1

What does this mean for your practice?

We encourage office managers to review the list of users and verify who should have access to remittance data. Office managers have the ability to add or delete the remittance role for your users under User Management:

1. Search for and select the appropriate user 2. Click on ‘Modify User’ 3. Select or deselect the ‘Remittance’ permission 4. Click ‘Submit’

J U N E / J U LY 2 0 1 3 V O L . 1 5 , I S S U E 4

Track Your Remittance Data OnlineIf your practice currently receives an 835 remittance advice, you can now conveniently keep track of all of your payment receipts online through the Provider Portal (CareFirst Direct). This capability is available to users who currently view claims status through CareFirst Direct and does not replace the remittance advice you currently receive from your clearinghouse.

To learn more, read the newsflash or register for one of our CFD – 835 Remittance Advice webinars at www.carefirst.com/cpet.

IN THIS ISSUE

WHAT ’S HAPPENING

We Asked. You Answered. We Listened. . .2

PPACA — Preventive Services Update . . . .3

What Don’t You Want? . . . . . . . . . . . . . . . .3

LabCorp and Quest Diagnostics are Cost-Effective Choices . . . . . . . . . . . . .3

In Case You Missed It . . . . . . . . . . . . . . . .3

Need a quick way to register for Provider News & Updates by email? . . . . . . . . . . . .3

CareFirst Goes Mobile . . . . . . . . . . . . . . . .4

CLAIMS AND BILLING

It’s Your Money – Claim It Now . . . . . . . . .4

CareFirst Selects LifeScan’s One Touch as Only Preferred Diabetic Test Strip . . . . . . .5

HEALTH CARE POLICY

New Technology Evaluated . . . . . . . . . . . .5

Medical Policy Updates . . . . . . . . . . . . . . .6

CPET CORNER

CPET Corner . . . . . . . . . . . . . . . . . . . . . . .9

PROVIDER SEMINARS

Practitioner and Staff Seminars and Training Sessions . . . . . . . . . . . . . . . . . .10

QUALITY IMPROVEMENT

Practitioner Satisfaction Survey 2012 . . .11

Let’s Hear From You. . . . . . . . . . . . . . . . .11

Practitioner’s Role in Resolving Member Complaints . . . . . . . . . . . . . . . .12

Availability of Members’ Rights and Responsibilities Statement . . . . . . . . . . .12

PHARMACY UPDATES

Prior Authorization . . . . . . . . . . . . . . . . .13

New Generics . . . . . . . . . . . . . . . . . . . . .13

QUICK LINKS TO:

> > Provider Representatives and Contacts

> > Phone Numbers and Claim Addresses

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CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

BLUELINK > > MAY 2013

W H A T ’ S H A P P E N I N G

We Asked. You Answered. We Listened.

A special congratulations to Carolyn D., who was last quarter’s winner. Thank you for your participation.

“I think they [CareFirst provider emails] are very informative and better because you don’t have to decipher through a lot of useless information to get to the point (just what I like), with website links you can go to, if you need more information. Very COOL!!!”

“I like the new accessibility of the CareFirst website. The [Institutional] manual is more detailed and informational.” – Sharon C.

“I really love the emails that CareFirst sends out. It is so helpful to be able to keep the ones that you want to refer back to in your mail box.” – Joan H.

“I have not personally used the Rx PreAuth tool, but think it is a great idea. I learned of it through a CareFirst email blast.” – Denise L.

If you liked the Institutional Manual, check out the redesigned Professional Manual – now available. You can access the provider manuals and reference guides anytime by visiting www.carefirst.com/providermanualsandguides.

All of the emails you receive from us can also be found in the Provider News Archives, at the bottom of the News section on www.carefirst.com/providers. Check back often to make sure you’re up-to-date on CareFirst provider news.

Save yourself time, submit your pre-auths online. Learn more in this online module at www.carefirst.com/cpet.

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Here are some of the responses we received:

Keep your comments coming – the next winner could be you.

While we can’t incorporate every piece of feedback you send us, we appreciate you taking the time to share what you think. Send your email to newsletter.editor@carefirst.com and be entered to win a free gift.

We continuously ask you to send feedback on our email, newsletter and web communications.

Why?Your comments help us make improvements to our communications so we can make it easier for you to focus on what’s most important – caring for our members.

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3WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

LabCorp and Quest Diagnostics are Cost-Effective ChoicesWe realize the importance of making proper care decisions and recommendations for your patients, our members. Our goal is to provide you with information and resources to help supplement your clinical decision-making and achieve the goals of improving quality and reducing the costs of health care.

LabCorp* and Quest Diagnostics*, the national laboratories for CareFirst, are cost-effective choices when referring patients. Members can easily request an appointment online with LabCorp at www.labcorp.com or with Quest Diagnostics at www.questdiagnostics.com.

Note: LabCorp is the only network national lab that BlueChoice (HMO) members can use. Do not refer HMO members to Quest Diagnostics.

For more information, visit www.carefirst.com/providers/qualityandaffordability.

In Case You Missed It:Coming Soon: Facets Paper Vouchers

In the coming months, paper vouchers for professional and institutional claims processed on the Facets system will be replaced with a new, more user-friendly format. Vouchers for claims processed on FEP, NASCO, CARE and Flexx will not change. Read Facets Vouchers Made Easy to learn more and enroll for training.

Stay in the LoopDon’t miss out on important updates that affect your practice. Visit www.carefirst.com/stayconnected and sign up to receive provider news right in your inbox.

Some recent email highlights include:

n Simplified Incentive Program for All HealthyBlue Products

n Important FirstLine Updates and CPT® Code Changes

n Online Rx Pre-Auths and PPACA Update

Catch up on our provider news updates now. Click the “In Case You Missed It” icon.

W H A T ’ S H A P P E N I N G

PPACA — Preventive Services UpdateAs part of our continuous effort to keep you informed of all details surrounding Health Care Reform (PPACA, Patient Protection and Affordable Health Care Act), outlined below are the most recent updates to the complete list of preventive services.

Effective May 1, 2013, the following preventive services have been added to the comprehensive list that must be covered at no cost to members:

n Fall prevention services

n Intimate partner violence screening and intervention

Want to learn more about Health Care Reform? Register for the Health Care Reform Act PPACA webinars offered at www.carefirst.com/cpet.

What Don’t You Want?Are you tired of sorting through email after email? Are you getting updates that aren’t relevant to your practice?

Take two minutes to adjust your Email Preferences and get only the news you need. Visit www.carefirst.com/stayconnected.

Customize your news by:

n Networks – CareFirst of Maryland, Inc., CareFirst BlueChoice, Inc., PCMH and more

n Provider Type – Institutional, Professional, or Dental

n Provider Role – Office Staff, Physician/ Dentist, Nurse Practitioner and more

n Practice Field – DME Supplier, Family Practice, PT/OT/ST and more

Stay Curious. Stay Engaged. Stay Connected.

In Case You Missed It

Need a quick way to register for Provider News & Updates by email?

Text CFPROVIDER to 67463

Standard messaging rates apply. You will receive only a registration and a confirmation text message from CareFirst. No additional text messages will be sent to your phone.

Stay Curious. Stay Engaged. Stay Connected.

*LabCorp and Quest Diagnostics are independent companies that provide lab services to CareFirst BlueCross BlueShield members.

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4WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

W H A T ’ S H A P P E N I N G

C L A I M S A N D B I L L I N G

CareFirst Goes Mobile

Help Your Patients Stay Healthy On-the-Go

CareFirst has released a mobile website and a free app called CareFirst Mobile that enables our members to use their My Account login for quick, secure access to their ID cards, benefits statements, claims status and answers to basic eligibility questions.

Members can also find a nearby doctor or urgent care center from their mobile device. The CareFirst Mobile app is available to both Apple and Android users.

We also offer two other free apps to help your patients stay healthy, including:

n Ready, Step, Go! – a pedometer app, available for Apple and Android users

n Symptom Checker – offers a guide to checking symptoms and choosing the appropriate level of care, available for Apple users

Visit www.carefirst.com/mobileaccess to learn more.

It’s Your Money – Claim It NowTips for Easier Filing

To help you better understand the claims filing process and get your money faster, here are several tips to consider before filing:

n Claims must be submitted within 365 days from the date of service. Claims submitted beyond the filing limits are rejected. If your claim is rejected, but you have proof that the claim was submitted to CareFirst within the guidelines, you may request processing reconsideration.

n Reconsideration requests must be received within six months of receipt of the original rejection notification

on the provider voucher or notice of payment. Requests received after six months will not be accepted and the charges may not be billed to the member. Documentation is necessary to prove the claim was submitted within the filing guidelines.

n When filing electronic claims, a confirmation from the clearinghouse that CareFirst accepted the claim is needed. Error records are not acceptable documentation.

n When filing paper claims, submit a screen print from the provider’s

software indicating the original bill creation date along with a duplicate of the clean claim or a duplicate of the originally submitted clean claim with the signature date in field 12, indicating the original bill creation date.

n Report services for only one practitioner per claim. If more than one provider in your practice renders services for a given member, separate claims must be submitted for each practitioner.

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5WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

H E A LT H C A R E P O L I C Y

C L A I M S A N D B I L L I N G

New Technology EvaluatedOur Technology Assessment Unit evaluates new and existing technologies to apply to our local indemnity and managed care benefit plans. The unit relies on current scientific evidence published in peer-reviewed medical

literature, local expert consultants and physicians to determine whether those technologies meet CareFirst and BlueChoice criteria for coverage. Policies for non-local accounts like NASCO and FEP may differ from our

local determinations. Please verify member eligibility and benefits prior to rendering services via FirstLine or CareFirst Direct. The Technology Assessment Unit recently made the following determinations:

CareFirst Selects LifeScan’s One Touch as Only Preferred Diabetic Test StripEffective July 1, 2013, the CareFirst BlueCross BlueShield Pharmacy & Therapeutics Committee has selected LifeScan’s OneTouch test strips as the sole preferred diabetic test strip on our Preferred Drug List. All other brands of test strips will be moved to tier three or non-preferred and will require prior authorization.

Members with a three-tier pharmacy benefit may realize a cost savings when prescribed LifeScan’s OneTouch test strips rather than other brands of test strips. Members who continue to use other brands will pay the highest tier copayment and be subject to prior authorization.

TECHNOLOGY DESCRIPTION CAREFIRST AND CAREFIRST BLUE CHOICE DETERMINATION

Ocular photoscreening A method of screening very young (pre-verbal) children for risk factors for amblyopia in the general pediatric setting

Considered medically necessary for children aged 6 months to 5 yearsCPT® reporting code 99174

Electric tumor treatment fields for recurrent glioblastoma multiforme

Applies low-level electrical current to the area of the scalp over the tumor to destroy tumor cells

Considered experimental / investigationalCPT® reporting code 64999

Fecal microbiota transplantation for chronic C. difficile infection

Fecal material from a donor is transplanted via endoduodenal tube or enema into the patient’s intestine to restore normal flora

Considered medically necessary only for chronic C. difficileCPT® reporting code 44705

CATEGORY III CPT® CODES EFFECTIVE JULY 1, 2013

0329T Experimental / Investigational

0330T Experimental / Investigational

0331T Experimental / Investigational

0332T Experimental / Investigational

0333T Experimental / Investigational

0334T Experimental / Investigational

0004M Not Medically Necessary

0005M Not Medically Necessary

To order a OneTouch blood glucose meter at no charge, please call LifeScan toll free at 1-888-474-3772 or order online at www.onetouch.orderpoints.com. Order Code: 145CAF002

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6WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

H E A LT H C A R E P O L I C Y

Medical Policy UpdatesOur Health Care Policy department continuously reviews medical policies and operating procedures as new, evidence-based information becomes available regarding advances on new or emerging technologies, as well as current technologies, procedures and services. The table below is a guide designed to provide updates on changes to existing or new local policies and procedures during our review process. Each local policy or procedure listed includes a brief description of its status, select reporting instructions and effective dates. Policies from non-local accounts, such as NASCO and FEP, may differ from our local determinations. Please verify member eligibility and benefits prior to rendering service through FirstLine or CareFirst Direct.

Note: The effective dates for the policies listed below represent claims processed on and after that date.

MEDICAL POLICYAND/OR PROCEDURE ACTIONS, COMMENTS AND REPORTING GUIDELINES POLICY STATUS AND

EFFECTIVE DATE

1.01.010Transcutaneous Electrical Nerve Stimulators (TENS)

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Under Benefit Applications, provided benefit clarification. Refer to policy for details. Report service with Category I CPT® code 64550 or appropriate HCPCS code.

Periodic review and updateEffective 5/20/13

1.01.061Transcutaneous Electroneural Stimulation for Relief of Nausea and Vomiting

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with HCPCS code E0765.

Periodic review and updateEffective 5/20/13

1.01.070ABreast Pumps and Related Supplies

Under Benefit Applications, updated third bullet to read “Benefits for a breast pump are limited to one (1) pump per delivery and only after delivery of the child.” Report equipment and supplies with the appropriate HCPCS code.

Operating Procedure revisionEffective 3/28/13

2.01.008Rhinomanometry and Acoustic Rhinometry

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with Category I CPT® code 92512.

Periodic review and updateEffective 5/20/13

2.01.061Ocular Photoscreening by Primary Physicians to Detect Amblyogenic Disorders

Policy statements revised. “Ocular photoscreening in the primary care physician’s office is considered medically necessary (see Policy Guidelines)” and “Ocular photoscreening performed by vision specialists (ophthalmologist or optometrist) is considered included in the benefit for the clinical evaluation for the suspected condition leading to amblyopia.” Under Policy Guidelines, added statement “Ocular photoscreening in the primary care physician’s office has been recommended for children from 6 months to five years as screening for risk factors for amblyopia.” Added 2013 rationale statement. Report service with Category I CPT® code 99174. Refer to policy for details.

Periodic review and updateEffective 5/20/13

2.01.064Corneal Cross Linking for Treatment of Keratoconus and Corneal Ectasia

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with the Category I CPT® unlisted code 66999.

Periodic review and updateEffective 5/20/13

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7WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

H E A LT H C A R E P O L I C Y

MEDICAL POLICYAND/OR PROCEDURE ACTIONS, COMMENTS AND REPORTING GUIDELINES POLICY STATUS AND

EFFECTIVE DATE

2.03.007Photodynamic Therapy

Under Policy statement, chronic central serous chorioretinopathy and choroidal hemangioma were added to the medically necessary indications for subfoveal choroidal neovascularization. Under Policy Guidelines, added 2013 rationale statement. Report services with the appropriate Category I CPT® and/or HCPCS code.

Periodic review and updateEffective 4/22/13

2.03.012Adjunctive Diagnostic Aids for Oral Cancer Screening

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with the Category I CPT® code 41899.

Periodic review and updateEffective 5/20/13

4.02.006AAssisted Reproductive Technology (ART): Artificial Insemination (AI) / Intrauterine Insemination (IUI)

Check the member’s contract for specific benefits regarding AI/ IUI. Under Provider Guidelines, updated prior authorization information. Refer to the operating procedure for details.

Periodic review and updateEffective 4/22/13

6.01.039Magnetic Resonance Neurography

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with the Category I CPT® unlisted code 76498.

Periodic review and updateEffective 4/22/13

7.01.011Bone Lengthening for Angular Deformities and Limb Length Discrepancies of Long Bones

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with the appropriate Category I CPT® code.

No further review scheduledEffective 4/22/13

7.01.013Keratoprosthesis

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with the Category I CPT® code 65770 or HCPCS L8609.

Periodic review and updateEffective 5/20/13

7.01.033Total Hip Resurfacing

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with the HCPCS code S2118.

Periodic review and updateEffective 5/20/13

7.01.044Sinus Antrostomy Using Dilation Balloon

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with the Category I CPT® codes 31256, 31276, 31287, 31295, 31296 or 31297.

Periodic review and updateEffective 4/22/13

7.01.071Prophylactic Mastectomy

Description updated. Policy statements revised to indicate prophylactic mastectomy is considered medically necessary in patients at high risk of breast cancer and in patients with such extensive mammographic abnormalities that adequate biopsy or excision is impossible. Prophylactic mastectomy remains medically necessary in patients with lobular carcinoma in situ. It is considered experimental / investigational for all other indications. Policy Guidelines updated, clarified high risk breast cancer definitions and added 2013 rationale statement. Report services with the Category I CPT® codes 19303 or 19304. Refer to policy for details.

Periodic review and updateEffective 8/19/13

Medical Policy Updates (CONTINUED)

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8WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

H E A LT H C A R E P O L I C Y

MEDICAL POLICYAND/OR PROCEDURE ACTIONS, COMMENTS AND REPORTING GUIDELINES POLICY STATUS AND

EFFECTIVE DATE

7.01.093Total Ankle Arthroplasty / Replacement

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with the Category I CPT® code 27702 or 27703.

Periodic review and updateEffective 4/22/13

7.01.098Cryosurgical Ablation of Renal Cell Carcinoma

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with the Category I CPT® code 50250, 50542 or 50593.

Periodic review and updateEffective 4/22/13

7.01.099Cryotherapy Dilation for Peripheral Arterial Disease

Policy statement is unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with the Category I CPT® unlisted code 37799.

Periodic review and updateEffective 5/20/13

7.01.120Peripheral Field Neurostimulation for Chronic Pain

Peripheral field neurostimulation for chronic pain is considered experimental/investigational. Report service with the Category III CPT® code 0282T or 0283T. Refer to policy for details.

New policyEffective 4/22/13

7.03.007Islet Cell Transplantation

Policy statements are unchanged. Under Provider Guidelines, report allogeneic islet cell transplantation with HCPCS code S2102. Report autologous islet cell transplantation with Category I CPT® code 48160.

Policy revisionEffective 5/20/13

10.01.011AEmergency Services: Auto Codes

New ICD-9 diagnosis codes have been added to the CareFirst, Inc. Emergency Services Auto Code List for Maryland-based indemnity and NASCO business, in compliance with COMAR 31.10.11. See the table effective 5/20/13, attached to the Operating Procedure 10.01.011A to view the list of the additional codes.

Operating Procedure revisionEffective 5/20/13

10.01.012ATelemedicine (Unified Communications)

Under Provider Guidelines, deleted sentence “Telemedicine services for new patients should be for consultations only. (Refer to the CareFirst General Information (Provider) Manual for requirements on reporting consultations and other evaluation and management services.)” Office or other outpatient visits for new patients, or home visits for the evaluation and management of a new or established patient via interactive audio and video telecommunication systems are allowed. Report diagnostic, consultative and treatment telemedicine services with the appropriate Category I CPT® code and the HCPCS modifier –GT. Refer to Operating Procedure for details.

Operating Procedure revisionEffective 5/20/13

11.01.001Tumor Markers

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with the appropriate Category I CPT® codes.

Periodic review and updateEffective 5/20/13

Medical Policy Updates (CONTINUED)

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9WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

H E A LT H C A R E P O L I C Y

MEDICAL POLICYAND/OR PROCEDURE ACTIONS, COMMENTS AND REPORTING GUIDELINES POLICY STATUS AND

EFFECTIVE DATE

11.01.002Genetic Testing for Inherited BRCA1 or BRCA2 Mutations

Testing for genomic rearrangements (BART) of the BRCA1 and BRCA2 genes is considered medically necessary in patients who meet criteria for BRCA testing. Under Policy Guidelines, added 2013 rationale statement. Clarified definition of high risk to include “A first or second degree relative or personal history of both breast and ovarian or fallopian tube or primary peritoneal cancer or pancreatic cancer at any age.” Report services with the Category I CPT® codes 81211, 81212, 81213, 81214, 81215, 81216 or 81217. Refer to policy for details.

Periodic review and update Effective 4/22/13

11.01.004Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer’s Disease

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with the Category I CPT® codes 81401, 81405, 81406 or 83520 or HCPCS codes S3852 or S3855.

Periodic review and updateEffective 5/20/13

11.01.019In Vitro Chemotherapeutic Drug Assays

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with the Category I CPT® code 88358 or unlisted code 88199.

Periodic review and updateEffective 4/22/13

11.01.032Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in Breast Cancer Patients

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report service with the HCPCS code S3854.

Periodic review and updateEffective 4/22/13

11.01.035Genetic Testing for Celiac Disease

Policy statements are unchanged. Under Policy Guidelines, added 2013 rationale statement. Report services with Category I CPT® codes 81370, 81375, 81382 or 81383.

Periodic review and updateEffective 5/20/13

Medical Policy Updates (CONTINUED)

CPET CornerA New Facets Paper Voucher webinar will begin in June and provide you with updates on the upcoming voucher changes. We’ve also added the iExchange Replacement Training webinar, which offers training on the new system that replaces iExchange. Find the webinar to fit your needs.

In addition to the upcoming Professional, Hospital and Ancillary seminars offered, the Center for Provider Education and Training provides an array of webinars that you can attend while sitting at your desk.

C P E T C O R N E R

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CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

P R O V I D E R S E M I N A R S

Practitioner and Staff Seminars and Training SessionsChoose the Professional or Institutional/Ancillary webinar that’s right for you.

Professional SeminarsDATE AND TIME LOCATION ROOMTuesday, June 11, 201310 a.m. to 1 p.m.Basics, Updates and More

Shady Grove Adventist9901 Medical Center DriveRockville, Md. 20850

Birch Room

Hospital SeminarsDATE AND TIME LOCATION ROOMTuesday June 4, 201310 a.m. to 1 p.m.Hospital Quarterly

Fair Oaks Hospital3600 Joseph Siewick DriveMedical Plaza BuildingFairfax, Va. 22033

Auditorium

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CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

Q U A L I T Y I M P R O V E M E N T

Practitioner Satisfaction Survey 2012CareFirst surveys its primary care physicians (PCP) each year to evaluate their satisfaction with the medical management of the BlueChoice and BluePreferred health plans. Due to a number of revisions, the survey was fielded later than usual: between November 2012 and January 2013. Of the 3,220 offices contacted, 226 physicians responded, for a response rate of 14.9 percent.

Physicians rated their satisfaction with CareFirst on a scale of 1-10 in the following areas: overall satisfaction, utilization management, specialist availability, claims processing, case management, patient information and communications, technology/social media and HealthyBlue. CareFirst is also compared to the competition in a number of areas and rated on a scale of 1-5 in which 5 is much better than the competition and 1 is much worse than the competition.

Strengths

n Overall satisfaction with BlueChoice and BluePreferred

n Utilization Management overall for BluePreferred

n General availability of specialists

n Claims process

n Case Managers overall

n CareFirst communications

n Electronic services

n Website: accuracy, timeliness, and ease of finding information

n HealthyBlue Health and Wellness Evaluation form

Better Than the Competition

n For both BlueChoice and BluePreferred, about half of the physicians rated utilization management better than the competition for ease of submitting and timeliness of receiving authorizations

n General availability of specialists

n Case Managers: willingness to work with you and expertise

Opportunities for Improvement

n Availability of behavioral health practitioners

n Appointment access to behavioral health specialists

n Feedback to PCPs on CareFirst patients from behavioral health practitioners, hospitals, home health agencies and skilled nursing facilities

n Fee Schedule

Improvement Efforts

n Recruitment and contracting by CareFirst and our behavioral health partner, Magellan Health Services

n Magellan provides assistance to physicians and members with locating a practitioner; Magellan’s contact number is located on the back of the member’s ID card

n Magellan will include an article on communication between behavioral health practitioners and PCPs in the Magellan provider newsletter

n CareFirst will communicate feedback recommendations to hospitals and ancillary services

Let’s Hear From YouHow does BlueLink help you do your job? Let us know how BlueLink has made an impact on the way that you do business with CareFirst. Tell us what you think — what we’re doing right and what we could do better. Your feedback helps us delivery timely, engaging news that will help you have more time to care for our members.

Our goal is to provide you with the best articles possible and your feedback is vital. Email your comments to newsletter.editor@carefirst.com and be entered to win a free gift.

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[ TABLE OF CONTE NTS] BLUEL INK > > J U N E/ J U LY 2013

12WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

Q U A L I T Y I M P R O V E M E N T

Practitioner’s Role in Resolving Member ComplaintsCareFirst’s Quality of Care Department investigates complaints related to the quality of care and service provided by practitioners and providers in the CareFirst network and takes action, when appropriate. We evaluate complaints annually to identify and address opportunities for improvement across the network.

What happens when we receive a complaint from a member involving a practitioner or provider?

The QOC Department has only the member’s perspective of the complaint and will contact you for additional information and your perception. At the conclusion of our investigation, we will advise you and the member of the findings and resolution. We are committed to resolving member complaints within 60 days, and your timely response helps us meet that goal.

Can I register a complaint on behalf of a CareFirst or CareFirst BlueChoice member?

A practitioner may register a complaint on behalf of a member regarding the quality of care or service provided to the member by another practitioner or provider. You may submit a complaint in one of three ways:

Availability of Members’ Rights and Responsibilities StatementCareFirst is committed to providing quality, cost-effective health care while maintaining a mutually respectful relationship with our members. The Members’ Rights and Responsibility statement acknowledges our responsibilities to provide services and information to members, and outlines expectations regarding members’ responsibilities.

The Members’ Rights and Responsibilities statement is provided to members in the Member handbooks, published annually in Vitality, the member newsletter and is available on the CareFirst website. To request a copy of the Members Rights and Responsibility statement, please call 800-842-5975.

Click here to view the Eligible Individuals’ Rights Statement Wellness and Health Promotion Services.

n Email quality.care.complaints@carefirst.com

n Fax a written complaint to 301-470-5866

n Mail a written complaint to: CareFirst Quality of Care Department Central Appeals Unit P.O. Box 17636 Baltimore, Md. 21297

Please include the following information when submitting a complaint:

n Your telephone number

n Your provider number

n Member’s name

n Member’s ID number

n Date(s) of service

n As much detail as possible about the event

BLUELINK > > J U N E/ J U LY 2013

CHIEF MEDICAL OFFICER AND SR. VICE PRESIDENT OF MEDICAL AFFAIRSJon P. Shematek M.D.

EDITORRobert Hilson

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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

WHAT ’S HAPPENING

CLAIMS AND BILLING

HEALTH CARE POLICY

CPET CORNER

SEMINARS AND WEBINARS

QUALITY IMPROVEMENT

PHARMACY UPDATES

P H A R M A C Y U P D A T E S

Prior AuthorizationThe following prescription drugs require prior authorization for prescriptions covered under the CareFirst and CareFirst BlueChoice prescription drug plan:

n Pomalyst® for the treatment of patients with multiple myeloma

n Signifor® for the treatment of patients with Cushing’s disease

n Tecfidera™ for the treatment of patients with relapsing forms of multiple sclerosis

n Diabetic Test Strips except LifeScan One Touch Test Strips

The following prescription drugs no longer require prior authorization for prescriptions covered under the CareFirst and CareFirst BlueChoice prescription drug plan:

n Flector® patch for the treatment of acute pain due to minor strains, sprains and contusions

n Suboxone® and Subutex® for the maintenance treatment of opioid dependence

n Voltaren® Gel and Pennsaid® for the relief of osteoarthritis pain in joints amenable to topical therapy (e.g., ankle, elbow, foot, hand, knee, wrist)

New GenericsThe following drugs will be available as generic. The generics will be covered on tier 1 and the brand-name drugs will be on tier 3 or non-preferred.

BRAND NAME GENERIC NAMELuvox CR® fluvoxamine maleate extended-release capsules

Migranal nasal spray® dihydroergotamine nasal spray

Ortho Tri-Cyclen® ethinyl estradiol and norgestimate (Tri-Estarylla)

Pristiq ER® desvenlafaxine extended-release tablet

Retin-A Micro® gel Tretinoin gel

Travatan® ophthalmic drops Travoprost ophthalmic drops

Zovirax® ointment acyclovir

For the most current preferred drug list, prior authorization forms and pharmaceutical management procedures, visit www.carefirst.com/rx. For a paper copy of the formulary and pharmaceutical management procedures, call 877-800-3086.

Reminder: Pharmacy pre-authorizations can now be done online.