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January 2014
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In this issue
Page
Administration
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2014 Provider webinar schedule
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Notification postcards have been discontinued-sign up for Network eUpdate
email alerts
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Provider manual update
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Appeals address: Make sure you submit appeals to the right place!
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Updated CMS 1500 Claim Form version 02/12 to be accepted beginning
January 6, 2014
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Three new online forms coming in 2014
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Survey says…Patients see room for improvement with physician care
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Participating providers are asked to refer to participating ambulance providers
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Remittance changes and medical records bar code notice
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Health care reform updates (including Health Insurance Exchange)
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New articles have been posted to bcbsga.com
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Products and programs
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OrthoNet Focused Claim Review program
BCBSGa engages Inovalon to conduct health assessments for members
enrolled in health plans purchased on and off the Exchange
Quality-In-Sights® Pay for Performance survey is due January 15, 2014!
HEDIS® 2014: it’s time to show our quality!
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E-business
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ProviderAccess changes and helpful tips for the Availity Web Portal
Clinical practice and preventive health guidelines available on the web
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State Health Benefit Plan
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SHBP precertification requirements
Mother and newborn claims must be submitted separately
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Senior business and Medicare Advantage
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2014 Medicare Advantage Plan Changes
Self-Administered Drugs
Routine physical exams not covered in 2014
BCBSGa encourages Medicare Advantage members to stay up -to-date on
preventive care
Annual surveys ask members to rate their quality of care and their Medicare
Advantage health plan
Adult BMI and HEDIS – please record exact number, not range
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bcbsga.com
Important phone numbers
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Update: Medicare Advantage Specialty Pharmacy Unit phone option
CuraScript moves to Accredo brand effective January 1, 2014
CPT II codes can help reduce administrative burden
Speaking the Language of ICD-10 - Part 3
Pharmacy
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Pharmacy information available on bcbsga.com
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Policy updates
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Precertification required for all hysterectomies
Medical Policy and Clinical Guideline updates
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Administration
2014 Provider webinar schedule
BCBSGa will continue facilitating FREE quarterly provider webinars in 2014. We encoura ge you or your office manager to
attend. The 2014 schedule is listed below and is also posted to our provider website, bcbsga.com.
First Quarter:
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Tuesday, February 11, 2014 – 10:00 – 11:30 a.m.
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Wednesday, February 12, 2014 – 1:30 – 3:00 p.m.
Second Quarter:
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Tuesday, May 13, 2014 – 10:00 – 11:30 a.m.
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Wednesday, May 14, 2014 – 1:30 – 3:00 p.m.
Third Quarter:
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Tuesday, August 12, 2014 – 10:00 – 11:30 a.m.
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Wednesday, August 13, 2014 – 1:30 – 3:00 p.m.
Fourth Quarter:
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Tuesday, November 11, 2014 – 10:00 – 11:30 a.m.
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Wednesday, November 12, 2014 – 1:30 – 3:00 p.m.
Please RSVP to the webinar you are planning to attend by emailing [email protected]
Register to receive Network eUpdate email communications
If you are not currently registered to receive our BCBSGa Network eUpdate (formerly Rapid Update) email notifications you
can sign up on our website. When you sign up, you’ll not only receive an email reminder for each newsletter posted online,
but also other late breaking news and important information you’ll need when providing services and filing claims for our
members. It’s easy to sign up. Just a few clicks and you’re done!
Notification postcards have been discontinued -sign up for Network eUpdate email alerts
In the past, we’ve sent a postcard via the US mail as a reminder when each issue of Network Update was posted online.
However, as previously communicated, we will no longer be sending a postcard notification. If you are not currently receiving
our Network eUpdate emails, including notif ication of when each issue of Network Update is posted online as well as other
late breaking news and important information you’ll need when providing services and filing claims for our members, you can
sign up to receive them on our website, bcbsga.com. It’s easy to sign up. Just a few clicks and you’re done!
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Our provider newsletter, Network Update, is our primary source for providing important information to health care providers
and professionals. Network Update is published bi-monthly. In 2014, Network Update will move to a new schedule and will
publish in January and February then printing bi-monthly starting in February. Network Update is then posted to the
Communications page of bcbsga.com for easy 24/7 access.
Provider manual update
The provider manuals will be updated mid-January 2014 and can be found on the Provider Manuals page of our provider
website, bcbsga.com.
Appeals address: Make sure you submit appeals to the right place!
All BCBSGa local and commercial business appeals should be mailed to:
PO Box 105568
Atlanta, GA 30348
All National Accounts (usually indicated with an Anthem logo on the member ID card) appeals should be mailed to:
PO Box 54159
Los Angeles, CA 90054
All claims and correspondence should be mailed to:
PO Box 105187
Atlanta, GA 30348
The following addresses are obsolete and should not be used for appeals:
PO Box 7368
Columbus, GA 31908
PO Box 9907
Columbus, GA 31908
If you are not sure where to send an appeal, claim, or correspondence, there should be addresses listed on the back of the
members ID card, or at minimum a phone number to call and obtain the correct information.
Updated CMS 1500 Claim Form version 02/12 to be accepted beginning January 6, 2014
In June 2013, the National Uniform Claim Committee (NUCC) announced the approval of an updated 1500 Claim Form
(version 02/12) that accommodates reporting needs for ICD-10 and aligns with requirements in the Accredited Standards
Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Report Type 3.
BCBSGa will begin accepting the updated 1500 Claim Form version 02/12 starting on January 6, 2014. Please follow the
guidelines set forth by the NUCC for completing the new claim form, or your claim may be rejected. For more information
about the revised 1500 Claim Form, please visit the National Uniform Claim Committee website, which provides helpful
resources such as a list of changes between the 08/05 and 02/12 claim versions and the 1500 Instruction Manual. Please
note that the NUCC’s transition timeline for use of the 1500 Claim Form version 08/05 includes a dual submission period
from January 6, 2014 – March 31, 2014. Effective April 1, 2014, paper claims should be submitted using only the revised
1500 Claim Form version 02/12.
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Three new online forms coming in 2014
Online Provider Maintenance Form
A new online Provider Maintenance Form will replace the current Provider Information Change (PIC) Form and should be
used by Georgia physicians, providers and professionals to submit demographic or other practice changes to BCBSGa.
Examples include but are not lim ited to: practice or provider name change, address change, tax ID change, opening or
closing a practice location. (Note: Do not use this form to request participation for a new provider or practitioner. Use the
Provider Application Form as outlined below.)
All requests must be received 30 days prior to change/update. Any request received with less than 30 days notice may be
assigned a future effective date. Contractual guidelines may supersede effective date request. Please provide 90 days notice
of termination from our network.
Benefits of new online Provider Maintenance Form:
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Automated form will allow you to enter all of your information online, press submit, and send directly to BCBSGa for
processing.
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You will receive automatic confirmation of receipt.
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Helping to avoid unnecessary delays due to incomplete requests, the online form edits for any required fields before
you can submit.
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We are anticipating shorter turnaround times once this online form is implemented.
Online New Provider Application Form
The online New Provider Application Form should be used by Georgia physicians, providers and professionals to apply for
participation with BCBSGa.
Benefits of online new provider application form:
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Automated form will allow you to enter all of your information online, press submit, and send directly to our Provider
Engagement and Contracting (PE&C) system for processing.
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You will receive automatic confirmation of receipt.
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Helping to avoid unnecessary delays due to incomplete requests, the online form edits for any required fields before
you can submit.
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If provider is already registered with the Council for Affordable Quality Healthcare ( CAQH), new form requires fewer
fields to be entered.
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You may also notice even shorter turnaround times once this online form is implemented.
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Upon credentialing approval, notification and effective date will be sent electronically back to submitter of the
request.
New online CAQH ID Number Request Form
We have also developed a new form to allow providers who requir e credentialing to request a CAQH ID number which is an
essential piece of the credentialing application. Physicians and practitioners who must be credentialed for our networks and
who do not yet have a CAQH ID number should first complete our online CAQH ID Number Request Form. Once you receive
the CAQH ID number, you can complete the online New Provider Application Form.
Benefits of the new online CAQH ID Number Request Form:

Automated form will allow you to enter all of your information online, press “submit”, and send directly to our
Provider Engagement and Contracting (PE&C) team for processing.

You will receive automatic confirmation of receipt.

Online form edits for any required fields before you can submit, helping to avoid unnecessary delays due to
incomplete requests.
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You may also notice even shorter turnaround times once this online form is implemented.
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Once available, all these forms will be available on our provider website, bcbsga.com. The Provider Maintenance Form will
be located on the Provider Forms page, and the New Provider Application Form and CAQH ID Number Request Form will be
located under the “Join our Networks” tab in the menu bar.
Survey says…Patients see room for improvement with physician care
Every year, BCBSGa sends out the Consumer Assessment of Healthcare Providers and Systems (CAHPS ®) survey to its
HMO/POS members. The survey gives BCBSGa members an opportunity to share their perceptions of the quality of care and
services provided by our HMO/POS network physicians. This same survey is used by all HMO/POS plans that undergo
accreditation review by the National Committee for Quality Assurance (NCQA).
The following charts compare results from 2012 with those in 2 013. You’ll also see two other columns. One reflects the score
trend from 2012 to 2013; the other shows the 2013 NCQA Quality Compass Percentile Achieved comparing Georgia’s
network scores to scores from other HMO plans across the country. Our goal is to a chieve the 75 th Percentile. This is the
level we encourage our network physicians to strive to achieve.
When you’re reviewing these results, we encourage you to focus on and address those areas of your own practice that may
have room for improvement. Addressing those areas will help ensure our members, your patients, have a positive experience
that meets their medical needs and their satisfaction with the level of services provided.
2013 BCBSGa HMO/POS
CAHPS Adult Member Satisfaction Survey Results
2012
2013
Trend
2013 HMO/POS
Percentile
Achieved 4
87%
87%
87%
81%
=

75 th
25 th
81%
79%

50 th
Getting Care Quickly 2
Got appointment for urgent care as soon
as needed
NA
88%
--
25
th
Got appointment for check-up or routine
care as soon as needed
82%
85%

50
th
Got help or advice needed when calling
doctor after regular office hours
63%
71%

DNA
How often personal doctor explained
things understandably to you
97%
99%

90th
How often personal doctor listened
carefully to you
96%
97%

90th
How often personal doctor showed respect
for what you had to say
97%
97%
=
75th
How often personal doctor spent enough
time with you
95%
96%

90th
Survey Question
Rating of Physician 1
Rating of Personal Doctor
Rating of Specialist seen most often
Rating of All Health Care Provided in past
12 months
Doctor’s Communication with Patients
2
Shared Decision Making
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Doctor discussed reasons to take a
medicine? 3
--
91%
--
DNA
Doctor discussed reasons not to take a
medicine? 3
--
65%
--
DNA
Did you and your doctor discuss ways to
prevent illness? 4
--
--
DNA

10th
Continuity of Care
74%
2
How often did your personal doctor seem
informed about care you received from
other health providers?
73%
75%
1 = Percent responding 8, 9 or 10 (0-10, where 0 is the worst and 10 is the best).
2 = Percent responding “Usually” or “Always.”
3 = responding “A lot” or “Some”
4 = % responding "Yes"
5 Percentile Definition - A score equal to or greater than 75 percent of all those attained on a survey question is said to be in the 75th percentile.
DNA = Data Not Available
NA = Number of survey respondents too low to be valid.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
*The source of data contained in this report is Quality Compass ® 2013 and is used with the permission of the National Committee for Quality Assurance (NCQA). Any
analysis, interpretation or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation or
conclusion. Quality Compass is a registered trademark of NCQA.
Participating providers are asked to refer to participating ambulance providers
BCBSGa recently implemented an Air Ambulance Member Redirection strategy. This approach encourages the use of the
BCBSGa participating provider network for non-emergent, air-ambulance transport. Currently, member certificate language
states that pre-authorization is required for non-emergent air ambulance services.
As a part of the partnership agreed upon as a participating provider, please remember, you have agreed to refer members to
other participating providers. Referring to participating providers is to the benefit of the member. When it is necessary to
refer a member to a non-participating provider, remember to inform the member that services provided by a non-participating
provider may result in reduced benefits. The non-participating provider may bill them for amounts other than deductibles and
copayments and for medical services not covered under the member’s benefit agreement.
Our collaboration and work on this effort is another strong example of how we can control medical costs and improve the
quality, affordability and safety of our members.
Remittance changes and medical records bar code notice
BCBSGa would like to make you aware of some upcoming changes to provider remittance, EFT payments, and how we will
request medical records.
Medical Records return address will follow a Bar Coding Process:

When a claim is submitted and medical records are necessary, providers will receive a letter requesting medical
records with a submission address that includes a bar code. The medical r ecords requested must be returned with
the letter containing the bar code to ensure the medical records are forwarded to the correct area.
Remittance changes:

All remittance will be cycled for payment each Friday. In the past, remittances were made on var ious days. This will
no longer be the case. Note – Member payments will not be impacted and will continue to be made each day.
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The contract type (e.g. PPO) will no longer be displayed on remittance.
Provider and member responsibilities will no longer b e broken down by type but will instead be displayed as a lump
sum with a reason code defining each charge.
Remittance sample and explanation:
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Note: This is a just an example. Information shown may be different from what appears on your BCBSGa remittance .
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Subscriber identification/patient name: The contract number under which the claim was processed. The name of the
patient for whom services were performed.
Claim number: The number assigned to a patient’s claim
Patient account/prescription number: Your internal patient number. For pharmacists, the number represents the
prescription number.
Column 1 – Service from and to dates: The first and last date of service reported for the patient’s claim.
Column 2 – Procedure code/CVD/NCVD: Procedure code identifies the reported code for specific procedure
administered. Covered day/noncovered day will show the total services days.
Column 3 – Total charges: this column represents your billed amount for the service(s) administered.
Column 4 – Allowed amount: The amount approved for payment prior to member liability.
Column 5 – Other insurance dollars: The amount paid by other insurance, including Medicare.
Column 6 – This column is currently not being used.
Column 7 – Subscriber’s liability: This column indicates the amount of the patient’s liability for the service(s)
performed.
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K.
L.
M.
N.
O.
P.
Column 8 – Approved to pay amount: The amount approved for payment after taking into consideration the
member’s liability.
Column 9 – Amount Paid: The amount paid for the service(s) reported.
Column 10 – Reason code: Codes shown refers to a specific message below each claim. These messages clarify a
payment situation or explain why you may be responsible for a service.
Accounts receivable created: This replaces a letter requesting a refund. You should return the amount indicated
in accordance to the timeframe noted in your contract of receipt of the remittance. Once the requested amount is
returned, the claim adjustment will be complete.
Accounts receivable applied: If you do not return the amount requested within your contracted timeframe, we will
auto recoup the money. The transaction will appear as an accounts receivable applied entry on a future remittance.
Accounts receivable number assigned: This AR number is assigned when a “receivable” is created, and will
correspond to the entry if the “receivable” is applied for tracking purposes.
EFT payment will be included in voucher and will continue to be available for immediate viewing on ProviderAcces s.
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ProviderAccess will be used to access authorizations and remittances. The log on for ProviderAccess Georgia will
remain the same.
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The Availity portal will be used to access Claims Statuses, Eligibility and Benefits. Please visit availity.com to view
Eligibility, Benefits and Claim status. You can also access ProviderAccess through Availity, without having to
complete a separate log-in.
Health care reform updates
Health care reform updates and notifications and Health Insurance Exchange information are posted as they become
available on the communications page of bcbsga.com.
Articles titled “Upcoming changes to ERA and EFT processes ” and “Coverage for Members in Clinical Trials” have been
posted to the Health care reform updates and notifications of bcbsga.com.
Products and programs
OrthoNet Focused Claim Review program
Effective April 14, 2014, BCBSGa has contracted with OrthoNet, LLC, a leading musculoskeletal benefits management
company, to perform coding reviews of certain musculoskeletal procedure codes. The review program will include all
BCBSGa Commercial Business as well as Medicare Advantage HMO and PPO.
In compliance with applicable American Medical Association (AMA), Correct Coding I nitiative (CCI), Current Procedural
Terminology (CPT), and BCBSGa reimbursement billing procedures and guidelines, the Focused Claim Review program will
compare the musculoskeletal procedure code billed to the associated operative/office notes. This coding review will confirm
that the claim coding accurately represents the professional services provided to the member, as documented in the office or
operative notes associated with the musculoskeletal procedure.
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The following provider specialties are included in this program:
 Reconstructive surgery
 Neurosurgery
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
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Plastic reconstructive surgery
Breast surgery
Otolaryngology
Orthopedic surgery




Podiatry
Pediatric neurosurgery
Hand surgery
Head/neck surgery
The procedure code categories to be reviewed include, but are not lim ited to:
 Total joint replacement
 Neck/thorax/head surgery




Physical medicine &
rehabilitation
Neurology
Sports medicine
Pain management

Wound care

Knee arthroscopy

Hand/finger surgery

Sinus endoscopy

Shoulder surgery

Foot surgery

Nose excision/repair

Spine/back surgery

Plastic surgery

Pain management
Please continue to submit your claims electronically to BCBSGa or via mail as usual. Claims should not be submitted
to OrthoNet. If a particular claim under coding review is submitted without records, the claim will be suspended and OrthoNet will issue a
communication to the billing provider requesting that the office or operative notes be submitted to OrthoNet directly. OrthoNet will review
the records and a determination will be made on the accuracy of the musculoskeletal procedure code. BCBSGa will process the claim
accordingly. If the determination is unfavorable, the rendering provider will receive a denial letter containing the available options to
administratively appeal.
If you have any questions about the OrthoNet Focused Claim Review program, please contact your Provider Representative or Pro vider
Customer Service at 800-428-4446.
BCBSGa engages Inovalon to conduct health assessments for members enrolled in health pl ans
purchased on and off the Exchange
The implementation of the Health Insurance Marketplace (often called the Exchange) brings new and unique challenges for
health plans, providers, consumers, and state and federal regulating agencies. BCBSGa is working to adhere quickly and
responsively to government guidance as it is issued. To that end, we want to share information about risk management
programs associated with the Exchanges, our business relationship with Inovalon (a health care technology company), an d
upcoming outreach efforts to both members and providers.
Three protective programs – the “three Rs”
As mandated by the Affordable Care Act (ACA), health insurers for both individual and small group markets will no longer
perform medical underwriting on individuals who apply for health insurance. This allows individuals who had previously been
unable to obtain health care coverage to enter the health insurance market.
As part of the ACA, the U.S. Department of Health and Human Services (HHS) introduced three protective programs – often
called the “three Rs” – with emphasis on risk management and premium stabilization. The provisions of these programs are
designed to help level the competitive playing field with health insurers and protect against advers e selection (attracting a
higher than average risk pool) on and off the Exchange beginning 2014. The three programs are:

Reinsurance (Temporary program that provides funding to health plans that enroll high -cost individuals).

Risk Adjustment (Permanent program that transfers funds from lower risk plans to higher risk plans, helping to
protect against adverse selection).

Risk Corridors (Temporary program that lim its issuers’ losses and gains to help protects against inaccurate rate
settings).
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BCBSGa works with Inovalon in outreach efforts to members and providers
To comply with the programs’ provisions, our company is updating member health documentation for members in the
individual and small group markets who purchased our health insurance plans on an d off the Exchange. We have engaged
Inovalon – an independent company that provides secure, clinical documentation services – to contact our members and
conduct health assessments beginning mid-January 2014.
The purpose of conducting these assessments is to collect clinical information regarding chronic disease diagnoses,
medications, recent physician visits and hospital stays, and clinical history. As a result of the outreach efforts, our memb ers
may have questions about their health care options and m ay contact their physicians for appointments.
As part of this initiative, Inovalon will be contacting certain network-participating providers to collect additional clinical
information about our members. This process is intended to help the treating pr ovider identify care gaps and encourage
members to meet with their physicians for overdue appointments and/or to overcome barriers to accessing care. Members
can be better supported with recommendations for member-specific interventions such as care management programs.
Providers can submit assessments electronically using ePASS® – an online or mobile application, encounter support
platform available through Inovalon. The easy-to-use, electronic tool compiles claims (including diagnoses), prescription
drug and lab information to help providers identify care gaps and potential health care recommendations/interventions.
Inovalon’s outreach efforts begin in the New Year
On our behalf, Inovalon will begin reaching out via written correspondence in mid -January 2014 to certain providers in our
networks that will support our 2014 product offerings. To help m inimize any potential disruptions in providers’ offices,
Inovalon will request only a small list of members for whom a patient assessment is needed. W e encourage providers to
comply with Inovalon’s requests for health assessments.
Watch for further updates about this process in upcoming editions of our Network Update provider newsletter and on our
provider website at bcbsga.com.
Quality-In-Sights® Pay for Performance survey is due January 15, 2014!
It is once again time to submit your Quality-In-Sights® Pay for Performance Practice Survey. If you have not already done
so, please remember to submit your Provider Survey for the BCBSGa Quality In -Sights Pay for Performance Program by
January 15, 2014. The 2013 Measurement Year Practice Survey can be accessed through our secure provider portal,
ProviderAccess, or by clicking here.
To access the survey through ProviderAccess, the member of your staff who is the Account Administrator for your
ProviderAccess account will need to log in. Once logged into ProviderAccess, you will see the "Rewards and Recognition"
banner. Click on the banner, acknowledge that you are not a third party billing entity, and you will be take n to the POIT home
page. On the POIT home page, you will find the survey on the "Programs" tab; click "Start Survey" in the box labeled
"Technical Survey."
Information on completing the survey for the Quality-In-Sights Primary Care Incentive Program can also be found on our
public provider website. You can complete the survey in its electronic format by clicking here. You will need to save the
survey to your computer, fill it out and then email it to the email address provided in the survey document.
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The survey is necessary to satisfy some of the measures of the Program. Only one Practice Survey is required for all
practice locations under a single tax id. Surveys must be completed and submitted no later than January 15, 2014 to
be considered in your 2013 Quality-In-Sights score. Surveys can be submitted through the ProviderAccess POIT link or
via email. Surveys cannot be mailed or faxed.
If you have any questions regarding this information, please send us an email at [email protected], call program
support at 888-650-5740 or contact your Provider Representative directly.
HEDIS® 2014: it’s time to show our quality!
In this time of multiple and rapid changes to our healthcare system, one thing is constant; HEDIS medical record collection
begins at this time every year! The 2014 HEDIS season begins in January and will close May 14 th.
The National Committee for Quality Assurance (NCQA) has mandated that all plans collect records during the same
timeframe. We know this can be a burden and that HEDIS requests can seem a little confusing, so we have placed clarifying
information on the Quality Improvement and Standards page of our provider website, bcbsga.com. There you will find the
HEDIS 101, HEDIS Physician Documentation Guidelines and the HEDIS Annual Calendar in addition to other useful
information about our Quality Programs. This information may be helpful for Medical Record personnel, Office Mangers and
others responding to HEDIS requests.
This year, we have partnered with Verisk, formerly known as Mediconnect, for storage of all records. Verisk is also the
vendor collecting and storing Medicare Advantage records for our Risk and Recovery area, as required by CMS, during the
mid-May to January timeframe. We will review those stored records for current information before calling your office, in order
to minimize additional requests for the same record. Many measures require the last visit in 2013 so we need data through
December.
Individuals are cho sen by random sample and when we do not have the current record, you will receive a call from our
HEDIS team followed by a fax requesting the information we need. We ask that those records be returned within 5 business
days to allow us time to abstract and verify all information. If not received in this timeframe we will call again to see how we
may assist you in completing this request. For questions, we provide a contact person whose name and number is on the
faxed form. When calling us, please provide your site ID number, which is located near your address on that form .
To make it easier for you, we request the minimum amount of information to meet the requirements. However, this means
that it may be necessary for us to call again to request specific or additional information (e.g. progress notes, health history
or health maintenance record, etc.) We apologize for this inconvenience, but the additional information is necessary for
compliance.
We request a large volume of records, so we understand tha t it may be difficult to get records to us when fax lines are busy.
This year, we recommend that you upload the medical records to our secure portal, using the directions on the request form
that we fax to you. You will receive confirmation and a tracking number for uploaded records, and hopefully fewer calls
saying we didn’t receive your records!
An even quicker option, if you use a web based EMR system, is to allow us to remotely access records for individuals in the
sample. Many offices have given us access to member records in their EMR system , and it has worked out well for all
parties. Please let us know if this is something you would be interested in. We will sign a confidentiality agreement and on ly
access the information needed, preserving the confidentiality of the individual’s protected health information (PHI).
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Last summer, a survey was sent to a random sample of offices, asking for input on our processes. We would like to thank
those who responded and let you know that we made changes where we could. We plan to send another survey later this
year and look forward to hearing from you.
We truly appreciate the quality care you provide to our members. The accurate and timely documentation of that care and
submission of only the information requested, within five business days is welcomed. In appreciation, offices meeting the five
day timeframe will be entered in a drawing to be held at the end of the HEDIS season (May/June) and prizes will be sent in
June/July. Winners will be announced in the third quarter newsletter. Good luck!
In addition to wishing you a very Happy New Year, we wanted to let you know how much we appreciate your partnership in
obtaining the highest HEDIS rates yet. We couldn’t do it without you!
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
E-business
ProviderAccess changes and helpful tips for the Availity Web Portal
BCBSGa member eligibility, benefits, and claim status inquiry successfully transitioned from ProviderAccess to Availity on
November 8, 2013. See below for the answers to some common questions concerning this change and helpful tips on how to
maximize your usage on the Availity Web Portal
What’s happened on November 8, 2013 with ProviderAccess?
On November 8, 2013, web portal access to eligibility, benefit and claim status inquiry transitioned from our legacy provider
portal, ProviderAccess to Availity. These functionalities are now available exclusively through Availity.
Note: Electronic transactions submitted via our Enterprise EDI Gateway are unaffected; you may continue to submit all X12
transactions through your current EDI transmission channels
Can users get to the BCBSGa website or to ProviderAccess from Availity?
Yes, access to the BCBSGa Provider Home Page from Availity is available by clicking on My Payer Portal then select Blue
Cross Blue Shield of Georgia Provider Portal.
Do users still need a ProviderAccess ID?
Yes, a ProviderAccess ID is needed to access information such as the Provider Manual and Reimbursement policies as well
as functionality that has not yet transitioned to Availity, including Online Remits and Fee Schedules.
Also, a ProviderAccess ID is needed to complete the BCBSGA Services Registration on Availity for users to navigate
seamlessly from Availity to ProviderAccess and to access Secure Provider Messaging.
If users do not see any services for BCBSGa under the Auth & Referral section on Availity, what do they need to do?
A link-out to AIM Specialty Health and Interactive Care Reviewer is the only functionality that BCBSGa offers under Availity’s
Auth & Referral. If users do not see these options, they need to contact their Availity PAA (Primary Access Adm inistrator)
and have their PAA grant the user access to Authorization and Referral Request.
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What if users do not have the Secure Messaging link under Claims Management?
Users must contact their Availity PAA (Primary Access Administrator) and have the PAA complete the BCBSGA Services
Registration for their profile. This will connect their ProviderAccess account with their Availity account.
What if our PAA is not familiar with the BCBSGa Services Registration process?
For more information, your PAA can type “BCBSGA Services Registration” into the Help search function on Availity and
follow the step by step instructions.
What is the Health Plan user ID?
The Health Plan user id is the user’s ProviderAccess User ID.
Will anything look different now on ProviderAccess?
Functionality no longer available on ProviderAccess is now grayed out.
Will the Account Administrator see anything different after 11/8 when attempting to add, disable or modify a user’s
access for ProviderAccess?
Yes, the administrator will no longer see Eligibility or Claims Inquiry as an option for a role and will see a new check box for
Secure Message Claim.
What if there are additional questions?
For Availity questions, users can contact Availity Client Services at 800 -AVAILITY (282-4548) or at [email protected].
For all other questions, please contact your local Provider Representative.
Clinical practice and preventive health guidelines available on the web
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted
nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our
website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are
reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All
guidelines are reviewed annually, and updated as needed. The current guidelines are available on the Health & Wellness
page of our provider website, bcbsga.com.
State Health Benefit Plan
State Health Benefit Plan Information is posted as it becomes available on the communications page of bcbsga.com.
An article titled “ 2014 SHBP Coinsurance Waiver Medication List ” was posted to the State Health Benefit Plan Information page
of bcbsga.com in November 2013.
SHBP precertification requirements
The lists of SHBP precertification requirements and codes have been posted to the precertification page of bcbsga.com.
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Mother and newborn claims must be submitted separately
Newborn Eligibility
Newborns are considered eligible only after the child has been added to the plan. The subscriber has 90 da ys to add their
newborn retro-active to the date of birth. Claims filed for a newborn that is not a member will be denied until the baby is
enrolled. Coverage can take effect either on the first d ay of the month following the request or on the date of birth, if
appropriate premiums are paid.
For questions regarding this information, please contact SHBP Provider Customer Service at 855 -641-4862, or Provider
Relations at 888-706-3475.
Senior business and Medicare Advantage
2014 Medicare Advantage Plan Changes
Annual benefits changes for Medicare Advantage plan members will be effective January 1, 2014. Each year, we renew our
contract with the Centers for Medicare and Medicaid Services (CMS) an d CMS re-evaluates and approves the benefits we’ll
offer to our Medicare Advantage members for the upcoming year.
The below changes apply to members enrolled in Medicare Preferred Core (PPO), BlueValue Secure (HMO) and
BlueValue Basic (HMO) plans. You can help members manage their health care costs by being aware of these changes. In
addition, remember to check the Member ID card at the beginning of each calendar year, as the member may have changed
plans.
Notable 2014 benefits changes and highlights by plan type.
Medicare Preferred Core (PPO) Plan Changes

In 2014 Medicare Preferred Core (PPO) will have a Medical deductible amount of $500 that will apply to all OON
Medicare covered services. This deductible will have to be met before we pay towards the member’s out-of-network
(OON) medical bills.

The Medicare Preferred Premier (PPO) H9947-002 and Medicare Preferred Standard (PPO) H9947 -004 will be nonrenewing for 2014. Most of these members will have access to another plan we offer.

We will be completely exiting the following counties: Appling, Baldwin, Bryan, Candler, Chattahoochee, Cobb,
Crawford, Emanuel, Evans, Fayette, Jeff Davis, Laurens, Long, Monroe, Montgomery, Morgan, Spalding, Stewart,
Tattnall, Wayne and Webster.

Members will see a premium increase in 2014.

Instituting network physician copayment and hospital inpatient copayment changes on some plans. The member ID
card will reflect the change, if any.

In 2014 the in-network copayment for Skilled Nursing Facility days will increase to $25 for days 1-20 and $100 for
days 21-100.

Member cost shares are changing for certain outpatient labs, diagnostic tests, X -rays and radiology procedures.

Diabetic shoes and inserts will be covered at a $0 copay in -network.

Worldwide coverage for urgent and emergency care has been removed in 2014.

If a member is admitted to the hospital within 72 hours for the same condition the emergency care copay will not be
waived in 2014.

The Visitor Travel Program now includes Montana , New Mexico and Oklahoma.
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
Please check the member ID card for any identification and/or group number changes that may affect claim
submissions.
Medicare Preferred Core (PPO) Plan Highlights

Maintaining the member in-network and combined maximum-out-of-pocket limits for Individual Medicare Advantage
plans in which all Medicare covered expenses apply.

In-network Primary care physician (PCP) copays are $15 and specialist copays are $30.

Medicare Preferred Core (PPO) participates in reciprocal network sharing. This network sharing allows all Blue MA PPO
members to obtain network-level benefits when traveling or living in the service area of any other Blue MA PPO Plan as long as
the member sees a contracted MA PPO provider. You can recognize a MA PPO member when their Blue Cross Blue Shield
Member ID card has the “MA” in the suitcase, which indicates the member is covered under the MA PPO network sharing
program.

$0 copay for in-network Medicare-covered preventive care.
Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the changes described above for PPO
plans. Our members in Group Sponsored Plans will continue to be covered through a national service area.
BlueValue Secure (HMO) and BlueValue Basic (HMO) Plan Changes

The maximum-out-of-pocket for BlueValue Secure (HMO) will be increasing for 2014 from $4600 to $5100.

Members of both plans will see a premium increase in 2014.

In 2014 the copayment for Skilled Nursing Facility days is changing as follows:
– BlueValue Basic (HMO): $25 for days 1-20 and $110 for days 21-100.
– BlueValue Secure (HMO): $25 for day 1-20 and $125 for days 21-100.

Instituting network physician copayment and hospital inpatient copayment changes on some plans. The member ID
card will reflect the change, if any.

Member cost shares are changing for certain outpatient labs, diagnostic tests, X-rays and radiology procedures.

BlueValue Basic (HMO) will no longer have the following counties available to them in 2014: Bryan & Cobb

BlueValue Secure (HMO) will no longer have the following counties available to them in 2014: Bryan, Chatham,
Effingham, Gwinnett, Muscogee, Rockdale & Talbot.

Diabetic shoes and inserts will be covered at a $0 copay in-network.

If a member is admitted to the hospital within 72 hours for the same condition the emergency care co pay will not be
waived in 2014.

Please check the member ID card for any identification and/or group number changes that may affect claim
submissions.
BlueValue Secure (HMO) and BlueValue Basic (HMO) Plan Highlights

Primary care physician (PCP) copays range from $10 to $20 and specialist copays range from $35 to $50.

$0 copay for Medicare-covered preventive care.

BlueValue Basic (HMO) is maintaining the member maximum-out-of-pocket lim its for Individual Medicare
Advantage plans in which all Medicare covered expenses apply.
Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the changes described above for HMO
plans. Our members in Group Sponsored Plans will continue to be covered through the same counties in the 2013 service
area.
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Optional Supplemental Benefits (OSB)
For 2014, many of our Medicare Advantage plans will offer three Optional Supplemental Benefit (OSB) packages for an
additional premium. OSB packages allow the Medicare Advantage plan to be tailored for additional dental, and vision
coverage. Please note, in 2014 OSB’s will no longer cover chiropractic and acupuncture benefits.
We will offer the below Optional Supplemental Benefit (OSB) packages on select plans. Members will have up to 90 days
from their plan effective date to enroll in one of the below packages:
1. Preventive Dental Package
2. Dental and Vision Package
3. Enhanced Dental and Vision Package
New Year! New Formulary Changes!
Each year we evaluate our benefits and formulary and may make changes to update them. Formulary changes in the
upcoming year include: tier changes, drug removals, and new Prior Authorization and Quantity Limit requirements.
Your patients will have formulary changes and will need your help to ensure they get their needed treatments at the most
affordable cost.
Encourage your patients to review the 2014 formulary information within their Annual Notice of Change (ANOC) mailing, or to
view the information online when it is available, beginning October 1. Ask them if the coverage for any of their prescriptions
has been changed, and consider alternative medications in a lower cost-sharing tier that m ay meets their need.

Initial Coverage Lim it (ICL) for Medicare Part D will decrease from $2,970 to $2,850.

TROOP amount will decrease from $4,750 to $4,550.

In 2014 we will offer daily fills for all MAPD plans. Daily fills give members an opportunity to try a high -priced drug
for adverse reactions before purchasing an entire prescription. The pharmacy network includes preferred and other
network retail pharmacies. You save more by paying a lower cost-sharing amount at preferred retail pharmacies.
Our preferred retail pharmacies include Kroger Pharmacy, Rite Aid Pharmacy and Walmart. Kroger Co. participating
preferred pharmacies include Kroger, FredMeyer, King Soopers, City Market, Fry’s, Smith’s, Dillons, Ralphs, QFC,
Baker’s, Scott’s, Owen’s, Pay Less, Gerbes and JayC. Walmart participating preferred pharmacies include Walmart,
Neighborhood Market and Sam’s Club. Members can fill a prescr iption at a network retail pharmacy, but their costsharing amount may be higher.
Deductible
In 2014 Medicare Preferred Core (PPO) will have a Part D deductible amount of $125 that will apply to Tier 2:
Nonpreferred Generic, Tier 3: Preferred Brand and Tier 4: Nonpreferred Brand drugs. BlueValue Basic (HMO) will have a
Part D deductible amount of $145 that will apply to Tier 2: Nonpreferred Generic, Tier 3: Preferred Brand and Tier 4:
Nonpreferred Brand drugs. BlueValue Secure (HMO) will have a Part D deductible amount of $60 that will apply to Tier 3:
Preferred Brand and Tier 4: Nonpreferred Brand drugs. This deductible will have to be met before those tier’s regular
copays/coinsurance will apply.

During the Catastrophic Coverage Phase: Members will p ay 5% or $2.55 whichever is more for generic drugs, and
members will pay 5% or $6.35 for brand drugs.
Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the changes described above for
Pharmacy plans.
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Diabetic Supplies
Beginning January 1, 2014, our Individual Medicare Advantage Members will only cover LifeScan, Inc ., OneTouch® or Roche
Diagnostics, ACCU-CHEK® diabetic blood glucometers and blood glucose test strips for our Individual Medicare Advantage
members. To be covered for a $0 copay, the members must purchase these supplies at an in -network: retail or mail-order
pharmacy, or Durable Medical Equipment supplier.
Covered blood glucometers and blood glucose test strips in 2014:
 LifeScan, Inc., OneTouch®
 Roche Diagnostics, ACCU-CHEK®
 A limit of 100 blood glucose test strips per month
Other blood glucometer or blood glucose test strip brands or quantities of more than 100 test strips per month are not
covered unless you as the doctor or provider tell us another brand or a l arger quantity is medically necessary for the
member’s treatment, no other brand or larger quantity limit will be covered.

If our member is currently using LifeScan, Inc., OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips
or glucometer products, you don’t need to do anything!

If our member is not using LifeScan, Inc., OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips or
glucometer products, then our member will need to get new prescriptions for the supplies by January 1 st for these
claims to be covered by us.

You should discuss these coverage changes and possible new prescriptions with our member/your patient. If it is
medically necessary for them to continue using a different brand of blood test strips or glucometer and/or more than
100 blood test strips per month, you will need to communicate this to us by requesting an exception. If your patient
purchases their supplies through the pharmacy or the ESI mail-order service exceptions may be requested after
December 1, 2013 by calling 1-800-338-6180. If your patient purchases their supplies through a Durable Medical
Equipment supplier, you will need to call the health plan.

To receive a pre-cert for a members diabetic brand glucometer or QLL on test strips fax pre-certs to 1-800-959-1537
or call 1-866-797-9884 and press option 1 for preauthorization , then press option 3 for all other services.
The benefit and brand limitations described above generally do not apply to our Group Sponsored Medicare Advantage
Health Benefit Plans. Please contact provider services for benefit information.
Insulin Exclusivity
Effective January 1, 2014, select Individual MAPD plans will establish an insulin exclusivity contract with Eli Lilly, the
manufacturer of Humulin and Humalog human insulin. Other insulin’s are considered non-formulary and are not eligible for
coverage beginning January 1, 2014.
Medicare Preferred Core (PPO), BlueValue Basic (HMO), & BlueValue Secure (HMO) plans will be impacted by tan
insulin change. Please have members check their plan name on the left hand corner of their member ID card to see if they
were impacted by this change. If members were impacted by this change the below formulary changes will apply:
The following chart provides the formulary covered insulin medicat ions in 2014:
Insulin Medication
Humalog pens
Humalog vials
Humulin 3 mL vials
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Tier
Tier 3
Tier 3
Tier 3
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Humulin pens
Humulin R u500 vials
Humulin vials
Relion vials / pens
Tier 3
Tier 3
Tier 3
Tier 3
Note: Novolin and Novolog vials and pens and all other insulins are considered non-formulary and not eligible
for coverage.
The benefit and brand limitations described above generally do not apply to our Group Sponsored
Medicare Advantage Health Benefit plans. Please contact provider services for benefit information.
Balance Billing Reminder
The Centers for Medicare and Medicaid Services and our plan does not allow you to “balance bill” Medicare Advantage HMO
and PPO members for Medicare covered services. CMS provides for an important protection for Medicare beneficiaries and
our members such that, after our members have met any plan deductibles, they only have to pay the plan’s cost -sharing
amount for services covered by our plan. As a Medicare provider and/or a plan provider, you are not allo wed to balance bill
members for an amount greater than their cost share amount. This includes situations where we pay you less than the
charges you bill for a service. This also includes charges that are in dispute.
Here is how this protection works for Medicare Preferred Core (PPO):

If the member cost sharing is a copayment (a set amount of dollars, for example, $15.00), then the member pays
only that amount for any services from a network provider. Copayments may be higher for services performed by an
out-of-network provider.

If the member cost sharing is a coinsurance (a percentage of the total charges), then the m ember never pays more
than that percentage. However, the cost depends on the type of provider:
– If the member obtains covered services from a network provider, the member pays the coinsurance percentage
multiplied by the plan’s reimbursement rate (as determined in the contract between the provider and the plan).
– If the member obtained covered services from an out-of-network provider who participates with Medicare, then
the member pays the coinsurance percentage multiplied by the Medicare payment rate for participating providers.
– If the member obtains covered services from an out-of-network provider who does not participate with Medicare,
then the member pays the coinsurance amount multiplied by the Medicare payment rate for non -participating
providers.
– If the member obtains covered services from a provider who has opted out of Medicare, then the plan will not pay
for these services, and dependin g upon the circumstances, the member may be liable for the entire amount.
Here is how this protection works for BlueValue Basic (HMO) & BlueValue Secure (HMO):

If a members cost sharing is a copayment (a set amount of dollars, for example, $15.00), then t he member pays
only that amount for any covered services from a network provider.

If a members cost sharing is a coinsurance (a percentage of the total charges), then the member never pays more
than that percentage. However, a members cost depends on which type of provider the member sees:

If a member receives the covered services from a network provider, members pay the coinsurance percentage
multiplied by the plan’s reimbursement rate (as determined in the contract between the provider and the plan).

If a member receives the covered services from an out-of-network provider who participates with Medicare, the
member pays the coinsurance percentage multiplied by the Medicare payment rate for participating providers.
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Employer or Union Group Retiree Changes
Group Sponsored Medicare Advantage Benefit Plan benefits vary from the Medicare Preferred Core (PPO), BlueValue
Secure (HMO) and BlueValue Basic (HMO) mentioned here. Employer or Union Group Plan names and benefit changes may
be different than what is described above. For Group Sponsored Medicare Advantage Health Benefit Plan members, please
refer to the member’s Evidence of Coverage or call Provider Services at the number on the member ID card for more benefit
detail. Medicare Advantage member ID cards con tain a CMS identifier in the lower right corner of the card. The number will
be five characters (XXXXX) followed by three characters (XXX). The member is in a Group Sponsored Medicare Advantage
Health Benefit Plan when the last three digits start with an eight (8XX).
Providers should reference the member’s ID card for changes at every visit to help ensure proper billing. You can also assist
your patients by passing on any ID card prefix or benefit change information to any ancillary providers who will be a sked to
serve your patient.
What does the Annual Wellness Visit cover
All of our Medicare Advantage plans cover the AWV. Members are encouraged to use this annual benefit as one way to help
assess current health status and future needs.
For the first visit, providers should bill G0438 for the AWV which includes the Personalized Prevention Plan Service.
Thereafter, providers should bill G0439 for the AWV and Personalized Prevention Plan Service, subsequent visit.
What if Additional Services Are Provided at the Same Time As the AWV?
If other evaluation and management services are provided in conjunction with the AWV, use CPT Modifier 25 (Significant,
separately identifiable evaluation and management service by the same physician on the same day of the pr ocedure or other
service) as appropriate.
Prior Authorization Updates for Medicare Advantage Plans
Providers are required to periodically review and comply with the latest Medicare Advantage Prior Authorization requirements
found at bcbsga.com/medicareprovider on the document named: Medicare Advantage Precertification Requirements
(updated 10/01/2013)
Please visit our website at bcbsga.com/medicareprovider for more detailed product information or contact Provider Services
at the number on the back of the member’s ID card. You can find important Medicare Advantage updates in the Plan &
Administrative Changes/Update section. Contact your provider representative for participation details for our contracted
plans.
Self-Administered Drugs
People with Medicare often need self-administered drugs while in a hospital outpatient settings, including the emergency
department, observation units, surgery centers, or pain clinics. “Self-administered drugs” are drugs the member would
normally take on their own. Medicare Advantage plans do not pay for self-administered drugs unless they are required as
part of the hospital outpatient service the member receives. Medicare Advantage plans may cover a limited number of drugs
in these settings such as drugs administered by infusion or injection that are not “usually self -administered.” Click Here for
the full article.
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Routine physical exams not covered in 2014
BCBSGa Medicare Advantage (MA) plans have been offering coverage for routine physicals (subject to plan benefits) to their
members as an additional benefit in 2013, as well as the past years, even when not covered under Traditional Medicare.
The Affordable Care Act created a benefit for Annual Wellness Visits (AWV) for Medicare beneficiaries and in response,
BCBSGA has decided effective for dates of services on and after 01/01/2014, to no longer cover Routine Physical Exams.
Click Here for full article.
BCBSGa encourages Medicare Advantage members to stay up-to-date on preventive care
BCBSGa is committed to helping your Medicare Advantage patients stay up -to-date on preventive screenings in 2014. Here
are a few of the ways we’ll be reaching out to members throughout the year.

Personalized Healthy Checklist for Preventive Services – Starting early in 2014, we will send members a healthy
checklist. This personalized checklist reminds them to ask you about preventive care and screenings they may
need. Members may bring the checklist to their office visits. Please review the checklist with them to help ensure
they understand and receive any preventive care or screenings they may need.

Preventive Service Outreach Calls: BCBSGa will analyze claim records to identify members who need preventive
care. The calls also will promote medication adherence, annual PCP visits, vaccines, eye exams and rheumatoid
arthritis care. At times, when potential gaps in care are identified, we will send faxes to you with recommendations
for you to consider for your patients.

Health Risk Assessment: The health assessment, which can be completed by phone, web or on paper, provides us
with unique member information. The HRA includes an assessment of the member’s motivation and perceived ability
to manage his or her health. The results of this assessment will help BCBSGa tailor programs to ensure our
members remain compliant with your treatment programs. Please encourage Medicare Advantage members to
complete the health assessment when and if they are contacted to do so.
If your patients participate in any of the following programs, we will send the results of all screenings, lab tests and othe r
assessments to you. The goal is to make it easier for your patients to stay up -to-date and to stay healthy.

Home Lab Kits – Some members will be able to get in-home kits for colorectal cancer, blood sugar and cholesterol
screenings.

Home Visits – This can be convenient for members who have transportation issues or who have recently been
discharged from the hospital. The home visit can include a comprehensive health assessment to identify potential
health issues and can help address care needs. Home visits may also include in -home lab kits for blood sugar,
cholesterol and colorectal screening.
We also can send you a report each month that will tell you when Medicare Advantage members are due, past due or soon
will be due for any preventive care or screenings. Please contact the Clinical Quality Department to obtain this report at
[email protected].
Annual surveys ask members to rate their quality of care and their Medicare Advantage health plan
Each year, the Centers for Medicare & Medicaid Services surveys Medicare Advantage health plan members to assess the
quality of care provided by their physician as well as member satisfaction with Medicare Advantage health plans. Health plan
members are chosen at random and may receive either the HOS (Health Outcome Survey) or the CAHPS (Consumer
Assessment of Healthcare Providers & Systems) survey .
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The surveys are distributed from February to July and ask questions about our members’ experience in the previous year.
CAHPS questions ask the members about access and availability of their physicians and communication with their
physicians. CAHPS questions are focused on areas that are important to Medicare Advantage consumers.

Getting Needed Care

Getting Care Quickly

Doctors Who Communicate Well

Coordination of Care
HOS questions ask members about bladder incontinence, fall risk, and in creasing physical activity. The survey also asks if
they have spoken with their doctor about the issue and if so, did their doctor provide tre atment.
Data from both surveys are publicly reported so consumers can use the information when choosing a Medicare Advantage
health plan; survey results also influence each Medicare Advantage health plan’s rating. Highly rated health plans should
attract greater membership, driving more patient visits to your practice. Please consider the following actions that can help
boost survey ratings.

At least annually assess Medicare Advantage members for bladder incontinence, fall risk, and level of physical
activity.

Offer the flu vaccine on an annual basis.

Ask members if they have any questions for you.

Ask members to repeat back instructions that you have given to them to ensure they understand correctly.

Give printed educational material and pertinent web sites to your patients; here are some helpful links:
– American College of Physicians: Health Tips including Urinary incontinence. Health tips are a tear off,
prescription type pad to share information with your patients. HEALTH TiPS - American College of Physicians
Foundation
– National Institute on Aging: Age Pages including Urinary Incontinence, Fall Prevention and Exercise. The Age
Pages are pamphlets that can be given to your patients or left in your waiting room. Healthy Aging. Age Pages
Adult BMI and HEDIS – please record exact number, not range
Healthcare Effectiveness Data and Information Set (HEDIS®) is updating the medical records specifications for Adult Body
Mass Index. In the past, it was acceptable to record a range for BMI, such as >30. In 2014, HEDIS specifies that the exact
BMI number should be recorded in the medical record, such as 32. Greater precision in charting the member’s BMI will help
the provider help the member achieve or remain at a healthy weight.
Update: Medicare Advantage Specialty Pharmacy Unit phone option
To pre-certify specialty drugs for Medicare Advantage members, please dial 1 -866-796-9884 and choose option 5. If you
participate in the e-review process, please continue to submit requests to the secure Medicare Advan tage e-review box at
[email protected].
If you have additional questions, please contact your local Provider Representative.
CuraScript moves to Accredo brand effective January 1, 2014
Express Scripts’ acquisition of Medco Health Solutions in 2012 resulted in the merger of ESI’s CuraScript Specialty
Pharmacy and Medco’s Accredo Specialty Pharmacy. Starting in 2014, unified pharmacy operations will be under the
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Accredo name and license. Members of our Medicare Advantage Prescription Drug plans transitioned to the Accredo
brand January 1, 2014.
Some of the limited changes members will experience:

They will see the Accredo name and label on their medication shipments and pharmacy lette rs

Expanded pharmacy hours – Monday-Friday, 8 a.m.-11 p.m. ET, Saturday, 8 a.m.-5 p.m., ET.

Upgraded assessments to include therapy-specific questions for improved adherence
How providers will be impacted – frequently asked questions
Q. What changes will impact providers as a result of the brand transition to Accredo?
A. Referral forms will be updated to reflect the change to Accredo and will be available on the Accredo website as
well as our website where applicable. However, if providers continue to use CuraScript-branded referral forms,
Accredo can accept them and there will be no disruption in service.
Q. Will the fax number remain the same?
A. Yes, providers will continue to use the same fax number, 1 -800-824-2642.
Q. Will the provider contact number remain the same?
A. Yes, providers will continue to use the same phone number, 1 -800-870-6419.
Q. Will the pharmacy hours remain the same?
A. The Accredo Specialty Pharmacy will have expanded hours, Monday-Friday, 8 a.m. – 11 p.m. ET, Saturday, 8
a.m. – 5 p.m. ET.
Q. Will prior authorization phone numbers change?
A. No. Prior authorization phone numbers will stay the same.
Q. Will the process for ordering office-administered drugs change?
A. No, the process for ordering office-administered drugs will not change.
Q. If providers or their staffs have questions about the brand change to Accredo, who should they contact?
A. Providers and their staffs should contact the CuraScript provider help desk, just as they would today.
Q. How will providers be notified about the change?
A. In addition to this article, a letter will be faxed by CuraScript to prescribing providers prior to member notification,
alerting providers to the change.
Pharmacy information available on online
Visit our website for more information on our Medicare Advantage Prescription Drug plans, including formularies, Part D
conditions and limitations, and forms.
CPT II codes can help reduce administrative burden
CPT II codes are supplemental tracking codes that help the CMS collect quality of care data by coding services and test
results that support nationally established performance measures that contribute to quality patient care.
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Since BCBSGa also often needs to gather this information about its Medicare Advantage members, using these codes should
reduce the need for record abstraction and chart review and help minimize your administrative burden. According to the
American Medical Association, these codes were originally developed to support the CMS -sponsored Physician Quality
Reporting Initiative. The codes are not required for correct coding and may not be used as a substitute for Category I codes.
These codes describe clinical components that may be typically included in evaluation and management services or clin ical
services and, therefore, do not have a relative value associated with them. Category II codes may also describe results from
clinical laboratory or radiology tests and other procedures, identified processes intended to address patient safety practice s,
or services reflecting compliance with state or federal law.
A list of frequently used CPT Category II codes acceptable for HEDIS collection and reporting is available here. CPTII codes
can be found in the right hand column of a document named HEDIS Guide for 2013.
Speaking the Language of ICD-10 - Part 3
In our previous articles we shared some basic information and recommendations to help you begin your journey of learning to
speak the language of ICD-10. We realize that this journey will not be an easy one as the ICD -10 code sets include greater
detail, changes in terminology and expanded concepts for injuries, laterality, and other related factors.
As with learning any new language it is important to have a good foundation to build on, which includes an understanding of
the basic language structure. To get you started let’s begin with ICD -10 basics. The following diagrams provide you with a
representation of the ICD-10 code structure and the basic features of ICD-9 as compared with ICD-10.
ICD-10 Code Structure:

Characters 1-3: Category

Characters 4-6: Etiology, anatomic site, severity, or other clinical detail

Character 7: Extension
– There may be instances where a placeholder “x” is used to fill previous empty digit
Comparison of the features of the ICD-9 and ICD-10 diagnosis code sets.
ICD-9-CM
ICD-10-CM
17 Chapters
21 Chapters
Approximately 13,000 codes
Approximately 68,000 codes
3-5 characters in length
3-7 characters in length
st
1 character may be alpha (E or V) or numeric; characters
2-5 are numeric; decimal is used after the third character
November 2013
st
1 character is alpha (except “U”)
nd
2 character is numeric
23 of 40
3 rd through 7 th characters are alpha or numeric and a
decimal is used after the third character
Limited space for adding new codes
Flexible for adding new codes
Lacks detail
More detail and specificity
Lacks laterality
Includes laterality (left vs. right)
Complete and accurate medical record documentation and diagn osis coding plays a critical role in managing our Medicare
Advantage membership. As the Centers for Medicare & Medicaid Services will not accept ICD -9 data for dates of service
which occur on or after October 1, 2014, your ICD -10 transition efforts will have a direct impact on our ability to receive
accurate risk adjusted payment from CMS.
BCBSGa continues to develop ICD-10 training and educational materials to assist you and your coding staff. Watch for
future articles about properly documenting and cod ing specific diseases as well as more details about the complexities and
changes that come with the ICD-10 transition.
As we take this journey together, please be reminded that neither CMS nor BCBSGa will accept ICD -9 diagnosis codes after
the conversion date of October 1, 2014. This will be critical, as all encounters/claims submitted with ICD -9 coding will reject
after that conversion date resulting in delay or denial of payment. We must all be prepared to meet CMS guidelines which
include submitting claims with only ICD-10 codes by the CMS October 1 st deadline.
The following resources also may be helpful as you prepare for ICD-10:
The one-page reference sheet produced by AAPC shows how the code sets are organized, with easy color coding to help you find what you're looking for. It also has
mnemonic tips (such as "C is for cancer" and "T is for toxicity") to help you remember where the new codes are located.
American Medical Association physician resource page
Centers for Medicare & Medicaid Services (CMS) Provider Resources
AAPC ICD-10 Implementation and Training Opportunities
Pharmacy
Pharmacy information available on bcbsga.com
Visit anthem.com/pharmacyinformation for more information on pharmacy copayment/ coinsurance requirements and their
applicable drug classes, Drug Lists and prior authorization criteria, procedures for generic substitution, therapeutic
interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements,
restrictions, or lim itations that apply to using certain drugs.
Policy updates
Precertification required for all hysterectomies
BCBSGa has revised what is reviewed for inpatient and outpatient hysterectomy procedures. Effective April 1, 2014, all
BCBSGa plans will require prior authorization/precertification for inpatient and outpatient hysterectomies. This change does
not apply to State Health Benefit Plan, National Accounts, Medicare, Medicare Advantage (MA), or Federal Employee Plan
(FEP).
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The list of services and codes requiring precertification can be found on the Precertification page of our provider website,
bcbsga.com.
Medical Policy and Clinical Guideline updates
The Medical Policy and Technology Assessment Committee adopted the following new and/or revised Medical Policies and
Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve
changes to policy position statements that might result in services that previously were covered being found to be either not
medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Blue Cross Blue Shield and
all the Medical Policies are available at bcbsga.com. Please note that our medical policies now include NOC (Not Otherwise
Classified) codes to expedite the process of determining services that may require medical review. If you do not have access
to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by
calling Provider Services at (800) 241-7475 Monday–Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying
the medical policy or guideline of interest, your name and address to where the info rmation should be sent) to:
BCBSGa
Attention: Prior Approval, MC: GAG009-0002
3350 Peachtree Road NE
Atlanta, GA 30326
AIM Specialty Health SM (AIM)
To submit your request for any of the services below, contact AIM online via AIM’s ProviderPortal SM at
aimspecialtyhealth.com/goweb. From the drop down menu, select BCBSGa. You may also call AIM toll free at 866 -714-1103,
Monday–Friday, 8:00 a.m.–6:00 p.m.
Diagnostic Imaging Management
Diagnostic imaging management services are provided AIM, a separate company, for certain health plan members.
Diagnostic imaging services may be reviewed against AIM’s Diagnostic Imaging Utilization Management Clinical Guidelines.
July 2013 AIM’s clinical guidelines are available on their website. If you have any questions about which guidelines are
applicable, please call the customer service number on the back of the member’s ID card.
Radiation Therapy Services
The review of BCBSGa outpatient radiation therapy services is done by AIM. AIM is a nationally recognized leader in
specialty benefits management. Providers must contact AIM for prior authorization for the following non -emergency
outpatient services: Intensity Modulated Radiation Therapy (IMRT), Proton Beam Radiation Therapy, Stereotactic
Radiosurgery (SRS)/Stereotactic Body Radiotherapy (SBRT) and Brachytherapy. Radiation therapy performed as part of an
inpatient admission will continue to be reviewed through the BCBSGa’s inpatient precertification process. Prior authorization
is required through AIM for all BCBSGa members, with the exception of members with Medicare supplemental policies,
Medicare Advantage plans, BCBSGa as secondary coverage and the Federal Employee Program.
Outpatient Sleep Testing and Therapy Services
The specialty benefit management program for outpatient sleep testing and therapy services for obstructive sleep apnea
program is also administered by AIM and includes the following:

Home sleep test (HST)

In-lab sleep study (PSG)

Titration study

Initial treatment order (APAP, CPAP, BPAP, or al devices, appliances and related supplies)

Ongoing treatment order (APAP, CPAP, BPAP, oral devices, appliances, and related supplies)
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BCBSGa uses sleep diagnostic and treatment guidelines developed by AIM. AIM’s Obstructive Sleep Apnea Diagnostic &
Treatment Management Guidelines are available at aimspecialtyhealth.com/gowebsleep. The precertification requirement
applies to BCBSGa members who participate in BC BSGa local and individual health plans as well as members covered by
Medicare Advantage. The requirement does not apply to those in the Federal Employee Program (FEP) and those for whom
BCBSGa is secondary coverage including those whose primary insurance carrier is Medicare.
By clicking on the links above, you will be linked to sites created and/or maintained by another, separate entity (“External Site”). Upon linking you are subject to the terms of
use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the
privacy practices of the External Sites. The information contained on the External Sites should not be interpreted as medical advice or treatment provided by us.
Effective
Date
Policy or Guideline Number
Title and Summary
NEW MEDICAL POLICIES AND CLINICAL UM GUIDELINES
04/02/14
04/02/14
04/02/14
1/14/2014
1/14/2014
1/14/2014
04/02/14
DRUG.00059
Romiplostim (Nplate®)
This document addresses romiplostim which is a subcutaneously administered thrombopoietin
(TPO) receptor agonist that stimulates bone marrow megakaryocytes to produce platelets.
DRUG.00060
Plerixafor (Mozobil™)
This document addresses the indications and criteria for the use o f plerixafor injection which is
a hematopoietic stem cell mobilizer that is given subcutaneously (SQ) to increase circulating
hematopoietic stem cells (HSCs) in the peripheral blood for collection and subsequent
autologous transplantation.
DRUG.00061
Radium Ra 223 Dichloride (Xofigo®)
This document addresses the use of radium Ra 223 dichloride which is an injection of an alpha
particle-emitting radioactive therapeutic agent which mimics calcium to bind with bone minerals
in areas of bone metastases. The agent has an anti-tumor effect which occurs due to energy
transfer from the radioactive material from nearby cancer cells.
GENE.00028
Genetic Testing for Colorectal Cancer Susceptibility
This document addresses genetic testing fo r individuals who are at higher than average risk for
the development of colorectal cancer.
GENE.00029
Genetic Testing for Breast and/or Ovarian Cancer Syndrome
This document addresses genetic testing for individuals who are at higher than aver age risk for
the development of breast and/or ovarian cancer.
GENE.00030
Genetic Testing for Endocrine Gland Cancer Susceptibility
This document addresses genetic testing for individuals who are at higher than average risk for
the development of endocrine gland cancer, including medullary thyroid cancer.
GENE.00031
Genetic Testing for PTEN Hamartoma Tumor Syndrome
This document addresses genetic testing for phosphatase and tensin homolog on chromosome
10 (PTEN) hamartoma tumor syndrome.
November 2013
26 of 40
04/02/14
04/02/14
04/02/14
04/02/14
11/18/2013
04/02/14
04/02/14
04/02/14
04/02/14
GENE.00032
Molecular Marker Evaluation of Thyroid Nodules
This document addresses the use of molecular markers in the evaluation of thyroid nodules.
GENE.00033
Genetic Testing for Inherited Peripheral Neuropathies
This document addresses genetic testing for genes identified as associated with peripheral
neuropathy.
MED.00113
Therapeutic Apheresis
This document addresses therapeutic apheresis which is a procedure by which blood is
removed from the body, separated into components, manipulated and returned to the
individual. The therapeutic apheresis procedures addressed in this document utilize devices
approved by the U.S. Food & Drug Administration (FDA).
RAD.00064
Myocardial Sympathetic Innervation Imaging with or without Single -Photon Emission
Computed Tomography (SPECT)
123
This document addresses use of the AdreView™ injectable tracer agent (iobenguane I
injection, MIBG)for cardiac imaging to assist with identification of increased risk for short-term
mortality associated with heart failure (HF).
CG-BEH-02
Applied Behavioral Analysis for Autism Spectrum Disorder
This document addresses the use of Applied Behavioral Analysis (ABA) or similar services that
utilize intensive behavioral intervention (collectively, ABA), when included in relevant state
mandates, as treatment for Autism Spectrum Disorder (ASD) when a state mandate requires or
benefit plan language explicitly provides coverage for ABA.
CG-DRUG-30
Oprelvekin (Neumega®)
This document addresses the clinical indications for oprelvekin for prevention of severe
thrombocytopenia (low platelet counts) and reduction of the need for platelet transfusions
following myelosuppressive chemotherapy in individuals with non-myeloid malignancies at high
risk of severe thrombocytopenia.
CG-LAB-09
Drug Testing or Screening in the Context of Substance Abuse and Chronic Pain
This document addresses the use of urine drug testing (UDT) in the outpatient setting fo r
compliance monitoring of controlled substance use as part of the management of chronic pain
and for individuals undergoing treatment for opioid addiction and substance abuse.
CG-SURG-36
Adenoidectomy
This document addresses the use of aden oidectomy, a surgical procedure to remove the
adenoids, which are also known as pharyngeal tonsils or nasopharyngeal tonsils.
CG-SURG-37
Destruction of Pre-Malignant Skin Lesions
This document identifies different types of skin lesions which are considered pre-malignant and
addresses the destruction of these lesions.
November 2013
27 of 40
04/02/14
04/02/14
CG-SURG-38
Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
This document addresses the uses of lumbar laminectomy, hemi -laminectomy, laminotomy
and/or discectomy.
CG-SURG-39
Pain Management: Epidural Injections for Pain Relief
This document addresses epidural steroid injections (ESIs) with or without anesthetic agents
used to treat radicular back pain.
REVISIONS TO EXISTING MEDICAL POLICIES OR CLINICAL UM GUIDELINES
1/14/2014
11/18/2013
1/14/2014
1/14/2014
1/14/2014
11/18/2013
11/18/2013
1/14/2014
ADMIN.00002
Preventive Health Guidelines
This document provides links to several national organizations' evidence -based guidelines for
preventive services.
DRUG.00002
Tumor Necrosis Factor Antagonists
This document addresses the indications for a class of biologic disease -modifying
antirheumatic drugs (DMARDs) known as tumor necrosis factor (TNF) antagonists (inhibitors),
that target specific pathways of the immune system and either enhan ce or inhibit immune
response.
DRUG.00035
Panitumumab (Vectibix™)
This document addresses the indications for panitumumab in the treatment of oncologic
conditions.
DRUG.00036
Cetuximab (Erbitux®)
This document addresses the indications and criteria for the use of cetuximab in the treatment
of oncologic conditions.
DRUG.00038
Bevacizumab (Avastin®) for Non -Ophthalmologic Indications
This document addresses the indications and criteria for the use of bevacizumab in the
treatment of oncologic conditions and other non -ophthalmologic indications.
DRUG.00041
Rituximab (Rituxan®)
This document address rituximab (Rituxan) which is a genetically engineered monoclonal
antibody that targets a specific protein, known as CD20 found on the surface of normal and
malignant B-lymphocytes.
DRUG.00042
Ustekinumab (Stelara®)
This document addresses the FDA approved indications for ustekinumab, a biologic agent used
for the treatment of moderate to severe plaque ps oriasis and active psoriatic arthritis in
individuals 18 years of age or older.
DRUG.00047
Brentuximab vedotin (Adcetris™)
This document addresses the indications and criteria for the use of brentuximab vedotin.
November 2013
28 of 40
11/18/2013
04/02/14
1/14/2014
11/18/2013
04/02/14
1/14/2014
1/14/2014
1/14/2014
DRUG.00052
Pertuzumab (Perjeta™)
This document addresses the indications and criteria for the use of pertuzumab (Perjeta) which
is a recombinant humanized monoclonal antibody that targets the human epidermal growth
factor receptor 2 protein (HER2).
DRUG.00055
Denosumab (Prolia®, Xgeva™)
This document addresses the use of denosumab for the treatment of individuals with
osteoporosis, treatment induced bone loss, bone metastases, giant cell tumor of the bone, and
for all other indications, including multiple myeloma and rheumatoid arthritis which are currently
being studied.
GENE.00001
Genetic Testing for Cancer Susceptibility
This document addresses genetic testing to determine whether an individual is at risk for the
development of cancer based on a gen etic test. This document includes criteria which may be
used to evaluate the medical necessity of a specific genetic test when there is no other more
specific document.
GENE.00004
Janus Kinase 2 (JAK2) V 617F Gene Mutation Assay
This document addresses the Janus Kinase 2 (JAK2) Mutation Assay which has been
developed to aid in the diagnosis of myeloproliferative disorders.
GENE.00019
BRAF Mutation Analysis
This document addresses BRAF which encodes a protein kinase that is implic ated in
intracellular signaling and cell growth and is a direct downstream effector of KRAS. KRAS
analysis has been studied as a tool to predict response to therapy for individuals with
metastatic colorectal or anal cancer, as well as other conditions, in cluding, but not necessarily
limited to those with non small cell lung, esophageal, pancreatic, gastric and endometrial
cancer
GENE.00020
Gene Expression Profile Tests for Multiple Myeloma
This document addresses the proposed use of gene expr ession profile (GEP) tests (for
example, the My Prognostic Risk Signature™ [MyPRS™/MyPRS Plus™], Signal Genetics LLC,
New York, NY) to analyze an individual’s genomic information to assist in the risk stratification
and clinical management of individuals with multiple myeloma. Previously titled: MicroarrayBased Gene Expression Profile Testing for Multiple Myeloma
GENE.00025
Molecular Profiling for the Evaluation of Malignant Tumors
This document addresses molecular profiling for the evaluation of malignant tumors.
MED.00080
Cryopreservation of Oocytes or Ovarian Tissue
This document addresses oocyte and ovarian tissue cryopreservation which are alternative
techniques to embryo cryopreservation for women who would become infertile du e to
gonadotoxic therapies such as, chemotherapy, radiation therapy or surgery.
November 2013
29 of 40
1/14/2014
1/14/2014
11/18/2013
11/18/2013
1/14/2014
04/02/14
04/02/14
11/18/2013
1/14/2014
RAD.00017
External Beam Intraoperative Radiation Therapy
This document addresses the delivery of external beam radiation therapy during surgery.
Previously titled: Intraoperative Radiation Therapy
RAD.00043
Computed Tomography Scans with or without Computer Assisted Detection (CAD) for
Lung Cancer Screening
This document addresses standard CT, helical CT, multidetector CT, low -dose CT, and electron
beam CT devices.
RAD.00058
Real-Time Intra-Fraction Target Tracking during Radiation Therapy
This document addresses real-time intra-fraction target tracking, as an adjunct to the delivery
of radiation therapy.
SURG.00017
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT)
This document addresses stereotactic radiosurgery (SRS) and stereotactic body radiotherapy
(SBRT) which are non-invasive treatments where high doses of focused radiation beams are
precisely delivered to intracranial and extracranial targets, thus sparing adjacent tissue and
structure from irradiation.
SURG.00037
Treatment of Varicose Veins (Lower Extremities)
This document addresses various modalities for the treatment of valvular inc ompetence (i.e.,
reflux) of the greater or lesser saphenous veins and associated varicose tributaries as well as
telangiectatic dermal veins.
SURG.00055
Cervical Artificial Intervertebral Discs
This document addresses the use of FDA approved cervical artificial intervertebral discs as
treatments for symptomatic cervical disc disease when conservative treatment options have
been unsuccessful.
SURG.00060
Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
This document addresses the use of implantable neurostimulation techniques including spinal
cord stimulators and subcutaneous target stimulation (also known as peripheral subcutaneous
field stimulation).
SURG.00064
Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter
Defibrillator (CRT/ICD) for the Treatment of Heart Failure
This document addresses biventricular cardiac pacing to deliver cardiac resynchronization
therapy (CRT) to alleviate the symptoms of moderate to severe con gestive heart failure
associated with left ventricular dyssynchrony. It also addresses a hybrid device that combines
CRT with an implantable cardioverter defibrillator (ICD).
SURG.00065
Locally Ablative Techniques for Treating Primary and Meta static Liver Malignancies
This document addresses surgical excision, cryosurgical ablation, microwave ablation,
radiofrequency ablation and percutaneous ethanol injection as ablative techniques to treat
primary or metastatic cancer of the liver.
November 2013
30 of 40
1/14/2014
04/02/14
04/02/14
04/02/14
1/14/2014
1/14/2014
1/14/2014
1/14/2014
04/02/14
04/02/14
SURG.00066
Percutaneous Neurolysis for Chronic Neck and Back Pain
This document addresses percutaneous radiofrequency neurolysis (RF) pulsed radiofrequency
(PRF), lasers, cryodenervation and chemical neurolysis used to ablate facet sources of pain.
SURG.00068
Implantable Infusion Pumps
This document addresses the use of implantable infusion pumps for long -term, continuous or
intermittent drug infusion.
SURG.00103
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
This document addresses surgical devices used in the treatment of refractory open - angle
glaucoma (OAG) to reduce intraocular pressure (IOP).
SURG.00104
Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
This document addresses the proposed use of extraosseous subtalar joint implantation and
subtalar arthroereisis. Previously titled: Subtalar Arthroereisis
SURG.00129
Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apn ea
This document addresses surgical treatments for obstructive sleep apnea (OSA), such as
uvulopalatopharyngoplasty (UPPP), hyoid myotomy and jaw realignment surgery, laser surgery,
radiofrequency ablation, palatal implants, and other procedures.
TRANS.00018
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic
Hematopoietic Progenitor Cell Transplantation
This document addresses the use of donor lymphocyte infusions (DLI) after an allogeneic
hematopoietic progenitor cell transplant to treat a hematologic malignancy (e.g., cancer of the
blood or bone marrow, such as leukemia or lymphoma).
TRANS.00023
Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell
Dyscrasias
This document addresses hematopoietic stem cell transplantation in multiple myeloma,
amyloidosis and POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M protein,
and skin changes).
TRANS.00029
Hematopoietic Stem Cell Transplantation for Genetic Diseases an d Aplastic Anemias
This document addresses hematopoietic stem cell transplantation for genetic diseases and
aplastic anemias.
CG-DME-06
Pneumatic Compression Devices for Lymphedema
This document addresses the home use of pneumatic compression devices.
CG-DRUG-07
Hepatitis C Pegylated Interferon Antiviral Therapy
This document addresses the treatment of Hepatitis C infection with pegylated interferon
therapy, peginterferon alfa-2a or peginterferon alfa-2b as monotherapy, as dual therapy in
combination with ribavirin, or as triple therapy utilizing ribavirin and a serine protease inhibitor
(boceprevir or telaprevir).
November 2013
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04/02/14
1/14/2014
1/14/2014
4/2/2014
1/1/2014
1/14/2014
CG-MED-02
Esophageal pH Monitoring
This document addresses the use of standard catheter -based 24 hour and wireless– based 48
hour esophageal pH monitoring for all indications.
CG-MED-08
Home Enteral Nutrition
This document addresses enteral nutrition which consists of nutritional support given via the
alimentary canal directly or through any of a variety of tubes used in specific medical
circumstances.
CG-REHAB-02
Cardiac Rehabilitation (Outpatient)
This document addresses cardiac rehabilitation services that are provided on an outpatient
basis during the immediate post-discharge period and are considered Phase II Cardiac Rehab
Programs.
CG-SURG-25
Injection Treatment for Morton's Neuroma
This document addresses the treatment of Morton's neuroma which is a common, paroxysmal
neuralgia affecting the web spaces of the toes, typ ically the third web space.
CG-SURG-28
Transcatheter Uterine Artery Embolization
This document addresses transcatheter uterine artery embolization for the treatment of heavy
bleeding and pelvic pain associated with fibroid tumors and as a treat ment for other acute
pelvic hemorrhagic conditions such as uterine hemorrhage and ectopic pregnancy.
CG-SURG-32
Pain Management: Cervical, Thoracic and Lumbar Facet Injections
This document addresses facet blocks in the lower back (lumbar spin e), mid back (thoracic
spine) and neck (cervical spine). Facet joint injections (FJI) for painful axial spinal conditions
can be done for both diagnostic and therapeutic reasons.
REVIEW OF EXISTING MEDICAL POLICIES OR CLINICAL UM GUIDELINES
1/14/2014
1/1/2014
No change
to previous
effective
date
DME.00035
Electric Tumor Treatment Field (TTF)
This document addresses electrical fields known as “tumor treatment fields (TTF)” which are
created by low-intensity, intermediate frequency (100 – 200 kilohertz [kHz]) electric currents
delivered to the malignant tumor site by insulated electrodes placed on the skin surface.
DRUG.00053
Carfilzomib (Kyprolis™)
This document addresses the indications and criteria for the use of carfilzomib in the treatment
of multiple myeloma.
DRUG.00057
Canakinumab (Ilaris®)
This document addresses the indications for use of canakinumab which is a humanized
monoclonal antibody, interleukin-1 beta (IL-1ß) inhibitor drug that works by binding human IL 1ß and neutralizes its activity by blocking interaction with IL -1 receptors.
November 2013
32 of 40
No change
to previous
effective
date
No change
to previous
effective
date
1/14/2014
1/14/2014
1/14/2014
1/1/2014
1/1/2014
No change
to previous
effective
date
DRUG.00058
Pharmacotherapy for Hereditary Angioedema (HAE)
This document addresses four drugs that have been specifically developed for the treatment or
prevention of hereditary angioedema (HAE) attacks. Berinert® and Cinryze ® (both C1 esterase inhibitor, human) supplement deficient or defective C1 - esterase-inhibitor (C1-INH).
Kalbitor® (ecallantide) and Firazyr® (icatibant) act by inhibiting kallikrein or bl ocking bradykinin
receptors which are the primary mediators for HAE.
LAB.00030
Measurement of Serum Concentrations of Infliximab (IFX) or Antibodies -to-Infliximab
(ATI)
This document addresses the measurement of seru m concentrations of infliximab (IFX) and
antibodies-to-infliximab (ATI) in individuals with various conditions. Such testing has been
proposed as a way to detect individuals with poor or lack of response to infliximab treatment
with the goal of altering treatment to optimize outcomes.
MED.00032
Treatment of Hyperhidrosis
This document addresses various treatments of hyperhidrosis, a condition characterized by
excessive sweating.
MED.00055
Wearable Cardioverter Defibrillators
This document addresses the wearable cardioverter defibrillator, an external vest -like garment
device that is intended to perform the same tasks as an implantable cardioverter defibrillator
(ICD), without requiring any invasive procedures.
RAD.00004
Peripheral Bone Mineral Density Measurement
This document addresses peripheral bone density studies including the use of heel
densitometry, peripheral dual energy x-ray absorptiometry (pDEXA), radiographic
absorptiometry of the fingers, single energy X -ray absorptiometry (SEXA), single photon
absorptiometry (SPA), and dual X-ray and laser (DXL).
RAD.00011
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial
Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
This document focuses on the use of TACE or TAE for the treatment of primary liver
malignancies and metastatic tumors to the liver in addition to indications for use in specific
individuals who are awaiting liver transplantation or who may become eligible for liver
transplantation.
RAD.00033
Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors
This document addresses the use of SIRT, also known as radioembolization, which targets the
delivery of small beads or microspheres containing yttrium-90 to the tumor since liver tissue is
radiation-sensitive.
RAD.00035
Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography
Angiography (CCTA), Coronary Magnetic Resonance Angiography (MRA), and Cardiac
Magnetic Resonance Imaging (MRI)
November 2013
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This document addresses contrast-enhanced computed tomography angiography (CTA) of the
coronary arteries (coronary CTA or CCTA), magnetic resonance angiography (MRA) and
magnetic resonance imaging (MRI) of the coronary arteries
1/14/2014
1/14/2014
1/14/2014
1/14/2014
11/18/2013
1/14/2014
1/14/2014
No change
to previous
effective
date
1/14/2014
RAD.00041
Intensity Modulated Radiation Therapy (IMRT)
This document addresses intensity modulated radiation therapy (IMRT) which refers to a
technique of external conformal radiation planning and delivery, in which non-uniform intensity
beams produce unique radiation dose distributions that are intended to better target the lesion
with better sparing of surrounding normal tissue than with conventional radiation therapy (RT),
thereby limiting side effects.
RAD.00060
Digital Breast Tomosynthesis
This document addresses digital breast tomosynthesis (three -dimensional [3-D] mammography)
(DBT) which is being investigated as an adjunct and alternative to x-ray mammography for the
screening and diagnosis of breast cancer.
SURG.00024
Surgery for Clinically Severe Obesity
This document addresses a variety of surgical procedures intended for the treatment of
clinically severe obesity.
SURG.00059
Recombinant Human Bone Morphogenetic Protein
This document addresses the use of recombinant human bone morphogenetic protein (rhBMP)
as an alternative to autologous bone graft in various orthopedic procedures.
SURG.00089
Balloon Sinus Ostial Dilation
This document addresses the use of balloon sinus ostial dilation for surgery of the sinuses,
including for the treatment of sinusitis. This procedure involves insertion of a balloon catheter
device into a nasal sinus cavity to open blocked sinus ostia.
SURG.00092
Implanted Devices for Spinal Stenosis
This document addresses implanted devices for the treatment of spinal stenosis.
SURG.00098
Mechanical Embolectomy for Treatment of Acute Stroke
This document addresses mechanical embolectomy which is designed to reo pen occluded
vessels by extracting occlusive thrombi from the cerebral vasculature.
TRANS.00008
Liver Transplantation
This document addresses liver transplantation which is performed for individuals with end -stage
liver disease.
CG-DRUG-01
Off-Label Drug and Approved Orphan Drug Use
This document address off-label or "unlabeled" drug use of an FDA approved drug for uses
other than those listed in the FDA approved labeling or in treatment regimens or popu lations
that are not included in approved labeling.
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No change
to previous
effective
date
No change
to previous
effective
date
No change
to previous
effective
date
CG-DRUG-19
Progesterone Therapy as a Technique to Prevent Preterm Delivery in High -Risk Women
This document addresses the use of intramuscular injections of 17 -alpha hydroxyprogesterone
caproate or progesterone vaginal suppositories for the prevention of preterm birth in individuals
at high-risk for preterm delivery.
CG-MED-35
Retinal Telescreening Systems
This document addresses retinal telescreening for the detection of diabetic retinopathy.
CG-SURG-30
Tonsillectomy for Children
This document addresses tonsillectomy in children. This surgery has been widely accepted as
a treatment method for children with recurrent throat infections, tonsil hypertrophy and sleep disordered breathing (SDB), and obstructive sleep apnea (OSA).
CG-SURG-33
Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID)
This document addresses two surgical procedures: lumbar fusion (also referred to as spinal
fusion) and the implantation of lumbar artificial intervertebral disc (LAID) devices.
CG-SURG-34
Diagnostic Infertility Surgery
This document addresses the use of hysteroscopy and laparoscopy for diagnost ic work-up of
infertility.
CG-SURG-35
Intracytoplasmic Sperm Injection (ICSI)
This document addresses the use of intracytoplasmic sperm injection (ICSI) during an infertility
treatment cycle, allowing couples with male factor infertility to attain live birth rates, similar to
those achieved with in vitro fertilization (IVF) using conventional methods of fertilization.
ANNUAL REVIEW TOPICS
1/14/2014
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4/2/2014
1/14/2014
1/14/2014
DME.00034
Standing Frames
DME.00036
Ultraviolet Light Therapy Delivery Devices for Home Use
DRUG.00028
Intravitreal and Periocular Injection Treatment for Retinal Vascular Conditions
DRUG.00034
Insulin Potentiation Therapy
DRUG.00048
Eribulin mesylate (Halaven®)
DRUG.00051
Ziv-aflibercept (Zaltrap®)
GENE.00006
Epidermal Growth Factor Receptor (EGFR) Testing
GENE.00017
Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies
(including ARVD/C)
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1/1/2014
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1/14/2014
1/14/2014
1/14/2014
1/14/2014
1/14/2014
1/14/2014
1/14/2014
1/14/2014
GENE.00018
Gene Expression Profiling for Cancers of Unknown Primary Site
GENE.00022
In Vitro Companion Diagnostic Devices
GENE.00023
Gene Expression Profiling for Uveal Melanoma
GENE.00027
The Panexia™ Test for Oncologic Indications
LAB.00026
Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and
Recurrence
LAB.00028
gMS® Dx and the gMS® Pro EDSS Serum Biomarker Tests for Multiple Sclerosis
MED.00005
Hyperbaric Oxygen Therapy (Systemic/Topical)
MED.00082
Quantitative Sensory Testing
MED.00083
Melanoma Vaccines
MED.00085
Antineoplaston Therapy
MED.00089
Quantitative Muscle Testing Devices
MED.00095
Anterior Segment Optical Coherence Tomography
MED.00096
Low-Frequency Ultrasound Therapy for Wound Management
MED.00099
Electromagnetic Navigational Bronchoscopy
MED.00103
Automated Evacuation of Meibomian Gland
MED.00108
Transcranial Magnetic Stimulation for Non-Behavioral Health Indications
OR-PR.00003
Microprocessor Controlled Lower Limb Prosthesis
RAD.00029
CT Colonography (Virtual Colonoscopy) as a Screening or Diagnostic Tes t for Colorectal
Cancer
RAD.00036
MRI of the Breast
RAD.00037
Whole Body Computed Tomography Scanning
RAD.00047
Neutron Beam Radiotherapy
RAD.00049
Low Field and Conventional Magnetic Resonance Imaging (MRI) f or Screening,
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Diagnosing and Monitoring
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1/1/2014
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1/14/2014
1/14/2014
1/14/2014
RAD.00057
Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary
Imaging
RAD.00061
PET/MRI
RAD.00062
Intravascular Optical Coherence Tomography (OCT)
SURG.00008
Mechanized Spinal Distraction Therapy for Low Back Pain Previously titled: Mechanized
Spinal Distraction Therapy for Low Back Pain (VAX -D® Therapy, DRS® System, Accu-Spina
System™ IDD Therapy)
SURG.00044
Breast Ductal Examination and Fluid Cytology Analysis
SURG.00082
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the
Appendicular System
SURG.00095
Viscocanalostomy and Canaloplasty
SURG.00101
Suprachoroidal Injection of a Pharmacologic Agent
SURG.00114
Facet Joint Allograft Implants for Facet Disease
SURG.00120
Open Treatment of Rib Fracture(s) Requiring Internal Fixation
SURG.00128
Implantable Left Atrial Hemodynamic M onitoring Systems
SURG.00135
Radiofrequency Ablation of the Renal Sympathetic Nerves
TRANS.00013
Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
TRANS.00027
Hematopoietic Stem Cell Transplantation for Pe diatric Solid Tumors
TRANS.00028
Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non -Hodgkin
Lymphoma
TRANS.00033
Heart Transplantation
TRANS.00034
Hematopoietic Stem Cell Transplantation for Diabetes Me llitus
TRANS.00036
Stem Cell Therapy for Peripheral Vascular Disease
CG-DME-09
Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion
Pump During the Post-Operative Period
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CG-DME-12
Home Phototherapy Devices for Neonatal Hyperbilirubinemia
CG-DME-13
Lower Limb Prosthesis
CG-DME-16
Pressure Reducing Support Surfaces - Groups 1, 2 & 3
CG-DME-18
Home Oxygen Therapy
CG-DME-20
Orthopedic Footwear
CG-DME-21
External Infusion Pumps
CG-DME-22
Ankle-Foot & Knee-Ankle-Foot Orthotics (Braces)
CG-DME-23
Lifting Devices for Use in the Home
CG-DME-25
Seat Lift Mechanisms
CG-DME-26
Back-Up Ventilators in the Home Setting
CG-DRUG-18 Nesiritide (Natrecor®)
CG-DRUG-24
Repository Corticotropin Injection (H.P. Acthar® Gel)
CG-MED-24
Electromyography and Nerve Conduction Studies
Previously titled: Electromyography and Ner ve Conduction Studies (EMG/NCS)
CG-MED-39
Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures
Using Dual Energy X-Ray Absorptiometry
CG-SURG-09
Temporomandibular Disorders
CG-SURG-10
Ambulatory or Outpatient Surgery Center Procedures
CG-SURG-12
Penile Prosthesis Implantation
CG-SURG-15
Endometrial Ablation
CG-TRANS-02
Kidney Transplantation
CODING UPDATES OF EXISTING MEDICAL POLICIES OR CLINICAL U M GUIDELINES
1/1/2014
DRUG.00006
Botulinum Toxin
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1/1/2014
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04/02/14
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1/1/2014
1/1/2014
04/02/14
1/1/2014
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04/02/14
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1/1/2014
DRUG.00013
Intravenous Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
DRUG.00054
Ocriplasmin (Jetrea®) Intravitreal Injection Treatment
DRUG.00056
Ado-trastuzumab emtansine (Kadcyla™)
GENE.00026
Cell-Free Fetal DNA-Based Prenatal Screening for Fetal Aneuploidy
LAB.00029
AmniSure® ROM (Rupture of Membranes) Test
MED.00064
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of
Atrial Fibrillation (Radiofrequency and Cryoablation)
MED.00107
Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum
Disorders and Rett Syndrome
RAD.00059
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial
Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous
System (CNS) and Spinal Cord
SURG.00011
Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft
Tissue Grafting
SURG.00025
Cryosurgical Ablation of Solid Tumors Outside the Liver
SURG.00047
Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
SURG.00054
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic
Dissection and Aortic Transection
SURG.00062
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion
Syndrome
SURG.00077
Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
SURG.00106
Ablative Techniques as a Treatment for Barrett’s Esophagus
SURG.00121
Transcatheter Heart Valves
SURG.00122
Venous Angioplasty with or without Stent Placement
SURG.00133
Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
CG-BEH-01
Assessment for Autism Spectrum Disorders and Rett Syndrome
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04/02/14
CG-DRUG-08
Pharmacotherapy for Gaucher Disease
04/02/14
CG-DRUG-09
Immune Globulin (Ig) Therapy
CG-DRUG-16
White Blood Cell Growth Factors
CG-REHAB-06
Speech-Language Pathology Services
04/02/14
1/1/2014
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