Just the Facts...Excellus BlueCross BlueShield, Central New York, Central New York Southern Tier Regions

Volume 11.4 The newsletter for Medical Office and Facility Staff April 2005

A nonprofit independent licensee of the BlueCross BlueShield Association

Inside this IssueProvider Service Corner, p. 2

Please Note: Our SubscriberIdentification Numbers HaveChanged, p. 3

Changes to our IRV TelephoneSystem, p. 3

Obtaining Member Informationfrom the Health Plan, p. 3

Southern TierProviders−Upcoming BluesEducation Classes, p. 4

New Tetanus Vaccine DECAVAC,p. 4

Safety Net Products NowAvailable in More Counties, p. 5

CODING CORNER− CorrectCoding for Lenses, p. 5

Differences in Eyeglass Benefitfor CHP, FHP, and MMC, p. 6

A1C Control in Patients withDiabetes, p. 7

Important to Test Patients withDiabetes for Protein in the Urine,p. 7

Eye Care for Diabetics Remainsa Serious Concern, p. 8

Some Member R&R IncludePractitioner Rights andResponsibilities, p. 9

Excellus BCBS Receives URACCase Management Accreditation,p. 10

Medical Policy/Protocol Update,p. 11

Diabetes Eye ExaminationReport

Half Tablet Incentive Program

www.excellusbcbs.com

ClaimCheck Changes Happening April 29!

We’ve finally completed our testing for converting all claims processingsystems to the same electronic claim review software! The remainingconversion is planned for the weekend of April 29. Providers should seean improvement in consistency after that.

While there may remain some inconsistencies in the processing systemsthat are outside of the ClaimCheck software, we hope to be able toaddress more of those once all systems have the same software.

Thank you for your patience!If you have any questions or concerns, please continue to contactProvider Service.

HIPAA Security Regulation

For most covered entities, the required date to comply with the HIPAASecurity Regulation is April 21, 2005. Small health plans have anadditional year to comply.

HIPAA security standards were designed to protect all electronic healthinformation from improper access or alteration, and to protect against theloss of these records. The regulation specifies a series of administrative,technical, and physical security procedures for covered entities to use toassure the confidentiality of electronic protected health information.

• Administrative Safeguards: Documentation of formal practices tomanage the execution of security measures to protect data and theconduct of individuals dealing with the protected data.

• Physical Safeguards: The protection of the physical computersystems and related housing and equipment to guard the integrity ofthe protected data.

• Technical Safeguards: Processes that protect, control and monitoraccess to information.

Excellus BCBS has all safeguards in place to comply with this importantregulation to protect our members’ health information.

Page 2 April 2005

You asked Provider Service the question…

…we publish the answer−For Everyone!

Introducing the Provider Service Corner!

The questions you’re asking our Provider Service Representatives are very important. In fact, we feelother providers will benefit from having the answers. That’s why we’ve created the Provider ServiceCorner! Each month, we’ll publish the answers to selected questions you ask.

Just look for the Provider Service Corner in the table of contents. You never know - our response toyour question may help other providers as well.

Q. We were told that the BlueCard Department was dissolved, but we’re receiving conflictinginformation. Can you clarify?

A. Last spring, we reorganized the Customer Service/BlueCard Unit in an effort to improve theefficiency of BlueCard inquiry resolution. The restructuring included pulling our dedicatedrepresentatives in the BlueCard Unit off the telephones, so they could focus on communicatingdirectly with other Health Plans to research and resolve complex BlueCard questions.

As part of this change, Provider Service Representatives received additional training to betterassist you with general BlueCard questions.

We hope the Customer Service/BlueCard unit reorganization is helping increase the number ofresolved BlueCard inquiries. Please continue to contact Provider Service at 1 (800) 920-8889with any BlueCard questions.

Don’t forget−Just the Facts is on the Web site!Provider newsletters for the past two years are available at www.excellusbcbs.com!

• Click on For Providers.

• Go to the bottom of the page and click on News and Updates.

• Look under Just the Facts.

• Select Just the Facts for your region.

• Select the month’s issue you would like to read.

April 2005 Page 3

Please Note: Our Subscriber Identification Numbers Have ChangedWe have recently changed the identification numbers for most of our subscribers. To better protectour subscribers’ privacy, and to comply with the laws of several other states, we’ve assigned newnon-SSN IDs to all subscribers who didn’t already have them.

The format of the randomly-assigned ID numbers is still nine characters, but with four numeralsfollowed by one letter and then four more numerals (example: 1234A5678). The three-letter prefix(for example, ZFA) in front of the ID number has not changed, unless the member alsoswitched to a different product.Mailing of new identification cards is being done over a period of weeks due to the large volume.While many subscribers will already have their new ID cards by the time you read this newsletter, it ispossible that you may have some patients who have not yet received their new ID card.We will continue to accept claims with the old ID for a period of time. If you submit the old ID,your remit will show the new ID. However, we urge you to ask all our members for the ID card, and tocopy both sides of the card for the patient’s file. If you have electronic records, please don’t forget tochange the patient’s Excellus BCBS ID number.

Getting the new ID via QuickLink or the Web

Providers can get the new number by entering the old number when checking eligibility on QuickLinkor the Web. (Note: You must be registered on QuickLink or the Web to use the eligibility check.)

When you enter the old ID number, the information that comes up will include the new ID number. Thesocial security number will no longer be available to the provider. All displays (claims, referral status,etc.) will show the new ID number rather than the old.

Changes to our IVR Telephone SystemOur IVR system has been enhanced to accept the alpha character in the new subscriber ID numberformat. Because our system cannot determine which of three letter characters assigned to onetelephone key is intended (for example, pressing 2 could be either a, b or c), providers must nowspeak the subscriber ID number rather than key it in via the telephone keypad.This applies whether you use the new or the old subscriber ID. If you don’t have the patient’s newsubscriber ID, the system will still accept the old ID. However, you must speak it rather than enter itvia the telephone keypad.

• Do not try to enter the ID number via the telephone keypad.• Speak slowly.• Speak clearly.• Do not include the 3-character prefix, or the suffix.• Say “zero” rather than “oh” for the numeral.

As before, we must be able to verify a provider/patient relationship before allowing providers accessto member information.

Obtaining Member Information from the Health PlanWhen a physician or other health care provider calls the Health Plan requesting information about amember (for example new member identification numbers), in order to be HIPAA compliant, theprovider will be required to answer a few questions before the Health Plan will release the information.

• First, the participating provider must confirm his/her identity by providing the Tax IdentificationNumber or Provider ID Number used for billing.

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Page 4 April 2005

Member Information Continued…• Next, the provider must confirm his/her relationship with the member by supplying the

member’s full name and ID number. If the provider is unable to provide the member IDnumber, the provider must supply at least one of the following (in addition to the patient’sname):- Patient birth date- A claim number or authorization number- Patient address and/or- Name of primary physician (when applicable)

Note: If the member is an Excellus BCBS employee (or dependent of an ExcellusBCBS employee), the provider must supply the subscriber ID if checking eligibility viaan online method.

If neither the provider’s identity nor the provider/patient relationship can be confirmed, the Health Planwill not release the information.

Southern Tier Providers – Upcoming Blues Education ClassesRemember that Provider Relations holds various Blues education classes in Binghamton and Elmiraeach month to help fulfill your education needs. Classes fill up quickly, so don’t forget to submit yourregistration form early.

The following classes are being held in May and June.

Class Date Time LocationBasic Blues Orientation 101 5/11/05, 6/09/05 8:30-11:30 BinghamtonBasic Blues Orientation 101 5/20/05, 6/17/05 8:30-11:30 ElmiraMember Eligibility 101 5/24/05 1:00-4:00 BinghamtonMember Eligibility 101 6/13/05 1:00-4:00 ElmiraBlues Vision Provider Orientation 101 5/24/05 8:30-11:30 BinghamtonBlues Vision Provider Orientation 101 6/13/05 8:30-11:30 ElmiraBlues Billing Overview 102 5/11/05, 6/09/05 1:00-4:00 BinghamtonBlues Billing Overview 102 5/20/05, 6/17/05 1:00-4:00 ElmiraNew Office Managers 103 6/15/05 10:00-4:00 BinghamtonNew Office Managers 103 5/16/05 10:00-4:00 Elmira

If you need a registration form, or would like more information about the classes, please contact yourProvider Relations Representative.

New Tetanus Vaccine DECAVACThe CPT procedure code for the new tetanus vaccine DECAVAC is 90714. While insurers have untilJuly 1, 2005 to implement it in our systems, Excellus BCBS has made a decision to accept the newcode effective immediately for dates of service on or after February 1, 2005.

Please be aware, however, that most health benefit programs do not cover adult immunizations. Forthose that do, reimbursement will be $17.50. The Health Plan will pay administration fees according tothe provider’s fee schedule.

April 2005 Page 5

Safety Net Products Now Available in More Counties

Family Health Plus – Five More CountiesExcellus BCBS recently received approval to market Family Health Plus in the following counties:• Chemung (including dental)• Madison (including dental)• Otsego (including dental)• Schuyler (no dental benefit)• St. Lawrence (no dental benefit)

Providers in any county in the Excellus BCBS service area who participate in this program may seeFHP members from these counties. Because some members enrolled in March, their benefits areeffective in April – so you may already be seeing these covered members!

Facilitated enrollers in each county handle enrollment. To find the lead agency for facilitatedenrollment in a specific county, interested individuals should call 1 (800) 231-0744.

The Health Plan now has approval to market Family Health Plus in the following counties: Broome,Chemung, Clinton, Essex, Franklin, Herkimer, Livingston, Madison, Monroe, Oneida, Onondaga,Ontario, Oswego, Otsego, Schuyler, St. Lawrence, Seneca, Wayne and Yates.

Healthy New York (B) EPO and ValuMed Plus Now in Lewis CountyWe’ve also just been approved to market Healthy New York (B) EPO and ValuMed Plus in LewisCounty. These products have different eligibility requirements and were created for individuals whoare not eligible for some of the other government safety net products. They provide basiccomprehensive coverage. Enrollment is through Excellus BCBS.

The member identification number prefix for both of these products is ZFV. The name of theproduct is on the ID card.

ValuMed Plus and Healthy NY “B” EPO are both EPO programs. This means that there are noreferrals, and limited preauthorization requirements. ValuMed Plus requires prior authorization fororgan transplants, home care outside our service area, and hospice care. Healthy New York (B) EPOrequires prior authorization for organ transplants.

Excellus BCBS now offers these products in the following counties: Broome, Cayuga, Chemung,Chenango, Clinton, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis,Madison, Montgomery, Oneida, Onondaga, Otsego, Oswego, Schuyler, St. Lawrence, Steuben andTioga.

Please be aware that members will have no out-of-network benefit, except for emergencies. Ifyou are not currently “in-network” for these products and would like to be, please contact yourProvider Relations Representative.

CODING CORNERCorrect Coding for LensesPlease remember that in HCPCS coding, V codes for lenses are perlens. Therefore, if you are billing for two lenses, and the focal lengthand diopter range of both lenses fall within the same V code, the unitamount should be 2. On the other hand, if the lenses are different from each other and not both thesame code, then each code should be for only 1 unit.

This applies for both spectacle and contact lenses, whether single vision, bifocal or trifocal, glass orplastic.

Page 6 April 2005

Differences in Eyeglass Benefit for CHP, FHP and Medicaid Managed CareAs Excellus BCBS expands its offering of Family Health Plus (FHP) and Medicaid managed care(HMOBlue Option) into additional counties, it is important for vision care providers to know that thereis a slight difference in benefit among these products when it comes to eyeglasses.

While all providers who participate with these products must have a selection of frames and lensesthey can offer the member at no additional charge, only Child Health Plus (CHP) members have theoption of upgrading to a “deluxe frame” and still be eligible for the basic benefit.

CHP members who wish to select special frames or eyeglass lenses (e.g., with coatings or tints) maydo so after they have first been shown the selection of frames and lenses that they may obtain withoutany out-of-pocket expense. The CHP member is responsible to pay the difference between theprovider’s normal charge for the deluxe item and the provider’s normal charge for the standard item.(A standard frame is any frame one can purchase at a discounted wholesale price of $25.00 or less.)

CHP members who have paid-in-full benefits may use their standard frame/lens benefit toward thepurchase of progressive lenses/frames.

FHP and Medicaid managed care members do not have this option. If they do not accept thestandard options for frames and lenses, they get no benefit. The member (or responsible parent orguardian) would need to pay the entire charge for the eyeglasses and sign a consent form statinghis/her understanding of the liability.

Billing Guidelines for Deluxe Frames• If a patient requests and agrees to deluxe frames, the provider should bill HCPCS code V2020 for

standard frames.• The difference in charge between the standard frame and the deluxe frame should be billed

separately.• The difference amount would be billed under HCPCS code V2025.• That difference will deny as patient liability.Providers may bill the patient the difference between the charge for the standard frame and thecharge for the deluxe frame. However, you may not bill the patient for the difference between ourreimbursement and your normal charge for the standard frame.

Billing Guidelines for Progressive Lenses• For progressive lenses, bill the appropriate standard bifocal or trifocal lens charge with the

appropriate HCPCS code.• Bill the difference in charge between the standard lenses and progressive lenses with NCPCS

V2781 (progressive lenses).• The difference will deny as patient liability.Providers may bill the patient the difference between the charge for a pair of standard lenses (bifocalor trifocal) and the charge for the progressive lenses. However, you may not bill the patient for thedifference between our reimbursement and your normal charge for the standard bifocal ortrifocal lenses.

April 2005 Page 7

A1C Control in Patients with DiabetesManagement of blood glucose levels is the primary key to control of diabetes and prevention ofconditions that can result from diabetes, such as retinopathy, coronary artery disease and end stagerenal disease. Keeping the A1C levels at or lower than 6.5 percent is the ideal goal, as reflected in theExcellus BCBS diabetic guideline, Continuing Care for Diabetic Adults.

During HEDIS data collection, our staff looks for an A1C level of less than 9 percent. The HEDISresults for Excellus BCBS commercial managed care members in our Excellus BCBS eastern regions(Central New York, CNY Southern Tier, and Utica Regions) indicate an opportunity for improvement.

Excellus BCBS eastern regions HEDIS 2004 10th percentile (goal)

A1C Poor Control (commercial managedcare) 25.3% 20.9%

*HEDIS Quality Compass 10th percentile

NOTE: For this measure, a lower rate indicates better performance. Therefore, the 10th percentile isthe goal.

These results indicate the percent of Excellus BCBS commercial managed care members withdiabetes who:

1. Did not have an A1C test done in the measurement year OR2. Whose most recent A1C test result in the measurement year was greater than 9.0%.

It is important for patients with diabetes to have their A1C tested every three to six months (two timesper year if stable, four times per year if changing therapy or not meeting glycemic goals).

In addition to getting tested, setting glycemic goals with your patients can give them a target towardwhich to work. Please take this opportunity to help improve this measure.

Important to Test Patients with Diabetes for Protein in the UrineAn important indicator of early kidney disease istrace amounts of protein in the urine, ormicroalbuminuria. Because kidney disease is acomplication of diabetes, it is critical to annuallytest those with diabetes for microalbuminuria,regardless of whether they are already prescribedan ace inhibitor or angiotensin receptor blocker(ARB). When detected early, microalbuminuriacan be treated, thereby reducing the chance ofkidney disease. Stringent control of blood glucoseand blood pressure can stabilize or reduce thedegree of microalbuminuria and subsequent kidneydamage.

The most recent HEDIS rates (2004) for ExcellusBCBS Central New York, CNY Southern Tier andUtica Regions (eastern regions) combined indicatethat microalbumin testing in our commercialmanaged care members with diabetes decreased from the prior year and is below the establishedbenchmark and performance goal.

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Page 8 April 2005

Important to Test Patients Continued…

Excellus BCBS eastern regions HEDIS 2003 HEDIS 2004 90th percentile(goal)

Microalbumin Testing (commercialmanaged care) 54.01% 48.66% (↓) *61.6%

*HEDIS Quality Compass 90th percentile

The test must be done in a laboratory, as a routine dipstick for protein will not identify thesmall elevations of urinary albumin amenable to early intervention. The laboratory requisition shouldrequest assay of microalbumin or microalbumin to creatinine ratio.

The following are indications of microalbuminuria:

• A spot urine sample (preferably a first-morning void) showing a microalbumin/creatinine clearanceratio greater than 30 mg of microalbumin per gram of creatinine

• A timed collection (e.g., 4-hour or overnight) showing more than 20 mcg of microalbumin perminute (>20 mcg/minute microalbumin)

• A 24-hour collection showing urinary albumin greater than 30 mg

Eye Care for Diabetics Remains a Serious ConcernDiabetes is a major health problem that is becoming more prevalent in all age groups. The increasingprevalence is attributed to both higher detection and poorer health habits. Complications of thedisease include blindness, kidney failure, nerve damage, and cardiovascular disease. For mostpersons with diabetes, many of these complications can be prevented or delayed with appropriatemonitoring and treatment. However, studies in both fee-for-service and managed care settingsindicate opportunities for improvement with this care standard.

The most recent HEDIS rates for Excellus BCBS Central New York, CNY Southern Tier and UticaRegions (eastern regions) combined show that annual eye exams for diabetic members in ourcommercial managed care products are below established benchmarks and performance goals.

Excellus BCBS eastern regions HEDIS 2004 90th percentile (goal)Eye Exam (commercial managed care) 57.7% *64.1%*HEDIS Quality Compass 90th percentile

Diabetic retinopathy affects half of all people in the US diagnosed with diabetes and is the leadingcause of blindness in US adults. Early detection and treatment can substantially reduce severe visionloss or blindness. People with diabetes should receive a dilated retinal eye exam on an annual basis.Annual dilated retinal eye exams are a covered benefit for diabetics.

Inside this newsletter, we’ve included a documentation tool, the Diabetes Eye Examination Report,developed by Excellus BCBS. Eye care providers may make as many copies as needed and use it todocument DRE (diabetic retinal eye exam) in the medical record of each patient with diabetes. Anddon’t forget the importance of sharing a copy with the member’s PCP.

Providers may also download the Diabetes Eye Examination Report from the Excellus BCBS Web sitewww.excellusbcbs.com. From the Provider page, click on Print Forms in the menu at the bottom.

April 2005 Page 9

Some Member R&R Include Practitioner Rights and Responsibilities

We’ve included a copy of our member rights and responsibilities. Please review them as many ofthem include responsibilities, as well as rights, of the practitioners providing service. They beginimmediately below.A member has the right to:

• Receive all the benefits to which he/she is entitled under his/her contract;• Receive quality health care through his/her provider in a timely manner and medically appropriate

setting;• Receive considerate, courteous and respectful care;• Be treated with respect and recognition of his/her dignity and right to privacy.• Receive information about services, staff, hours of operation and his/her benefits, including access

to routine services as well as after-hours and emergency services and members’ rights andresponsibilities;

• Participate in decision-making with his/her physician about his/her health care;• Obtain complete, current information concerning a diagnosis, treatment and prognosis from a

provider in terms that he/she can reasonably be expected to understand;• Refuse treatment as allowed by law, and be informed by his/her physician of the medical

consequences;• Refuse to participate in research;• Retain the confidentiality of medical records and information, with the authority to approve or

refuse the Health Plan's disclosure of such information, to the extent protected by law;• Receive all information needed to give informed consent for any procedure or treatment;• Have access to his/her medical records as permitted by New York State law;• Express concerns and complaints about the care and services provided by physicians and other

providers, and have the Health Plan investigate and respond to these concerns and complaints;• Engage in candid discussion of appropriate or medically necessary treatment options for his/her

condition, regardless of cost or benefit coverage;• Receive care and treatment without regard to age, race, color, sex or sexual orientation, religion,

marital status, national origin, economic status or source of payment;• Voice complaints and recommend changes in benefits and services to staff, administration and/or

the New York State Insurance Department or Department of Health, without fear of reprisal;• Formulate advance directives regarding his/her care (to obtain a Health Care Proxy form, contact

the Health Plan);• Contact one of the Health Plan’s service departments to obtain the names, qualifications and titles

of providers who are responsible for his/her care;• Obtain all information about his/her health plan, its services and its providers and procedures.• Make recommendations regarding the organization’s member rights and responsibilities.

A member has the responsibility to:

• Be an active partner in the effort to promote and restore health by:- Openly sharing information about his/her symptoms and health history with his/her physician;- Listening;- Asking questions;- Becoming informed about his/her diagnosis, recommended treatment and anticipated or

possible outcomes;(continued on page 10)

Page 10 April 2005

Member R&R Continued…

- Following the plans of care he/she has agreed to (suchas taking medicine and making and keepingappointments);

- Returning for further care, if any problem fails to improve;and

- Accepting responsibility for the outcomes of his/herdecisions.

• Participate in understanding his/her health problems anddeveloping mutually agreed upon treatment goals.

• Have all care provided, arranged or authorized by his/herprimary care physician (PCP);

• Inform his/her PCP if there are changes in his/her health status;• Obtain services authorized by his/her PCP;• Share with his/her PCP any concerns about the medical care or services that he/she receives;• Permit the Health Plan to review his/her medical records in order to comply with federal, state and

local government regulations regarding quality assurance, and to verify the nature of servicesprovided;

• Respect time set aside for his/her appointments with providers and give as much notice aspossible when an appointment must be rescheduled or cancelled;

• Understand that emergencies arise for his/her providers and that his/her appointments may beunavoidably delayed as a result;

• Respect Health Plan staff and providers;• Follow the instructions and guidelines given by his/her providers;• Show his/her ID card and pay his/her visit fees to the provider at the time the service is rendered;• Become informed about Health Plan policies and procedures, as well as the office policies and

procedures of his/her providers, so that he/she can make the best use of the services that areavailable under his/her contract;

• Abide by the conditions set forth in his/her contract.

Excellus BCBS Receives URAC Case Management AccreditationWe are proud to report that URAC, a Washington, DC-based health care accrediting organization thatestablishes quality standards for the health care industry, recently accredited our case managementprograms. This is an important milestone!

Our Case Management Program assists members with complex, chronic illnesses or behavioralhealth conditions to maintain or improve their health and quality of life. Case managers collaborate onbehalf of members and their families directly or indirectly with physicians, specialists, communityresources, and Health Plan resources. By coordinating medical services, case managers helpmembers navigate the health care system and respond to the individual’s special needs to findsolutions to roadblocks to wellness and independence. They do this through support of the physician’streatment plan, advocacy, communication, education, and coordination of service resources, andfacilitation of solutions.

The Health Plan provides case management services at no additional cost to members whosecontract supports case management, and who meet the qualifying criteria stated in the contract.Members may benefit from education, preventive care and intense management of acute needs thatcould vary by intensity levels.

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April 2005 Page 11

URAC Case Management Accreditation Continued…URAC’s case management accreditation standards address approaches to ensuring appropriatepatient protections have been established, such as policies for confidentiality of patient information,informed consent, dispute resolution and other issues. The standards cover staff structure andqualifications, quality improvement, information management, oversight of delegated functions, ethics,complaints, and the case management process.

URAC, an independent, nonprofit organization, is a leader in promoting health care quality throughaccreditation and certification programs. URAC’s standards keep pace with the rapid changes in thehealth care system, and provide a mark of distinction for health care organizations to demonstratetheir commitment to quality and accountability. Through its broad-based governance structure and aninclusive standards development process, URAC ensures that all stakeholders are represented insetting meaningful standards for the health care industry.

For more information, visit www.urac.org or our Web site, www.excellusbcbs.com.

Medical Policy UpdateTo ensure that the development of corporate medical policies occurs through an open, collaborativeprocess, we encourage our participating practitioners to become actively involved in medical policydevelopment. Each month, draft policies are posted in the Provider section of our Web site(www.excellusbcbs.com) for participating practitioners’ review and comment. Click on For Providers,then Medical Policies. Next, click on Preview & Comment on Draft Policies located at the bottom ofthe menu on the left side under Medical Policies. The following policies are tentatively scheduled tobe available for comment in April 2005:• Allogeneic Stem Cell or Bone Marrow Transplant• Autologous Stem Cell or Bone Marrow Transplant• Cardiac CT Angiography• Carotid Artery Stents• Continuous Passive Motion• End-Diastolic Pneumatic Compression• External Counterpulsation• Functional Neuromuscular Stimulation• Transrectal Ultrasound• Therapeutic Electrical Stimulation• Varicosities, Alternative Treatment Options for Vein Stripping and Ligation

Corporate medical policies are used as a guide. Coverage decisions are made on a case-by-casebasis and in accordance with the member's contract. While a technology or service may be medicallynecessary, payment of benefits is subject to the member's eligibility on the date the service isrendered and the benefit/exclusion provisions in the member's contract. Before rendering care,providers should verify the member's eligibility for the service by calling the Provider ServiceDepartment of your local plan.

The following new and updated medical policies have been reviewed and approved by the CorporateMedical Policy Committee, including practitioner representatives from Excellus BlueCross BlueShield,Central New York Region, Central New York Southern Tier Region, Utica Region, and RochesterRegion.

(continued)

Page 12 April 2005

Complete detailed policies are available on our Web site at www.excellusbcbs.com. Click onthe For Providers menu option, then on View Our Medical Policies. Questions regarding medicalpolicies may be directed to your Provider Relations Representative or to the Provider ServiceDepartment of your local health plan.

Medical policies are also located on the Web site for Excellus BlueCross BlueShield members atwww.excellusbcbs.com. To access our policies, members need to click on For Members, followed byHealth and Wellness, then Research Health Conditions and lastly View our Medical Policies.

Policies and protocols referenced in this newsletter are written for commercial contracts only. A briefdescription of CMS coverage has been provided for some Excellus BlueCross BlueShield medicalpolicies that differ from CMS. Please refer to the Centers for Medicare & Medicaid Services (CMS) formedical policies pertaining to Senior contracts. Web sites for review of CMS policies are:

• www.cms.hhs.gov/mcd/indexes.asp for the Medicare Manual• www.umd.nycpic.com/lmrp.html for local Upstate New York Medicare policies

Please note: Although medical policies are effective on the date they are approved by the MedicalPolicy Committee, updates to the claims processing systems may not occur for up to 90 days in orderto allow you to update your billing systems accordingly.

NEW POLICIES recently approved by Corporate Medical Policy CommitteeCeliac Disease Testing addresses the use of serologic measurements of antibodies and geneticmarkers associated with celiac disease. Serologic measurement of antibodies associated with celiacdisease (TTG-IgA or EMA-IgA) is medically appropriate for the following indications:

• As part of the clinical armamentarium to assist in the diagnosis of patients with symptomssuggestive of celiac disease;

• To monitor adherence to a gluten-free diet and assess response to treatment; or• As a tool to identify biopsy candidates in symptomatic patients considered at high-risk for celiac

disease. Patients considered at high risk for celiac disease include, but are not limited to: 1stdegree relatives of individuals with celiac disease, individuals with type I DM, Turner or Downsyndrome, or other autoimmune endocrinopathies.

Genetic testing for celiac disease (HLA DQ2 and DQ8) is considered medically appropriate only whenthe diagnosis of celiac disease remains uncertain because of indeterminate or equivocal test results(including intestinal biopsy), despite clinical presentation and when offered in a setting by a specialist(gastroenterologist or geneticist) with expertise in treating people with the disease.

CURRENT POLICIES recently updated by Corporate Medical Policy CommitteeCochlear Implants are intended to restore a level of auditory sensation to individuals with severe toprofound sensorineural hearing loss by electrical stimulation of the acoustic nerve. Unilateral cochlearimplants have been medically proven to be effective and are medically appropriate as a prostheticfor hearing loss when ALL the following criteria are met:

• At least 1 year of age;• Severe to profound bilateral sensorineural hearing loss (defined as a hearing threshold of 70

decibels or greater) that cannot benefit from hearing aids, and• Cognitive ability to use auditory clues and a willingness to undergo an extended program of

auditory rehabilitation.Extracorporeal Shockwave Therapy (ESWT) for Musculoskeletal Conditions is offered as a non-surgical treatment option for conditions such as chronic plantar fasciitis and tendonitis of the shoulderor elbow.

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April 2005 Page 13

ESWT is considered investigational, as there is insufficient scientific evidence on its effectiveness intreating musculoskeletal conditions. Upstate Medicare provides coverage for ESWT as an alternativeto surgery for plantar faciitis and epicondylitis when the patient has failed to respond to a thoroughtrial of conservative methods.

Uterine Artery Occlusion in the Treatment of Uterine Fibroids, formally titled Uterine ArteryEmbolization, now addresses 2 occlusive methods for treating uterine fibroids. Uterine arteryembolization involves the insertion of catheters into uterine arteries that give rise to the fibroid(s) andthe injection of an appropriate embolic agent to permanently seal arterial flow. The cessation ofarterial flow to the fibroid causes ischemia and infarction of the fibroid. Uterine artery embolization,with a FDA approved embolic agent, in the treatment of symptomatic uterine fibroids and severemenorrhagia, despite an adequate trial of hormonal therapy when appropriate, is a medicallyappropriate treatment option. Laparoscopic occlusion of the uterine arteries utilizing vascular clips orbipolar coagulation has been proposed as an alternative to uterine artery embolization. Laparoscopicocclusion of the uterine arteries by vascular clips or coagulation is considered investigational as thereis insufficient evidence to demonstrate that this method of treating uterine fibroids improves clinicaloutcomes.

NEW PROTOCOLS recently approved by Corporate Protocol CommitteeThe Cervical Traction Devices protocol addresses the use of pneumatic, hydraulic and over-the-door home units. Over-the-door traction devices are considered medically appropriate for patients withthe following conditions: degenerative disc disease, posterior facet syndrome, herniated cervical disc,spinal stenosis and cervical muscle strain/spasm. Pneumatic and hydraulic cervical traction devicesare considered medically appropriate only when patients have failed at a trial of an over-the-doorcervical traction device or for those patients where the over-the-door device can not be used due topain or anatomic reasons (e.g., radical neck resection or temporal mandibular joint dysfunction).

CURRENT PROTOCOLS recently updated by Corporate Protocol CommitteeThe Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Surgery protocollists the situations where anesthesia and ambulatory surgery charges are eligible for coverage. Thisprotocol applies only for those contracts where language exists stating that the Health Plan will coverincurred hospital and anesthesia charges when a Health Plan Medical Director determines anunderlying medical, not dental, condition requires the member be hospitalized. This protocol alsodoes not address coverage for dental benefits.

Prostate Cancer Screening is eligible for coverage at the following intervals:

• At any age for men having a prior history of prostate cancer;• Annually for men age 40 and over who have a family history of prostate cancer or other prostate

cancer risk factors; and• Annually for men age 50 and over who are asymptomatic.

CURRENT POLICIES AND PROTOCOLS recently updated with minimal changesThe following policies and protocols required only minimal changes (e.g., updating of references,changing language to meet legal needs). The coverage intent of the policies/protocols was notaltered. These policies/protocols were recently approved for updating by the Health Plan MedicalDirectors and are available on our Web site.

Policies• Genotypic Analysis of Thiopurine S-Methyl-Transferase in Patients Treated with Azathiopurine

and 6 Mercaptopurine• Intensity Modulated Radiation Therapy• Kidney Transplant

(continued)

Page 14 April 2005

• Measurement of Nitric Oxide for Asthma Patients• Metabolite Markers for Inflammatory Bowel Disease• Pancreas Transplant (Pancreas Transplant alone, Pancreas after Kidney transplant,

Simultaneous Pancreas Kidney Transplant)• Serologic Diagnosis of Inflammatory Bowel Disease• Small Bowel and Multivisceral Transplantation

Protocols• Accelerated Fracture Healing Devices• Audiology Screening for Newborn• Cervical Cancer Screening• Clinical Trials• Comfort, Convenience, Custodial or Cosmetic (archived)• Electrical Bone Growth Stimulator• Experimental and Investigational Services• Knee Braces• Management of Breast Implants

Diabetes Eye Examination ReportA nonprofit independent licensee of the BlueCross BlueShield Association

To: _____________________________________ Phone: ________________ Fax: ________________ PRIMARY CARE PHYSICIAN

Address: ________________________________________________________________________________________

Patient Name: _______________________________ Patient ID#: ______________________________________

Date of Dilated Retinal Exam: ____________________ Visual Acuity: Intraocular Pressure:Retinal Examination Findings: __________ R _________L __________ R _________L

_____ No retinopathy or past retinopathy and should be examined in one year

_____ Needs no laser now, but should return in _____ months because of risk of developing diabetic macular edema (DME) or high risk proliferative diabetic retinopathy (PDR)

_____ Diabetic macular edema requiring focal laser photocoagulation

_____ High risk proliferative diabetic retinopathy or iris neovascularization requiring panretinal photocoagulation

_____ Tractional retinal detachment or vitreous hemorrhage requiring vitrectomy

Cataracts: Glaucoma:_____ Interferes with activities of daily living _____ Controlled

_____ Does not interfere with activities of daily living _____ Sub-optimally controlled

Other Ocular Conditions: __________________________________________________________________________

Plan of Treatment:_____ Follow up in _______ weeks / ________ months

_____ Refer to Retina Specialist OR:Check appropriate treatment plan (Circle right eye, left eye or both)

_____ Fluorescein angiogram R L

_____ Panretinal laser photocoagulation R L

_____ Focal laser photocoagulation R L

_____ Vitrectomy R L

_____ Cataract surgery R L

_____ Other: ___________________________________________________________________________________

Eye Care Provider (MD or OD):______________________________________________ ____________________________________ ___________PRINT NAME SIGNATURE DATE

______________________________________________ _______________________ _______________________ADDRESS PHONE FAX

I, _____________________________________, authorize my eye care provider, ________________________________, PATIENT NAME EYE CARE PROVIDER NAME

to disclose the above protected health information to my primary care provider, __________________________________ PRIMARY CARE PROVIDER NAME

Patient Signature: __________________________________________________ Date: ____________________

Rev. Jan 2005

April 2005

Save Patients Up To 50% On Cholesterol Medicationswith the Half Tablet Incentive Program

The Excellus BlueCross BlueShield voluntary Half Tablet Incentive Program is an easy wayfor your patients to save up to 50% on their costs for the following prescription cholesteroldrugs: Crestor®, Lipitor®, Pravachol®, and Zocor®.

If your patient pays a flat dollar copayment for prescriptions, thecopayment will be cut in half through this incentive program. If your patientpays a percentage of drug costs through a coinsurance program, thecoinsurance will be based on a lower medication cost.

How the Program Works:

If patient agrees to participate in this program, a new prescription for the higher strengthtablet will be required.

Thousands of patients are taking advantage of this cost savings opportunity. To calculatepotential patient savings, visit www.excellusbcbs.com and try our Half Tablet Calculator. Toaccess the calculator:• Click on the Providers page• Click on the Prescription Drugs tab located on the top toolbar• Under the “Helping Patients Save Money” section, click on the Half Tablet Incentive

Program Link• You’ll find the calculator in the Related Resources Link

If you have questions regarding this program, please contact the FLRx Help Desk at 1-800-724-5033.

Patient currentlytaking Lipitor 20 mg

Prescribe Lipitor 40 mg½ daily for #15 for a

30-day supply

Patient was paying $20 for 30-daysupply, now pays $10 for 30-day supply

and gets two doses per tablet!

344 South Warren StreetSyracuse, New York 13202

PRSRT STDU.S. POSTAGE

PAIDROCHESTER, NY

Permit No. 201