A nonprofit independent licensee of the BlueCross BlueShield Association

Volume 12.6 Utica Region June 2006 Effective June 19, 2006, all paper claim

Inside this Issue

Provider Service Corner, Ordering Brochures and Educational Materials, p. 2

Adjustment Versus Appeal, p. 2

HEDIS and QARR Data Collection Complete-Thank You, p. 3

Illegible Paper Claims Will Be Returned, p. 3

Out-of-Network Referrals for Managed Care Members, p. 3

Reminder-Prefix for NYS Employees, p. 4

Clarification on Electronic Submission of Secondary Claims, p. 4

Vaccines for Children Program Expands to Child Health Plus, p. 4

Addressing Disparities in Health Care, p. 4

2005 Behavioral Health Surveys, p. 5

BH Appointment Availability Results, p. 5

BH Continuity of Care Results, p. 5

Medical Policy/Protocol Update, p. 6

Corporate Medical Policy Changes, p. 9

Also

ClaimCheck Update

News from FLRx

Health Care Debit Card Information

Medical Orders for Life-Sustaining Treatment (MOLST) Program Information

Order Form for Free Educational Resources

New Mailing Address for Paper Claims and More! Excellus BlueCross BlueShield continues to implement modifications to make it easier for our providers to do business with us. To help streamline document submission, we have consolidated our mail operations.

This new address also applies to claims for Monroe Plan members, Federal Employee Program (FEP) claims and Medical Records Unit (MRU) requests. If you receive a letter from us requesting medical records, please send the records to the address above and remember to include a copy of our request and put the patient’s name and member ID on every page.

To assist with this transition we have updated the Web site, QuickLink and Customer Service phone systems (IVR) with the capability to provide you with the new address. All three of these tools will continue to require a provider pin number and/or password.

Thank you for your cooperation. If you have any questions, please contact Provider Service.

Improvements to BlueExchange Good news! We have enhanced BlueExchange to improve response time. In the past, you may have experienced an excessive wait time, or your inquiry may have timed out. This problem has been corrected and your next visit to BlueExchange will provide a timely response.

Effective June 19, 2006, all paper claims, medical records, requests for adjustment, appeals and inquiries should be mailed to: Excellus BlueCross BlueShield P.O. Box 22999 Rochester, NY 14692

Visit our Web site at excellusbcbs.com

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You asked Provider Service the question…

…We publish the answer − for everyone!

Q. Do you have pamphlets and other educational materials that I can order for our office?

A. Yes, we do, and you may order them free of charge! We have included an order form with this issue that you may use to request brochures, reference guides and educational materials. Here are just a few examples of the educational materials available:

• Advance Care Planning Booklet • Pain Management Guides • The Importance of Mammography • Heartburn Prevention and Treatment • Medical Orders for Life-Sustaining Treatment (MOLST) Form • Elder Abuse Assessment and Management Tool

The order form may be printed from our Web site, excellusbcbs.com. From the Provider Home Page, click on Administration, then Forms & Templates. The order form is listed under the Brochures category.

Adjustment Versus Appeal Our Provider Service Department reports that there has been some confusion regarding the difference between an adjustment and an appeal. Callers to Provider Service have inquired about the status of an appeal, when, in fact, they have submitted a request for adjustment. We hope that the following information will help to clear up any confusion between the two terms. An adjustment is used to correct a claim that has already been processed. Provider offices often request adjustments to correct errors found on the remittance. All claim adjustments require the completion and submission of a Request for Adjustment form. If additional paperwork is needed to support the adjustment, it must be included. You will find the Request for Adjustment form on our Web site, excellusbcbs.com. From the Provider Home Page, click on Administration, then Forms & Templates. The form is located under Billing and Remittance. All requests for adjustment must be submitted within 60 days from the date of the remittance, Explanation of Benefits (EOB), or denial notice. Appeal refers to the process available when a member or provider is not satisfied with the medical necessity or experimental/investigational determination made by Excellus BCBS.

Any member, authorized designee or provider may appeal a decision made by us for denials based on medical necessity or considered experimental or investigational. An appeal may be requested by calling the telephone number listed on the member’s ID card, or by submitting the request for appeal in writing to the address on the member’s ID card. For more information, please consult your Excellus BCBS Participating Provider Manual, or contact Provider Service.

June 2006 Page 3

HEDIS and QARR Data Collection Complete─Thank You! Thank you to all the physicians and office staff who participated in our 2006 annual data collection process. Our Quality Management department representatives visited approximately 2,500 physician offices and completed more than 15,000 medical record reviews. Analysis of this data will be very helpful to us as we work to identify opportunities for quality initiatives that will enable us to improve the health and well being of our members. Additionally, the National Committee for Quality Assurance (NCQA) and the New York State Department of Health require us to report specific measures annually. The 2005 Health Plan Employer Data and Information Set (HEDIS) and Quality Assurance Reporting Requirements (QARR) define these measurements.

We appreciate your time and cooperation with this initiative. Please watch future editions of Connection for a report of our findings.

Illegible Paper Claims Will Be Returned The Optical Character Recognition (OCR) technology we use to scan and enter paper claims reduces claim processing time and assists us in paying claims more efficiently. However, if OCR cannot read a claim, we will return it to your office along with a cover letter requesting that you resubmit a better copy. To avoid receiving returned paper claims, please:

• Use the original two-color (red and white) version of the CMS-1500 form rather than photocopies of the original. This will make it easier for OCR to read the claim form.

• Type or key in the form, do not handwrite it. Be sure to keep the typed/keyed information inside the box lines.

• Do not tape the EOMB strip across top of the CMS-1500 or covering information entered on the CMS-1500. OCR cannot read or process information that is covered or blocked.

• Make sure your printer cartridge is fresh and that characters are clearly visible. Print that is too light will not be read by the OCR scanner.

• Check your printer to be sure it is properly aligned so that information prints in the correct fields and double check the form before submitting it.

For more helpful hints to improve the submission of paper claims, please see the tip sheet included with the April 2006 issue of this newsletter. You can view and print back issues of the newsletter on our Web site, excellusbcbs.com. From the Provider Home Page, click on News & Updates at the bottom of the screen, and then click on the link for your region under the Newsletters for Providers section.

Out-of-Network Referrals for Managed Care Members In some cases, a member enrolled in one of our managed care products (e.g., HMOBlue, BluePoint, Child Health Plus, Family Health Plus, Healthy NY A) may require treatment from a provider who does not participate with Excellus BCBS. If the appropriate expertise is not available from a participating provider, the member may be referred to an out-of-network provider for non-urgent/emergent care. However, all in-network provider options must be ruled out first. Our managed care enrollees must involve their PCP in the referral process. We will require clinical documentation from the PCP that supports why it is necessary for the member to seek treatment outside of the plan, and prior approval must be obtained before the member's visit to the out-of-network provider. When possible, please make every effort to refer our members to participating providers. Managed care members who do not obtain a referral prior to seeking treatment and/or services from an out-of-network provider may be held financially responsible for the cost of the services received. If you have any questions regarding this information, please contact Provider Service.

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Reminder─New Prefix for NYS Employees Due to recent claim issues for these members, we would like to remind you that in April 2005, some New York State employees covered by the Empire Plan were changed from the YLS prefix to YLA. Unlike cards with the YLS prefix, the YLA prefix is located on the back of the Empire Plan ID card. Most of the Empire Plan members that now have the YLA prefix are New York State correctional officers. Please note that these members are uniquely identified by the number “89” in the first two positions of the identification number (e.g., YLA 89XXXXXXX or YLS 89XXXXXXX). Empire BCBS no longer accepts social security numbers for billing purposes. Billing with a social security number will result in claim denial and delay in payment. Please be sure to bill Empire Plan members with the unique “89XXXXXXX” number.

Clarification on Electronic Submission of Secondary Claims In the April 2006 issue of this newsletter, we included an article regarding electronic submission of secondary claims. It generated some questions, so we’d like to clarify. If your vendor has been approved and you are already submitting secondary claims, you do not need to test with Trading Partners Support (TPS). You only have to test with TPS if your office has never submitted electronic secondary claims.

Vaccines for Children Program Expands to Child Health Plus Effective August 1, 2006, the NYS Department of Health requires that all providers administering vaccines to children with Child Health Plus (CHP) coverage participate in the New York Vaccines for Children (VFC) program. VFC will provide the vaccines free of charge. Excellus BCBS will continue to pay the vaccine administration fee, but we will not cover the cost of these vaccines after August 1, 2006. It is important for you to continue submitting vaccine codes for quality reporting indicators for childhood immunization.

If you currently participate in the VFC program, you will be able to order vaccines for your CHP patients by July 1, 2006 to prepare for the August 1, 2006 effective date. Providers who do not participate in the VFC program will not receive free vaccines and will not be reimbursed for the cost of vaccines (after the August 1, 2006 effective date) for children enrolled in CHP. If you have questions about the VFC process or wish to participate in the VFC program, please contact Mr. Gary Rinaldi of NYS DOH’s Immunization Program at (518) 474-4578.

Addressing Disparities in Health Care National studies indicate continuing inequalities around access to health care services for many in the United States. Members of racial and ethnic minorities, low-income groups, rural residents and those with special health care needs are all identified as priority populations for outreach efforts. Data-gathering for these groups has been imperfect but is improving both nationally and at the health plan level. Among the African-American population, for example, specific opportunities exist to identify and reduce health disparities. African-Americans generally experience higher rates of asthma, diabetes, heart disease, hypertension, obesity and prostate cancer. This is particularly significant because many of these conditions are included on the list of leading causes of death in the U.S. Ongoing access to general medical care is recognized as central to the goal of decreasing these disparities. The good news in African-American health is that screening rates have improved. Screening rates for mammography, cervical cancer, cholesterol and high blood pressure are similar or better nationally than comparable measures for Caucasians. A study of tobacco use among high school seniors has shown that the smoking rate for African-American students was 15 percent lower than that of Caucasian students. Although some disparities have decreased in recent years, there is still work to do. It is our

June 2006 Page 5

hope that practitioners will become more familiar with diversity in health care and will consider special needs when developing treatment plans for their culturally diverse patients. Excellus BCBS offers assistance in managing your patients with complex medical conditions through our Disease Management programs. These programs focus on asthma, diabetes, heart disease, and many other conditions. For more information about our Disease Management programs, visit our Web site at excellusbcbs.com. From the Provider Home Page, click on Patient Care, then Disease & Case Management.

Reports on 2005 Behavioral Health Surveys Regulatory and accreditation agencies require that we track and trend certain information about service to our managed care members, including appointment availability and the sharing of information with the patient’s primary care physician (PCP) for continuity of care. The results of the 2005 Behavioral Health (BH) surveys are highlighted below.

2005 Behavioral Health Appointment Availability Survey Behavioral Health (BH) Access and Availability Standards are relevant to the entire managed care enrolled population, including our commercial, Medicare and Medicaid members. The standard requires appointment access for established or current patients within 48 hours for an urgent care appointment and within 10 business days for a routine care appointment follow-up. The BH practitioners surveyed were 100 percent compliant for urgent care access and ninety-seven percent compliant for routine care access appointments. Congratulations on these results and thank you for providing excellent access to our members seeking BH services! This annual survey was performed with 63 BH high volume practitioners being credentialed in 2005, and met criteria for a treatment record review or the continuity of care survey for the same time frame. The survey presented examples of urgent care and routine care appointment requests by established patients

and asked how soon those patients would be seen for the respective appointments. You may view the BH Access and Availability Policy on our Web site, excellusbcbs.com. From the Provider Home Page, click on Patient Care and then Behavioral Health Guidelines. You may also request a copy of the policy by contacting Jim Riter, LMSW at (315) 671-7043.

2005 Behavioral Health Continuity of Care Continuity of care is relevant to the entire managed care population, including commercial, Medicare and Medicaid members. Behavioral Health (BH) standards require documentation of an exchange of information between the BH practitioner and the member’s PCP and other practitioners. The member’s written consent is required for all exchanges of information. The community-wide Behavioral Health Practitioner Quality Advisory Committee (BHPQAC) considers practitioners in compliance when the aggregate score for each of these measures is 85 percent. The 2005 scores were as follows:

• Exchange of Information with the PCP- 72 percent

• Exchange of Information with Other Practitioners, as necessary - 89 percent

• Consent for Release of Information- 80 percent

An audit was performed with 63 high volume BH practitioners credentialed in 2005 in the Central New York, Southern Tier, and Utica Regions. These participating Excellus BCBS practitioners met criteria for a Treatment Record Review (TRR) or for the Continuity of Care self-reported survey. The exchange of information with the PCP was assessed for timeliness, frequency, and content of communication. There were two prevalent barriers to the overall compliance:

1. Many practitioners who were out of compliance with this measure expressed a lack of understanding about the importance of the PCP in coordinating patient care, unless it appeared to be warranted for a medication evaluation, change, or other medical concern addressed during therapy.

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2. The majority of BH practitioners not in compliance with the requirements for obtaining a written consent for “Release of Information” were unaware that this is a NYS DOH mandate which supersedes the less stringent HIPAA.

The BH Department and the BHPQAC would like to emphasize the importance of coordinating care with the PCP and other BH practitioners. It is crucial to the

relationships between BH and other medical practices.

For sample tools related to continuity of care, visit our Web site, excellusbcbs.com. You may also view the BH Continuity and Coordination of Care policy on the Web site. From the Provider Home Page, click on Patient Care and then Behavioral Health Guidelines. For further information, please contact Jim Riter, LMSW at (315) 671-7043.

Medical Policy/Protocol Update To ensure that the development of corporate medical policies occurs through an open, collaborative process, we encourage our participating practitioners to become actively involved in medical policy development. Each month, draft policies are posted in the Provider section of our Web site 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 of the menu on the left side under Medical Policies. The following policies are tentatively scheduled to be available for comment in June 2006:

• Breast Nipple Aspirate Fluid (NAF) Collection for Cytologic Analysis • Stereotactic Radiosurgery • Urethral Bulking Agents for Urinary Incontinence

Corporate medical policies are used as a guide. Coverage decisions are made on a case-by-case basis and in accordance with the member's contract. While a technology or service may be medically necessary, payment of benefits is subject to the member's eligibility on the date the service is rendered 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 Service Department of your local plan. The following new and updated medical policies have been reviewed and approved by the Corporate Medical Policy Committee, including practitioner representatives from Excellus BlueCross BlueShield, Central New York Region, Central New York Southern Tier Region, Utica Region, and Rochester Region.

Complete detailed policies are available on our Web site at excellusbcbs.com. Click on the For Providers menu option, then click the Medical Policies link under Provider Tools. Questions regarding medical policies may be directed to your Provider Relations Representative or to the Provider Service Department of your local health plan.

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

Medical policies and protocols apply to commercial and Medicaid products only when a contract benefit for the specific service exists. Excellus BCBS medical policies/ protocols only apply to Medicare products when a contract benefit exists and where there are no National or Local Medicare coverage decisions for the specific service. A brief description of the Centers for Medicare and Medicaid Services (CMS) coverage has also been provided for Excellus BCBS medical policies at the end of each medical policy if a CMS coverage determination exists. Please refer to CMS for medical policies pertaining to Medicare 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.

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Please note: Although medical policies are effective on the date they are approved by the Medical Policy Committee, updates to the claims processing systems may not occur for up to 90 days.

NEW POLICIES recently approved by Corporate Medical Policy Committee There were none this reporting period.

CURRENT POLICIES recently updated by Corporate Medical Policy Committee An Extracranial Carotid Artery Angioplasty and Stent procedure is a minimally invasive alternative to carotid endarterectomy, which involves the introduction of catheters, balloons, stents and other devices through a peripheral artery and into the carotid artery to alleviate carotid stenosis. Carotid artery angioplasty with stenting is considered medically appropriate for symptomatic patients, with greater than 50 percent stenosis, who are considered at risk for adverse outcomes (morbidity and mortality) during carotid endarterectomy surgery.

Genetic Assay of Tumor to Determine Prognosis of Breast Cancer (Oncotype DX) has been proposed as a test to improve patient selection criteria for adjuvant chemotherapy in breast cancer treatment by determining specific risk factors through examination of gene expression in tumor tissue. Assays of genetic expression in tumor tissue are considered investigational, as there is limited evidence that this technology can be utilized in the management of patients with breast cancer to improve clinical outcomes.

Surgical Management of Obesity (bariatric surgery) by open or laparoscopic, Roux-en-Y gastric bypass or duodenal switch procedure has been medically proven to improve health outcomes and is considered medically appropriate for selected patients who meet specific criteria outlined in the medical policy. Mini-gastric bypass and adjustable gastric banding (e.g., LAP-BAND) procedures for the surgical treatment of morbid obesity have not been medically proven to improve health outcomes and therefore, are considered investigational. Surgical treatment of morbidly obese adolescents is also considered investigational, as there is insufficient outcome data to support its use in this age group. This year’s medical policy update has included the use of a 2-staged bariatric procedure for the super-obese patient using a sleeve gastrectomy as the initial procedure. The staged bariatric procedure is considered investigational at this time as there is insufficient evidence that a staged approach reduces the risk for surgical complications from more extensive surgeries performed initially.

The Sleep Studies policy defines various diagnostic methods used in the diagnosis of patients with disorders of sleep and daytime alertness and provides indications and coverage policy for polysomnography (PSG), home sleep studies, EEG topography, multiple sleep latency test/maintenance of wakefulness test, nocturnal oximetry and actigraphy. Our current policy stance regarding the use of home sleep studies has been expanded to include coverage of a home sleep study using a type III device for carefully selected patients whose symptoms demonstrate a high pre-test probability of obstructive sleep apnea. The home sleep study must be ordered and interpreted by a sleep medicine specialist. Nocturnal oximetry is considered medically appropriate for follow-up studies when a diagnosis has been established by standard polysomnography and therapy has been initiated and when ordered by a pulmonologist or sleep medicine specialist. The intent is most often to evaluate response to therapy.

Evoked Potentials (EP) are responses (electrical signals) produced by the nervous system in response to a stimulus. These computerized tests help diagnose nerve disorders, locate the site of nerve damage, and help evaluate the patient’s condition after treatment or during surgery. Several types of evoked potentials and their medically appropriate uses are outlined within the medical policy: somatosensory evoked potentials, auditory evoked potentials, visual evoked potentials and motor evoked potentials.

Treatment of Tinnitus (previously titled Tinnitus Retraining) often depends on the severity of the patient’s condition and is supportive rather than curative. These treatments include, but are not limited to: biofeedback, cognitive behavioral therapy, drug therapy (e.g., misoprostol), electrical stimulation, electromagnetic energy, hearing aids and cochlear implants, hyperbaric oxygen therapy,

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masking with a tinnitus masker device, tinnitus retraining therapy (TRT), and transmeatal laser irradiation. Based upon our criteria and assessment of peer-reviewed literature, all proposed treatment modalities for the treatment of tinnitus have not been medically proven to be effective and are considered investigational. Ultraviolet Light for Dermatologic Conditions (previously titled Ultraviolet Light Therapy for the Treatment of Psoriasis) is a treatment where the skin is exposed to non-ionizing radiation for therapeutic benefit. It may involve exposure to ultraviolet B (UVB) or ultraviolet A (UVA) or various combinations of UVB and UVA radiation. Photochemotherapy is the therapeutic use of radiation in combination with a photosensitizing chemical. Psoralens and UVA radiation (PUVA) are currently used for photochemotherapy. Psoralens makes the skin more sensitive and responsive to this particular wavelength of UV light. The medically appropriate indications (severe psoriasis, eczema/atopic dermatitis, mycosis fungoides) for UVB, PUVA and home phototherapy units are outlined within the medical policy.

The Varicosities, Treatment Options to Varicose Vein Stripping and Ligation policy describes various treatments for varicosities and outlines coverage and criteria for specific procedures. Varicose veins must be symptomatic and unresponsive to conservative treatment. Conservative treatment includes: wearing of compressive hose for 12 weeks, NSAIDS for 4 weeks, leg elevation, and modification of activities which aggravate symptoms. Ambulatory phlebectomy, trans-illuminated powered phlebectomy (TPP/TIPP, TriVex), stab phlebectomy, compressive sclerotherapy, endoluminal radiofrequency ablation (such as VNUS®) and laser ablation (e.g., ELAS or EVLT) are considered medically appropriate treatment options for symptomatic varicose vein tributaries. Alternative procedures considered investigational for the treatment of varicose veins include intense pulsed light source/photodermal sclerosis and transcutaneous laser ablation. This year’s update has added the following: Subfascial endoscopic perforator surgery (SEPS) has been medically proven to be effective and is considered a medically appropriate treatment option for symptomatic chronic venous insufficiency which has not responded to conservative therapy (e.g., wearing of compressive hose for 12 weeks, leg elevation and correction of other causes of edema).

CURRENT POLICIES recently updated with minimal changes The following policies required only minimal changes (e.g., updating of references, changing language to meet legal needs). The coverage intent of the policies was not altered. These policies were recently approved for updating by the Health Plan Medical Directors and are available on our Web site.

• Electrothermal Collagen Shrinkage for Orthopedic Conditions • Extracorporeal Photochemotherapy/Photopheresis • Fecal DNA Analysis as a Technique for Colorectal Cancer Screening • Genetic Testing for Familial Alzheimer’s Disease • Genetic Testing for Inherited Susceptibility to Colorectal Cancer • Magnetic Resonance Angiography (MRA) • Meningococal Vaccine • Optical Coherence Tomography • Transcatheter Closure Devices for Cardiac Defects and Patent Ductus Arteriosis • Transurethral Microwave Thermotherapy • Viscosupplementation of the Knee for Osteoarthritis

NEW PROTOCOLS recently approved by Corporate Protocol Committee There were none this reporting period.

CURRENT PROTOCOLS recently updated by Corporate Protocol Committee

The Cervical Cancer Screening protocol allows for routine cervical cancer screening by FDA approved techniques, with the physician determining the most appropriate sampling technique. The

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medical policy previously addressing PapSure® has been incorporated into this medical protocol with this year’s update. Papsure® as an adjunct to cervical cancer screening has not been medically proven to be effective in improving net health outcomes and is, therefore, considered not medically necessary. Since the utilization of the automated slide reading systems, the FocalPoint™ and the ThinPrep® Imaging systems, have not been proven to have a significantly greater sensitivity than the manual reading of specimens, the benefit for the use of these systems will generally be provided at the same level as that for manual reading of the specimen.

Foot Care is defined as the treatment or care of corns, calluses, trimming of nails, trimming of simple ingrown nails, and other preventive hygienic or maintenance procedures. Routine foot care is not covered. Foot care is eligible for coverage for patients with systemic conditions of sufficient degree to cause severe circulatory insufficiency and/or areas of desensitization in the feet or legs.

Mycotic Nails are caused by a fungus that produces a sponge-like growth on the nail. A confirmed diagnosis of fungal infection is necessary (positive culture or KOH) prior to treatment. Treatment of mycotic nails (including trimming and shaving of the nail) is limited to patients who have: • vascular impairment or hazardous medical condition causing a severe circulatory embarrassment,

and/or areas of desensitization in the feet or legs and pain/limitation of activity related to the thickened, dystrophic nails; or

• a compromised immune function (e.g., infection with human immunodeficiency virus – HIV).

The Screening Tests protocol provides a general statement on coverage for screening tests, which is generally dependent on benefits listed within a member’s contract.

CURRENT PROTOCOLS recently updated with minimal changes The following protocols required only minimal changes (e.g., updating of references, changing language to meet legal needs). The coverage intent of the protocols was not altered. These protocols were recently approved for updating by the Health Plan Medical Directors and are available on our Web site.

• Acupuncture • Early Intervention Services • Occupational Therapy • Physical Therapy • Speech Pathology/Therapy • Medical Response to Terrorist Attacks • Blepharoplasty • Cryotherapy Devices • Foot Orthotics • Treatment of Hirsutism • Prosthetic Devices • Temporal Mandibular Joint (TMJ) Dysfunction • Medical/Non-surgical Weight Loss Programs • Wheelchairs/Power Operated Vehicles

Corporate Medical Policy Changes As part of the review of Excellus BCBS corporate medical policies, you may notice changes regarding requirements for supporting documentation. These changes may include the following:

• Supporting documentation will be required for some services that currently do not require documentation.

• Supporting documentation for certain services may no longer be required when procedure and diagnosis combination meets medical policy criteria.

• Supporting documentation will no longer be required for certain services. To view our medical policies, visit our Web site at excellusbcbs.com.

OFFICE OPERATIONS

ClaimCheck Update

In the May issue of this newsletter, we notified you that our ClaimCheck editing software will be updated to accommodate the 2006 CPT/HCPCS codes and edits. We would like to take this opportunity to provide you with additional information regarding the updates. To be more consistent with national code editing standards, the newest version of our editing system will be implemented in early fall. The new edits will reflect the national coding practices that have been in effect since January 1, 2005, as well as our local medical policies. The following is a list of the specialties we anticipate will be affected by the update, although other specialties may be affected as well:

• Anesthesiology • Cardiology • Dermatology • Gastroenterology • General Surgery • Gynecology • Orthopedics • Otolaryngology • Pulmonology • Radiology • Vascular Surgery • Any provider who bills inpatient consults or confirmatory consults • Any provider who bills drug administration codes • Any provider who bills moderate conscious sedation codes • Any provider who bills domiciliary E/M codes • Any provider who bills nursing facility E/M codes

The following edits are consistent with the Centers for Medicare and Medicaid Services Coding (CMS) Guidelines and are examples of some of the changes you may see:

Current Edit New Edit Both codes allowed 73140 incidental to 73120 19140 mutually exclusive to 19318 19318 mutually exclusive to 19140 20550 allowed with 20600, 20605, or 20610 20550 incidental to 20600, 20605, or 2061020551 allowed with 20600, 20605, or 20610 20551 incidental to 20600, 20605, 20610 20600 allowed with 64470 or 64475 20600 incidental to 64470 or 64475 20605 allowed with 64470 or 64475 20605 incidental to 64470 or 64475 20610 allowed with 64470 or 64475 20610 incidental to 64470 or 64475 Both codes allowed 83721 mutually exclusive to 80061

If you have any questions regarding this notification, please contact Provider Service at 1 (800) 311-3536.

Thank You For Your Responses to the Prescribing Summaries Since mailing the updated prescribing summaries, we’ve received many requests for Generic Tool Kits and Patient Chart Reminders, as well as requests for lists of patients with generic opportunities. Thank you for taking the time to review your prescribing summaries and provide us with feedback. We recently launched a community-wide campaign that encourages patients to ask their physicians if there is a generic medication that is right for them. Our goal is to provide you with the information needed to help answer this question. The prescribing summary provides you with a quick reference that outlines key areas where generic opportunities may exist. However, we recognize that the decision to change a patient’s medication is a decision only you can make. To complement the prescribing summary, we’ve prepared physician tool kits, which include a generic options chart, posters, a brochure about generic medications, and key prescribing information. We can also provide individual patient chart reminders and a list of your patients who have a generic opportunity. You may obtain any of the information mentioned above by completing the bottom of the prescribing summary cover letter you received and faxing it to 1 (877) 812-5306. You may also contact your Pharmacy Services Consultant. Generic Trial Program: No Separate Rx, No Stickers! The Generic Trial program promotes the use of cost-effective generic alternatives by providing the first fill of select generic medications at no cost to your patients. To make participation in the program easier for both you and your patients, we have streamlined the process. You no longer need to write a separate prescription for the free trial. The first time a patient fills a prescription for one of the generic medications included in the trial program, his/her first 30-day copay will automatically be waived. The chart below lists the medications eligible for the Generic Trial program. All doses and forms are included unless otherwise noted: IF TREATING AND PRESCRIBING THESE BRANDS CONSIDER A GENERIC IN THE TRIAL PROGRAM Depression Prozac®, Zoloft®, Paxil® fluoxetine 20 MG capsules

Celexa®, Lexapro® citalopram tablets

Heartburn Prilosec®, Aciphex®, Nexium®, Prevacid®, Protonix® Prilosec OTC 20 MG

Tenormin®, Inderal LA®, Corgard® atenolol

Lopressor®, Toprol XL® metoprolol

Hydrodiuril® hydrochlorothiazide

High Blood Pressure

Prinivil® / Zestril®, Accupril®, Altace® lisinopril

High Cholesterol Mevacor®, Lipitor®, Pravachol®, Zocor®, Lescol® lovastatin

Incontinence Ditropan®, Detrol LA®, Oxytrol®, Sanctura® oxybutynin tablets

(over)

The Excellus BCBS Internal Pharmacy Benefit Administrator

• The program applies to new starts only. • Write the prescription for the generic medication. • At the pharmacy, the first 30-day supply of medication will process at no cost to the patient. • The cost of all refills and future prescriptions will be at the patient’s usual generic

copayment/coinsurance amount. • Only one free 30-day trial per generic medication is permitted. • The patient may receive one free 30-day trial of any generic medication included in the

program.

A small number of benefit plans may not allow member copayments to be waived. If you have any questions about this information, please contact the FLRx Pharmacy Help Desk at 1(800) 724-5033.

OFFICE OPERATIONS The Health Care Debit Card

During an office visit, one of our members may present you with a health care debit card. This card will have the nationally recognized Blue Cross and/or Blue Shield logos, along with the logo from a major debit card, such as MasterCard® or Visa®. The health care debit card can save time and money and may simplify your administration process by: • Reducing paperwork for billing statements • Minimizing bookkeeping and patient account functions for handling cash and checks • Avoiding unnecessary claim payment delays Members may use the card to pay for out-of-pocket costs using funds from their Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA). Some cards are “stand-alone” debit cards to cover out-of-pocket costs, while others also serve as member ID cards. The card is easy to use and can be swiped just like an ordinary debit card. Funds are deducted automatically from the member’s appropriate HRA, HSA or FSA account. If your office currently accepts credit card payments, there is no additional cost or equipment necessary. The cost to you is the same as the current cost you pay to swipe any other signature debit card.

If a member presents you with a health care debit card, be sure to verify the copayment amount and submit the claim for service prior to seeking full reimbursement from the member. Once copayment has been verified, you may use the debit card to collect the copayment amount from the member. However, do not use the card to process full payment upfront. It is best to wait to collect the coinsurance and deductible after claim processing is complete. Following claim payment, the member may be billed for the appropriate deductible or coinsurance amount. The debit card may be used to pay the balance due, or the member may issue a check from their HSA funds.

If you have questions about member benefits, please contact Provider Service for local members, or call BlueCard at 1 (800) 676-2583 for out-of-area members. For questions about debit card processing instructions or payment issues, please call the toll-free number on the back of the debit card.

CARE MANAGEMENT

Medical Orders for Life-Sustaining Treatment (MOLST) Program

Patricia A. Bomba M.D., F.A.C.P.

Vice President & Medical Director, Geriatrics Excellus BlueCross BlueShield

The Medical Orders for Life-Sustaining Treatment (MOLST) Program is designed to improve the quality of care people receive at the end of life by helping physicians, nurses, health care facilities and emergency personnel honor patient wishes for life-sustaining treatments. MOLST was created by the community-wide End of Life Palliative Care Initiative to provide a single document that would function as an actionable medical order and could transition with a patient through all health care settings. The MOLST Program assists health care professionals in discussing and developing treatment plans that reflect patient wishes. Providers should continue to document conversations with the patient or his/her surrogate in the medical record. Patients should share their preferences with family and individuals who will be involved in their care at the end-of-life. NYSDOH Approval and the MOLST Community Pilot The Department of Health has approved the revised MOLST form for use statewide by health care providers and facilities as the legal equivalent of an inpatient Do Not Resuscitate (DNR) form. As a result of the Department's approval, the MOLST form may be used in health care settings, including hospitals and nursing homes to indicate the patient's end of life treatment preferences. Governor Pataki signed legislation on October 11, 2005 to permit a community pilot of the MOLST program in Monroe and Onondaga counties and allow for the use of the MOLST form in lieu of the New York State Non-hospital Do Not Resuscitate (DNR) form (DOH 3474). The MOLST Community Pilot was launched on May 1, 2006. During the pilot, Emergency Medical Service (EMS) personnel will follow the orders on the MOLST form for individuals living in Monroe and Onondaga counties. For all other counties, the New York State Non-hospital Do Not Resuscitate (DNR) form is the required form to indicate DNR orders in non-hospital settings and should be attached to the MOLST form. A chapter amendment has been introduced to permit authorization for EMS personnel in Onondaga and Monroe counties to honor Do Not Intubate (DNI) instructions prior to full cardiopulmonary arrest during the MOLST pilot. More Information on MOLST MOLST forms can be obtained by using the order form which is included with this newsletter. The 8 Step MOLST Protocol, a useful tool for health care professionals, is available at www.compassionandsupport.org. If you have questions regarding the MOLST Program, please feel free to contact me at patricia.bomba@lifethc.com.

B-1545 12/04

FREE EDUCATIONAL RESOURCES FOR PATIENTSQuantity Quantity

____ Advance Care Planning Booklet (B-1576) ____ Medications May Help You Stop Smoking (TF-121)

____ La Planificación del Cuido Avanzado(Advance Care Planning Booklet in Spanish) ____ Thinking of Quitting Smoking, Now's the Perfect Time! (TF-120)

____ Advance Care Planning Trifold Brochure (TF-73) ____ Methods and Strategies to Help Stop Smoking (TF-122)

____ Pain Management Patient Guide ____ Heartburn Prevention and Treatment (TF-42)

____ El Manejo del Dolor: Un Manual Para el Paciente(Pain Management Patient Guide in Spanish) ____ Pregnancy and HIV/AIDS (TF-21)

____ Alcohol and Medication Don’t Mix (MA-384) ____ Ten Commandments for Healthy Living (B-1752)

____ Safe Use of Over-the-Counter Medications (TF-97) ____ Excellus BCBS Mental Health and Chemical DependencyBenefits brochure (TF-23)

____ The Importance of Your Pap Test (TF-10) ____ Excellus BCBS Mental Health and Chemical DependencyBenefits brochure in Spanish (TF-23sp)

____ The Importance of Mammography (TF-11) ____ My Health Connection –Guide to the “Online Medical ID Bracelet” (TF-45)

____ Osteoporosis: The Silent Disease (TF-72) ____ Click with Us – Guide to the Excellus BCBS Web Site (B-1450)

FREE EDUCATIONAL RESOURCES FOR PROVIDERSQuantity

_____ Equianalgesic Table Pocket Card (B-1537)

_____ Pain Assessment Progress Note Pad (B-1540)

_____ Pain Fax Referral Form Pad (B-1541)

_____ Adult Pain Principal Guide Laminated (Limit 10 per order)

_____ Pediatric Pain Principal Guide Laminated (Limit 10 per order)

_____ Nurse’s Pain Principal Guide Laminated (Limit 10 per order)

_____ “Faces” Pain Scale Stickers (1 lot = 10 stickers)

_____ Pain Toolkit Folder (consists of one of each of the above Resources for Providers)

Pain

Man

agem

ent

_____ Pain Management Booklet: Rochester (B-1519) CNY (B-1520) Utica (B-1521) Southern Tier (B-1522)

_____ The Bomba Letter (Electronic Edition of the Palliative Care and Elder Abuse Newsletter) Email Address (please print clearly) : __________________________________

_____ “It Shouldn’t Hurt to be Old.” Elder Abuse Awareness Educational CD-ROM (Limit 10 per order)

Elde

r Abu

se

_____ Elder Abuse Assessment and Management Tool Laminated (Limit 10 per order)

_____ MOLST: Medical Orders for Life-Sustaining Treatment (Four-Page Pink Form) (B-1620)

_____ ADULT Supplemental Forms for MOLST: Documenting Lack of Capacity for Adults (B-1621)

_____ MINOR Supplemental Forms for MOLST: Documenting Lack of Capacity for Minors (B-1622)

MO

LST

_____ Guidebook to MOLST (B-1623)

(If a limit is specified for an item and you need more than the pre-determined limit, please call (585) 453-6306 to make arrangements for delivery.)

Name: ______________________________________

Office of: ____________________________________

Office Address: _______________________________

______________________________________

Mail This Order Form to:Excellus BlueCross BlueShieldAttn: Document Services Fulfillment165 Court StreetRochester, NY 14647

or Fax: 585-238-4400

A nonprofit Independent Licensee of the BlueCross BlueShield Association

Date Ordered: _________________________

Requested Date of Delivery: _______________ (Please allow a minimum of 10 business days for delivery)

Utica Business Park, 12 Rhoads Drive Utica, New York 13502

PRSRT STD U.S. POSTAGE

PAID ROCHESTER, NY

Permit No. 201