partners in health update: january 2014 · re-issue of member id cards for migrated members...

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance

Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

updateSM

Re-issue of member ID cards for migrated members page 5

IBC and Health Care Reform page 7

Update on our Business Transformation page 3

January 2014

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2013. www.dreamstime.com. All rights reserved.Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.The Blue Cross and Blue Shield names and symbols, BlueCard, and Baby BluePrints are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.The third-party websites mentioned in this publication are maintained by organizations over which IBC exercises no control, and accordingly, IBC disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.NaviNet® is a registered trademark of NaviNet, Inc., an independent company.FutureScripts® and FutureScripts® Secure are independent companies that provide pharmacy benefits management services.CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (IBC), created to provide valuable information to the IBC-participating provider community. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with IBC. This publication is the primary method for communicating such general changes. Suggestions are welcome.

Contact information:Provider CommunicationsIndependence Blue Cross1901 Market Street 27th FloorPhiladelphia, PA [email protected]

Keystone 65 HMO has an accreditation status of Excellent from the National Committee for Quality Assurance (NCQA).

Keystone Health Plan East, Personal Choice®, and Personal Choice 65SM PPO have an accreditation status of Commendable from NCQA.

Inside this editionBusiness Transformation

► Update on our Business Transformation

Administrative ► Re-issue of member ID cards for migrated members ► Keystone Direct POS: Offering members more direct access to participating specialists

► IBC and Health Care Reform ► Out-of-pocket maximums for commercial HMO, POS, and PPO members beginning January 1, 2014

► Reminder: Contraceptive coverage update for religious organizations ► Important information about Medicare-eligible members

● 2013 Cumulative Index now available ● Provider Automated System not available for migrated members

Credentialing ► Certified Registered Nurse Practitioners may apply for credentialing for our PCP network

BlueCard® ► Winter 2013 edition of Inside IPP now available

Billing ► Use a valid NPI for all claims ► Updated payer ID grids now available

Medical ► Policy notifications posted as of December 30, 2013

● Download the latest precertification requirement list ► Updated policy for interstitial continuous glucose monitoring systems

ICD-10 ● New article series to help providers prepare for October 2014

ICD-10 deadline ● Putting ICD-10 into Practice: Correction to October 2013 coding

exercises

NaviNet® ► Updated NaviNet transactions for QIPS-participating providers

Products ● Cost-sharing for Keystone HMO Proactive members ● Medicare Advantage HMO and PPO benefit changes now in effect

Health and Wellness ● Discuss routine preventive immunizations with your patients at their

wellness visits ● Health Coaches: Supporting your patients, our members

Quality Management ● Cervical cancer screening guidelines

► Articles designated with a blue arrow include notice of changes or clarifications to administrative policies and procedures.

January 2014 | Partners in Health UpdateSM 3 www.ibx.com/providers

BUSINESS TRANSFORMATION

Update on our Business TransformationThroughout 2012, IBC announced its plans to transition core processing activities to a new platform managed and operated by Highmark, Inc. (Highmark), an independent company. The new platform will offer greater capabilities, increased flexibility in benefit design, and enhanced functionalities to improve the overall customer experience.

In 2013, we made significant progress on this important transition, including the following two milestones:

● Transition of X12 transactions. One of the key early steps in IBC’s Business Transformation was the transition of X12 transactions from the former X12 Gateway to the Highmark Gateway. This task was completed before November 1, 2013, and as a result, all trading partners now send and receive transactions to/from the Highmark Gateway.

● First groups migrated to new platform. Claims processing for Federal Employee Program (FEP), Host BlueCard®, and a few small employer groups was migrated to the new platform on November 1, 2013.

Many more group customers have been migrated to the new platform as of January 1, 2014. As a result, providers will notice growing numbers of migrated members by way of newly issued ID cards.

We will continue to migrate our membership to the new platform in stages, generally based on when the customer/member’s contract renews. We anticipate that claims processing for all IBC membership will be transitioned to the new platform by mid-2015.

Dual claims-processing environment During the migration, we will be working with you in a dual claims-processing and business-operating environment until all of our business is on the new platform. In other words, we will begin to process a larger portion of claims and business transactions on the new platform as members are migrated, and we will continue to process claims and conduct business transactions on the current IBC platform for members who have not yet been migrated. The date of service will determine the platform on which these claims will be processed.

continued on the next page

2013

Transitioned all trading partners from the former X12 Gateway to the Highmark Gateway

Mid-2013 – October 31, 2013

Migrated claims processing for FEP, Host BlueCard, and a few small employer groups to the new platform

November 1, 2013

Complete migration to the new platform

Through mid-2015

Migrated a larger portion of groups/members to the new platform

January 1, 2014

2014

2015


BUSINESS TRANSFORMATION

Here are some of the important changes we communicated in 2013 that will affect the way you do business with us:

● Member ID cards/numbers. As members are migrated to the new platform, they will be issued a new member ID card with a new ID number and, in some cases, a new alpha prefix. The subscriber and all members covered under the subscriber’s policy will share the same ID number. Due to these changes, it is imperative that you obtain a copy of the member’s current ID card at every visit to ensure that you submit the most up-to-date information to IBC.

● Provider payment. For claims processed on the new platform, you will receive a different format of the Statement of Remittance (SOR). On the new format for facility claims, services will be combined and displayed on one line. You will continue to receive our current format of the SOR for claims processed on the current IBC platform. In addition, 835 transactions generated on the new platform will contain additional and updated information.

● Claims processing. Additional data elements are required to ensure proper claims processing on the new platform. For example, taxonomy codes are required on all claims submissions. Information regarding the specific data elements required can be found in the IBC HIPAA Transaction Standard Companion Guide, which is available at www.highmark.com/edi-ibc.

● Provider Automated System. The Provider Automated System is being retired in stages, as previously communicated. Once a member has been migrated to the new platform, providers will no longer be able to use the Provider Automated System for that member for any functionality (e.g., eligibility, claims status, authorizations). Providers must use the NaviNet® web portal to retrieve this information.

● NaviNet. Many changes have been implemented on IBC NaviNet Plan Central, including adding, removing, and enhancing transactions. For more specific details, please refer to the NaviNet Transaction Changes section of our Business Transformation site at www.ibx.com/pnc/businesstransformation. This section of our site contains user guides and webinars for many updated transactions.

ResourcesWe are committed to working closely with you and our entire provider network as we complete our Business Transformation. During this interim state, we will continue to provide comprehensive communications and tools to support our members and provider network, both during and after the transition to the new platform.

For more information about our Business Transformation, please visit our dedicated site at www.ibx.com/pnc/businesstransformation. On this site you will find a communication archive as well as a Frequently Asked Questions (FAQ) document. If you still have questions after reviewing the FAQ, send us an email at [email protected].

continued from the previous page

We are committed to working closely with you and our entire provider network as we work to complete our Business Transformation. During this interim state, we will continue to provide comprehensive communications and tools to support our members and provider network, both during and after the transition to the new platform.

www.ibx.com/pnc/businesstransformation


ADMINISTRATIVE

Re-issue of member ID cards for migrated membersAs of November 1, 2013, IBC is in the process of transitioning to a new claims processing platform, which will offer greater capabilities, increased flexibility in benefit design, and enhanced functionalities for an improved overall customer experience.

As members are migrated to the new platform, they will be issued a new member ID card with a new ID number and, in some cases, a new alpha prefix. For this reason, it is imperative that you obtain a copy of the member’s current ID card at every visit to ensure that you submit the most up-to-date information to IBC. Please also verify eligibility and benefits using the NaviNet® web portal prior to rendering service.

ID cards for non-migrated membersNon-migrated members have a 10-digit member ID number to identify each member, and dependents have a unique suffix. We refer to this number as a “unique subscriber ID” (USI). See below for sample ID cards for non-migrated members:

New ID cards for migrated membersAs IBC members are migrated to the new platform, they will be issued a new ID card. For these migrated members, IBC will assign a new 12-digit member ID number, called a “unique member ID” (UMI). The subscriber and all members covered under the subscriber’s policy will share the same ID number.

Note: Members with our Medicare Supplement plan – MedigapSecurity – will be assigned a 13-digit ID number, with the last digit being an alpha character.

Some plans will also be assigned a new 3-character alpha prefix, which will also appear as part of the ID number.

Each member ID card will include the member’s name and subscriber UMI.

See below for sample ID cards for migrated members:

For more informationTo assist you in successfully submitting claims for IBC members during this interim state, payer ID grids are available at www.ibx.com/edi. These payer ID grids include alpha prefix information for both migrated and non-migrated members.

For more information about our Business Transformation, please visit our dedicated site at www.ibx.com/pnc/businesstransformation. On this site, you will find a communication archive and Frequently Asked Questions (FAQ) document. If you still have questions after reviewing the FAQ, email us at [email protected].


ADMINISTRATIVE

Keystone Direct POS: Offering members more direct access to participating specialistsThe Keystone Direct Point-of-Service (POS) benefits plan allows members to see most providers without a referral. Direct POS requires primary care physician (PCP) referrals only for routine radiology, physical/occupational therapy, and spinal manipulations. Obtaining a referral for these services ensures that the member receives the highest level of benefits.

For laboratory services, Direct POS members must obtain a laboratory requisition form from their PCP or specialist. These members will be directed to their designated (capitated) laboratory site for laboratory services. For all other services, members may visit any Keystone Health Plan East (Keystone HMO) network provider without a referral. Using providers in the Keystone HMO network gives Direct POS members the highest level of benefits and the lowest out-of-pocket costs.

Keystone’s capitation program remains in effect for Direct POS. As they would for our Keystone HMO and POS benefits, PCPs must refer Direct POS members to capitated providers for capitated services (i.e., radiology, physical/occupational therapy, laboratory) for members to receive the highest level of benefits.

Note: For podiatry services, a referral has not been required since January 1, 2013, when the capitation program for podiatry ended.

How the plan works ● Direct POS members select a participating PCP from the Keystone HMO network.

● No referrals are required for Direct POS members to see participating specialists.

● Referrals are required for routine radiology, physical/occupational therapy services, and spinal manipulation.

● A requisition form is required for laboratory services. ● Direct POS members are responsible for applicable cost-sharing.

● Direct POS members do not need to file claim forms when services are provided by participating specialists.

Note: For services requiring precertification through AIM Specialty Health®, an independent company, (CT/CT scans, MRI/MRA, nuclear cardiology services, and PET scans), a separate PCP referral is not required. Additionally, referrals are never required for mammography.


ADMINISTRATIVE

IBC and Health Care ReformWhat providers need to know as coverage for new plans becomes effectiveAs the Patient Protection and Affordable Care Act (also known as Health Care Reform) brings unprecedented change to our industry, IBC is leading the way in transforming health care and delivering what members need to meet these new challenges. This includes innovative strategies to:

● increase flexibility and efficiency in administering health care;

● provide tools for managing costs and improving outcomes;

● establish a coordinated health care system that rewards providers for providing safe, effective care.

IBC offers new health plans both on and off the Health Insurance Marketplace (Marketplace). These commercial plans are available to small groups and individuals for coverage as of January 1, 2014. These commercial plans are covered under your current Provider Agreement and are reimbursed in accordance with your payment rates for commercial products.

Frequently Asked QuestionsQ. WhatspecificbenefitpackagesisIBCoffering

on the Marketplace? A. Individuals and small groups can choose from 13

unique health insurance plans, including PPO and HMO plans, as well as more affordable versions of these plans, such as PPO plans with a health savings account (HSA) and HMO plans with a tiered provider network. Plans that are available on the Marketplace are also available for purchase off of the Marketplace (i.e., directly through IBC). Plans fall into one of four metallic tiers (Platinum, Gold, Silver, Bronze).

The following is a list of plans available to individuals and small groups both on and off the Marketplace. Coverage for these plans began as early as January 1, 2014.

● Keystone HMO Platinum ● Keystone HMO Gold ● Keystone HMO Gold Proactive (tiered

network plan) ● Keystone HMO Silver ● Keystone HMO Silver Proactive (tiered

network plan)

● Keystone HMO Bronze ● Personal Choice® PPO Platinum ● Personal Choice PPO Gold ● Personal Choice PPO Silver ● Personal Choice PPO Silver Reserve ● Personal Choice PPO Bronze ● Personal Choice PPO Bronze Reserve ● Personal Choice PPO Catastrophic

All IBC plans available through the Marketplace cover the ten essential health benefits that are required by Health Care Reform:

● preventive, wellness, and disease management services (e.g., annual physical, flu shot, gynecological exam, birth control);

● emergency care; ● ambulatory services (e.g., minor surgeries,

blood tests, X-rays); ● hospitalization; ● maternity and newborn services (i.e., care

through the course of a pregnancy, delivery of the baby, and check-ups after the baby is born);

● pediatric services (includes dental and vision); ● prescription drugs; ● laboratory services (blood tests); ● mental health and substance abuse services; ● rehabilitation and habilitation services

(e.g., physical therapy, speech therapy, occupational therapy).

In addition, IBC covers certain designated preventive services with no cost-sharing (i.e., copayments, coinsurance, and deductibles) when the services are received from a participating provider, such as wellness visits, immunizations, screenings for cancer, and other diseases. That means that members will not pay any cost-sharing for these services. For more information about services covered as preventive care, go to www.ibx.com/medpolicy and review the current version of Medical Policy #00.06.02: Preventive Care Services.



ADMINISTRATIVE

Q. Howcanprovidersverifyeligibilityandbenefitsfor plans purchased on the Marketplace?

A. Just as you would for existing IBC products, continue to verify member eligibility and benefits (including cost-sharing amounts) for plans purchased on the Marketplace through the NaviNet® web portal. Be sure to obtain a copy of the member’s current ID card at every visit to ensure that you submit the most up-to-date information to IBC.

Q. What will the member ID cards look like if members purchase an IBC plan via the Marketplace?

A. Member ID cards for plans purchased on the Marketplace will contain the same information as ID cards for non-Marketplace plans, which includes member name, member ID number, provider network (i.e., Keystone Health Plan East, Personal Choice), coverage effective date, basic copayment information, and indicators for benefits such as vision and pharmacy. There are no differences in ID cards for plans purchased on or off the Marketplace.

Note: For our Keystone HMO Proactive plans, the member ID card will indicate “Gold Proactive” or “Silver Proactive,” and copayment information will be listed by provider benefit tier level (i.e., Preferred, Enhanced, Standard).

Q. How does Keystone HMO Proactive differ in terms of pricing from other IBC plans being offered on the Marketplace?

A. Keystone HMO Proactive is a tiered network product being offered at both the Silver and Gold metallic tier levels. The 2014 premiums for Keystone HMO Proactive are priced approximately 15 percent lower than comparable HMO products within the Silver and Gold metallic tiers.

Resources available to you and your patients Your patients, our members, may require more information to understand Health Care Reform. To help, we have created a comprehensive website devoted exclusively to the topic of Health Care Reform — www.ibx.com/CareForMe. We encourage you to visit this site if you or your patients have questions about Health Care Reform.

On this site, existing and prospective members can access a guide called Health Care Law & You, which includes the ABCs of health insurance, major changes for 2014, and information to help them better understand their health coverage options. If you would like a supply of our Health Care Law & You guide for display or distribution at your office/facility, please submit an online request at www.ibx.com/providersupplyline or call the Provider Supply Line at 1-800-858-4728. A Spanish version of the guide is also available.

If you have specific questions about submitting claims for members with coverage under the new products listed in this article, please contact your Network Coordinator.


Health Care Law & You How to get the most out of your health care dollars

www.ibx.com/providersupplyline


ADMINISTRATIVE

Out-of-pocket maximums for commercial HMO, POS, and PPO members beginning January 1, 2014Under the Patient Protection and Affordable Care Act, also known as Health Care Reform, members should not be charged any cost-sharing (i.e., copayments, coinsurance, and deductibles) once their annual limit has been met. These limits are based on the member’s benefit plan. While individual and group benefit limits may be lower, they cannot exceed the following amounts:

● Individual: $6,350 ● Family: $12,700

Once members have reached their out-of-pocket maximum, providers should not collect additional cost-sharing.

To verify if members have reached their out-of-pocket maximum, providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal. However, due to our transition to a new operating platform, the process differs depending on whether the member has been migrated. The steps are outlined below.

For migrated membersOnce on the Eligibility and Benefits Details screen, the member’s current out-of-pocket expense (Accumulated Amount) and the maximum dollar limit (Threshold Amount) will be displayed at the bottom of the screen in the Benefit Accumulator section.



ADMINISTRATIVE

For non-migrated membersOnce on the Eligibility and Benefits Details screen, providers will first need to select the Additional Copays

link to verify the copayment maximums and secondly select the Dollar Accumulators link to view the total out-of-pocket amount accumulated to date.



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ADMINISTRATIVEcontinued from the previous page



ADMINISTRATIVEcontinued from the previous page

If your office is not yet NaviNet-enabled, you can sign up by going to www.navinet.net and selecting Sign Up at the top right.

If you have any questions about this change, please call Customer Service at 1-800-ASK-BLUE. If you have questions regarding NaviNet transactions, please call the eBusiness Hotline at 215-640-7410.

Look for additional information about this requirement in future editions of Partners in Health Update.

Note: Cost-sharing amounts are available to members through their benefit materials or by logging on to our secure member website, ibxpress.com.


ADMINISTRATIVE

Reminder: Contraceptive coverage update for religious organizationsThe Patient Protection and Affordable Care Act, also known as Health Care Reform, requires non-grandfathered health plans to cover contraceptive services for women with no out-of-pocket costs (i.e., $0 cost-sharing). There are two exceptions to this requirement:

● Religious employer exemption. Religious employers can elect not to provide contraceptive coverage, and their employees are not eligible for contraceptive coverage.

● Non-profitreligiousorganization. Non-profit religious organizations can elect not to cover contraceptives for religious reasons but are not exempt as a “religious employer.”

For these non-profit religious organizations, Health Care Reform requires IBC to pay the cost of certain contraceptive services for eligible employees and eligible dependents of non-profit religious organizations that elect not to cover contraceptives.

Eligible members within these organizations will receive a separate ID card that indicates “Contraceptive Coverage.” Using this ID card, contraceptive methods approved by the U.S. Food and Drug Administration will be covered at an in-network level with no cost-sharing under the medical benefit and covered with no cost-sharing for generic products and for those brand products for which we do not have a generic equivalent under the pharmacy benefit at retail and mail order pharmacies.*

For these members, it is important that only contraceptive services be billed using the ID number on the Contraceptive Coverage ID card.*

Contraceptive Coverage ID card sample

For a complete listing of medical contraceptive services, please refer to the current version of Medical Policy #00.06.02: Preventive Care Services at www.ibx.com/medpolicy.

Please contact your Network Coordinator if you have any questions about this coverage or billing.

*Contraceptive services are covered under the pharmacy benefit only if the member has an IBC prescription drug plan.

IBC Medical and Rx Contraceptive Coverage

IBC & KHPEWPHCS Sample ID Card

Medical with Rx

SAMPLEMEMBER

Rx BIN CONTRACEPTIVE COVERAGE600428Rx PCN 03820000

USI1234567800

Pharmacy Benefits Administrator

Visit www.ibxpress.com

Member: Use this card for eligible medical and/or prescription contraceptive services only.

Submit Paper Claims to: PPO ClaimsP.O. Box 69352 Harrisburg, PA 17106-9352

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Customer Service1-800-ASK-BLUE

Independence Blue Cross, QCC Insurance Company and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.

Pharmacy Benefits1-888-678-7012

Medical Contraceptive Coverage Only — No IBC Rx Coverage*

IBC & KHPEWPHCS Sample ID Card

Medical Only

SAMPLEMEMBER

Rx BIN CONTRACEPTIVE COVERAGE600428Rx PCN 03820000

USI1234567800

Visit www.ibxpress.com

Member: Use this card for eligible medical contraceptive services only.

Submit Paper Claims to: PPO ClaimsP.O. Box 69352 Harrisburg, PA 17106-9352

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Customer Service1-800-ASK-BLUE

Independence Blue Cross, QCC Insurance Company and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.


ADMINISTRATIVE

Important information about Medicare-eligible membersWe will be contacting Medicare-eligible members to communicate the Medicare Exclusion and how this exclusion applies to their benefit plan.

What is the Medicare Exclusion?Members who are eligible for Medicare and for whom Medicare would be the primary payer will be responsible for paying their doctor, hospital, or other medical professional the amount Medicare would have paid and any applicable copayment, coinsurance, or deductible. In turn, their group health benefit plan will only pay the remaining balance on claims submitted as if the member had enrolled in Medicare Parts A and B.

Who is eligible for Medicare? Individuals who are eligible for Medicare, include:

● Most people 65 and older. Generally people are Medicare-eligible if they or their spouse worked for at least ten years in a Medicare-covered employment and are 65 or older and a citizen or permanent resident of the United States. Note: People are eligible for Medicare when they turn 65, even if they are not eligible for Social Security retirement benefits.

● Some people younger than 65. People younger than 65 who have certain disabilities and illnesses, such as Lou Gehrig’s disease (ALS) or other disabilities for which people are eligible for Social Security Disability benefits.

● People with kidney failure. People of any age with kidney failure who require dialysis or a kidney transplant.

If your patients have questions about eligibility for Medicare Part A or Part B or want to apply for Medicare, they should call Social Security at 1-800-772-1213 or visit or call their local Social Security office. TTY users should call 1-800-325-0778. They can also get information about buying Part A as well as Part B if they do not qualify for premium-free Part A.

2013 Cumulative Index now availableThe 2013 Provider Publication Cumulative Index (Cumulative Index) is included with this edition of Partners in Health Update. This index lists all of the 2013 articles that were published in Partners in Health Update, the edition in which they can be found, and the provider audience type for which the article was intended.

A complete archive of all cumulative indexes is also available by clicking on the Cumulative Index link under Quick Links on our Provider News Center located at www.ibx.com/pnc.

Printed copies of the 2013 Cumulative Index can be ordered by submitting an online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

2013 Provider Publication Cumulative Index

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance

Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

January 2013

www.ibx.com/providers

► Articles designated with an orange arrow include notice of changes or clarifications to administrative policies and procedures.

Inside this edition ANNOUNCEMENTS

► Updated QIPS Program Manual now available ● 2012 Cumulative Index now availableBLUECARD®

► Winter 2012 edition of Inside IPP now availableICD-10

► Putting ICD-10 into Practice: Coding exercises and scenarios

MEDICAL ► Policy notifications posted as of December 21, 2012 ► New policy for athletic pubalgia effective March 5, 2013

● New report available for primary care practicesHEALTH AND WELLNESS ● Discuss routine preventive immunizations with your patients at their wellness visits ● ConnectionsSM Health Management Program: Supporting your patients, our members

Discuss routine preventive immunizations with your patients at their wellness visits page 8

July 2013



BUSINESS TRANSFORMATION ● Stay informed during our transition to a new operating platformNAVINET®

► Stay tuned: Upcoming NaviNet changesPRODUCTS ● Reminder: New IBC products available through health insurance marketplaces

BILLING ► Updated payer ID grids now available

MEDICAL ► Policy notifications posted as of June 28, 2013 ● Reminder: An incentive opportunity for professional providers

► Updated policy for intraoperative neurophysiological monitoring ► ClaimCheck® upgrade and edit clarificationHEALTH AND WELLNESS ● Health Coaches: Supporting your patients, our members

ICD-10 ► Putting ICD-10 into Practice: Coding exercises and scenarios

Inside this edition

Updated policy for intraoperative neurophysiological monitoring page 5

October 2013



CONSUMERISM ► New features available in the Find a Doctor tool on ibx.com

ADMINISTRATIVE ► Electronic submission of clinical information for procedures that require precertificationBILLING

► New member ID cards and submitting claims for members migrated to the new platform ► Upcoming changes to mom/baby claims submission process ► SOR changes for members migrated to the new platform ► Updated CMS-1500 claim form effective January 6, 2014MEDICAL

► Policy notifications posted as of September 27, 2013 ► Changes to medical policy for self-injectable drugs ► Annual Synagis® (palivizumab) distribution program ► Updates to precertification requirements effective January 1, 2014BUSINESS TRANSFORMATION ► Stay informed during our transition to a new operating platformICD-10 ● Putting ICD-10 into Practice: Coding exercises and scenarios ● What’s Up Wednesday

PRODUCTS ● Reminder: PPACA and our tiered network products ► Upcoming Medicare Advantage HMO and PPO benefits changes

NAVINET® ► Changes to NaviNet authorization and referral transactions coming this month

QUALITY MANAGEMENT ● Quality ranking for primary care physician officesHEALTH AND WELLNESS ● The importance of lead screening and lead safety ● Help your Medicare Advantage HMO and PPO patients prepare for a hospital discharge ● Health Coaches: Supporting your patients, our members

Inside this edition

Upcoming Medicare Advantage HMO and PPO benefits changes page 15

December 2013



ADMINISTRATIVE ► Contraceptive coverage update for religious organizations ● Stay connected: New features available on IBX App ► New payment option for migrated members with spending accounts ● Verify member cost-sharing at the time of service ● Provider Automated System not available for migrated membersBILLING

► Revised time line for new CMS-1500 (02/12) claim form ► Change in reimbursement display for multiple outpatient surgical procedures ► Updated Claims Preprocessing Edits Claims Resolution Document now available ► Enforcement of industry standards related to platform transition ► Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2014 ► Medically Unlikely Edits now applied to professional and facility claims

BUSINESS TRANSFORMATION ● Stay informed during our transition to a new operating platformMEDICAL

► Policy notifications posted as of November 25, 2013 ► Coverage for injectable drugs that reduce the risk of preterm birth ► Coverage for certain surgical procedures ► Changes to sleep study precertification requirements for Medicare Advantage HMO and PPO members ● Reminder: Updates to precertification requirements effective January 1, 2014PHARMACY

► New FutureScripts® Preferred Pharmacy Network ► Select Drug Program® Formulary updates ► Prescription drug updatesICD-10 ● Putting ICD-10 into Practice: Coding exercises and scenarios ● What’s Up Wednesday

NAVINET® ► New NaviNet functionality for ePayment, Cap/QIPS Rosters, and other transactions

PRODUCTS ► Keystone HMO Proactive coverage starting in 2014QUALITY MANAGEMENT ● Our Quality Management Program promotes quality of care and service ● Standards for medical record documentationHEALTH AND WELLNESS ● Help your older adult patients understand the connections among depression, sleep, and exercise

Inside this edition

Verify member cost-sharing at the time of service page 6

Submit claims for Blue Cross® Blue Shield® Medicare Advantage PPO members to IBCUnderstand the process for submitting claims to IBC for these members

Use NaviNet® to get eligibility information for out-of-area membersLearn how to easily and efficiently obtain eligibility information using the BlueExchange® Out of Area transaction in NaviNet

Updated payer ID grids now availableDownload the updated payer ID grids for the most current information

I N S I D E T H I S E D I T I O N

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Correct paid or denied claims using the Claim INFO Adjustment Submission transactionTo correct an existing claim in a paid or denied status, use the Claim INFO Adjustment Submission transaction on the NaviNet® web portal. Please do not resubmit a paper claim to correct an existing claim.

Using the Claim INFO Adjustment Submission transaction, providers can submit claim adjustments for claims in a paid or denied status for a period of up to 18 months following the initial date of service. To review the status of submitted requests, providers should use the Claim INFO Adjustment Inquiry transaction.For more informationStep-by-step instructions on how to navigate through these two transactions are available in the Administrative Tools & Resources section of IBC NaviNet Plan Central under the “User Guides” category. These guides were recently updated.If you have any questions or need assistance with a NaviNet transaction, please call NaviNet Customer Care at 1-888-482-8057 or our eBusiness Provider Hotline at 215-640-7410.Note: The Claims INFO Adjustment transactions are available only for users who have the proper INFO permissions. v

May 2013



BUSINESS TRANSFORMATION ● New Primary Health Coach model ● Enrollment changes for Baby BluePrints® to begin this month

CONSUMERISM ● New release of IBX App features helpful Doctor’s Visit Assistant

ADMINISTRATIVE ► An updated Hospital Manual coming soon ● Save the date: QIPS High-Performing Office Summit on June 19

BILLING ► Updated payer ID grids now available

BLUECARD® ► Spring 2013 edition of Inside IPP now available

MEDICAL ► Updated policy for artificial intervertebral disc insertion ► Changes to preferred products to treat osteoarthritis of the knee

● In-home assessments of high-risk members ► No member cost-sharing for breast pumps ► Policy notifications posted as of April 26, 2013NAVINET®

► NaviNet Claim INFO Adjustment requirement now in effect


HEALTH AND WELLNESS ● May is Mental Health Awareness month ● New screening resources available for primary care physicians

Updated policy for artificial intervertebral disc insertion page 10

Inside this edition


ADMINISTRATIVE

Provider Automated System not available for migrated membersThis article is a reminder about the retirement of the Provider Automated System. Please read this notice carefully if you use the Provider Automated System, as your day-to-day operations will be affected.

As previously communicated, the Provider Automated System is no longer available for submitting or retrieving referrals or submitting encounters. Primary care physicians should use the NaviNet® web portal to submit encounter data and referrals to IBC (paper referrals and encounters are not permitted by IBC).

As of November 2013 and continuing through mid-2015, IBC is migrating membership to a new operating platform. Once a member has been migrated to the new platform, you will no longer be able to use the Provider Automated System for that member. This includes all additional functionality, such as eligibility and claims status. You must use NaviNet for this information.

For more informationVisit our Business Transformation site at www.ibx.com/pnc/businesstransformation frequently for the most up-to-date information about our transition to the new platform. A Frequently Asked Questions document and communication archive are available on this site for your reference throughout the migration.

Note: All participating providers were required to register for NaviNet by April 1, 2013. If you have not yet done so, go to www.navinet.net and select Sign Up from the top right. If your office is currently NaviNet-enabled but would like training, please contact our eBusiness Provider Hotline at 215-640-7410.

Once a member has been migrated to the new platform, you will no longer be able to use the Provider Automated System for that member. You must use NaviNet for this information.

www.ibx.com/pnc/businesstransformation

CREDENTIALING

Certified Registered Nurse Practitioners may apply for credentialing for our PCP network Effective January 1, 2014, IBC began providing the option for Certified Registered Nurse Practitioners (CRNPs), practicing independently within a participating primary care physician practice, to be recognized as a participating provider. To elect this option, a CRNP must complete the credentialing and contracting process. Once completed, CRNPs may bill directly for their services as the performing provider using their newly assigned provider number.

Reimbursement for CRNP services shall be made in accordance with IBC medical and claim payment policies and, where applicable, the contracted CRNP fee schedule. In the event a CRNP fee schedule is not included in the contract, reimbursement shall be based on 85 percent of the applicable contracted professional fee schedule. Reimbursement for covered vaccines shall be based on 100 percent of the applicable contracted professional fee schedule.

If your PCP practice is interested in credentialing a CRNP as a PCP to participate in our network, please complete the Council for Affordable Quality Healthcare (CAQH) credentialing form, located at https://upd.caqh.org/oas. Once the form is completed, providers should notify our Contracting Provider Network Contract Administration Department at [email protected].

Please include the following information in your email: ● CRNP’s name ● CRNP’s mailing address ● CRNP’s office address ● CRNP’s CAQH ID number ● CRNP’s NPI (Note: A group NPI for the CRNPs in your office will need to be provided.)

● contact person’s name, telephone number, and email address.

If you have any questions regarding this process, please contact Customer Service at 1-800-ASK-BLUE.


Winter 2013 edition of Inside IPP now available The Winter 2013 edition of Inside IPP, an inter-plan programs publication, is now available and features the following articles:

● Update on our Business Transformation ● Enforcing industry standards ● Expediting medical record requests from the Host Plan

● Medically Unlikely Edits for facility claims ● Reminder: Ask all members for their current ID card ● Facilities should submit mom and baby claims separately

● Discontinue use of Bill Type 33X ● Available now: Updated payer ID grids

Go to www.ibx.com/insideipp to read this edition. You will also find a complete archive of past editions there. Printed copies of Inside IPP are available by submitting online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

Inside IPP is a newsletter intended to increase awareness of and satisfaction with the BlueCard Program. It highlights BlueCard-specific initiatives and plans for improvement.

BLUECARD®


BILLING

Use a valid NPI for all claimsWhen submitting claims for IBC members, please be sure to continue using a valid National Provider Identifier (NPI). This requirement applies to all claims — including those that are processed on our current and new operating platforms as we continue our transition of membership to the new claims processing system.

It is critical that you submit claims with a valid NPI, as the claims processing system reviews each claim for this data. Providers should work with their clearinghouse/trading partner to ensure accurate claims submission.

The most common reasons that an NPI would be considered invalid are:

● The NPI is terminated. ● The NPI is entered incorrectly. ● The number is invalid.

Using an invalid NPI could delay processing and payment.

Resources For additional information about NPI regulations, implementations, reports, and resources, go to www.ibx.com/npi. For more information about our Business Transformation, please visit our dedicated site at www.ibx.com/pnc/businesstransformation.

Using an invalid NPI could delay processing and payment.

Download updated payer ID grids at www.ibx.com/edi.

Updated payer ID grids now availableThe professional and facility payer ID grids, which are designed to assist you in claims submission, were recently updated with the following changes:

● The new 2014 products and their corresponding alpha prefixes were added.

● Alpha prefixes were added for Independence Administrators. ● New alpha prefixes for account-specific BlueCard® PPO members were added.

Please be sure to use the most current grids, which are available on our website at www.ibx.com/edi.


MEDICAL

PolicynotificationspostedasofDecember30,2013Beginning with the February 2014 edition of Partners in Health Update, the policy notifications article will include new policies, re-issued policies, policy updates, and coding updates. This additional information is intended to give providers greater detail regarding our medical policy activity.

Below is a listing of the policy notifications that we have posted to our website as of December 30, 2013.

Policy effective date Policy # Notificationtitle NotificationissuedateDecember 26, 2013 06.03.04h Apheresis Therapy September 27, 2013

December 26, 2013 11.01.02j Cochlear Implant September 27, 2013

January 1, 2014 05.00.24j Interstitial Continuous Glucose Monitoring Systems (CGMSs)October 3, 2013 (Revised Nov. 25, 2013)

January 1, 2014 05.00.37e Compression Garments December 2, 2013

January 1, 2014 05.00.39i Ankle-Foot/Knee-Ankle-Foot Orthosis October 3, 2013

January 1, 2014 07.00.03k Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen TherapyOctober 3, 2013 (Revised Nov. 22, 2013)

January 1, 2014 07.00.20e Routine Costs Associated with Qualifying Clinical Trials October 3, 2013

January 1, 2014 07.03.05p Sleep Disorder Testing October 3, 2013

January 1, 2014 07.05.02jWireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

October 3, 2013

January 1, 2014 07.10.05b Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System November 21, 2013

January 1, 2014 08.00.13o Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)October 3, 2013 (Revised Dec. 16, 2013)

January 1, 2014 08.00.78j Self-Administered Drugs October 3, 2013

January 1, 2014 08.00.92e Coagulation Factors for Hemophilia October 3, 2013

January 1, 2014 10.03.01c Physical Medicine, Rehabilitation, and Habilitation Services October 3, 2013

January 1, 2014 11.07.01l Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant) October 3, 2013

January 1, 2014 11.14.24 Manipulation under Anesthesia October 3, 2013

January 1, 2014 12.04.03a Air or Sea Ambulance Transport Services December 2, 2013

January 3, 2014 07.02.05i External Counterpulsation (ECP) December 4, 2013

January 7, 2014 07.03.08d Neuropsychological Evaluation/Testing October 9, 2013

January 8, 2014 11.17.04lSacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence

December 9, 2013

January 10, 2014 08.00.57e Complex Regional Pain Syndrome (CRPS) Parenteral TreatmentsDecember 11, 2013 (Revised Dec. 16, 2013)

February 4, 2014 11.08.02f Reduction Mammoplasty November 6, 2013



MEDICAL

Policy effective date Policy # Notificationtitle NotificationissuedateFebruary 5, 2014 05.00.42e Patient Lifts November 6, 2013

February 5, 2014 07.00.02g Intravenous Chelation Therapy November 7, 2013

February 5, 2014 11.14.10k Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty November 6, 2013

February 18, 2014 07.02.03g Implantable Cardiac Loop Monitor November 20, 2013

February 18, 2014 11.02.12ePercutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery

November 20, 2013

February 19, 2014 11.11.01f Evaluation and Treatment of Erectile Dysfunction (ED) November 21, 2013

March 4, 2014 08.01.10 Octreotide acetate (Sandostatin® LAR Depot) December 4, 2013

March 19, 2014 09.00.10p Brachytherapy December 19, 2013

March 19, 2014 11.16.01g Septoplasty, Rhinoplasty, and Septorhinoplasty December 19, 2013

To view the policy notifications, go to www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, and click on the Policy Notifications box. You can also view policy notifications using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Once these policies are in effect, they will be available by using the Search box on the Medical Policy homepage. Be sure to check back often, as the site is updated frequently.



MEDICAL

Downloadthelatestprecertificationrequirement listEffective January 1, 2014, IBC uses a single precertification requirement list across all managed care products. This change was made as we continue to look for ways to improve and simplify the precertification process.

For the most up-to-date list of services and specialty drugs that require precertification, download the latest version of the precertification requirement list at www.ibx.com/preapproval.

As a reminder, significant changes went into effect January 1, 2014, for the following three categories:

● Outpatient surgical procedures. For standard HMO products, only select outpatient surgical procedures require precertification.

● Durable medical equipment (DME) and prosthetic items. The precertification requirement list has been updated to specify only certain DME and prosthetic items that require precertification, regardless of the cost of these items.

● Injectable and infusion therapy drugs. Precertification approval has been added for Acthar H.P.®, Adcetris®, Kyprolis®, Naglazyme®, Perjeta®, Simponi® Aria, Veletri®, and Xofigo®. Precertification is no longer required for Lucentis®, Macugen®, Mozobil®, and Temodar®. In addition, precertification requirements for 23 drugs have been removed for members who have Flex products. These drugs include Aranesp®, Neulasta®, and Eligard®.

If you have any questions, please contact Cheryl McGurk, Manager of Precertification, at 215-241-4542.

Download the latest version of the precertification requirement list at www.ibx.com/preapproval.


MEDICAL

Updated policy for interstitial continuous glucose monitoring systems Effective January 1, 2014, IBC’s medical policy on interstitial continuous glucose monitoring systems (CGMS) has been updated to include billing requirements for the low-threshold suspend artificial pancreas device system (APDS) (e.g., MiniMed® 530G System), which is not covered by IBC.

About interstitial CGMSs and APDSsInterstitial CGMSs are minimally invasive devices that record interstitial glucose levels every one to five minutes. In contrast to traditional self-monitoring of blood glucose, a CGMS automatically measures interstitial glucose levels and uses this data to reveal trends in glucose measurement. CGMSs also use an alarm to alert the individual when sudden or potentially harmful changes in blood sugar levels occur.

An APDS, or an artificial pancreas, is emerging technology that combines two devices approved by the U.S. Food and Drug Administration (FDA), CGMSs and insulin pumps, and links them to an APDS Control algorithm. The ultimate goal of the APDS is to monitor glucose levels and automatically adjust insulin levels. These systems are called closed-loop systems, or autonomous systems, for glucose control. There are currently no APDSs approved for use by the FDA.

One technology associated with closed-loop artificial pancreas development is a low-glucose suspend (LGS) feature. The LGS feature is designed to suspend insulin delivery when plasma glucose levels fall below a prespecified threshold. On September 26, 2013, the FDA approved the MiniMed 530G System (Medtronic, Inc., CA), a threshold-suspend APDS.

Although the FDA has approved the MiniMed 530G System, IBC has determined that its safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature. APDSs, including LGS technology, are considered experimental/investigational by IBC and are therefore not covered.

HCPCS code A9279 (monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components, and electronics, not otherwise classified) shall be used to represent the MiniMed 530G System, which is not covered by IBC. Providers must not combine codes that separately correspond to the insulin pump and continuous glucose monitor to represent an APDS, including those with an LGS feature.

Please visit www.ibx.com/medpolicy to review Medical Policy #05.00.24j: Interstitial Continuous Glucose Monitoring Systems (CGMSs) in its entirety.

Visit www.ibx.com/medpolicy to review Medical Policy #05.00.24j: Interstitial Continuous Glucose Monitoring Systems (CGMSs).


ICD-10

New article series to help providers prepare for October 2014 ICD-10 deadlineThe deadline to convert from ICD-9 to ICD-10 is quickly approaching. As of October 1, 2014, the following changes will be in effect, as required by the Health Insurance Portability and Accountability Act (HIPAA):

● Outpatient claims with dates of service on or after October 1, 2014, must be submitted with ICD-10 codes.

● Inpatient claims with discharge dates on or after October 1, 2014, must be submitted with ICD-10 codes.

Adherence to these guidelines is required under HIPAA, and claims that are submitted with non-compliant ICD-9 codes after the effective date will be rejected.

Since 2012, we have communicated information specific to ICD-10 coding conventions, general guidelines, and chapter-specific guidelines through our two series, Know the Codes and Putting ICD-10 into Practice. These series and coding exercises are available for your reference at www.ibx.com/icd10.

Stay tunedIn 2014, we will continue to communicate ICD-10-specific information through a new series of articles that will include preparation work to be fully ready for October 1, 2014, and our testing experiences with providers. Because we cannot possibly test with all network providers, we will share with you our successes and challenges that we experience with our testing partners. Testing will occur throughout the first half of 2014 to help us all be fully ready for ICD-10.

We encourage you to keep up with the latest news and information as well as share your own experiences with us by way of our ICD-10 inbox at [email protected].

Putting ICD-10 into Practice: Correction to October 2013 coding exercises This article contains corrections for the coding exercises in the October 2013 edition of Putting ICD-10 into Practice. Please take note of the differences between what was published in October and the corrections at right.

Thank you to the provider who took the time to notify us of this discrepancy!

Condition Previously communicated Correction

Transfusion-related hemochromatosis E83.110 E83.111

Hereditary hemochromatosis E83.111 E83.110

Systemic lupus erythematosus M32.10 M32.9

Benign mucous membrane pemphigoid L10.89 L12.1

Stay tuned to future editions of Partners in Health Update for continued information about ICD-10.


NAVINET®

Updated NaviNet transactions for QIPS-participating providersAs previously communicated, IBC is in the process of transitioning our claims processing system to a new platform, and this transition affects how you are paid for the Quality Incentive Payment System (QIPS) program.

During the migration, we will be working with you in a dual claims-processing and business-operating environment until all of our business is on the new platform. Providers will likely have a mix of migrated and non-migrated members on their panel.

For all members who have not yet been migrated to the new platform, all current business practices for QIPS will remain in effect, and we will continue to issue QIPS payments by paper check.

The following QIPS payment changes apply for members who have been migrated to the new platform: ● Capitation and QIPS payments will be combined into one payment and disbursed each month via electronic funds transfer (EFT) on the current capitation schedule. Please note that if your practice is not yet enrolled for EFT, you must register through the NaviNet web portal. Refer to the EFT User Guide, available on IBC NaviNet Plan Central under Administrative Tools & Resources.

● Retroactivity of up to six months will be applied to QIPS payments in the same way it is currently applied to capitation payments.

● You will only be able to view reports to support the QIPS payments at a member level on NaviNet — paper copies are not available for members who have been migrated to the new platform.

Note: To view reports for members of our Keystone Health Plan East affiliate in Northampton, Lehigh, Berks, and Lancaster counties in Pennsylvania and New Castle County in Delaware, providers must access the appropriate NaviNet Plan Central.

Accessing your QIPS rosters on NaviNetThe following are brief instructions to help you navigate through the new QIPS Rosters transaction:

● From the Plan Transactions menu, select ePayment, and then QIPS Rosters.



NAVINET®

● Next, you will see a screen that allows you to search by month, provider, or tax ID number. With each new month, you will begin to build a history of stored reports, up to 13 months. Note: The January 2014 report will be the first one available to you.

● Select Search, and the results of your search will appear. The results that appear reflect member-level detail of your QIPS payment for migrated members only. This information will help you determine the EFT payment made in the month selected that corresponds to migrated members eligible under QIPS.

At the top of your QIPS roster is a summary of your payments by membership, product, and QIPS type. Below the summary is member-level detail, including the following:

● the ability to sort by all fields (ascending and descending);

● the ability to export the report in PDF format or text format so that the data can be manipulated as needed;

● the ability to filter your search by: - member last name - member ID number - QIPS rate

- payment type - QIPS type - provider ID

QIPS rosters will be available after the EFT payment has been deposited into your account.

Note: If you are enabled for EFT, you will no longer receive paper rosters/reports for migrated members. All EFT-enabled providers must access QIPS rosters using NaviNet.

For more informationTo help you better understand these changes, a new user guide is available that describes this transaction in greater detail. We encourage you to review the new guide in the NaviNet Transaction Changes section of our Business Transformation site at www.ibx.com/pnc/businesstransformation.

If you have any questions regarding NaviNet transaction changes, please call the eBusiness Hotline at 215-640-7410.



PRODUCTS

Cost-sharing for Keystone HMO Proactive membersAs previously communicated, IBC has begun offering new health plans both on and off the Health Insurance Marketplace. Coverage for these commercial products began January 1, 2014, including our lower-cost tiered provider network product called Keystone HMO Proactive.

Our HMO network providers have been categorized into one of three benefit tiers for Keystone HMO Proactive:● Tier 1 – Preferred: Members pay the lowest

cost-sharing for most services.● Tier 2 – Enhanced: Members pay a higher

cost-sharing for most services compared toTier 1 – Preferred.

● Tier 3 – Standard: Members pay the highestcost-sharing for most services.

Note: Certain services have the same cost-sharing for all benefit tier levels, including preventive care, emergency room, ambulance, urgent care, pharmacy, behavioral health, transplants, outpatient laboratory, imaging, and physical/occupational/speech therapy.

Cost-sharing for Keystone HMO Proactive membersCost-sharing (deductible, coinsurance, and/or copayments) for Keystone HMO Proactive members varies based on the member’s benefit plan (i.e., Silver or Gold) and the provider’s benefit tier placement.

If a Keystone HMO Proactive member presents to you for service, use the NaviNet® web portal to view a summary of the member’s benefits. Through the Eligibility and Benefits Inquiry transaction, NaviNet will display the appropriate cost-sharing amounts for all three tiers. Therefore, you will need to know your benefit tier placement to determine the appropriate amount of cost-sharing to collect from the Keystone HMO Proactive member.

To find your benefit tier placement, search for your practice/facility by selecting Reference Tools from the Plan Transactions menu, and then Provider Directory. Be sure to select Keystone HMO Proactive in the Select a Plan drop-down menu as shown below.

For more information about Keystone HMO Proactive, go to www.ibx.com/providers/interactive_tools/tiered_limited_network and select Keystone HMO Proactive.

www.ibx.com/providers/interactive_tools/tiered_limited_network


PRODUCTS

Medicare Advantage HMO and PPO benefit changes now in effectAs a reminder, effective January 1, 2014, there are several changes to our current Medicare Advantage HMO and PPO plans including the following highlights:

● Keystone 65 Select HMO with Rx is now available with a $0 premium in Philadelphia and Bucks counties.

● Keystone 65 Select HMO plan features a $0 premium for medical-only plans in Philadelphia, Bucks, Chester, Delaware, and Montgomery counties.

● Our Personal Choice 65SM PPO coverage area has expanded to Chester, Delaware, and Montgomery counties, where members can choose a medical plan with prescription drug coverage for a $98.50 monthly premium.

We are also pleased to introduce the Member Help Team, IBC’s new Medicare Customer Service program. Recognizing that Medicare-eligible members have unique needs, the Member Help Team ensures they

receive special care and attention. This dedicated service team is designed to work closely with other areas within IBC — as well as with billing agencies, pharmacies, and doctor’s offices — to respond to members’ concerns quickly and resolve their issues the first time around. Members will experience this new service when they call the Customer Service number on the back of their ID cards.

The following tables highlight some of the Medicare Advantage HMO and PPO benefits changes for 2014. Please note that this is a list of our significant benefits changes, not a comprehensive list of all benefits changes.

Please contact Customer Service if you have any questions.

Medicare Advantage HMO and PPO monthly plan premiums

Plan typeKeystone 65 Select HMO

Keystone 65 Preferred HMO

Personal Choice 65SM PPO

Medical onlyPhiladelphia/Bucks: $0

Chester/Delaware/ Montgomery: $0

Philadelphia/Bucks: $125.40

Chester/Delaware/ Montgomery: $184.80

Philadelphia/Bucks: $145

Medical with Choice Program (hearing/dental/vision)



Not available Not available

Medical with RxPhiladelphia/Bucks: $0





Chester/Delaware/ Montgomery: $98.50

Medical with Rx and Choice Program



Not available Not available



PRODUCTS

MedicareAdvantageHMOandPPObenefithighlights

Service categoryKeystone 65 Select HMO

Keystone 65 Preferred HMO

Personal Choice 65SM PPO

Primary care physician visits

$15 copay per visit for medical only

$18 copay per visit for medical with Rx

$5 copay per visit $10 copay per visit

Specialist visits $45 copay per visit $40 copay per visit $40 copay per visit

Emergency room (United States and worldwide)

$65 copay per visit (not waived if admitted)



Urgent care

$15 – $45 copay; not waived if admitted to the hospital

$18 – $45 copay for medical with Rx; not waived if admitted to the hospital

(Urgent care center: $25 copay)





Outpatient surgery

$75 copay per visit for ambulatory surgical centers;

$0 – $400 copay per visit for outpatient hospital facility





Inpatient hospital

$245 per day for days 1 – 7 ($1,715 per stay maximum);

Unlimited days each benefit period

$215 per day for days 1 – 7 ($1,505 per stay maximum);

Unlimited days each benefit period

$850 per admission; unlimited days per admission

Dental, vision, hearing Benefits available for additional $7 per month in plan premiums

Dental: $15 copay for exams and cleanings once every 6 months

Vision: $40 copay; up to $100 for eyewear every 2 years

Hearing: $40 copay; up to $500 for hearing aids (2 aids) every 3 years

Not covered



HEALTH AND WELLNESS

Discuss routine preventive immunizations with your patients at their wellness visitsRoutine immunizations are considered preventive and therefore are covered with no cost-sharing (i.e., copayments, coinsurance, and deductibles) when received from a participating provider for commercial IBC members under the medical benefit. We encourage you to discuss the following immunizations — as recommended by the Advisory Committee on Immunization Practices (ACIP) — with your patients during their wellness visits.

The coverage information included in the table below applies to commercial IBC members. Vaccination coverage for Medicare Advantage HMO and PPO

members will vary by plan. Medicare Advantage HMO and PPO members should review their Evidence of Coverage for information on preventive care and immunization coverage.

Note: IBC continually reviews coverage for immunizations benefits. Coverage may change according to ACIP recommendations.

This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Customer Service for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number listed on their ID card.

Immunization Coverage

Hepatitis B virus (HBV)

• Routine vaccination for infants birth through 18 months;

• Catch-up vaccination for children through age 18;

• Routine vaccination for adults ages 19 through 59 with diabetes mellitus who have not been vaccinated previously;

• Nonimmune individuals requesting protection from HBV infection.

Diphtheria, tetanus, and pertussis (DTaP)/Tetanus, diphtheria, and pertussis (Tdap)

• Routine DTaP vaccination regimen for children ages 2 months through 6 years;

• Catch-up vaccination up to age 7;

• One dose Tdap for under-vaccinated children ages 7 through 10;

• One dose of Tdap for adolescents ages 11 through 18 who have completed the childhood DTaP vaccination series;

• One-time dose for adults ages 19 through 64 who have not received Tdap previously or who lack evidence of immunity;

• Booster vaccination covered for adults and adolescents (any age) who have, or anticipate having, close contact with an infant younger than 12 months who previously have not received Tdap;

• Booster vaccination for pregnant women during each pregnancy regardless of number of years since prior Td or Tdap vaccination (preferred administration is between 27 – 36 weeks gestation); if not vaccinated during pregnancy, Tdap should be administered immediately postpartum;

• One-time dose of Tdap for adults ages 65 and older without a risk indicator.

Tetanus, Diphtheria (Td) • Booster vaccination once every ten years for adults ages 19 and older.



HEALTH AND WELLNESS


Pneumococcal (PCV13; PPSV23)*

• Routine PCV13 vaccination for infants ages 2 through 15 months (first dose can be administered as early as 6 weeks);

• Catch-up PCV13 vaccination to age 5;

• PCV13 vaccination for children ages 2 through 6 with certain medical conditions (see ACIP immunization schedule);

• One dose of PCV13 for unvaccinated individuals ages 19 and older who have specific health conditions that affect the immune system; individuals should receive one dose of PCV13 followed by one dose of PPSV23 at least 8 weeks later;

• One dose of PPSV23 vaccination for nonimmune adults ages 65 and older. A second dose of PPSV23 for adults ages 65 and older if it has been five or more years since their first dose, or if received before turning 65;

• PPSV23 vaccination (first and second dose) for individuals ages 19 through 64 who have underlying medical conditions (e.g., chronic lung disease, chronic cardiovascular diseases, diabetes mellitus, cirrhosis, alcoholism, functional or anatomic asplenia, cochlear implants, cerebrospinal fluid leaks, chronic renal failure, nephrotic syndrome, HIV/AIDS, lymphoma, leukemia, Hodgkin’s disease, organ or bone marrow transplant, taking immunosuppressive drugs);

• PPSV23 vaccination for adults ages 19 through 64 who smoke;

• PPSV23 vaccination for American Indians, Alaska Natives, and individuals ages 50 through 64 who live in areas where the risk for invasive pneumococcal disease is increased;

• PPSV23 vaccination for American Indians, Alaska Natives, and individuals younger than 65 who have underlying medical conditions.

Influenza

• Annual influenza vaccination for individuals ages 6 months and older (two-dose regimen for first-time influenza vaccination recipients ages 6 months through 8 years);

• Annual influenza vaccination with inactivated influenza vaccine (IIV) for adults ages 50 and older;

• Annual influenza vaccination with live attenuated influenza vaccine (LAIV) or inactivated influenza vaccine (IIV) for healthy, non-pregnant individuals ages 2 through 49.

Varicella

• Routine vaccination or combination vaccination (measles, mumps, rubella, and varicella or MMRV) for children ages 12 months through 6 years;

• Catch-up vaccination for children and adolescents up to age 12;

• A two-dose regimen of single-antigen varicella vaccination for unvaccinated adults who lack evidence of varicella immunity;

• A second dose of single-antigen varicella vaccination for nonimmune adults with incomplete varicella vaccination.

Zoster • Nonimmune individuals ages 60 and older who have not received the varicella vaccine.




HEALTH AND WELLNESS


Human papillomavirus (HPV4, HPV2)*

• Three-dose regimen of quadrivalent human papillomavirus (HPV4 [types 6, 11, 16, and 18]) vaccination for individuals ages 9 through 26;

• Three-dose regimen of bivalent human papillomavirus (HPV2 [types 16 and 18]) vaccination for females ages 11 through 26; first dose can be given at age 9;

• Catch-up vaccination for females ages 13 through 26 who have not been vaccinated previously or who have not completed the three-dose series. If a female reaches age 26 before the vaccination series is complete, remaining doses can be administered after age 26.

• Routine three-dose regimen of either HPV2 or HPV4 for females ages 11 or 12;

• Routine three-dose regimen of HPV4 for males ages 11 or 12; first dose can be given at age 9;

• Catch-up vaccination for males ages 13 through 21 who have not been vaccinated previously or who have not completed the three-dose series;

• Males in a defined risk group for human papillomavirus (i.e., immunocompromised, HIV infection, MSM); the remaining doses can be administered from ages 22 through 26.

Haemophilus influenza type B (Hib)*

• Routine vaccination for infants ages 2 through 6 months, with booster vaccination ages 12 through 15 months;

• Catch up vaccination for children up to age 5;

• Individuals with specific health conditions that may affect the immune system.

Polio*

• Routine vaccination for infants and children ages 2 months through 6 years;

• Catch-up vaccination for children and adolescents up to 18 years;

• Three-dose primary vaccination series for unvaccinated adults who are at increased risk;

• Catch-up for under-vaccinated adults who are at risk.

Measles, mumps, rubella (MMR)*

• Routine vaccination of MMR or MMRV (measles, mumps, rubella, and varicella) for children ages 12 months through 6 years;


• Vaccination for certain high-risk groups (see ACIP recommendations);

• A two-dose regimen of MMR vaccination for nonimmune adults at risk for measles and mumps infection;

• One dose of MMR vaccination for individuals who lack evidence of rubella immunity.

Hepatitis A virus (HAV)*

• Routine two-dose regimen for childhood vaccination; first dose between ages 12 through 23 months, and second dose 6 to 18 months after the first;


• Nonimmune individuals at risk for HAV infection.




HEALTH AND WELLNESS


Meningococcal (MCV4, MCV4-CRM, MPSV4)*

• Routine one-dose regimen of meningococcal vaccination for adolescents ages 11 or 12, with a one-time booster at age 16;

• One-dose regimen for first-year college students up through age 21 who are living in residence halls if they have not received the booster vaccination at ages 16 or older;

• One-dose regimen for nonimmune individuals ages 2 through 55 with an increased risk for meningococcal disease, then every 5 years if individual remains at increased risk;

• Two-dose regimen (3 months apart) of MCV4 for infants and toddlers ages 9 through 23 months at increased risk for invasive meningococcal disease; initial booster 3 years after completion of regimen; then booster vaccinations every 5 years;

• Two-dose regimen (3 months apart) of MCV4 2 for individuals ages 2 through 55 at increased risk for invasive meningococcal disease; ages 2 through 6 initial (first) booster 3 years after completion of regimen, ages 7 and older initial (first) booster 5 years after completion of regimen; then booster vaccinations every 5 years regardless of age if remains at risk.

Rotavirus (RV5, RV1)

• Three-dose regimen (RV5) for ages 2 through 6 months;

• Two-dose regimen (RV1) for ages 2 through 4 months;

• A total of three doses if prior vaccination included use of different or unknown rotavirus vaccine.

*Denotes coverage for at-risk population

Health Coaches: Supporting your patients, our membersHealth Coaches are available through the following programs to enhance your ability to provide coordinated care for your patients and promote integration of care among members and their families, physicians, and community resources:

● Condition management. Condition management is available 24/7/365 to eligible members for common chronic conditions such as asthma, diabetes, COPD, and hypertension.

● Case management. Through a Health Coach, case management provides support to members who are experiencing complex health issues or challenges in meeting their health care goals.

For additional information about our condition management and case management, visit our website at www.ibx.com/providers/resources. Members can reach their Health Coach by calling 1-800-ASK-BLUE.

Refer a patient to an IBC Health Coach today by completing the online physician referral form at www.ibx.com/providerforms or by calling 1-800-ASK-BLUE.



QUALITY MANAGEMENT

Cervical cancer screening guidelinesIBC is working to reduce the incidence and mortality rates of cervical cancer by promoting regular cervical cancer screenings. Through our Cervical Cancer Screening Program, reminders are sent to our female members to encourage them to schedule their regular Pap tests and Humanpapillomavirus (HPV) tests, as appropriate. We encourage you to discuss screening recommendations, lifestyle risk factors, prevention, early detection, and treatment options with your patients.

According to the American Cancer Society, incidence of cervical cancer and associated mortality rates have decreased significantly in the past decades, with most of the reduction attributed to widespread use of Pap tests.1 The reduction in mortality through screening is due to:

● an increase in the detection of invasive cancer at early stages, when the five-year survival rate is approximately 92 percent;2

● the detection and treatment of pre-invasive lesions, which reduces the overall incidence of invasive cancer.

Since the introduction of cervical cytology in the United States in the middle of the 20th century, cervical cancer, once the most frequent causes of cancer death in women, now ranks 14th for cancer deaths.3

The new screening guidelines from the American Cancer Society, American College of Obstetrics and Gynecology, and other nationally recognized medical organizations address appropriate ages for screening, medical conditions that affect screening, such as hysterectomy, appropriate screening intervals, and additional screening technologies, such as HPV with DNA co-testing.

The following are the screening recommendations: ● Ages 21–29: Cytology alone is recommended every three years. HPV testing is not recommended for screening in this age group.

● Ages 30–65: HPV with cytology every five years is the preferred method for screening; cytology alone every three years is an acceptable alternative. Recommendations state that women should have three consecutive negative Pap tests before expanding to screening every five years.

● Ages 65 and older: No further screening with adequate screening history is recommended.

● HPV-vaccinated women: Follow the same age-specific recommendations as for unvaccinated women.4

Additional screening recommendations are listed for women who have had a diagnosis of cervical intraepithelial neoplasia (CIN2 or CIN3) with or without hysterectomy, or who have a higher risk for cervical cancer (immunocompromised, family history, HPV or chlamydia infections, exposure to DES [Diethylstilbestrol]).

For more information on screening and risk factors, visit the American Cancer Society’s website at www.cancer.org.

References1Statistics, 2004. CA: A Cancer Journal for Clinicians. VOL.54/NO.1 January/February 2004.

2-3American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. 2012. CA: A Cancer Journal for Clinicians. DOI: 10.3322/caac.21139. http://onlinelibrary.wiley.com/doi/10.3322/caac.21139/full.

4Centers for Disease Control and Prevention (CDC) Cervical Cancer Guidelines for the Average-Risk Woman: www.cdc.gov/cancer/cervical/pdf/guidelines.pdf.

Through the IBC Cervical Cancer Screening Program, reminders are sent to female members to encourage them to schedule their regular Pap tests and HPV tests, as appropriate.

I m p o r t a n t R e s o u r c e s

V i s i t o u r w e b s i t e : w w w . i b x . c o m / p n c

Anti-Fraud and Corporate Compliance

Hotline 1-866-282-2707www.ibx.com/antifraud

Care Management and CoordinationBaby BluePrints® 215-241-2198 / 1-800-598-BABY (2229)*

Case Management 1-800-ASK-BLUE

Condition Management Program 1-800-ASK-BLUE

Credentialing

Credentialing Violation Hotline 215-988-1413www.ibx.com/credentials

Customer Service/Provider ServicesProvider Automated System† (eligibility/claims status/precertification) 1-800-ASK-BLUE

Provider Services user guide www.ibx.com/providerautomatedsystem

eBusinessHelp Desk 215-241-2305

FutureScripts®(commercialpharmacybenefits)Prescription drug prior authorization 1-888-678-7012

Fax 1-888-671-5285

Direct Ship Specialty Pharmacy Program 1-888-678-7012

Mail order program toll-free fax 1-877-228-6162

Blood Glucose Meter Hotline 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.ibx.com/rx

FutureScripts®Secure(MedicarePartDpharmacybenefits)FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.ibxmedicare.com

Mail order program toll-free fax 1-877-344-1318

Other frequently used phone numbers and websitesIBC Direct Ship Injectables Program (medical benefits) www.ibx.com/directship

Medical Policy www.ibx.com/medpolicy

NaviNet® portal registration www.navinet.net

Provider Supply Line 1-800-858-4728www.ibx.com/providersupplyline

*Outside 215 area code

†The Provider Automated System will be phased out as members are migrated to the new operating platform. For more information go to www.ibx.com/pnc/businesstransformation.

www.ibx.com/pnc

2013 Provider Publication Cumulative Index

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

January 2013www.ibx.com/providers


Inside this edition ANNOUNCEMENTS

► Updated QIPS Program Manual now available

● 2012 Cumulative Index now available

BLUECARD®

► Winter 2012 edition of Inside IPP now available


MEDICAL ► Policy notifications posted as of December 21, 2012

► New policy for athletic pubalgia effective March 5, 2013

● New report available for primary care practices

HEALTH AND WELLNESS ● Discuss routine preventive immunizations with

your patients at their wellness visits

● ConnectionsSM Health Management Program: Supporting your patients, our members

Discuss routine preventive immunizations with your patients at their wellness visits page 8

July 2013www.ibx.com/providers


BUSINESS TRANSFORMATION ● Stay informed during

partners in health update: january 2014 · re-issue of member id cards for migrated members...

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