact us at (800) 451-0287.

Our Provider Customer Service department is open8:00 am - 6:00 pm (CST). We will work with you toanswer your questions and resolve your concerns asquickly as possible.

How to Avoid Claim Problems

Generic Drugs verses Brand DrugsKeeping health care costs down is a major issue. In the debate over generic drugs versus brand name drugs, cost appears tobe the one true difference. Generic drugs help save money, without sacrificing quality, safety or effectiveness. A generic drugis the chemical equivalent of a brand-name drug that has an expired patent.

Generic drugs are usually less expensive than their brand name counterparts due to the high cost of research and developmentassociated with producing brand name drugs. A generic drug is a drug manufactured and sold by a company other than theinnovative maker. However, some generic drugs are made by the same company, but are packaged differently. Generic drugsmust meet the same strict FDA standards as brand name drugs. Also, generic drugs may look different than brand namedrugs, but that is because trademark laws do not allow them to look the same.

An example of a company that made both a brand name and generic medication:• Brand: Elavil®

• Generic: Amitriptyline• Company: Mylan pharmaceuticals

A pharmacist may dispense a generic drug equivalent legally, as long as the physician has not indicated on the prescription that abrand is medically necessary and the patient agrees with generic dispensing. Keep in mind, not all drugs have generic equivalents.

Expected Generic Drugs in 2006

Use Brand name Possible generics in 2006

Cholesterol Zocor®, Pravachol® Simvastatin, Pravastatin

Depression Zoloft® Sertraline

Insomnia Ambien® Zolidem

Nausea/Vomiting associated with chemotherapy Zofran® Ondansetron

Source: Drug Pipeline, Prime Therapeutics LLC

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Blue Review

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SSRI’s (Selective Serotonin Reuptake Inhibitors)

Trade Name Generic Name Initial starting doses Usual dosage range Comments

Zoloft® Sertraline 25-50mg 50-200mg SSRI’s are often selected as first-choice(generic expected mid-2006) antidepressants in adolescents and elderly patients

Prozac® Fluoxetine 10-20mg 10-80mg(available as a generic)

Paxil® ParoxetinePaxil CR®

(available as a generic) 10-20mg 20-50mg(no generic available)

Celexa® Citalopram 20mg 20-60mg(available as a generic)

Lexapro® Escitalopram 10mg 10-40mg(no generic available)

Luvox® Fluvoxamine 50mg 50-300mg(available as a generic)

Dose Conversions (4:2:1 Ratio)1,2,4

Lipitor 10mg Zocor 20mg Mevacor 40mg or Pravachol 40mg Lescol 80mg Crestor 10mg

Lipitor 20mg Zocor 40mg Mevacor 80mg or Pravachol 80mg Crestor 20mg

Lipitor 40mg Zocor 80mg Crestor 40mg

Lipitor 80mg

References:1) http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf2) http://online.factsandcomparisons.com3) Armstrong LL, Goldman MP, Lacy CF, Lance LL. Drug Information Handbook. Hudson, Ohio: Lexi Comp Inc., 2002-20034) http://www.vhpharmsci.com5) www.lipitor.com6) Mcphee SJ, Papadakis MA, Tierney, LM. Current Medical Diagnosis & Treatment. Mcgraw-Hill Companies, Inc., 20057) http://www.fda.gov/cder/orange/default.htm

HMG Co-A Reductase Inhibitors

Trade Generic Name Usual Starting Maximum Lipid/Lipoprotein Comments*Name (available as generic) Dose FDA-approved Dose Effects (LDL HDL, TG) 1

Simvastatin (generic LDL (_18-55%)Zocor®

expected mid-2006) 20mg 80mg HDL (_ 5-15%)TG (_7-30%)

Pravachol® Pravastatin (generic 20mg 80mg Same Not metabolized through major CYP450 3A4expected mid-2006) enzyme pathway (less risk of side effects)

Mevacor® Lovastatin 20mg 80mg Same(available as generic)

Lescol®, Fluvastatin 20mg 80mg Same Safety and efficacy have not been establishedLescol XL® (No generic available) in patients younger than 18 years of age

Lipitor® Atorvastatin 10mg 80mg Same Can be taken anytime of the day(No generic available)

Crestor® Rosuvastatin 10mg 40mg _HDL & _ LDL more, Eliminated via kidney’s(No generic available) same change in TG

*All, except Lipitor, should be taken in the evening with food for improved results. NOTE: Cerivastatin (Baycol®) was voluntarily withdrawn from the market by the manufacturer in August 2001

HEB Wellness Benefit ReminderHEB would like to remind physicians and professional providers about the wellness benefits andpreventive care services for their members and dependents that are covered at 100 percent of theallowed amount. Please note: The deductible is waived if services are performed by in-networkphysicians or professional providers, or if an in-network physician or professional provider refersthe member to an in-network lab or x-ray facility.

Please refer to the following list of services below:Office Visits• One visit per year for routine physical exam • One visit per year for well woman exam• One visit per year for pap smear • One visit per year for routine digital rectal exam• One visit per year for prostate specific antigen test

Lab and X-ray ServicesIncludes lab and x-ray services performed in an in-network physician’s or professionalprovider’s office or if an in-network physician or professional provider refers the memberto an in-network lab or x-ray facility.

Hearing ExamsRoutine Mammograms age 35 & over (this age differs from the 2006 Wellness Guidelines)

Prostate Cancer Screening (PSA)

For additional information on the Wellness Guidelines, please visit the provider sectionof the BCBSTX Web site at www.bcbstx.com/provider, click on Wellness Guidelines underUM/QI/Medical Management.

Provider Customer Service Post Call SurveyBeginning in May 2006, BCBSTX Provider Customer Service began offering providers and their

staff an opportunity to rate their service experience. Randomly selected callers are being offered theoption to participate in a post call survey to capture the level of service they received. When the

caller elects to participate, he/she remains on the line after the Customer Service Representative hashandled the call. Upon completion, the caller is automatically transferred to the six-question survey with

the Representative unaware the caller has been offered the choice to participate. BCBSTX encouragesproviders and their staff to use this convenient feedback opportunity regarding their experience with our

Provider Customer Service.

Reminder to Use In-Network Facilities and ProvidersWith respect to the care of your patients, BCBSTX understands you have the ultimateresponsibility for and professional authority over your practice. As a reminder, your participatingprovider agreement requires you to utilize participating in-network facilities. Failure to useparticipating facilities could result in the termination of your participation in the BCBSTX

PPO/POS network. If you have any questions regarding the participating facilities in your area,please visit our Web site at www.bcbstx.com/provider/provider finder or contact your local

Professional Provider Network Representative.

BlueChoice® News

Randomly

selected

callers

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Blue Review

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BlueChoice Solutions Large Employer Groups List For your reference, the following is an alphabetical list of large employer groups currently enrolled in BlueChoice Solutions.Please note the employer groups listed below include insured and self-funded health plans. These employer groups mayhave chosen the BlueChoice Solutions network as an optional network for their employees. For example, Blue Cross andBlue Shield of Texas, HEB, TXU and Vought Aircraft offer BlueChoice Solutions as an optional network for their employees.

BlueChoice Solutions Large Employer Groups

Alabama-Coushatta Tribe of Texas International Muffler CompanyAmeri-Tech Kidney Center, P.A. KBA Group LLPAustin Traffic Signal Construction Co. Lantern Drilling CompanyBancroft & Sons Transportation, Inc. Linco-Electromatic, Inc.Bert Ogden Olds, Nissan & BMW, Inc. Lone Star Communications, Inc.Blue Cross and Blue Shield of Texas Mammoet U.S.A., Inc.Boccard USA Corporation Mid-Coast Electric Supply, Inc.Britt Rice Electric, L.P. Orval Hall Excavating, Ltd.Brock Enterprises Inc. R & R Marine Fabrication & DrydockCentral Cardiovascular Institute Red Dot CorporationCFF Recycling USA Security General International, Ltd.Challenger Process Systems Co. Southern Services, Inc.City of Corsicana Specialized Maintenance ServicesCity of Desoto Toromount IndustriesCity of Pharr Trinidad Drilling USA Ltd.City of South Houston TXUCrowley Independent School District Tyler Pipe, a Division of McWaneDel Papa Distributing Company United Services Mechanical Corp.DIAB LP DBA DIAB, Inc. Valence Operating CompanyDouble B Foods, Inc. Vought AircraftEagle Construction and Environmental Services Whitney National BankFirst National Bank of Huntsville, Texas Ypone Operations, LLCGalveston County W.C.I.D. #1 Zyvex CorporationHEB Grocery Company

A sample of the BlueChoice Solutions ID card is provided to theright. Each subscriber ID card includes the BlueChoice Solutionslogo for easy recognition. The Network Number is also specific toBlueChoice Solutions — PSNOA.

Note: In Texas, BlueChoice Solutions subscribers must useBlueChoice Solutions providers for in-network benefits.

For additional information about BlueChoice Solutions, please visitthe BCBSTX Web site at www.bcbstx.com/provider, click on“Learn More — BlueChoice Solutions.”

BlueChoice News

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Reimbursement and Filing of DrugsBCBSTX utilizes the Prime Therapeutics Rx Claim System to obtainthe Average Wholesale Price (AWP) for drugs submitted on claims.

The AWP in Prime Therapeutics reflects individual units/dosage pricing.Conversion calculations must be performed to determine the appropriateallowance for a drug according to the units administered. (i.e., the AWPmay need to be divided by the package size to obtain the individualunit/dosage pricing since the unit cost of a drug reflects individual unitpricing (per tablet, capsule, etc)).

The equation used is AWP x % of payment x package size x units.Some exceptions may apply, including, but not limited to, Home InfusionTherapy and Durable Medical Equipment providers.

Before using an unclassified code, providers are encouraged to referencethe most current HCPCS coding manual to determine if there is alreadyan established J code. In the event an unclassified code is necessary, thena narrative is required to ensure accurate processing. The narrative mustinclude these elements: Drug name, dosage, National Drug Code (NDC),NDC units administered, NDC units of measure and NDC unit price.

For Home Infusion Therapy services, providers are encouraged to use thecorrect HCPCS code (J or S code) for submission of drug claims.

Please note: coverage for services is subject to terms and conditions ofthe member’s health benefit plan. BCBSTX’s reimbursement, if any, isreduced by any applicable deductibles, co-payments and/or co-insuranceas defined in the member’s health benefit plan.

A Few RemindersAbout Filing Claims1) Please confirm the patient

relationship and be sure to checkthe correct corresponding boxon the HCFA 1500 forms.

2) Please try to include descriptionsof unlisted codes, such as J3490,Q9949, etc. as this will helpreduce phone calls to providers.

3) Please be sure to check theProvider Assign Benefits box“Y”, if payment is to be issuedto the provider.

BlueChoice Solutions – 2006 Fall EvaluationInformation To meet demands from both the physician/professional provider and the employer communities,adherence to evidence-based medicine will be included in the participation criteria for theBlueChoice Solutions network. This additional measurement component will begin with the nextBlueChoice Solutions network re-evaluation scheduled in the fall of 2006 for an effective date ofJanuary 1, 2007.

BCBSTX has partnered with Health Benchmarks Inc. (HBI) for 26 evidence-based indicatorsthat measure important aspects of physician performance based on claims and enrollment data.These indicators cover significant areas of care in diabetes, coronary artery disease, preventivehealth services and others.

Additional information on BlueChoice Solutions criteria, a list of evidence-based indicators andavailable resources can be found on the BCBSTX Web site at www.bcbstx.com/provider, clickon “Learn More — BlueChoice Solutions.”

13www.bcbstx.com/provider

Blue Review

Independence Blue Cross Plan Claim Filing InformationThe Independence Blue Cross (IBC) plan has been experiencing problems regarding BlueCard claim filing from Texasproviders. The Independence Blue Cross plan has converted to an 8-digit unique ID number. However, claims from severalTexas providers are being received with additional digits added to the Member Number field causing an error inmembership when the claim is received. The unique 8-digit number is all that should be entered. Please do not zero fillthe Member Number field. Copies of the two IBC ID cards are below for your reference.

Medicare-related Claims for BlueCard MembersIn BCBSTX’s ongoing efforts to better serve you, we are providing information to helpmake filing your BlueCard Medicare-related claims easier. Medicare-related claims are thosewhich are secondary or supplemental to Medicare and coverage is provided by a Blue Crossand Blue Shield plan. If you are a provider who accepts Medicare assignments andrenders care to members from other Blue Plans, we recommend you contact BlueCardeligibility at (800) 676-BLUE (2583) to check the patient’s membership and coverage priorto providing services.

When Medicare is primary, submit claims to your Medicare intermediary and/or Medicarecarrier first. It is essential that you enter the correct Blue Plan name as the secondary carrier,which may be different from BCBSTX. The member ID must include the alpha prefix inthe first three positions. The correct alpha prefix is critical for confirming membership andcoverage and key to facilitating prompt payments.

After receipt of the explanation of payment, or Medicare Remittance Notice from Medicare,check to see if the claim has been automatically forwarded (crossed-over). If the remittanceshows that the claim was crossed-over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and theclaim is in process. Please allow ample time to receive payment and/or processing information from the appropriate Blue Planprior to initiating any inquiries. If the claim was not crossed-over, submit the claim electronically to BCBSTX withMedicare’s Remittance Notice data.

Please do not submit Medicare-related claims to BCBSTX before receiving a Medicare Remittance Notice from theMedicare intermediary and/or Medicare carrier. Duplicate claims submissions can delay claim processing and createadministrative inefficiencies.

Outpatient Clinical Reference Laboratoryfor HMO Blue Texas

Laboratory Corporation of America (LabCorp) is the exclusive outpatient clinical referencelaboratory provider for HMO Blue Texas members (see note below for exceptions).

To find the closest LabCorp Patient Service Center, please call LabCorp’s automated phonesystem toll-free at 888-LABCORP (888-522-2677) or visit their Web site at www.labcorp.com.

Both systems will prompt you for your Zip Code and will provide those service centers nearest thatZip Code location.

You may also find a complete list of participating providers by using the Provider Finder® searchtool at www.bcbstx.com/provider or by contacting your local Professional Provider Network office.

For physicians located in certain counties, only the lab services/tests indicated on the ReimbursableLab Services list will be reimbursed on a fee-for-service basis if performed in the physician’s office for

HMO Blue Texas members. Please note that all other lab services/tests performed in the physician’s officewill not be reimbursed. You may access the county listing and the revised Reimbursable Lab Services list

that was effective June 1, 2006 at www.bcbstx.com/provider under the General Reimbursementsection. The password for the General Reimbursement section is “manual.”

Note: HMO Blue Texas physicians who are contracted or affiliated with a capitated IPA/Medical Groupmust contact the IPA/Medical Group regarding outpatient laboratory services.

Physicians Score High on After-HoursAccess SurveyIn November 2005, HMO Blue Texas performed an annual statewide After-Hours AccessPhysician Office Survey. Of the sample of primary care and high-volume specialty care physicianssurveyed, 100 percent met the after-hours accessibility standard. State regulations requireHMO Blue Texas to include after-hours access provisions in physician contracts and to monitorcompliance. Members should be able to contact their primary care physician and specialtycare physician/professional provider, or their participating on-call designee for medical advice24 hours a day, seven days a week.

To be compliant, after-hours access must be provided as follows:•Answering service (or other party) answers the telephone; offers to page the

physician/professional provider or on-call designee; or

• Recorded message directs the caller to an answering service or provides thenumber to page the physician.

Providing after-hours accessibility increases members’ satisfaction with their health planand improves the quality of service members receive from their physicians/professionalproviders. Your participation in this matter is greatly appreciated. If you have any questionsconcerning after-hours accessibility requirements, please contact your local ProfessionalProvider Network Representative.

HMO Blue® Texas News

100 percent

of primary

care and

high-volume

specialty care

physicians

met the

after-hours

accessibility

standard

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Blue Review

15

2005 2004

Overall satisfaction with Magellan 85.3% 86.6%

Amount of time to be offered provider 90.3% 94.4%

Referral process total time involved 97.2% 91.3%

Referral process satisfaction 100.0% 87.3%

CSR completely addressed purpose of call 100.0% 95.9%

CSR spoke in caring manner 100.0% 93.2%

CSR treated member with courtesy 100.0% 96.7%

CSR was knowledgeable 97.2% 91.2%

CSR answered questions clearly & completely 98.6% 94.6%

CSR did what they said they would do 98.6% 98.0%

Service satisfaction when called & talked to Magellan 98.6% 94.0%

Availability of Care Mgr to discuss treatment options/concerns 100.0% 78.6%

Choice of providers offered by Magellan CSR 83.3% 81.1%

Choice of providers in the directory 90.0% 50.0%

Ease of making first appointment 94.2% 94.8%

Availability of a follow-up appointment 92.4% 96.6%

Distance to professional’s office 87.0% 87.4%

Time spent waiting past scheduled appointment time 88.4% 86.7%

Concern shown for condition 98.6% 91.0%

Helpfulness of treatment 95.5% 88.4%

Explanation provided about problem/diagnosis 92.5% 84.0%

Involvement in the development of the treatment plan 87.9% 87.0%

Explanation given about medication 93.9% 55.0%

Overall quality of care 94.1% 85.1%

Overall Average — Magellan 94.8% 89.6%

2005 HMO Blue Behavioral Health Member Satisfaction SurveyAnnually, BCBSTX conducts a survey of HMO Blue Texas members to determine their satisfaction with our contractedbehavioral health vendor, Magellan Health Care Service Corporation (Magellan).

The survey was conducted with members who had contacted Magellan six months prior to the survey which was conductedin September and October 2005. Below are the results:

If you have any questions concerning the survey you may contactRichard Luttrell, Sr. Marketing Research Representative (972) 766-6861.

HMO Blue Texas News

Blue Review Published quarterly for BlueChoice®, ParPlan and HMO Blue® Texas contractingphysicians and other health care providers. Ideas for articles and letters to the editor are welcome.

Please mail to: Corporate Communications, Blue Review Editor,Blue Cross and Blue Shield of Texas, P.O. Box 655730, Dallas, Texas 75265-5730.

© 2006 Health Care Service Corporation

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an IndependentLicensee of the Blue Cross and Blue Shield Association

HealthSelectSM administered by Blue Cross and Blue Shield of Texas

The information provided in Blue Review does not constitute a summary of benefits, and all benefit informationshould be confirmed or determined by referring to the appropriate benefit booklet. 42600.0606

A Provider Publication

HMO Blue Texas Claim Processing SystemIn May 2006, HMO Blue Texas began processing certain HMO claims on the same claim processing system utilized forall other lines of BCBSTX business, including PPO, POS and ParPlan/Traditional. This system consolidation will allowfor improved efficiency in processing claims and responding to inquiries.

With the exception of the University of Texas and Dillard’s HMO members, HMO claims for member groups in theWest Texas, Austin and San Antonio areas began processing on the BCBSTX claim system for dates of service May 1, 2006and after. The Houston and Corpus Christi areas HMO member groups claim processing is scheduled to transition for dates ofservice beginning July 1, 2006, and the Northeast Texas area HMO member groups claim processing is scheduled for transitionbeginning with dates of service September 1, 2006.

The University of Texas HMO member groups will transition in two phases: July 1, 2006 and September 1, 2006 dates ofservice. The group numbers transitioning on July 1, 2006 are: 77179H, 71779N, 71779P, 71779Q, 71779S and71779X. The group number transitioning on September 1, 2006 is 71779C.

The Dillards’ HMO member groups will transition beginning with dates of service September 1, 2006. The Dillards’ groupnumbers transitioning on September 1, 2006 are: 83592H, 83592N, 83592P, 83592Q and 83592S.

As each phase is completed, physicians and providers will begin to see HMO Blue Texas claims included in their existingBCBSTX notices, including the Provider Claims Summary (PCS) and Electronic Remittance Advice (ERA).

If you experience difficulty accessing HMO claims through online inquiries during the claim processing system consolidationperiod, please contact the HMO Blue Texas Provider Customer Service Department at (877) 299-2377 for assistance.

As announced in the third quarter 2005 Blue Review, ClaimCheck Version 35 will be implemented for HMO Blue Texasas each HMO member group is transitioned to the BCBSTX claim processing system. For further information aboutpayment policies, medical policies and bundling methodologies, or to request specific code to code bundling, please accessthe provider section of the BCBSTX Web site at www.bcbstx.com/provider.

Inside Blue ReviewAll Product News 2Information applicable to all lines of business for BlueCross and Blue Shield of Texas and HMO Blue Texas

BlueChoice News 10BlueChoice is a PPO and POS product provided oradministered by Blue Cross and Blue Shield of Texaswith networks for contracting PPO and POS providers

HMO Blue Texas News 14