Download Provider News April 2015

APRIL 2015
Provider news
For participating physicians, dentists, other health care professionals, facilities and their office staff
WHAt’S InSIde
Click on a title below to read the article.
ICD-10 readiness is critical ................. 1
About Provider News/Stay up to date ..... 2
AIM servicing provider enhancement ... 2
Pre-authorization list updates.............. 3
New joint and pain management
program ............................................ 3
Physical Medicine Program changes......4
Reimbursement policy updates ............ 5
New reimbursement policies................6
Non-reimbursable services .................6
Medical policy updates .....................7-8
Medical and reimbursement
policy reviews ....................................8
Coding Toolkit updates........................8
Monthly updates to medical and
dental policies ...................................9
Clinical Practice Guidelines review.......9
Join our medical policy discussion ........9
Medication policy updates ................. 10
RegenceRx adopts OmedaRx name .......11
Obtaining current member cards.........11
Submit corrected claims
electronically ....................................12
Administrative Manual updates ...........12
National Infant Immunization week .... 13
Peer-to-peer changes ....................... 13
Referring to in-network providers...... 13
This symbol indicates articles that include critical information.
BridgeSpanHealth.com
ICD-10 readiness
is critical
Implementation of the International Classification of Diseases 10th
revision (ICD-10) is fast approaching, with October 1, 2015 now just six
months away. Are you ready to submit all medical claims with dates
of service on or after October 1 using ICD-10 codes? If you have not
already begun to prepare, start now by working with your billing staff,
practice management vendor or clearinghouse; training your staff and
practicing coding. Completion of ICD-10 readiness activities will help
ensure your claims can be processed accurately and efficiently after
the implementation.
Below are some of the many resources available to help you get ready:
• Idaho ICD-10 Collaborative: idahoicd10.org
• ICD-10 Information Central on OneHealthPort: https://www.
onehealthport.com/content/icd-10-information-central/
• ICD-10 Resources, including testing information, on the Utah Health
Information Network (UHIN) website: uhin.org/icd-10
• Preparing for ICD-10 on the Availity website: availity.com/
resources/icd-10/icd-10-revenue-cycle-management/#testing
• Road to 10, a CMS online tool designed to help small practices
jumpstart their ICD-10 transition, plus webinars, flyers and other
information: cms.gov/Medicare/Coding/ICD10/index.html
• In addition, our provider website provides many helpful resources,
including how to register for free testing, answers to frequently
asked questions and an ICD-10 flyer: Claims and Payment>Claims
Submission>ICD-10
We appreciate that many providers and facilities are actively preparing
for the upcoming transition. For those that have not yet begun, it is
critical that you start your ICD-10 readiness activities now so you can
avoid claims processing and payment issues that could put the financial
health of your office or facility at risk. ■
1
About Provider
News
This publication includes important updates for
you and your staff, in addition to information about
updates to policies and procedures, and notices we
are contractually required to communicate to you. In
the Table of Contents on page 1, this symbol indicates
articles that include critical updates . In order to save
you time, you can click on the titles to go directly to
specific articles. You can also return to the Table of
Contents from any page by clicking on the link at the
bottom of each page.
Issues are published by the first of the following months:
February, April, June, August, October and December.
Medical and Dental Policy Bulletin coming
in May
Beginning May 1, 2015, we will publish a monthly
Medical and Dental Policy Bulletin as a supplement
to this bi-monthly provider newsletter. This monthly
bulletin will provide you with updates to medical and
dental policies, including any policy changes we are
contractually required to communicate to you. See
the Monthly updates to medical and dental policies
beginning in May article on page 9 for
more information.
Subscribe today
It’s easy to subscribe to Provider News. Simply complete
the subscription form available in the Library section of
our provider website.
Stay up to date
View the What's New section
on the home page of our
website for the latest news
and updates.
AIM servicing
provider
enhancement
Beginning May 1, 2015, servicing providers (free­
standing or hospital facilities that perform imaging
procedures) can initiate radiology order number requests
via Aim Speciality Health's (AIM’s) ProviderPortal,
providerportal.com, for our Radiology Quality Initiative
(RQI) program. Previously, servicing providers could only
request a radiology exam authorization by phone. The
ProviderPortal is available 24 hours a day, seven days
a week.
Learn more about our RQI and Advanced
Imaging Authorization programs on our website:
Programs>Medical Management>Radiology
Quality Initiative.■
Encourage everyone in your office to sign up.
Share your feedback
Is Provider News meeting your needs? Share
your feedback by sending an email to provider_
[email protected]. ■
2
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Pre-authorization list updates
In order to make our pre-authorization list easier to search by code, we have removed any PDF lists related to our
Radiology Quality Initiative, Physical Medicine and Sleep Medicine Programs. We have, instead, created sections
that show all the applicable codes that require authorization related to these programs. We have also noted the
contact information when the authorization is required through CareCore National, LLC (CareCore) or AIM Specialty
Health (AIM).
We added clarifying concurrent review language under “Payment implications for failure to timely notify or
pre-authorize services” section related to how we handle elective services that require pre-authorization that need
to occur during the course of an inpatient admission. Under the “Notification timeframe reimbursement” section
we have clarified “compelling evidence” and added a bullet that addresses when a surgery which requires
pre-authorization occurs in an urgent/emergent situation.
The following updates apply to our Pre-authorization List:
PRoCeduRe/MedICAL PoLICy
CodeS
Genetic Testing; Hereditary Hearing Loss (Genetic
Testing #36)
Added CPT 81252, 81253, 81254
Effective March 1, 2015
Laboratory and Genetic Testing for Use of
Added CPT 81401
5-Flourouracil in Patients With Cancer (Laboratory #64) Effective March 1
Genetic Testing; Rett Syndrome
(Genetic Testing #68)
Added CPT 81404, 81405, 81406
Effective April 1
Sacroiliac Joint Fusion (Surgery #193)
Adding CPT 27280
Effective May 1
Our pre-authorization list is available in the Pre-authorization section of our website. Please review the list and
pre-authorize services accordingly. ■
New joint and pain management
program
We are expanding our Physical Medicine Program effective for dates of service on or after July 1, 2015. The
program will include an authorization process for interventional pain management and arthroscopy/arthroplasty.
Our goal is to partner with affected providers to help our members prepare for procedures, navigate the health care
system and engage in their care. We partnered with CareCore National LLC (CareCore) to administer this program,
as a component of our overall Medical Management program.
We will add specific CPT/HCPCS codes to our Pre-authorization List for joint and pain management to reflect
authorization requirements for dates of service on or after July 1:
• You will be required to contact CareCore to receive an authorization for all specified CPT/HCPCS codes via their
website, carecorenational.com, or by phone at (855) 252-1115 and can begin requesting authorizations on
June 15 for dates of service on or after July 1.
• Failure to obtain authorization or notification for required services by the servicing provider will result in claim
non-payment and will become a provider liability.
Additional program details, including links to our pre-authorization list can be found on our website:
Programs>Medical Management>Physical Medicine. ■
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3
Upcoming Physical Medicine Program changes
Thank you for your patience and willingness to work with us
over the past year as we introduced and/or revised guidelines
for our Physical Medicine Program. Our provider community
and our members have provided valuable feedback that helps
us create a better experience for you and your patients.
As a result, we are adjusting the program, effective for
authorization requests received on or after July 1, 2015,
to deliver a more uniform experience regardless of the
in-network provider seen.
key RevISIonS to tHe PRogRAM ARe:
• Chiropractic and physical therapy (PT) providers will no
longer be assigned to a tier: A/B/C.
• All providers will follow the same authorization process
for initial notification and for submission of clinical
documentation when medical necessity review
is required.
Providers will still be able to view their performance results
relative to peers on the Practitioner Performance Summary
dashboard. At this time, the dashboard on CareCore National,
LLC's (CareCore's) website, carecorenational.com, allows
providers to monitor how they perform on several efficiency
measures relative to their peers. We recently asked providers
to voluntarily begin submitting outcome data on their
authorization requests. This will allow the collected outcome
measures to eventually be added to the dashboard.
Thank you for your participation and feedback as we partner
to ensure members receive the care they need, when they
need it at an affordable cost.
View additional information about the Physical
Medicine Program on our website: Programs>Medical
Management>Physical Medicine. ■
• All additional authorization requests will require clinical
submission and medical necessity review.
- Initial authorization request (Notification)
- Eligible for a six-visit episode of care (this is based
upon our data showing average number of
visits used)
- PT providers will be eligible for additional visits in
the episode of care, when a qualifying condition is
presented (e.g., Post-Operative) and not based on
the specific provider requesting authorization
- Subsequent request for a new episode (new condition or gap in care of at least 60 days) - Eligible for a six-visit episode of care
- PT providers will be eligible for additional visits for
the episode of care based on a qualifying condition
and not based on the specific provider requesting
authorization (e.g., Post-Operative)
- Subsequent request for an existing episode
- Clinical submission for medical necessity review will
be required
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Reimbursement policy updates
The following reimbursement policies will be updated
effective July 1, 2015. The updated policies will be
available on our website on April 2: Library>Policies and
Guidelines>Reimbursement Policy.
Modifier 62;Two Surgeons/Co-surgeons
(Modifier #113)
This policy will be revised as part of our annual review
to clarify our reimbursement guidelines and when to
bill assistant surgeon modifiers. In addition, we will
not reimburse for an additional assistant surgeon on a
procedure where reimbursement has been provided
as co-surgeons.
Urine Drug Testing (Medicine #106)
This reimbursement policy will be updated with a title
change (previously Drug Screening Qualitative and
Quantitative) to include both drug screening and drug
testing. We will also:
• Add a daily unit maximum edit of ‘1’ to all HCPCS drug
assay codes G6030-G6057
• Limit HCPCS G6030-G6057 to one unit per patient
encounter; up to a maximum of two units regardless of
the number of drugs, drug classes or drug panels tested
• Require providers to bill HCPCS G codes G0431,
G0434, G6030-G6058 instead of CPT codes
80300-80304, 80320-80377 and 83992 for both
drug screening and drug testing
We will be adding the non-reimbursable services edit to the
following immunization codes on July 1:
• HCPCS J3520, S0023, S0081, S5013, S5014
• CPT 90653, 90660, 90702, 90721, 90735, 90739
• HCPCS J0205, J0745, J0890, J1330, J1600, J1655,
J1945, J3472, J7196, J7505, J7513, J8562, J8565,
J9010, J9160, J9212, J9300, Q2034, Q2039, Q9954
The codes listed above describe products that are no
longer produced by drug manufacturers and are, therefore,
obsolete. Claims should be submitted with the correct
product CPT or HCPCS code for what is being administered
to be eligible for payment. For example, the FluMist
trivalent formula, billed with CPT 90660 is no longer
manufactured. Instead, the current FluMist quadrivalent is
now reported under CPT 90672.
We are also adding a statement to this policy indicating
CPT 80300-80304; 80320-80377 and 83992 are no
longer reimbursable. We require the use of the appropriate
HCPCS G codes. See the information on the left regarding
the Urine Drug Testing (Medicine #106) policy.
View specific CPT and HCPCS codes that are considered
non-reimbursable services in the Clinical Edits by Code
List located on our website: Claims and Payment>Claims
Submission>Coding Toolkit. ■
• Reimburse HCPCS G6058 when the initial qualitative
screening indicates drug abuse, misuse or diversion
or when the immunoassay (qualitative) test is not
commercially available
Non-Reimbursable Services
(Administrative #107)
This policy explains invalid services that are
non-reimbursable. If billed, non-reimbursable services are
not payable, are denied as a provider write-off and cannot
be billed to our member. This policy applies to ambulatory
surgical centers, physicians, laboratories, other qualified
health care professionals, hospitals and other facilities.
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5
New reimbursement
policies
This policy applies to hospitals and ambulatory
surgical centers.
For more information, view these reimbursement
policies on our website: Library>Policies and
Guidelines>Reimbursement Policy. ■
The following new policies are effective July 1, 2015.
Ambulance Guidelines (Administrative #121)
The policy is based upon CMS requirements and outlines
our reimbursement guidelines for ground ambulance and
air ambulance services, including:
• HCPCS coding
• Acceptable ambulance modifiers
• What services are included in ambulance transportation
Reimbursement of Medications for Facilities
(Facility #102)
Medications must be recorded in the patient’s Medication
Administration Record (MAR) or the electronic version of
the MAR to be eligible for reimbursement. Medications
not documented in this manner are not reimbursable.
Reimbursement for medications, regardless of route of
administration, is governed by this policy. Drugs that
are administered as part of a procedure are not
separately reimbursable.
Non-reimbursable
services
Our Non-Reimbursable Services (Administrative #107)
reimbursement policy which explains invalid services that
are considered to be non-reimbursable, is located on our
website: Library>Policies and Guidelines. If billed,
non-reimbursable services are considered not payable,
are denied as a provider write-off and cannot be billed to
our member.
View specific CPT and HCPCS codes that are considered
non-reimbursable services in the Clinical Edits by Code
List located on our website: Claims and Payment>Claims
Submission>Coding Toolkit. ■
Anesthesia care documented in a graphic anesthesia record
which denotes the anesthesia care given, the drugs and
fluids administered and the patient’s responses to the
anesthesia care are eligible for reimbursement based upon
the terms of this policy.
Implant Supplies (Facility #101)
Our health plan considers reimbursement for a covered
surgical implant procedure to include all related implant
supplies that are necessary to perform the implant
procedure. Implant supplies are not eligible for
separate reimbursement.
We will not reimburse implant supplies that include, but
are not limited to:
• Implant supplies or components that are dropped or
opened and then found to be incorrect and not used.
• Implants or implant components that are implanted
then removed (e.g., implant screw removed and
replaced when the wrong length of screw is used on
a plate.)
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Medical policy updates
Listed below are summaries of recent changes to our medical policies. View all detailed policies on our
website: Library>Policies and Guidelines. This list does not include medications.
neW oR uPdAted InveStIgAtIonAL oR MedICAL neCeSSIty PoLICy CRIteRIA
ALLIed HeALtH
Administrative Guidelines to Determine Dental versus
Medical Services (#35)
Clarified general anesthesia and facility criterion
genetIC teStIng
Assays of Genetic Expression in Tumor Tissue as a
Technique to Determine Prognosis In Patients With
Breast Cancer (#42)
Updated criteria
Evaluating the Utility of Genetic Panels (#64)
Added new panel tests
Genetic and Molecular Diagnostic Testing (#20)
Changed criteria to include panel testing and added a list of required
information for review
Genetic Testing for Hereditary Breast and/or Ovarian
Cancer (#02)
Updated policy criteria with additional populations, including
invasive and ductal carcinoma in situ being considered as
breast cancer
Genetic Testing for Hereditary Hearing Loss (#36)
New policy
KRAS, NRAS, and BRAF Mutation Analysis in
Colorectal Cancer (#13)
Added NRAS to investigational criterion
LABoRAtoRy
Laboratory and Genetic Testing for Use of
5-Fluorouracil (5-FU) in Patients with Cancer (#64)
Expanded policy to include genetic mutation testing
(e.g., TheraGuide)
MedICIne
Fecal Microbiota Transplantation (#154)
New policy
New and Emerging Medical Technologies and
Procedures (#149)
Added CPT 0075T, 0076T, 0329T and C9742 to policy; Removed
CPT 44705 and HCPCS G0455 from policy and moved to new Fecal
Microbiota Transplantation (#154) policy
MentAL HeALtH
Applied Behavior Analysis for the Treatment of
Autism (#18)
Modified criteria and added a list of required information for review
SuRgeRy
Bariatric Surgery (#58)
Clarified criteria regarding reoperation and gastric
banding procedures
Baroreflex Stimulation Devices (#183)
Added heart failure as investigational; Noted member contract may
apply to treatment of consequences of non-covered services
Gastroesophageal Reflux Surgery (#186)
Revised criteria regarding fundoplication in conjunction with
paraesophageal hiatal hernia repair and achalasia
Saturation Biopsy for Diagnosis and Staging of
Prostate Cancer (#170)
Clarified criterion definition of saturation biopsy as not limited to 20
or more core tissue samples
Spinal Cord Stimulation (#45) (Formerly: Spinal Cord Added heart failure as investigational indication
Stimulation for Treatment of Pain)
continued on page 8
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7
Medical policy updates continued from page 7
neW oR uPdAted InveStIgAtIonAL oR MedICAL neCeSSIty PoLICy CRIteRIA effeCtIve
JuLy 1, 2015
MedICIne
Surgeries for Snoring and Obstructive Sleep Apnea
Syndrome in Adults (#166)
Defining "adult" as 18 and older; Adding hypoglossal nerve
stimulation as investigational; Removing requirement for
failure of maximum treatment of underlying disease
tRAnSPLAnt
Isolated Small Bowel Transplant (#09)
Adding retransplant and updating criteria for patients who
tolerate Total Parenteral Nutrition (TPN) to apply to
any age
Medical and reimbursement
policy reviews
Our medical and reimbursement policies are reviewed due to the following:
• Updates from CMS
• Regularly scheduled review
• Changes in published scientific literature
• Requests from physicians, other health care professionals or facilities
• Addition, deletion or revision of codes published in the CPT, HCPCS and ICD-9-CM manuals ■
Coding Toolkit updates
Our Coding Toolkit is a listing of our clinical edits and includes information specific to Medicare’s National Correct
Coding Initiative (NCCI). These coding requirements are updated and posted on a monthly basis in the Clinical Edits by
Code List in the Coding Toolkit.
In addition, our Correct Code Editor (CCE), also located in the Coding Toolkit, has additional CPT and HCPCS code
pair edits that we have identified and are used as a supplement to Medicare’s NCCI. This supplemental list of code
groupings in the CCE is updated quarterly in January, April, July and October.
The Coding Toolkit is available on our website: Claims and Payment>Claims Submission>Coding Toolkit.
As a reminder, we perform ongoing retrospective review on claims history that should be processed against our clinical
edits. We follow our existing notification and recoupment process when we have overpaid based upon claims processing
discrepancies and incorrect application of the clinical edits. View the notification and recoupment process on our
website: Claims and Payment>Receiving Payment>Overpayment Recovery.
Please remember to review your current coding publications for codes that have been added, deleted or
changed and to use only valid codes. ■
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Monthly updates to
medical and dental
policies beginning
in May
Beginning May 1, 2015, we will begin publishing a monthly Medical and Dental Policy Bulletin as a supplement to the bi-monthly provider newsletter. This monthly bulletin will include updates to medical and dental policies, including any policy changes we are contractually required to communicate to you.
This bulletin will be available by the first of each month and
will be emailed to those who have subscribed. To subscribe,
please complete the subscription form available on the home
page of our website.
You can view our monthly medical and dental policy updates
along with current and previous issues of our bi-monthly
newsletter online. Easily access them from the home page or
Library section of our website: Library>News and Updates. ■
Join our medical
policy discussions
We welcome your input on our
draft medical policies. Please
consider completing the Contact
Medical Policy Staff request form on
our website: Library>Policies and
Guidelines>Medical Policy. Make sure
to check the box to be contacted on a
regular basis to review and comment on
our policies, and we will send the draft
policies to you for review. All feedback
is confidential and will not be shared.
Clinical Practice
Guidelines review
Clinical Practice Guidelines are systematically developed
statements on medical and behavioral health practices that help
physicians and other health care professionals make decisions
about appropriate health care for specific conditions. View these
guidelines on our website: Library>Policies and Guidelines.
The following practice guidelines were recently reviewed and had
no changes:
• Perinatal Care
• Depression: Screening and Treatment
• Preventive Services Guidelines for Adults
• Preventive Services Guidelines for Children and Adolescents
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Medication policy updates
Listed below is a summary of upcoming changes to our medication policies. View all policies in the Medication Policy
Manual, available on our website: Library>Policies and Guidelines. This list does not include other medical policy
updates. The formularies or preferred medication lists for our products are available at omedarx.com.
If CMS has designated a medication as product not available (PNA) for ninety days, we consider it a
non-reimbursable service (NRS) and not eligible for reimbursement. We review medication codes quarterly and
update any drugs with a PNA code status to NRS.
Since medical offices or facilities may have small quantities already in stock, we provide the 90-day timeframe
to allow for use of any existing medication supply. View our Non-Reimbursable Services (Administrative #107)
reimbursement policy in the Reimbursement Policy Manual available on our website: Library>Policies and Guidelines.
Also, read the related Reimbursement policy updates article in this issue.
New medication policy effective July 1, 2015:
MedICAtIon PoLICy
deSCRIPtIon of neW PoLICy on exIStIng MedICAtIon
• Fabrazyme , agalsidase beta (dru391)
Limiting administration to non-hospital outpatient settings
(e.g., provider’s office, infusion centers, home infusion) for Idaho,
Oregon and Washington members. Administration in a hospital
outpatient setting will be considered not medically necessary.
®
• Lumizyme , alglucosidase alfa (dru392)
®
Medication policies changing effective July 1:
MedICAtIon PoLICy
deSCRIPtIon of neW PoLICy on exIStIng MedICAtIon
Prolia , denosumab (dru223)
Limiting administration to non-hospital outpatient settings
(e.g., provider’s office, infusion centers, home infusion) for Idaho,
Oregon and Washington members. Administration in a hospital
outpatient setting will be considered not medically necessary.
Intra-articular Hyaluronic Acid Derivatives
(dru351):
Intra-articular hyaluronic acid derivatives are considered not
medically necessary or investigational for all uses, including, but
not limited to:
®
• 1% sodium hyaluronate (Euflexxa®)
• Osteoarthritis of the knee
• high molecular weight hyaluronan
(Orthovisc®)
• Osteoarthritis of joints other than the knee
• hylan G-F 20 (Synvisc , Synvisc-One ,
Gel-One®, Monovisc®, Hyalgan®, Supartz®)
®
®
• Cosmetic indications such as wrinkles
In the February 2015 issue of this newsletter, we notified you of changes that limit the administration of specific
medications to non-hospital outpatient settings effective May 1, 2015. We have since removed this language from
the following policies, but all other policy updates remain in place:
• Kalbitor®, ecallantide (dru375)
• Cinryze®, C1 Inhibitor (human) (dru172)
• Ruconest®, recombinant human C1 esterase inhibitor (dru373)
• Berinert®, plasma-derived C1 esterase inhibitor (dru374)
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RegenceRx adopts OmedaRx name
As of April 1, 2015, all Pharmacy Benefit Management
(PBM) services for our members will operate solely under
the OmedaRxTM brand, and the RegenceRx brand will
retire. We expect this to have a minimal impact on our
providers and members:
• Member cards and customer service numbers remain
the same.
• Staff and services remain the same for our members
and providers.
• All prescription-related correspondence will continue
to be branded as BridgeSpan.
• Medication policies, prior authorization information
and other provider materials that have been available
on the RegenceRx website will be available on the
OmedaRx website, omedarx.com.
Obtaining current
member cards
is critical
Remember, your patients’ member card information can
change throughout the year. Therefore, it is critical that you
always ask for your patients’ most current member card when
they come into your office or facility for care. Our member
cards include important information that will help
you determine:
• Who to contact for assistance
• Current member identification numbers
• The provider network, product and/or types of coverage
your patient has
Please make a photocopy of the front and back of the member
card at each visit and place it in the patient's file.
You can also access our free, secure web portals on our
website’s home page. Sign in to:
• Verify the member number
• Verify patient coverage, benefit types and eligibility
effective dates
• View real-time deductible, coinsurance maximum, and
dental and medical multi-year accumulation amounts
• View detailed patient benefit information, including office
visit copays and major medical information (Note: Copay
amounts for your patients may change upon plan renewal.
Please verify the copay amount prior to your patient’s visit.)
View more information on our website:
Claims and Payment>Identifying Members. ■
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11
Submit
corrected claims
electronically
Did you know that corrected claims must be submitted
electronically? We require any claim that has a change or
correction to any information (e.g., the amount charged,
procedure or diagnostic code[s], date[s] of service,
member name, etc.) to be submitted electronically along
with standard medical and dental claims.
Decrease claims processing time
In two quick steps, you can submit a corrected claim in
an electronic format:
1. In the 2300 Loop, the CLM segment (claim
information), CLM05-3 (claim frequency type code)
must indicate one of the following qualifier codes:
- "7" – REPLACEMENT (Replacement of Prior Claim)
- "8" – VOID (Void/Cancel of Prior Claim)
2. The 2300 Loop, the REF segment (Claim
Information), must include the original claim number
issued to the claim being corrected. Note: The
original claim number is listed on your electronic
claims receipt confirmation report or on the electronic
remittance advice.
If you use a software vendor for electronic transactions,
please share this information with them. They can then
advise you where, in their particular software, these two
fields reside.
Administrative
Manual updates
On April 1, 2015, the following sections of the manual
will be updated.
Care Management:
• Changed RegenceRx name and website to OmedaRx
• Updated Physical Medicine Program to include
upcoming pain and joint management
• Changed peer-to-peer timeframe from 10 to 15
calendar days and added clarifying language
Facility Guidelines:
• Idaho, Oregon and Utah:
- Removed outdated content
- Added ambulatory surgical center content
- Documented existing processes in the Durable
Medical Equipment (DME) section
• Washington:
- Removed outdated content
- Revised the rental/purchase guidelines section
- Updated ambulatory surgical center facility
accreditation language
Our manual sections are available to view and print in
the Library section of our website. ■
Additional information is available on our website: Claims
and Payment>Claims Submission and
Benefit Coordination. ■
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National Infant
Immunization Week –
April 18-25, 2015
National Infant Immunization Week (NIIW) is an annual event to highlight the
importance of protecting infants from vaccine-preventable diseases. Since
1994, local and state health departments, national immunization partners,
health care professionals, community leaders and the Centers for Disease
Control and Prevention (CDC) have worked together during NIIW to highlight
the positive impacts of vaccinations on the lives of infants and children, and
to call attention to immunization achievements.
Please encourage your patients at every visit to follow the recommended
immunization schedule, and emphasize to parents and caregivers the
importance of routine and timely vaccination. For more information, please
view these helpful resources:
• CDC’s website includes immunization schedules to order or print,
recommendations to consult, and tools to download at
cdc.gov/vaccines/schedules.
• CDC’s NIIW page includes information about NIIW, including promotional
and educational resources, at cdc.gov/vaccines/events/niiw/index.html.
• Scientific AmericanTM recently published an article, How to get more
parents to vaccinate their kids at scientificamerican.com/article/how-to­
get-more-parents-to-vaccinate-their-kids.
• A guide for Talking with Parents about Vaccines for Infants: Strategies for
Health Care Professionals is available at cdc.gov/vaccines/hcp/
patient-ed/conversations/downloads/talk-infants-color-office.pdf.
Peer-to-peer changes
The timeframe for requesting a peer-to-peer discussion has changed from 10
to 15 calendar days from the letter determination date and before an appeal
has been initiated.
A peer-to-peer discussion is a telephone conversation between the provider
requesting coverage of the service and a BridgeSpan medical director.
This process is intended to be a dialogue about a utilization management
determination (pre-authorization) before services are performed. Contact
Customer Service to request a peer-to-peer discussion. Note: A peer-to-peer
discussion does NOT take the place of an appeal.
More details about peer-to-peer discussions are located in the Care
Management section of our Administrative Manual on our website:
Library>Administrative Manual. ■
BridgeSpanHealth.com
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Referring to
in-network
providers saves
members money
As a reminder, except in cases
of an emergency, you must refer
members to participating
in-network medical and
dental providers.
By making referrals to in-network
providers and facilities, you
help your patients make more
informed choices about how they
spend their health care dollars.
By staying in-network, your
patients will:
• Minimize their out-of-pocket
expenses
• Receive the highest level of
medical and dental benefits
• Ensure that they have convenient
access to quality services
Referrals to non-participating
providers should only be made
after notifying the member in
writing that services may not be
covered or may result in higher
out-of-pocket costs.
Use the Find a Doctor link on
our website to locate in-network
providers. Locate providers by
name, location or specialty type.
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Our Customer Service team is dedicated to helping you and can be reached at
1 (855) 522-8894. As a participating provider, you also have access to our Provider
Relations team who will assist you and your staff with questions and claims issues.
Visit the Contact Us section of our website for a complete list of phone numbers and
email addresses.
editors
Kathy Neys Hove, Publications Editor and Writer
Sara Perrott, Managing Editor, Writer
Paula Russell, Writer and Designer
Sheryl Johnson, Writer
BridgeSpan Health Company is a Qualified Health Plan issuer on Washington Healthplanfinder, Cover Oregon, Your Health Idaho, and the Utah Individual Marketplace.
© 2015 BridgeSpan Health Company
BridgeSpanHealth.com
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