REVIEW - Hcsc.bcbsil
REVIEWSMFor contracting institutional and professional providersFEBRUARY 2013What’sInside?Manipulation Procedures Performedunder Anesthesia 2In the Know: Taxonomy Code Reminders forProviders with Multiple Specialties 2Administrative SimplificationOperating Rules Update 3ICD-10 Office Changes Map 4, 5Provider Learning Opportunities 62012 HMO Member Survey Results 6, 7Medicare Part D Pharmacy Update: RanbaxyPharmaceuticals Atorvastatin Recall 7New Account Groups 7Be Smart. Be Well. : Discussing Sexual Health 8ICD-10 Updates and ResourcesThe October 2012 Blue Review called forvolunteer panelists for an upcoming discussionregarding the transition to ICD-10. The paneldiscussion may take place later in 2013, ratherthan in the first quarter of 2013, as previouslyreported.We continue our efforts to provide you witheducational resources to help you plan yourtransition to ICD-10. Turn to pages 4 and 5of this month’s Blue Review for an illustrationof the potential impact of ICD-10 on your practice.A Letter from Wes Chick, Our New Senior Directorof Provider RelationsDear Provider:I want to introduce myself to you as the new leader ofProvider Relations at Blue Cross and Blue Shield ofIllinois (BCBSIL). I am replacing Gail Larsen, whoserved in this capacity for over 20 years and recentlyretired in December 2012. While Gail will be sorelymissed, I am assuming this important role with thevigor and attention you have come to expect from ourorganization over the years regarding issues that areimportant to the provider community.With the anticipated reductions in Medicare andMedicaid fee-for-service unit prices, the pressuresproviders and health care delivery systems are facingare higher than I have seen in my 20 years workingin managed care, large provider organizations,Blue Cross and Blue Shield of Texas (BCBSTX) andnow BCBSIL.Additionally, the complexity of the Affordable Care Act (ACA) and the deliverychannels of health insurance through public health insurance exchanges have createda tremendous “unknown” for the provider community. All industries within the healthcare continuum are being affected as we move to this new and evolving environment.At BCBSIL, we will be the organization standing right beside you, as we face the manychallenges ahead together. We intend to help lead the way with our innovativeapproaches to compensation models for the delivery of quality, affordable health carefor our members, your patients.I am looking forward to supporting the great tradition of excellent provider relationsyou have experienced to date with our incredible team of Provider NetworkConsultants. My goal is to continue to foster and enhance your experience with BCBSILby building on the relationships and service we have developed with you and yourteams over the last 75 years.Visit our Website at bcbsil.com/prOVIDER
Manipulation ProceduresPerformed underAnesthesiaBCBSIL periodically performs audits ofprovider-submitted claims to determine ifthere may be a need for provider outreachor training. Recent claim audits haverevealed an upward trend in thesubmission of claims to BCBSIL with thefollowing Current Procedural Terminology(CPT ) codes for manipulation proceduresperformed under anesthesia:22505 Manipulation of Spine24300 Manipulation of Elbow (Left & Right)25259 Manipulation of the Wrist (Left & Right)27275 Manipulation of the Hip Joint (Left & Right)27570 Manipulation of Knee Joint (Left & Right)27860 Manipulation of Ankle (Left & Right)27194 Closed Treatment of Pelvic RingThe BCBSIL Medical Policy for SpinalManipulation under Anesthesia(THE803.016) states: “Spinalmanipulation under any kind ofanesthesia, with or withoutmanipulation of other joints (e.g., hipjoint), is considered experimental,investigational and unproven.”These procedures are therefore ineligiblefor benefit coverage for PPO Members.If a Primary Care Physician (PCP)/Participating Specialist Provider (PSP)deems such procedures to be medicallynecessary for an HMO member, it may bea covered benefit, with a referral.Active and pending medical policiescan be viewed in the Standards andRequirements/Medical Policy section ofour website at bcbsil.com/provider. Whilemedical policies may be used as a guide,HMO providers should refer to the HMOScope of Benefits in the BCBSIL ProviderManual, available in the Standards andRequirements section of our Providerwebsite.IN THEKNOW Taxonomy Code Reminders for Providerswith Multiple SpecialtiesThe Health Care Provider Taxonomy Code set is intended to identify the provider’s type andspecialization in HIPAA-standard transactions. The code set comprises unique 10-characteralphanumeric codes structured into three levels—provider type, classification and area ofspecialization—to enable individual, group or institutional providers to clearly identify theirspecialty category or categories.Specification of your taxonomy code(s) was required when you completed the NationalProvider Identifier (NPI) application process with the National Plan and ProviderEnumeration System (NPPES). If you have more than one taxonomy code, you should haveindicated one primary code as part of the self-reporting process.Use of taxonomy codes on claims will assist BCBSIL in selecting the appropriate providerrecord during the claims adjudication process.If you have obtained a unique Organization (Type 2) NPI number for each of your specialties,you should bill with the appropriate Individual (Type 1) and Organization (Type 2) NPInumber combination. If you do not have a unique Organization (Type 2) NPI number foreach specialty, you are strongly encouraged to include the applicable taxonomy code whensubmitting claims. If you submit electronic professional or institutional claims (ANSI 837P or 837I):Taxonomy codes should be placed in segment PRV03, Loop 2000A at the billing level;segment PRV03, Loop 2310B at the claim/rendering level; and if applicable, segmentPRV03, Loop 2420A at the service line level, if the rendering information is differentthan data given at the 2310B Level. If you submit paper CMS-1500 professional claims: The taxonomy code for therendering provider should be placed in the shaded portion of field 24j, with the qualifier“ZZ” in the shaded portion of field 24i. The taxonomy code for the billing providershould be placed in field 33b, preceded by the “ZZ” qualifier. If you submit paper UB-04 institutional claims: The taxonomy code should be placedin Form Locator 81, along with the “B3” qualifier.You may conduct a search for registered taxonomy codes and assigned NPIs via the onlineNPI Registry at .Additional information about taxonomy codes, along with the entire Health Care ProviderTaxonomy Code set, can be found within the HIPAA-related Code Lists section of theWashington Publishing Company (WPC) website at wpc-edi.com. Providers without onlineaccess may contact the WPC at 425-562-2245 to find out how to purchase a printed code list.CPT copyright 2010 American MedicalAssociation (AMA). All rights reserved.CPT is a registered trademark of the AMA.21Visit our Website at bcbsil.com/prOVIDER
Administrative Simplification Operating Rules UpdateFairnessininContractingContractingFairnessIn an effort to comply with fairness incontracting legislation and keep ourindependently contracted providersinformed, BCBSIL has designated acolumn in the Blue Review to notifyyou of any significant changes to thephysician fee schedules. Be sure toreview this area each month.Effective Feb. 1, 2013, the followingcode will be updated: J9355.Effective March 1, 2013, the followingcode ranges will be updated:A9576-A9586, A9604, J0000-J9999,P9041-P9048, Q0138-Q0181, Q0515,Q2009-Q2027, Q2043, Q3025-Q3026,Q4074-Q4136, Q9951-Q9968 andS0012-S0191. Please note that not allcodes in these ranges will be updated.Administrative Simplification is a provision of the Affordable Care Act (ACA). Under ACA,new Operating Rules for HIPAA-standard transactions must be implemented to promote greateruniformity in the delivery of electronic health care data from a health plan to a provider. TheseOperating Rules also apply to software vendors and any other electronic business entities thatprovide transaction-related services, such as billing services and third party administrators.In December 2012, BCBSIL successfully deployed the mandated Operating Rules for Eligibility andBenefits (ANSI 270/271) and Claim Status (ANSI 276/277) transactions for health informationtechnology vendors such as Availity , Passport/Nebo Systems and RealMed . Online Eligibility andBenefits and Claim Status options are now available continuously Monday through Saturday, withthe exception of 8 p.m. to midnight on Sunday, for providers who are conducting administrativetransactions for local and BlueCard /out-of-area members. This includes the Claim Research Tool(CRT), which providers may access on the Availity portal.The information above is not intendedto be an exhaustive listing of all thechanges. Annual and quarterly feeschedule updates can also be requestedby using the Fee Schedule Request Form.Specific code changes that are listedabove can also be obtained bydownloading the Fee Schedule RequestForm and specifically requesting theupdates on the codes listed in theBlue Review. The form is available in theEducation and Reference Center/Formssection of our Provider website atbcbsil.com/provider.In addition to extended hours of operation for electronic administrative transactions, enhancementsinclude: Capability to obtain eligibility and benefit information for past and future dates of service A dditional parameters when searching by name that will return more comprehensive datameeting the search criteria A new notification process to help ensure that users are aware of any scheduled or unscheduledoutagesFunctionality changes are reflected in the Availity Eligibility and Benefits tip sheet in the Educationand Reference/Provider Tools section of our Provider website at bcbsil.com/provider. CompanionGuides for each administrative transaction are available in the Standards and Requirements/Government Regulations section of our Provider website under HIPAA Regulations andImplementation Guidelines. Additional updates will be included in upcoming issues of theBlue Review.Availity is a registered trademark of Availity, L.L.C., RealMed is a registered trademark of RealMed Corporation,an Availity Company. Availity, L.L.C. Passport/Nebo Systems, RealMed Corporation and Availity, L.L.C. areindependent third party vendors and are solely responsible for their products and services. BCBSIL makes norepresentations or warranties regarding any of these vendors. If you have any questions or concerns about theproducts or services they offer, you should contact the vendor(s) directly.FEBRUARY 20133
ICD-10will changeICD-10will changeevereClinical AreaPhysicians Patient CoveHealth plan pnew ABN1 for Superbills:Revisions reqbe impossibl ABNs:Health plansor NCD3s, etcand patients Documentation:laterality, stages of healing, weeks in pregnancy, episodes of care,and much more. Code Training:Codes increase from 17,000 to 140,000. Physicians must be trained.Nurses Forms:Every order must be revised orrecreated. Documentation: Prior Authorizations:Policies may change, requiringtraining and updates.Lab Documentation: Reporting:Health plans will have newrequirements for the orderingand reporting of services.CodingBilling1. Advance Beneficiary Noticeof Non-coverage2. Local Coverage Determination3. National Coverage Determination4. Physician Quality ReportingInitiative Policies and Procedures:All payer reimbursement policies maybe revised. Training:Billing department must be trained on newpolicies and procedures and the ICD-10-CMcode set. Code Set:Codes will increase from 1books and styles will com Clinical Knowledge:More detailed knowledge Concurrent Use:Coders may need to use Irently for a period of timeOffice graphics 2012 AAPC. All rights reserved. Used with permission of AAPC.4AAPC can help every aspecto ICD-10. Whether you jusVisit our Website at bcbsil.com/prOVIDERcomplete implementation
everything.ything.aerage:policies, coverage limitations, andrms are likely.quired and paper superbills mayle.will revise all policies linked to LCD2sc., ABN forms must be reformattedwill require education.Managers New Policies and Procedures:Any policy or procedure associatedwith a diagnosis code, diseasemanagement, tracking, or PQRI4must be revised. Vendor and Payer Contracts:All contracts must be evaluatedand updated. Budgets:Changes to software, training, newcontracts, new paperwork willhave to be paid for. Training Plan:Everyone in the practice will needtraining on the changes.Here’s thewhere and how.Check out the Blue Cross andBlue Shield of Illinois ICD-10Provider Resource Center forideas and tools to get youstarted, and take ourReadiness Survey, atbcbsil.com/provider.Will yoube ready?Front Desk HIPAA:Privacy policies must be revisedand patients will need to sign thenew forms. Systems:Updates to systems are likelyrequired and may impact patientencounters.AAPC can help. For assistancein transitioning your office toevery aspect of ICD-10, go towww.AAPC.com/ICD-1017,000 to 140,000. As a result, codempletely change.e of anatomy and medical terminol-ICD-9-CM and ICD-10-CM concure until all claims are resolved.ct of your practice’s transitionst want the basics or needjuLYFEBRUARY2012has2013training,AAPCa solutionA Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of theBlue Cross and Blue Shield Association24491.07125
Provider LearningOpportunitiesBCBSIL WEBINARSBelow is a list of complimentarytraining sessions sponsored byBCBSIL. For details and onlineregistration, visit the Workshops/Webinars page in the Education andReference Center of our website atbcbsil.com/provider.2012 HMO Member Survey ResultsThe 2012 HMO Member Survey was conducted in July and August of 2012. The primary purpose ofthis survey was to assess member satisfaction in a variety of areas at the MG/IPA* site level, includingmedical care and services rendered by PCPs and Specialists, access to care and overall MG/IPA service.A random sampling of adult patients who have been BCBSIL HMO members for at least one year wassurveyed. The overall response rate for this year was 22 percent.In the past, BCBSIL used the Top 3 Box scores (Excellent, Very Good and Good) as positive responsesin the HMO Member Survey analysis. Starting with the 2011 survey, Top 2 Box scores (Excellent andVery Good) were counted as positive responses. This change was made to recognize top-performingMGs/IPAs and to encourage all MGs/IPAs to improve the service provided to HMO members. The2012 results below are based on the revised methodology implemented in 2011.2012 Acco la d esMany items in the 2012 survey received a score of 80 percent or better, including the following:Electronic RefundManagement (eRM)(All sessions: 2 to 3 p.m.)Feb. 6, 2013Feb. 13, 2013Feb. 20, 2013Feb. 27, 2013iEXCHANGE WebinarsiEXCHANGE is a Web-based application thatcan be used to submit transaction requests forinpatient admissions and extensions, treatmentsearches, provider/member searches and selectoutpatient services and extensions. Customizedtraining is available upon request.To request training, contact us atiexchange helpdesk@bcbsil.com andinclude your name, telephone numberand the topics of interest.To view available topics, visit theWorkshops/Webinars page in the Educationand Reference Center on our websiteat bcbsil.com/provider.PCP Management/Coordination of the Member’s CareOverall member rating of PCP (percent of “Excellent” or “Very Good” responses)80%Members’ rating of PCP for thoroughness of examinations(Percent of “Excellent” or “Very Good” responses)80%Members’ rating of PCP for respect shown and attention to privacy(Percent of “Excellent” or “Very Good” responses)85%Members’ rating of PCP for medical care received(Percent of “Excellent” or “Very Good” responses)81%Length of time waited for a routine appointment (within 2 weeks)Results are based on respondents who had appointments82%Length of time waited for an urgent appointment (within 24 hours)85%PCP’s office contacted the member about test results (Percent of “Yes”responses) Results are based on respondents who had tests performed82%PCP gave the member clear instructions on health problems or symptomsbothering the member (Percent of “Always” and “Usually” responses)89%PCP’s office reminded the member about getting preventive care(Percent of “Yes” responses)83%PCP talked with the member about different medicines he or she is using,including ones prescribed by a specialist (Percent of “Yes” responses)82%PCP gave the member easy-to-understand instructions about taking his orher medicines (Percent of “Always” and “Usually” responses)88%Referral ProcessSatisfaction with MG’s/IPA’s referral process (percent of “Yes” responses)AVAILITY WEBINARSAvaility also offers free webinars fortheir registered users. For a currentlisting of webinar topics, dates andtimes, registered Availity users maylog on to the secure Availity providerportal—the Live Webinar Schedule islocated under the Free Training tab.Not yet registered with Availity? Visittheir website at availity.com for details;or call Availity Client Services at800-AVAILITY (282-4548) forassistance.685%Specialist-related QuestionsMembers’ rating of Specialist for thoroughness of examinations(Percent of “Excellent” or “Very Good” responses)82%Members’ rating of Specialist for explanation of medical tests andtreatments (Percent of “Excellent” or “Very Good” responses)81%Members’ rating of Specialist for respect shown and attention to privacy(Percent of “Excellent” or “Very Good” responses)84%Members’ rating of Specialist for medical care received(Percent of “Excellent” or “Very Good” responses)81%ReportsUsefulness of information contained in the Blue Star MG/IPA ReportSM(percent of “Yes” responses)Visit our Website at bcbsil.com/prOVIDER88%
O P P O RT U N I T I E S FO R I M P ROV E M E N TSelect items that received a score of less than 80 percent including the following: PCP and Specialist response time to an emergency phone call (within 30 minutes)New Account Groups PCP talking with member about eating habits and exercise or physical activity (percent “Yes”) P CP explaining possible side effects or medicine in an easy-to-understand way (percent “Always”and “Usually”) P CP suggesting ways to help member remember to take medicines (percent “Always” and“Usually”) L ength of time waited for a routine (less than two weeks) or urgent (less than 24 hours) examappointment from a Specialist Specialist’s office contacted member about test results (percent “Yes”)‘ B lue R ibb o n ’ S tatusThe Blue Ribbon designation ( ) recognizes MGs/IPAs that received a Top 2 Box score of at least75 percent for 21 specified survey questions. Of the 96 MGs/IPAs analyzed in 2012, for a Blue RibbonDirectory Indicator: Forty-four MGs/IPA sites received a Blue Ribbon Forty-two MGs/IPA sites did not receive Blue Ribbon status Ten MGs/IPA sites received an “Insufficient Responses” designation*Medical Group/Independent Practice AssociationMedicare Part D Pharmacy UpdateRanbaxy Pharmaceuticals Atorvastatin RecallOn Nov. 9, 2012, Ranbaxy Pharmaceuticals announced that it was initiating a voluntary recallof its popular cholesterol lowering medication atorvastatin, which is the generic version ofPfizer’s Lipitor. The reason for Ranbaxy’s recall was due to the possibility of small (less than1 mm) glass particles in its product. It also reported that
ICD-10 Office Changes Map 4, 5 . ICD-10 will change everything. Will you be ready? AAPC can help every aspect of your practice’s transition to ICD-10. Whether you just want the basics or need
2/3/2012 4 7 Course Content Interactive Scenarios Timely Examples Knowledge Checks 8 Lessons Learned Board Members are not all that different from employees. Course must be challenging, but not burdensome. Course must be customized to HCSC business. Course must include exa
ICD-10: Put Your Claims to the Test It’s time to face the facts: The transition to ICD-10 is happening, there’s a lot you need to do to prepare and no one can do it for you. BCBSIL is nearing completion of updates to all applicable systems in preparation for the wide variety of scenarios that may occur related to processing of ICD-10 codes.
Instructional OverviewExpanded Overview Electronic Remittance Advice (ERA) or ANSI 835 is a HIPAA-compliant method of receiving claim payment and remittance details from Blue Cross and Blue Shield of Illinois (BCBSIL). In addition, ERA files may be automatically posted to your patient accounting system.
call Customer Service at the number shown on your ID card to determine if you are in the Network Service Area or logontotheWebsiteatwww.bcbsil.com; and. — If Medicare eligible, have both Part A and Part B coverage. YOUR BLUE CROSS AND BLUE SHIELD IDENTIFICATION CARD You willreceive an
Illinois since 1936. As a customer-owned health insurer, our focus is on our members, not shareholders. We work hard to make sure you have choices for your health care coverage. As health care in America changes, our dedication to our community will stay strong. BCBSIL will be here serv
BCBSIL Member Services 800-538-8833 General Website www.bcbsil.com Pharmacy Benefits—Prime Therapeutics For Help With: h Questions about prescription coverage Prime Therapeutics 800-423-1973 Website www.primetherapeutics.com Dental Care—Delta Dental For Help With: h Finding netwo
The New Medicare Crossover Process Medicare Primary, Blue Cross and Blue Shield Secondary Paper Claims . The BCBSIL formulary is a list of preferred drugs that have been carefully reviewed and selected by our Pharmacy Benefit Manager's (PBM) national Pharmacy and Therapeutics . brand name products that have generics available and non .
Secret Wall O2 Pit to Q2 X2 To Level 7 (X3) A1 Portal to L10 (A2) [] Button Q1 From Pit O1 X3 To Level 7 (X1) 0 Pressure Pad Q2 From Pit O2 X4 To Level 5 (X2) Y Nest In the place where you found a lot of Kenkus (bird creatures) is a place called "Nest." After killing both Kenkus, put all ten Kenku eggs on the floor. The wall will disappear, and .
