November 2013
In this issue
Page
Administration
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Misrouted Protected Health Information (PHI)
Important reminder: 2013 National Uniform Billing Committee (NUBC)
UB-04 Code Changes
Attention psychiatrists and psychiatric offices: Corrections to behavioral
health claims
Make sure your transplant global case rate claims are complete and correct
Americold Logistics, LLC returns to Anthem National Accounts
BCBSA announces agreement with Verisk Health for medical record requests
ICD-10 Check-up: How am I doing?
Get it right the first time – Receive payments accurately, predictably
and reliably
Clinical practice and preventive health guidelines available on the web
Health care reform updates (including Health Insurance Exchange)
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Products and programs
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2014 FEP Benefit information available online
Important 2014 diabetic supply coverage changes for DME providers
AIM sleep disorder guideline updates and program change
Quality-In-Sights® Pay for Performance survey is due January 15, 2014!
HEDIS® 2013 results
Habit Heroes delivers message of good health
Case Management: Better health for patients who need care the most
NurseLine offers 24/7 access to nurses
Future Moms promotes healthy pregnancies and healthy babies
MyHealth Advantage works with you to help your patients
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14
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E-business
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ProviderAccess is going away Nov. 8 th
Interactive Care Reviewer (ICR) now accepts inpatient requests
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bcbsga.com
State Health Benefit Plan
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Important information about the State Health Benefit Plan
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Important phone numbers
Senior business and Medicare Advantage
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Please ensure referred physicians are in the Medicare Advantage Network
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21
Senior business and Medicare Advantage continued
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Physicians to receive home test kits results for Medicare Advantage
Members
Record exact adult BMI number, not range
Update: Avoidable Medicare Advantage readmissions may lead to
administrative claim denials
Medicare reports on osteoporosis management after bone fracture
Medicare Advantage Part D formulary changing for 2014
2014 Medicare Advantage coverage changes for diabetic supplies
American Diabetes Association offers medication guidelines for
patients with diabetes/hypertension
Speaking the Language of ICD-10 - Part 2
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Pharmacy
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Pharmacy information available on bcbsga.com
Coverage for compound drugs
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Policy updates
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Always Bundled Policy: Certain bundled services ineligible for
separate reimbursement
Medical Policy and Clinical Guideline updates
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Administration
Misrouted Protected Health Information (PHI)
Providers and Facilities are required to review all member information received from BCBSGa to ensure no misrouted PHI is
included. Misrouted PHI includes information about members that a Provider or Facility is not currently treating. PHI can be
misrouted to Providers and Facilities by mail, fax, or e-mail. Providers and Facilities are required to immediately destroy any
misrouted PHI or safeguard the PHI for as long as it is retained. In no event are Providers or Facilities permitted to misuse
or re-disclose misrouted PHI. If Providers or Facilities cannot destroy or safeguard misrouted PHI, Providers and Facilities
must contact Provider Services at 800-428-4446 to report receipt of misrouted PHI.
Important reminder: 2013 National Uniform Billing Committee (NUBC) UB-04 Code Changes
The following changes have been made by the National Uniform Billing Committee (NUBC) and are outlin ed below:
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New Patient (Discharge) Status Codes
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Type of Bills (TOB) 32X and 34X: Description Change
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Type of Bill 33X: Code Eliminated
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Type of Bills 084X and 089X: Revised
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New Revenue Code: 0953
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Source of Admission: Required on all Types of Bills except 014X
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New Patient Discharge Status Codes (FL-17) approved by NUBC effective October 1, 2013 are as follows:
NOTE: Patient Discharge status codes are required by NUBC on both the inpatient and outpatient claims.
Value
Description
69
81
Discharge transferred to a designated disaster alternate care
Discharged to Home or Self Care with a Planned Acute Care Hospital Inpatient Readmission
Discharged/Transferred to a Short Term General Hospital for Inpatient Care with a Planned
Acute Care Hospital Inpatient Readmission
Discharged/Transferred to a SNF with Medicare Certification with a Planned Acute Care
Hospital Inpatient Readmission
Discharged/Transferred to Facility that Provides Custodial or Supportive Care with a Planned
Acute Care Hospital Inpatient Readmission
Discharged/Transferred to a Designated Cancer Center or Children’s Hospital with a Planned
Acute Care Hospital Inpatient Readmission
Discharged/Transferred to Home Under Care of Organized Home Health Organization with
Planned Acute Care Hospital Inpatient Readmission
Discharged/Transferred to Court/Law Enforcement with a Planned Acute Care Hospital
Inpatient Readmission
Discharged/Transferred to a Federal Health Care Facility with a Planned Acute Care Hospital
Inpatient Readmission
Discharged/Transferred to a Hospital-based Medicare Approved Swing Bed with a Planned
Acute Care Hospital Inpatient Readmission
Discharged/Transferred to an IRF including Rehabilitation Distinct Part of a Hospital with a
Planned Acute Care Hospital Inpatient Readmission
Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH) with a
Planned Acute Care Hospital Inpatient Readmission
Discharged/Transferred to Nursing Facility Certified by Medicaid but not Certi fied by Medicare
with Planned Acute Care Hosp IP Readmission
Discharged/Transferred to Psychiatric Hospital or Psychiatric Distinct Part of a Hospital with a
Planned Acute Care Hosp IP Readmission
Discharged/Transferred To a Critical Access Hospita l (CAH) with a Planned Acute Care
Hospital Inpatient Readmission
Discharged/Transferred to Another Type of Health Care Institution not Defined in this Code List
with a Planned Acute Care Hosp IP Readmission
82
83
84
85
86
87
88
89
90
91
92
93
94
95
Type of Bill (FL-4) Description Changes:
032X
Description change - Home Health Services under a Plan of Treatment (eff 10/01/13)
034X
Description change - Home Health Services not under a Plan of Treatment (eff 10/01/13)
Type of Bill (FL-4) Eliminated:
033X
Code Eliminated - No longer a valid code as of 10/01/13
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Type of Bill changes (FL-4) from Inpatient / Outpatient to Outpatient ONLY:
084X
Change from Inpatient / Outpatient to Outpatient only service designation - Specialty Facility
Free Standing Birthing Center (eff 07/01/12)
089X
Change from Inpatient / Outpatient to Outpatient only service designation - Specialty Facility
Other (eff 07/01/13)
New Revenue Code (FL-42):
0953
Chemical Dependency effective for claims received on or after 10/01/2013
Source of Admission (Point of Origin) (FL-15) required on all claims (except 014x):
Effective 10/01/2013, the Blue Cross Blue Shield Association (BCBSA) is requiring Source of
Admission/Point of Origin codes for all TOB's (except 014X Lab services). This BCBSA
ALL
modification is needed by Home Plans for pricing non-Par claim encounters and is in alignment
with the NUBC changes.
Please make sure all billing staffs are aware of these changes. Changes affect Commercial, FEP and Medicare Advantage
products. Additional information regarding the Discharge status codes may be communicated by CMS in the future.
Attention psychiatrists and psychiatric offices: Corrections to behavioral health claims
As you know, the American Medical Association adopted new CPT codes for behavioral health services effective January 1,
2013. We are writing to let you know about certain technical difficulties BCBSGa has had in implementing those codes.
Specifically, we have experienced claims processing system errors as a result of the new codes that might have affected the
payments you received for services provided since January 1, 2013, and also might have resulted in incorrect and/or multiple
deductibles and co-payments for your patients. This problem is being addressed with the highest priority.
In order to ensure that you have been properly reimbursed and that your patients have not paid more than their plans
require, we also are reviewing claims that may have been affected by these system errors. Where we identify claims that
were processed incorrectly, we will re-process the claim and correct the co-payment due from the member, and you will
receive a new remit with the correct amounts attributed to your patients. You do not need to resubmit claims to have them
reprocessed; we will do that automatically. However, if you have any questions or concerns about whether a claim was
processed correctly, please do not hesitate to contact Provider Services at 800 -428-4446.
We apologize for any inconvenience and confusion these system errors may have caused. BCBSGa values your commitment
to our members, and we want to assure you that we are committed to making sure you are properly reimbursed for the
services you provide.
Make sure your transplant global case rate claims are complete and correct
When submitting a transplant global case rate claim it is imperative to include a cover sheet or an Attachment H, whichever
is applicable, that clearly reflects all the claim information included in the global case rate package. Prior to sending a global
case rate package, review the claim information included in the package to make sure that it matches what is indicated on
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the cover sheet or Attachment H. All claims pertaining to the transplant must be included in the global case rate packet.
Individual transplant claims submitted separately by an individual physician may be denied because that claim should be
included in the global case rate claim.
When a global case rate package is received by BCBSGa, we review the claim to ensure that the cover sheet or Attachment
H accurately reflects the claims included in the package. If the claims included do not match the information indicated on the
cover sheet or Attachment H, BCBSGa will require more information and claim payment will be delayed.
Individual providers that are unclear of transplant global case rate claim guidelines should contact the facility performing the
transplant in order for everyone to receive timely reimbursement.
If you have any questions about this information please contact your Provider Repr esentative.
Americold Logistics, LLC returns to Anthem National Accounts
Beginning January 1, 2014, Americold Logistics, LLC will be administered by the Richmond Service Center in Virginia.
Americold Logistics associates and their enrolled family members who live in Georgia will be covered under the Blue Open
Access PPO network and will receive new member ID cards with the alpha prefix LQZ. Those living outside of the Blue Open
Access POS network area will use the BlueCard PPO network and will receive new member ID cards with the alpha prefix
LGO.
Please remember to verify the member’s ID card on each visit to ensure your claims are submitted with the correct member
ID for that particular date of service. Electronic claim submission is the most efficient way to submit your claims; however, if
you submit a hard copy claim please refer to the back of the members ID card for the appropriate claim submission address
and customer service number.
For questions or additional information, call the Americold Log istics dedicated customer service center at 877-344-2942.
BCBSA announces agreement with Verisk Health for medical record requests
The Blue Cross and Blue Shield Association (BCBSA) has contracted with vendor Verisk Health to obtain out -of-area medical
records for all Blue Plans. (Verisk Health helps employers, providers and payers mitigate risk, reduce health care costs and
improve patient outcomes.)
BCBSGa supports the association’s agreement that allows Blue Plans – if appropriate – to request medical records from a
provider who is out of the Plan’s service area. These medical record requests support HEDIS reporting, commercial risk
adjustment and Medicare risk adjustment.
It is important to note that medical record requests for the purpose of cla ims processing will remain the same.
Beginning October 2013, providers may receive letters or calls from Verisk Health with record requests for patients who are
members of a Blue Plan outside of our service area.
Please be assured that all medical information will be used and maintained in a confidential manner in accordance with
privacy regulations specified by the Health Insurance Portability and Accountability Act (HIPAA) and BCBSGa corporate
policies. As a reminder, you do not need the member’s permission to release medical records associated with this request.
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As in the past, the time frame for obtaining and reporting HEDIS and risk adjustment information is limited. The return of
requested medical records is usually five business days. We appre ciate your cooperation and time in working with us to
promptly submit the requested information.
ICD-10 Check-up: How am I doing?
The end of the year is a great time to look back and review the status of important projects and activities. The
implementation plan for your practice’s transition to ICD-10 is one of those long term efforts where periodic check -ups can
help to make sure you are still on target to be ready by October 1, 2014. Below is a list of some of the planning activities
that your practice should have completed during the last year.
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Processes/Workflows Changes – You should have identified which internal processes and workflows will be affected
by using the new code set, how each workflow is affected and have a plan to address the change s that need to
occur to incorporate ICD-10.
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Systems Changes – Assessment of all systems used by your practice should be completed. You should have a
comprehensive list of all necessary system changes, upgrades and/or other adjustments, the cost of these c hanges,
the amount of time it will take to complete these changes and the timeline for implementation.
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External Partners – You should have a clear picture of how each of your vendors, clearinghouses and/or billing
services plan to handle the transition to ICD-10 and how their plan will affect your practice.
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Documentation Requirements –You should have assessed a sample of your practice’s patient records to determine
if the clinical documentation is complete and detailed enough to properly code claims using I CD-10 diagnosis codes.
With the new level of specificity of each code, having the right documentation available for your medical coders will
lessen the potential for decreased productivity associated with using the new code set.
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Training – You should have a comprehensive list of the education and training needs for your staff members. The
list should detail the type of training needed (coding, systems, etc.), who will receive the training and timeline for the
training to occur. Training costs should also be determined and budgeted as appropriate in future fiscal planning.
As you move into the active phases of your implementation plan for ICD-10, having this knowledge as your foundation will be
the key to a smooth transition to ICD-10.
Get it right the first time – Receive payments accurately, predictably and reliably
While the coordination of benefits process works well most of the time, difficulties associated with the process — from
paperwork to inaccurate payments to claims appeals — make the healthcare system cumbersome and have long burdened
the healthcare industry.
Typically, coordination of benefits issues stem from confusion over a patient’s insurance status, particularly for individual s
who have lost or changed jobs or have multiple sources of coverage. Recognizing that these difficulties have cost the
healthcare system millions, BCBSGa is working closely with other health plans and CAQH® to improve the accuracy of
coordination of benefits processes for providers and patients.
COB Smart™, a CAQH® Solution, is a registry of coverage information that will correctly identify which patients have
benefits that should be coordinated in order for corresponding claims to be processed correctly the first time. Starting
November 3, 2013, each week, BCBSGa and other CAQH participating health plans and clearinghouses will supply coverage
information to the registry, where it will be compared with information from other participating health plans to identify
individuals with more than one form of coverage. Standard primacy rules are then applied to determine the correct order of
benefits. Starting in 2014, providers can access this complete and accurate coordination of benefits information through
processes that integrate with most existing workflows.
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The CAQH COB Smart registry will help increase payment accuracy and timeliness, reduce paperwork and improve cash flow
for all providers. This solution will save the system money by reducing administrative resources and hassle when determining
coverage.
To learn more about COB Smart, and BCBSGa’s involvement, please review the Frequently Asked Questions on the
Answers@BCBSGa page of our provider website, bcbsga.com.
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 advance s 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.
Health care reform updates
Health care reform updates and notifications and Health Insurance Exchange information is posted as they become available
on the communications page of bcbsga.com.
Articles titled “Important information about provider referrals for plans purchased on and off the Exchange ” and “Many
members will have new health plans in 2014” have been posted to the Health Insurance Exchange page of bcbsga.com.
Products and programs
2014 FEP Benefit information available online
To view the 2014 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal
Employee Program (FEP), go to bcbsga.com/fep and select a Coverage Options in the tool bar. Here you will find the 2014
Service Benefit Plan Brochure and Plan Benefit Summary information for year 2014. For questions please contact FEP
Customer Service at 800-282-2473.
Important 2014 diabetic supply coverage changes for Durable Medical Equipment (DME) providers
Effective January 1, 2014, all of our Individual Medicare Advantage Plans will only cover LifeScan, Inc., OneTouch ®
or Roche Diagnostics, ACCU-CHEK ® diabetic glucometers and blood test strips. This benefit change is meant to help
control out-of-pocket expenses while not compromising on quality.
Covered glucometers and blood test strips in 2014:
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LifeScan, Inc., OneTouch ®
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Roche Diagnostics, ACCU-CHEK ®
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A limit of 100 blood test strips per month
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Other blood glucometers or blood test strip brands or more than 100 test strips per month are not covered unless the
member’s doctor or other treating provider tells us that another brand or a larger quantity is medically necessary for their
treatment.
What will you need to do?
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If your customers are currently using OneTouch ® or ACCU-CHEK ® blood test strips or glucometer products, no
action is required on your part.
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If your customers are not using OneTouch ® or ACCU-CHEK ® blood test strips and glucometer products, you will
need to have the customer get new prescriptions from their doctor for their supplies by January 1 st in order for these
claims to be covered.
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If the customer’s doctor says 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, their doctor will need to call the provider
service number listed on the back of the member’s card.
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If the customer has questions, direct the customer to call the health plan’s customer service number found on the
back of their ID card.
Grace Period:
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To allow you time to transition these customers over to LifeScan, Inc., OneTouch ® or Roche Diagnostics, ACCUCHEK ® blood test strips and glucometers we will continue to cover the current brands for up to two fills during the
first 90 days of the year. After the grace period has expired, if a network provider bills for non-covered brands or
exceeds the quantity limit without having an exception on file, the DME provider will be liable for the charges, not
the member.
As always, we reserve the right to conduct random audits to ensure compliance with the plan’s benefit administration.
Plans that are included in this coverage change include:
CONTRACT #
Plan Benefit Package (PBP) PLAN NAME
H5422
002
BlueValue Secure (HMO)
H5422
006
BlueValue Basic (HMO)
H9947
001
Medicare Preferred Core (PPO)
PLAN TYPE
GA-HMO
GA-HMO
GA-LPPO
If you are in doubt as to whether or not your customer is one of our Individual Medicare Advantage Prescription Drug (MAPD)
versus an Employer or Union Sponsored plan, please have them check the front of the ID card which will show the contract
and Plan Benefit Package (PBP) number (example: H1234-001). Note: If the PBP (the last three digits of the contract-PBP
number) is in the 800 series, that member is in an Employer or Union Sponsored plan and these changes do not apply to
their plans.
Please contact the plan’s Provider Service Department listed on the back of the member’s ID card if you have any questions
about these coverage changes.
The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact
the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network,
premium and/or co-payments/co-insurance may change on January 1 of each year.
For more information about the exception process or the appeals policy, pleas e see the plan’s Provider Manual located on
the Answers@BCBSGa page of our provider website, bcbsga.com.
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AIM sleep disorder guideline updates and program change
Effective for dates of service on or after January 1, 2014, the following AIM Specialty Health SM (AIM) Sleep Disorder
Management Diagnosis and Treatment Guidelines will be revised as follows:
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A new guideline, Utilization of Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing
(MWT), has been added for the diagnoses of narcolepsy and hypersomnia. This guideline replaces the previous
BCBSGa clinical guideline CG-MED-43, Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness
Testing (MWT).
The following clarifications have been made:
– The terms “respiratory disturbance index” (RDI) and “apnea hypopnea index” (AHI) may be used interchangeably.
– When an attempt has been made to use auto-titrating positive airway pressure (APAP) to titrate continuous
positive airway pressure (CPAP) or bi-level positive airway pressure (BPAP) and that attempt has been
unsuccessful, in-lab titrations may be performed.
– The list of contraindications to home sleep testing has been expanded. Individuals meeting criteria for a sleep
study that have any of these contraindications should have their studies performed at a facility.
– The oral appliances guideline has been clarified to indicate that prefabricated oral appliances are not considered
to be clinically appropriate under any circumstances.
The current and revised guidelines can be accessed at aimspecialtyhealth.com or on the Medical Policy, Clinical UM
Guidelines, and Pre-Cert Requirements section of our provider website, bcbsga.com. Please note that these changes are
effective January 1, 2014.
Please note: With the adoption of the new guideline, “Multiple Sleep Latency Testing (MSLT) and Maintenance of
Wakefulness Testing (MWT),” as part of our sleep program managed by AIM, effective January 1, 2014, MSLT and MWT
(CPT code 95805) will now be reviewed by AIM, rather than BCBSGa, along with polysomnography and home sleep testing.
This requirement is effective for members of our local and individual health plans who participate in the sleep management
program managed by AIM.
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 taken to the POIT home
page. On the POIT home page, you will find the survey on the "Prog rams" 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.
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
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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 prrprogramsga@bcbsga.com, call program
support at 888-650-5740 or contact your Network Representative directly.
HEDIS® 2013 results
Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) data collection for
2013. You play a central role in promoting the health of our members. One way to improve care is to document ser vices in a
consistent way. This makes it easy for you to track care provided and see what additional care is needed to meet the
recommended timeframes. Consistent documentation will also help improve HEDIS scores, both by improving care itself and
by improving our ability to report validated data.
Further information regarding HEDIS documentation guidelines will soon be available on the Quality page under the Health &
Wellness section of our provider website, bcbsga.com. There you will soon find reference documents entitled “HEDIS
Timeline,” “HEDIS 101 for Providers” and “HEDIS Documentation Guidelines”.
The table below shows comparison of some of our key measure rates to the NCQA
Commercial HMO/POS Measures
HEDIS 2013
Rate
(Percent)
Effectiveness of Care – Prevention and Screening
Adult BMI Assessment
69.34
Breast Cancer Screening
67.07
Cervical Cancer Screening
74.40
Childhood Immunization Status - DTAP
89.05
Childhood Immunization Status - MMR
89.78
Childhood Immunization Status – HEP B
92.94
Childhood Immunization Status - PCV
88.08
Childhood Immunization Status – HEP A
42.58
Childhood Immunization Status - ROTAVIRUS
77.86
Childhood Immunization Status - INFLUENZA
54.01
Colorectal Cancer Screening
61.73
Immunizations for Adolescents - MENINGITIS
67.50
Immunizations for Adolescents – TDAP/TD
77.50
Weight Assessment and Counseling – BMI TOTAL
44.53
Weight Assessment and Counseling – Physical Activity- TOTAL
45.01
Access/Availability of Care
Children & Adolescents’ Access to PCP (25 mos-6yrs)
92.30
Children & Adolescents’ Access to PCP (12-19 yrs)
85.41
Effectiveness of Care – Respiratory Conditions
Appropriate Testing for Children w/ Pharyngitis
82.50
Appropriate Treatment Children w/ URI
82.37
Spirometry Testing for COPD
46.68
November 2013
Quality Compass ® National Averages.
2013 National
Comparison to
Average
National Average
(Percent)
66.11
70.27
75.50
87.18
91.82
89.17
86.72
65.50
76.67
63.33
63.26
65.99
79.24
51.57
50.37
91.64
89.68
80.20
84.04
43.52
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Effectiveness of Care - Cardiovascular
Cholesterol Management – LDL-C Control <100
Persistence of Beta-Blocker Treatment after AMI
Effectiveness of Care - Diabetes
Comprehensive Diabetes Care – HbA1c Testing
Comprehensive Diabetes Care – Poor HbA1c Control (>9)*
Comprehensive Diabetes Care – Eye Exams
Comprehensive Diabetes Care – LDL-C Screening
Comprehensive Diabetes Care – LDL-C Controlled (LDL-C<100
mg/dL)
Comprehensive Diabetes Care – Blood Pressure Control
<140/80
Comprehensive Diabetes Care – Blood Pressure Control
<140/90
Effectiveness of Care - Musculoskeletal
Use of Imaging Studies for Low Back Pain
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Acute
Antidepressant Medication Mgmt – Continuation
FU Care Children’s ADHD Medication – Initiation
FU Care Children’s ADHD Medication - Continuation
Utilization & Relative Resource Use
Well-Child Visits in the first 15 Months of Life (6+ visits)
Adolescents Well-Care Visits
65.36
74.45
59.87
83.86
92.88
22.45
45.80
88.50
49.45
90.09
28.47
56.82
85.42
48.42
40.33
44.34
67.52
66.48
67.40
75.26
64.02
47.44
35.10
40.82
69.15
53.58
38.64
45.71
76.04
35.01
78.19
43.26
*lower rate is better
Commercial PPO Measures
Effectiveness of Care – Prevention and Screening
Adult BMI Assessment
Breast Cancer Screening
Cervical Cancer Screening
Childhood Immunization Status – DTAP
Childhood Immunization Status – IPV
Childhood Immunization Status – MMR
Childhood Immunization Status – HIB
Childhood Immunization Status – HEP B
Childhood Immunization Status – VZV
Childhood Immunization Status – PCV
Childhood Immunization Status – HEP A
Childhood Immunization Status – ROTAVIRUS
Childhood Immunization Status – INFLUENZA
Colorectal Cancer Screening
Immunizations for Adolescents – MENINGITIS
November 2013
HEDIS 2013
Rate
(Percent)
2.69
64.73
70.84
63.01
68.98
81.68
72.03
46.46
82.43
63.06
78.17
56.17
50.63
47.75
49.03
2013 National
Average
(Percent)
Above or below
National Average
35.17
66.52
73.61
79.98
86.26
88.32
88.29
77.32
88.04
78.94
61.12
69.77
59.84
55.77
57.05
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Immunizations for Adolescents – TDAP/TD
Weight Assessment and Counseling – BMI TOTAL
Weight Assessment and Counseling – Nutrition Counseling
TOTAL
Weight Assessment and Counseling – Physical Activity TOTAL
Access/Availability of Care
Children’s & Adolescents’ Access to PCP (25 mos-6 yrs)
Children’s & Adolescents’ Access to PCP (7-11 yrs)
Children’s & Adolescents’ Access to PCP (12-19 yrs)
Effectiveness of Care – Respiratory Conditions
Antibiotic Treatment Adults w/ Acute Bronchitis
Appropriate Testing for Children w/ Pharyngitis
Appropriate Treatment Children w/ URI
Utilization & Relative Resource Use
Well-Child Visits in the first 15 Months of Life (0 visits)
Well-Child Visits in the first 15 Months of Life (1 visit)
Well-Child Visits in the first 15 Months of Life (3 visits)
Well-Child Visits in the first 15 Months of Life (6+visits)
Adolescent Well-Care Visits
Effectiveness of Care - Cardiovascular
Cholesterol Management – LDL-C Control <100
Persistence of Beta-Blocker Treatment after AMI
Effectiveness of Care - Diabetes
Comprehensive Diabetes Care – HbA1c Testing
Comprehensive Diabetes Care – Poor HbA1c Control (>9)*
Comprehensive Diabetes Care – Eye Exams
Comprehensive Diabetes Care – LDL-C Screening
Comprehensive Diabetes Care – LDL-C Controlled (LDL-C<100
mg/dL)
Comprehensive Diabetes Care – Medical attention for
nephropathy
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Acute
Antidepressant Medication Mgmt – Continuation
FU Care Children’s ADHD Medication – Initiation
FU Care Children’s ADHD Medication - Continuation
58.23
2.58
0.95
69.92
31.19
35.38
0.52
32.57
82.92
84.20
79.25
90.08
90.51
87.60
29.01
77.61
78.12
21.37
78.94
82.33
9.52
2.61
3.54
63.77
29.47
2.88
1.31
2.11
76.36
40.15
79.96
78.77
49.66
79.47
84.03
88.36
27.30
77.85
8.87
87.17
35.25
48.80
81.68
41.65
68.35
78.59
66.12
48.78
34.95
41.95
68.91
53.40
38.11
44.94
*lower is better
In Georgia many scores for Commercial HMO showed either slight improvement or exceeded the National Average, not both.
Some of the largest increases over last year include Persistence of Beta -Blocker Treatment after AMI with 6.62%,
Antidepressant Medication Mgmt-Acute with 7.31%, Antidepressant Medication Mgmt-Continuation 5.46%, FU Care
Children’s ADHD Medication-Initiation 2.82% and FU Care Children’s ADHD Medication-Continuation 3.82%. Each of these
remains below the National Average.
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The Commercial PPO shows double digit rate increases for many of the immunization measures including DTAP 18.43%, IPV
17.73%, MMR 5.85%, HIB, 14.76%, HEP B 27.82%, VZV 5.96%, PCV 16.93%, HEP A 47.88%, Rotavirus 16.21%, Influenza
9.82% and Combo 2 increased 26.24%. Colorectal Cancer Screening increased 6.41%, Persistence of Beta -Blocker
Treatment after AMI increased 15.01% and Comprehensive Diabetes Care -Nephropathy increased 10.85%. While much
improved only Hep A exceeds the National Average. Other increases a re in the less than 5% range and do not meet the
Average.
Overall, the Commercial HMO rates fell 5% or less from last year. There are opportunities for improvement for the measures
with the most significantly decreased rates including: Cervical Cancer Screening which fell 2.33% and both IMA measures
fell, TDAP 2.19% and Meningococcal 2.55% while Meningococcal did exceed the National Average. All Medication
Management measures fell this year with declines ranging from 3.36% to11.35% for Digoxin. Appropriate Testing for Children
with Pharyngitis fell 1.96% but exceeded the National Average.
This year the Commercial PPO plan had the greatest number of decreased rates, although some were above the National
Average. The most significant declines were the FU after Hospitalization for Mental Illness -30 days 24.36% and 7 days
16.54%. The Comprehensive Diabetes Care-Eye Exams fell 7%, Children’s & Adolescents’ Access to PCP 12 -24 months fell
7.53% and 25 months - 6yrs fell 4.08%.
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Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS project, and to
demonstrate the exceptional care that you have provided to our members. In an effort to improve our scores, you and your
office staff can help facilitate the HEDIS process improvement by:

Responding to our requests for medical records within five days

Providing the appropriate care within the designated timeframes

Accurately coding all claims

Documenting all care in the patient’s medical record
Again, we thank you and your staff for demonstrating teamwork and partnership as we work together to improve the health of
our members and your patients. We look forward to working with you next HEDIS season.
The source for data contained in this publication is Quality Compass® 2013 and is used with the permission of the National Committee for Quality Assurance (NCQA).Quality
Compass 2013 includes certain CAHPS data. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA
specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Habit Heroes delivers message of good health
Through a joint alliance with Walt Disney World® Resort, BCBSGa has launched Habit Heroes™, an interactive, multimedia
experience designed to bring the message of good health to people of all ages.
An interactive comic adventure, Habit Heroes™ aims to teach families about building healthy habits. The program includes
an exhibit at INNOVENTIONS at Epcot® at Walt Disney World® Resort, an informational website and an innovative mobile
application. The free mobile application features the Habit Heroes comic characters and fun tools for tracking and building
“hero power,” and is available for download by anyone at habitheroes.com, iTunes or Google Play.
Supporting Habit Heroes™ is one way BCBSGa is working to reverse the trends of unhealthy lifestyle choices, which can
lead to obesity and rising health care costs. A recent Centers for Disease Control study 1 showed staggering statistics,
revealing that 17 percent of U.S. citizens ages 2–19 are obese, and nearly 80 percent of children who were overweight
between ages 10 and 15 were obese by age 25.
A limited number of comic books featuring the Habit Heroes™ characters are available in both English and Spanish free of
charge. If you are interested in sharing these with your patients, please contact your local Network Relations consultant.
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Case Management: Better health for patients who need care the most
Our Case Management program helps members who are at risk for greater illness and cost, and would benefit from outreach
and support. Our goal is to offer information and guidance to optimize members’ health, from the very sick to those returning
to full health.
We offer Case Management to members who are currently going through major medical care. We also reach out to members
who are likely to need a lot of health care services in the near future. Our goals are:

To help you by supporting your plan of care for your patients.

To help your patients have better health, which could lower their cost of care.
Who qualifies for the program?
Case Management uses more than 500 health markers to find members who may be at highest risk for serious conditions.
We also reach out to members who currently have serious health problems. These are members who are going through major
procedures and treatments and may need extra help and follow-up care.
Some typical conditions for which members often need significant care:

Multiple sclerosis

Severe heart problems

Major stomach diseases

Severe neurological issues

Any major hospitalization from a diagnosis or injury
How the program works
We call members who qualify for the program and tell them how we can help. When they join the program, our nurse coaches
work closely with them to support your treatment plan. The nurses answer questions about diagnosis and drugs, and set
goals for better health. Members who have recently left the hospital get support on discharge planning, home health care,
follow-up appointments and community resources. We focus mainly on spotting and resolving gaps in care. Our outreach for
enrollment includes live and automated telephone calls and letters to members.
Case Management gets a thumbs-up*

More than 86% of members were “satisfied” or “very satisfied” with Cas e Management.

93% of members thought our program was “extremely valuable” or “very valuable.”
*2012 Member Satisfaction Survey
NurseLine offers 24/7 access to nurses
Our 24/7 NurseLine program gives our members access to trained registered nurses any time of the day or night. Members
can get help deciding what kind of care they need. NurseLine is a great resource for members, especially after office hours –
and even on weekends.
24/7 NurseLine doesn’t replace medical care or handle emergencies. During the call, if the nurse believes that the member
needs emergency care, the nurse starts a three-way 911 call. The nurse stays on the call until emergency help comes.
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How 24/7 NurseLine serves members:

24/7 NurseLine records and tracks each call along with data from our programs. For instance, if a member is
enrolled in our diabetes program, the nurse can access the member’s records. Members can get help based on their
health history and receive resources to drive their care.

The NurseLine staff is skilled and dedicated. Our nurses average 19 years of nursing experience. They also have
quick access to doctor support on all shifts.

Each call center has a medical director who provides clinical oversight and advice to our nurses.

We use a huge database with about 5,000 topics. They cover signs, medical tests, drugs, wellness and general
health problems. Our audio library has more than 400 topics in both English and Spanish.

We have nurses who speak Spanish and a language line for interpreters for most languages.
Members whose benefit plans include 24/7 NurseLine may have the toll-free number on the back of their member ID card.
24/7 NurseLine by the numbers

In 2011, callers to 24/7 NurseLine were mostly women (62% overall). Studies show that women are more likely to be
seekers of health information in a family.

The highest users were 23 to 55 years old (52%), followed by 0 to 17 years old (23%).

The top health topic was pediatrics (24%). Users also asked about digestion (12%), bone/muscle/joint (12%),
dermatology (6%), neurology (6%) and cardiovascular (5%) issues. The other 34% fell under one of 15 other topics.
The next time you see patients who are BCBSGa members, please tell them about the 24/7 NurseLine program. It’s a helpful
resource any time they have a health issue.
Future Moms promotes healthy pregnancies and healthy babies
Our Future Moms program helps women have a healthy pregnancy, a safe delivery and a healthy baby. The program serves
you and your patients through education, risk assessments a nd early interventions. Future Moms supports your plan of care
for your patients and works with you to:

Help them understand the importance of prenatal care and regular clinical visits.

Encourage them to make better decisions about their health

Spot risks and problems to ensure they get the help they need.

Lower the risk of birth defects and low birth weight.
How Future Moms supports you
Maternity care providers benefit when we offer these services to their patients:

Self-help resources so your patients can be well-informed about their health and care. This takes some of the
burden off you.

24/7 phone access to a nurse. We do encourage members to talk to you about any concerns. But we take care of
basic questions on health, benefits and care management so you don’t have to.

Multilingual resources that help members who don’t speak English talk more easily with nurses. Resources include a
Network Services Language Line, educational materials in Spanish and TTY capabilities for the speech- and
hearing-impaired. Again, this takes some of the burden off you when language is a barrier.

Help in authorizing and arranging for home health or other outpatient services. This frees up your time and ensures
your patients get the extra care they need.

Updates for you on the health status of high-risk members and proposed interventions.
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How Future Moms helps members
Future Moms guides women toward a healthy lifestyle from the start of the pregnancy until after the baby is born. Participants
get:

Help tracking the progress of the pregnancy from the first trimester through delivery. Each participant is placed in a
high- or low-risk group based on health status and care needs.

Customized support from nurses experienced in obstetrics. Participants work with a nurse care manager with at
least three years of OB experience.

24/7 toll-free access to nurses. Participants can call with questions or concerns any time.

Education on proper self-care, diet, signs of pre-term labor and other problems linked to pregnancy.

Help on health issues that may affect their pregnancy. We offer support for conditions such as diabetes and high
blood pressure. We also help participants with high-risk issues such as smoking, drug use, high stress levels and
domestic matters.

Help finding health care services and getting referrals.

Follow-up support after the baby is born. The nurse:
– Checks for postpartum depression.
– Sends educational materials.
– Refers members to behavioral health and EAP programs, social workers and lactation experts as needed.
If you’d like to refer patients who are BCBSGa members into the program, please call 800-828-5891. You can also find a
Future Moms referral form by going to the Health & Wellness page of our provider website, bcbsga.com.
MyHealth Advantage works with you to help your patients
MyHealth Advantage uses advanced technology to help our members follow your plan of care. The program helps improve
patient health and coordination of care. We work with doctors to find and address medical gaps and health risks.
How it works
MyHealth Advantage scans medical, pharmacy and lab claims. We compare the information with current medical guidelines
and best clinical practices. If we find health risks, members get a confidential message called MyHealth Note by mail.
We suggest specific actions that when endorsed by their doctors can help the members improve their health. All MyHealth
Notes tell members to speak with their doctors before making any changes in their medical care. MyHealth Note also
includes a list of recent medical, lab and pharmacy claims that a member can share with you. These may be helpful for you in
providing care, especially if members have other doctors.
We keep you in the loop
If we find a clinical issue, we let you know by mail, too. For example, if the member is overdue for an annual test or if there’s
a drug therapy issue, we tell you. If you get a notice, you may add medical information about the member or about the
recommendation. You may fax a form back or call a MyHealth Advantage representative.
Messages are also posted on two websites, Availity, and MMH+. You can get real-time information when treating patients in
the ER or in the office. MMH+ is a secure and free Internet site where you can check patient history. Availity is a payment
website that shows benefit eligibility, which you can check before an office visit or procedure. Our goal is to offer you
updated information to help you take care of your patients.
Program benefits
MyHealth Advantage alerts members if they can save money by switching to a generic drug.
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The results of the program can include better health through improved compliance with medical standards. A recent study
showed 46% of participants who received a MyHealth Note were brought back into clinical compliance. 1
The personal health guidance in MyHealth Note can help members understand their current health status. With MyHealth
Note, members can make better decisions for their health and wellness.
Currently, MyHealth Advantage is available to all our members except those with Medicaid coverage.
1 Based
on an internal review of current participants; members acted within 12 months of getting the first MyHealth Note.
E-business
ProviderAccess is going away Nov. 8 th
The transition of BCBSGa member eligibility and benefit information and claim status inquiry from ProviderAccess to the
Availity Web Portal is almost here. The new address to access this valuable information is availity.com. You will not be able
to access this information via ProviderAccess for Providers after November 8, 2013. We need you fully transitioned to the
Availity Web Portal prior to shutdown.*
Availity’s Web Portal currently offers BCBSGa providers access to the following functionality at no cost:

Member eligibility and benefits inquiry – includes out-of-state BlueCard® members

Claim status inquiry – includes out-of-state BlueCard members

Claim submission – submit a single, electronic claim

Secure messaging* – submit a question on a claim via a secured email to the appropriate provider inquiry area.

Patient care summary (formerly known as CareProfile ® ) – real-time, consolidated view of a member’s medical
history across multiple providers.

Patient reminders (formerly clinical messaging) – clinical alerts on patients’ care gaps and medication compliance
indicators.

AIM Specialty Health SM (AIM) – link to precertification requests and inquiries through AIM .

Member Certificate Booklet – view a local plan member’s certificate of coverage, when available.

Online Remits* – link to online remits under Claims Management/Remittance Review.

New! Interactive Care Reviewer – secure, online provider precertification tool.
*The user must be registered with ProviderAccess for these roles.
Registered but forgot your password?
On theAvaility portal login page, click Help! I can’t login!
Note: You must know the answers to the security questions you provided during initial login.
Registered but locked out?
Your PAA can unlock your access. If you don’t know who your PAA is contact 1.800.AVAILITY (282.4548) toll free (Monday –
Friday 8:00a.m. – 7:00p.m.ET.
Not sure if your organization is registered?
Call Availity Client Services for registration status of your Tax ID.
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You can make it even easier for your users to navigate between the Availity Web Portal and ProviderAccess. Here’s how!
By entering each user’s ProviderAccess user ID in to BCBSGa Services Registration on Availity’s Web Portal and checking
the box next to the access called BlueCross BlueShield Provider Portal, each user will be able to go to My Payer Portal/Blue
Cross Blue Shield of Georgia Provider Portal on Availity and navigate to their ProviderAccess account without entering
another log in and password.
Free Training
Once you log into the secure portal, you'll have access to many resources to help jumpstart your learning, including free liv e
training, on-demand training, frequently asked questions, and comprehensive help topics. To view the current training
resources, click Free Training at the top of any page in the Availity portal or click here to find a current schedule of FREE
Availity workshops and webinars.
Still need help? Contact Availity Client Services

Call: 1-800-AVAILITY (282-4548) toll free Monday–Friday; 8:00a.m.–7:00p.m.ET

E-mail: support@availity.com
Don’t Delay, Get Registered for Availity Today!
*Note: BCBSGa trading partners (providers, clearinghouses) exchanging electronic transactions via our Enterprise EDI Gateway are unaffected by our Provider Access
functionalities moving exclusively to Availity on November 8, 2013. EDI trading partners will continue to use their existing EDI transmission channels to submit X12
transactions.
Availity, an independent company, provides claims management services for Blue Cross and Blue Shield of Georgia.
Interactive Care Reviewer (ICR) now accepts inpatient requests
Our ICR tool continues to evolve, improving the precertification process. In the latest upgrade, new features now offer you
the ability to submit both inpatient and outpatient precertfications online, plus ordering and servicing providers can submit an
inquiry to find information on any precertification previously submitted via ICR. These are the most recent enhancements to
our online precertification tool but not the last, so please stay tuned …
In the meantime, if you have not already done so, we invite you to attend one of our upcoming informational webinars. To
learn more about how you can streamline the precertification process by taking advantage of our ICR’s many features,
register today by clicking here.
As a reminder, you can access our ICR tool free of charge via the Availity Web Portal. If your organization has not yet
registered for access, go to availity.com and click on Register Now. If your organization already has access to the
Availity’Web Portal, your Primary Access Administrator can grant you acce ss to Authorizations and you can start using our
tool right away.
For questions regarding our ICR, please contact your local Network Management consultant. For questions on accessing our
tool, call Availity Client Services at 800-AVAILITY (800-282-4548) or email questions to support@availity.com. Availity Client
Services is available Monday-Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration questions.
*Note: ICR is not currently available for Medicare Advantage, Medicaid, FEP, BlueCard®, and some National Account
members; requests involving Behavioral Health or transplant services; or services administered by AIM Specialty Health SM.
For these requests, follow the same precertification process that you use today.
November 2013
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IBM, the IBM logo, ibm.com, and Watson are trademarks of International Business Machines Corp., registered in many jurisdictions worldwide. Other product and service
names might be trademarks of IBM or other companies. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at
www.ibm.com/legal/copytrade.shtml
State Health Benefit Plan
Important information about the State Health Benefit Plan
State Health Benefit Plan information is posted as it becomes available on the State Health Benefit Plan page on our
provider website, bcbsga.com.
State Health Network – SHBP
The State Health Network – SHBP includes OpenAccess POS for members who are residents in the state of Georgia and
BlueCard® PPO for members who are residing outside the state of Georgia. This network is used for all three HRA benefit
options SHBP offers to its members. For all plans, covered in-network preventive care services will be paid at 100% for
members. The three HRA metal level benefit options include the following:

Gold: 85% is paid by Plan for approved in-network services; 60% is paid by Plan for approved out-of-network
services.

Silver: 80% is paid by Plan for approved in-network services; 60% is paid by Plan for approved out-of-network
services.

Bronze: 75% is paid by Plan for approved in-network services; 60% is paid by Plan for approved out-of-network
services.
Communications
BCBSHP will be adding an SHBP specific section to our bi-monthly provider newsletter, Network Update, as well as adding a
SHBP specific page to our provider website, bcbsga.com. We will also email late breaking important information via Network
eUpdate (formerly Rapid Update). If you have not yet registered to receive Network eUpdate, please do so by visiting the
Communications page of our provider website, bcbsga.com, or contact your Provider Representative for help. Webinars will
be held in November.
Precertification
SHBP requires precertification for some services that are not required for non-SHBP members. This revised precertification
list will be posted to the Precertification page and the SHBP page on our provider website, bcbsga.com. Providers must
obtain precertification for the services listed in order to receive reimbursement. Future notifications of changes to the posted
precertification list will be done through Network Update and posted to the Precertification page and the SHBP page of our
provider website, bcbsga.com.
AIM Specialty Health sm (AIM) Programs
AIM programs include management of high-tech imaging, echocardiography, specialty pharmacy, radiation therapy and sleep
studies and sleep therapy/treatment. All of these services require precertification. In addition, for providers of high -tech
imaging services, sleep testing and sleep therapy/treatment, AIM requires the completion of an OptiNet SM online site
assessment. The following AIM programs apply to SHBP:
Diagnostic Imaging Program
Imaging Cost and Quality Program
Outpatient Radiation Therapy Program
Sleep Management Program
More information on the AIM programs can be accessed on the Answers@BCBSGa page, the Precertification page on our
bcbsga.com provider website, by visiting AIM’s website at aimspecialtyhealth.com, or calling 800-252-2021.
November 2013
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Specialty Pharmacy
SHBP has contracted directly with Express Scripts, Inc (ESI) as its ph armacy vendor. The list of pharmaceuticals that will be
included in the pharmacy benefit program, managed by ESI, will be posted to the SHBP page of our provider website,
bcbsga.com. Contact information can also be found on the SHBP page.
Claim Processing
Certain benefits, as defined by SHBP, will require specific standard industry codes in order for the service to be considered a
covered benefit. Claim submission requirements will be posted to the bcbsga.com provider website.
SHBP Contact Information
SHBP has a designated Provider Customer Service department and address. SHBP Provider Customer Service can be
reached the following ways:
Any SHBP related claims or correspondence should be mailed to:
Phone: 855-641-4862
Blue Cross and Blue Shield of Georgia
P.O. Box 105370
Atlanta, GA 30348-5370
For questions regarding the information in this letter, please contact SHBP Provider Cu stomer Service at 855-641-4862,
Provider Relations at 888-706-3475, or your local Provider Representative.
Senior business and Medicare Advantage
Please ensure referred physicians are in the Medicare Advantage Network
When referring a BCBSGa Medicare Advantage member to a specialist, please ensure that the physician participates in the
member’s health plan. Depending on the member’s benefit plan, services may not be covered or a significant member cost
share may exist when seeking services from a non-participating provider.
You can use Find a Doctor at bcbsga.com to make sure the referral is to an in-network provider.
Physicians to receive home test kits results for Medicare Advantage members
Medicare Advantage members who appeared to be missing key tests or screenings for colorectal cancer, blood sugar, and
cholesterol screenings began receiving a home test kit from us in August and will receive these home test kits as needed
through the end of the year. Providers will receive a letter from us detailing the member’s test results. Please review the t est
results and discuss the member as needed.
Record exact adult BMI number, not range
Healthcare Effectiveness Data and Information Set (HEDIS ®) is updating the medical records specifications for Adult Body
Mass Index (BMI). 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.
November 2013
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Update: Avoidable Medicare Advantage readmissions may lead to administrative claim denials
To achieve the best possible quality of care outcomes f or our Medicare Advantage members and in support of the clinical
quality issue that is being driven by CMS’ Readmission Quality Improvement Program (QIP), we have an obligation to review
readmissions for clinical relatedness. In accordance with the Diagno sis Related Groups (DRG) payment methodology,
WellPoint will be following a uniform 30-Day Readmission Review Program for our Medicare Advantage program that is
consistent with Centers for Medicare & Medicaid Services (CMS) quality improvement guidance. 1
Payment for a Medicare Advantage member’s DRG readmission to the same acute facility within 30 days of the first
admission may be administratively denied if, the readmission is determined to be related to the previous admission.
This Program will apply to facilities’ claims only. We will not administratively deny professional or ancillary claims based upon
the 30-Day Readmission Review Program. The administrative denial of these claims will apply to participating and non participating facilities. 2 As a reminder, all claims denied administratively under this Readmission Review Program are denied
as provider liability. Our member is not liable for these denied claims. Providers are not permitted to balance bill the memb er
for the denied claim.
Additional information can be found in the BCBSGa Medicare Advantage Guidebook.
Please share this information with clinical staff and others involved with admissions.
1. Chapter 4, Section 4240 (Readmission Review) of the Medicare Quality Improvement Organization Manual: Readmission review involves admissions to an acute, general,
short-term hospital occurring less than 31 calendar days from the date of discharge from the same or another acute, general, short-term hospital (See §1154(a)(13) and 42
CFR 476.71(a)(8)(ii)).
Medicare QIO Manual, Chapter 4, Section 4240: Perform case review on both stays. Analyze the cases specifically to determine whether the patient was prematurely
discharged from the first confinement, thus causing readmission. Perform an analysis of the stay at the first hospital to determine the cause(s) and extent of any problem(s)
(e.g., incomplete or substandard treatment). Consider the information available to the attending physician who discharged the patient from the first confinement. Do not base
a determination of a premature discharge on information that the physician or provider could not have known or events that could not have been anticipated at the time of
discharge.
2. Subject to explicit language that sets forth a different payment methodology
Medicare reports on osteoporosis management after bone fracture
Once a woman has had a fracture, she has a four times greater risk of another fracture, reports the National Institute of
Arthritis and Musculoskeletal and Skin Diseases.
To monitor osteoporosis management, the National Committee for Quality Assurance reports to Medicare which of your
female patients 67 years old or older has had a fracture and has had either bone mineral density testing or medication to
treat or prevent osteoporosis within six months of the fracture.
Screening and treatment can significantly improve health outcomes by preventing f ractures. Osteoporosis therapy may
reduce the risk of fracture by nearly 50 percent, according to the Journal of Rheumatology.
Medicare-covered bone density scans are covered with no cost share to member. With some plans, there may be a cost
share if the member receives these services out of network.
All qualified people with Medicare who are at risk for osteoporosis and meet one of the following five criteria are eligible:

A woman whose doctor determines she's estrogen deficient and at risk for osteo porosis, based on her medical
history and other findings
November 2013
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



A
A
A
A
person
person
person
person
whose X-rays show possible osteoporosis, osteopenia, or vertebral fractures
taking prednisone or steroid-type drugs or is planning to begin this treatment
who has been diagnosed with primary hyperparathyroidism
who is being monitored to see if their osteoporosis drug therapy is working
Medicare Advantage Part D formulary changing for 2014
Please help members with new choices
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.
Members will have formulary changes and will need your help to ensure they get their needed treatments at the most
affordable cost.
For your insulin dependent diabetic patients, it is important to note that many of BCBSGa’s plans will be removing the
Novolin line of products from formulary. BCBSGa is communicating thi s change directly to impacted members by letter and
phone encouraging them to contact their provider regarding this change in coverage.
Please encourage members to review the 2014 formulary information within their Annual Notice of Change (ANOC) mailing,
or to view the information online. Ask them if the coverage for any of their prescriptions has been changed, and consider
alternative medications in a lower cost-sharing tier that may meets their need.
2014 Medicare Advantage coverage changes for diabetic supplies
Beginning January 1, 2014, our Individual Medicare Advantage plans will only cover LifeScan, Inc., OneTouch ® or
Roche Diagnostics, ACCU-CHEK ® diabetic glucometers and blood test strips at a $0 copay when the members
purchases their supplies from an in-network supplier. This benefit change is meant to help control out-of-pocket
expenses while not compromising on quality.
Covered glucometers and blood test strips in 2014:

LifeScan, Inc., OneTouch ®

Roche Diagnostics, ACCU-CHEK ®

A limit of 100 blood test strips per month
Next steps

If our member is currently using OneTouch or ACCU-CHEK blood test strips or glucometer products, you don’t need
to do anything!

If our member is not using OneTouch or ACCU-CHEK blood test strips or glucometer products, then our member will
need to get new prescriptions for the supplies by January 1st 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 800-338-6180. If your patient purchases their supplies through a Durable Medical
Equipment supplier you will need to call the health plan.
– 866-797-9884 (call for Diabetic brand glucometer/Quantity limit on test strips)
– 800-959-1537 (fax for Diabetic brand glucometer/Quantity limit on test strips)
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Please contact Provider Service if you have any questions about these coverage changes or your patient’s benefits.
Plans that are included in this coverage change include:
CONTRACT #
Plan Benefit Package (PBP) PLAN NAME
H5422
002
BlueValue Secure (HMO)
H5422
006
BlueValue Basic (HMO)
H9947
001
Medicare Preferred Core (PPO)
PLAN TYPE
GA-HMO
GA-HMO
GA-LPPO
BCBSGa is a PPO plan with a Medicare contract. Enrollment in BCBSGa depends on contract renewal.
If a member or a provider is in doubt as to whether or not a member is in an Individual Medicare Advantage Prescription Drug
(MAPD) plan or an Employer or Union Sponsored plan, please have them check the front of the ID card which will show the
contract and PBP number (example: H1234-001). If the PBP (the last three digits of the contract-PBP number) is in the 800
series, that member is in an Employer or Union Sponsore d plan and these changes do not apply to their plans.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the
plan. Limitations, copayments, and restrictions may apply. Benefits, formul ary, pharmacy network, provider network, premium
and/or co-payments/co-insurance may change on January 1st of each year.
For more information about the exception process or the appeals policy, please see the plan’s 2014 Evidence of Coverage.
American Diabetes Association offers medication guidelines for patients with
diabetes/hypertension
The Centers for Medicare & Medicaid Services (CMS) tracks several performance and quality measures in place for Medicare
Part D members. To ensure that we are in alignme nt with CMS, one of the measures we’ll be focusing on for the remainder of
this year is medication treatment for patients with diabetes and hypertension.
The American Diabetes Association guidelines recommend that ACE inhibitors or ARB medications be give n to patients with
diabetes and hypertension to help reduce the risk of cardiovascular events and the progression of nephropathy indicated by
levels of microalbuminuria/albuminuria. If your patients have hypertension, we ask that you please consider whethe r an ACE
inhibitor or ARB medicine may be an appropriate treatment at this time.
Based on the American Diabetes Association guidelines, we offer you this information with the hope that you may find it
useful in your efforts to help ensure high-quality care for your patients.
Speaking the Language of ICD-10 - Part 2
In the last publication, as part of our implementation ICD-10 efforts, we discussed the critical role complete and accurate
medical record documentation and diagnosis coding plays in managing o ur Medicare Advantage membership. Remember,
your coding and record documentation efforts have a direct impact on accurate risk adjusted payment, as well as the
services and benefits BCBSGa is able to provide to our membership.
ICD-10 Preparation
You and your coding staff do not have to learn the entire code set. One way to help your practice prepare for the upcoming
ICD-10 changes is to review your documentation for the most commonly used ICD -9 codes in your practice. You can then
begin working with your coding staff to select the appropriate corresponding ICD-10 codes. Identifying the challenges now
November 2013
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will help reinforce the documentation requirements in order for your coders to assign the most appropriate diagnoses code
for ICD-10. This may also provide you with a tool for assessing your staff and training needs. As a guideline, coding
professionals recommend that any required coding training take place approximately six months prior to the ICD -10
compliance deadline.
ICD-10 Impact on Clinical Documentation
While ICD-10 will not change the way you provide care to your patient, the amount of details documented in the medical
record for your coding staff will need to be expanded. Specificity will be a key component to ICD -10 documentation. It will be
even more important to ensure you are documenting to the highest degree of specificity.
For example, in ICD-10, the selection of laterality is expanded. Clinical documentation for the diagnosis should include
information as to which side of the body is affected (i.e., right, left, or bilateral). BCBSGa realizes that concepts that are new
to ICD-10 may not be new to you. However, to assist you with your preparation, you will find an example of what to include in
your documentation for a fracture diagnosis to ensure your coders can accurately assign ICD-10 codes:
To code for the diagnosis of a fracture in ICD-10, the following details will need to be provided:

Site

Laterality

Type

Location
For traumatic fracture, the ICD-10 code set has the following 7 th character selection:

A Initial encounter for closed fracture

B Initial encounter for open fracture

D Subsequent encounter for fracture with routine healing

G Subsequent encounter for fracture with delayed healing

K Subsequent encounter for fracture with nonunion

P Subsequent encounter for fracture with malunion

S Sequela
In addition to providing details for the diagnosis of the fracture, it is important to also document how the injury occurred and
where. For accurate code assignment, provide the following information for injuries:

External cause – Provide the cause of the injury; when meeting with patients, ask and document “how” the injury
happened.

Place of occurrence – Document where the patient was when the injury occurred; for example, include if the patient
was at home, at work, in the car, etc.

Activity code – Describe what the patient was doing at the time of the injury; for example, was he or she playing a
sport or using a tool?

External cause status – Indicate if the injury was related to military, work, or other.
This example was provided as acute injury codes are included in the 2013 HCC Model for risk adjustment. As you can see
from this example, fracture is one of the diagnoses that have expanded the level of specificity required to code the fracture
which includes the activity codes involved.
In our next article in this 3-part series our focus will be on specific diseases, providing you with suggestions and
recommendations to help you prepare for the transition to ICD-10. We at BCBSGa have been busy transforming our business
as well in preparation for this upcoming transition, not only for working toward the ICD -10 deadline requirement, but to also
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add value and innovation. You will also find some valuable information on the CMS website and American Medical
Association website.
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, t herapeutic
interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements,
restrictions, or limitations that apply to using certain drugs.
Coverage for compound drugs
Due to the recent enhancement of the HIPPA standard for electronic submission of prescription drug claims we now have the
ability to better administer our drug benefits as they pertain to compounded drugs. During a recent review, we learned that
claims for certain compounded drugs have been submitted and paid as a prescription drug benefit. For a compound drug to
be covered it must contain at least one ingredient/drug that requires a prescription to obtain. Additionally, that
ingredient/drug must also be approved by the Food and Drug Administ ration (FDA).
Claims for certain compound drugs currently being paid will no longer be paid effective November 1, 2013. These include:

Compounded bulk powders (not FDA approved)

Pharmaceutical Adjuvants (compounding vehicles, not FDA approved)
Letters have been mailed to impacted members.
Please note: We will still cover compound drugs whose primary ingredient is FDA -approved and not otherwise excluded, as
defined under the plan.
Policy updates
Always Bundled Policy: Certain bundled services ineligible for separate reimbursement
There are services and supplies that are always considered part of providing another service and therefore are not eligible
for separate reimbursement when reported by a professional provider. These bundled services may be performed or provided
either on the same or different date of service as the primary service. The services listed below are being added to
BCBSGa’s Bundled Services and Supplies policy effective January 1, 2014:
Codes
A4216
Sterile water, saline and/or dextrose,
diluent/flush, 10 ml
A4218
Sterile saline or water, metered dose dispenser,
10 ml
A4264
Permanent implantable contraceptive intratubal
occlusion device(s) and delivery system
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Please refer to the Always Bundled reimbursement policy to inform of services and supplies not eligible for separate
reimbursement when billed with another specific procedure or service. The following identifies some of the procedures that
are described in Section 2 of the Always Bundled reimbursement policy. The exclusion of a specific code does not indicate
eligibility for reimbursement under all circumstances. These code relationships are proved as an informational tool only to
help identify some of the procedures described within the policy.
A4264 (or a reported unlisted code such as L8699) with the occlusion of the fallopian tubes by hysteroscopy code 58565
Following Current Procedural Terminology (CPT®) reporting guidelines, 76942 (Ultrasonic guidance for needle placement
(eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) is not eligible for separate
reimbursement when reported with any of the procedure codes CPT identifies 76942 should not be separately with.
The Always Bundled updated reimbursement policy will be available online to view by December 1, 2013.
View BCBSGa Professional Reimbursement policies at bcbsga.com
If you are not a registered secure provider portal user on the bcbsga.com provider website you will need to register before
you can view the Professional Reimbursement policies. In the left corner of the Provider Home Page is an option to register.
Complete the registration form and your ID and Password will be mailed to you within two weeks. If you are a registered
bcbsga.com secure provider portal user, go to left side of the screen and select Login, enter login and password, select
Policy and Procedures tab, select the link labeled Reimbursement Policies.
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 information 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 A IM’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 27 of 35
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.
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Radiation Therapy Services
Effective November 1, 2012, BCBSGa transitioned the review of outpatient radiation therapy services to AIM. AIM is a
nationally recognized leader in specialty benefits management. Providers must contact AIM for prior authorizat ion 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. Members who were already undergoing treatment on November 1, 2012 are not impacted. 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
A specialty benefit management program for outpatient sleep testing and therapy services for obstructive sleep apnea
became effective on November 1, 2012. This program is administered by AIM and includes the following:

Home sleep test (HST)

In-lab sleep study (PSG)

Titration study

Initial treatment order (APAP, CPAP, BPAP, oral devices, appliances and related supplies)

Ongoing treatment order (APAP, CPAP, BPAP, oral devices, appliances, and related supplies)
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. Effective November 1, 2012, the
precertification requirement applies to BCBSGa members who participate in BCBSGa local and individual health plans.
Effective January 1, 2013, it also applies to members covered by Medicare Advantage. The requirement does not apply to
those in the Federal Employee Program (FEP) and those for whom BCBSG a 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
Policy or Guideline Number
Date
Title and Summary
NEW MEDICAL POLICIES AND CLINICAL UM GUIDELINES
2/1/2014
DME.00037
Cooling Devices and Combined Cooling/Heating Devices
This policy addresses both passive and active cooling devices, as well as devices that combine compression
or heat therapy for the relief of pain and swelling due to trauma, surgery and other conditions. This policy
does not address the use of whole body or head cooling devices for adult or pediatric individuals with acute
neurologic injury or after sudden cardiac death.
2/1/2014
DRUG.00055
Denosumab (Prolia®, Xgeva™)
This policy addresses the use of denosumab which is a subcutaneous, fully human monoclonal antibody that
is specifically designed to target the human receptor activator of nuclear factor kappa -B ligand (RANKL) 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.
November 2013
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2/1/2014
DRUG.00057
Canakinumab (Ilaris®)
This policy addresses the indications for use of canakinumab which is a humanized monoclonal antibody,
interleukin-1 beta (IL-1 ß) inhibitor drug that works by binding human IL-1ß and neutralizes its activity by
blocking its interaction with IL-1 receptors.
2/1/2014
DRUG.00058
Pharmacotherapy for Hereditary Angioedema
This policy 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 blocking bradykinin receptors which are the primary mediators for
HAE.
2/1/2014
LAB.00030
Measurement of Serum Concentrations of Infliximab (IFX) or Antibodies -to-Infliximab (ATI)
This policy addresses the measurement of serum concentrations of infliximab (IFX) and antibodies -toinfliximab (ATI) in individuals with various conditions. Such te sting 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.
10/8/2013
CG-BEH-03
Psychiatric Disorder Treatment
This guideline addresses psychiatric disorder treatment for:
Acute Inpatient;
Residential Treatment Center (RTC);
Partial Hospitalization Program (PHP);
Intensive Structured outpatient Program (IOP);
Inpatient/Outpatient Electroconvulsive Therapy (ECT).
10/8/2013
CG-BEH-04
Substance Abuse Treatment
This guideline addresses substance abuse treatment for:
Inpatient Acute Detoxification;
Inpatient Acute Rehabilitation;
Residential Treatment Detoxification;
Residential Treatment Center (RTC);
Partial Hospitalization Program (PHP);
Intensive Structured Outpatient Program (IOP);
Outpatient Treatment;
Outpatient Detoxification Outpatient Treatment With Extended On -Site Monitoring;
Outpatient Detoxification Without Extended On -site Monitoring (Office Based);
Outpatient (Office Based) Medication Assisted Treatment (MAT) of Opioid Dependence.
10/8/2013
CG-BEH-05
Eating Disorder Treatment
This document addresses eating disorder treatment for:
Acute Inpatient;
Residential Treatment Center (RTC);
Residential Treatment Center (RTC) without 24 Hour Nursing;
Partial Hospitalization Program (PHP);
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Intensive Structured Outpatient Program (IOP);
Outpatient.
10/8/2013
CG-BEH-06
Psychiatric Outpatient Treatment
This guideline addresses psychiatric outpatient treatment (including treatmen t provided by a clinician
licensed at the independent practice level) and medication management.
10/8/2013
CG-BEH-07
Psychological Testing
This guideline addresses psychological testing.
10/8/2013
CG-BEH-08
Employee Assistance Program Outpatient Treatment
This guideline addresses Employee Assistance Program (EAP) Outpatient Treatment Criteria and these
criteria apply only to California DMHC Regulated Business.
2/1/2014
CG-DME-35
Breastfeeding Pumps
This guideline addresses the non-standard, electric, heavy-duty, hospital-grade breast pump for initiating
and maintaining expression of human breast milk in specified situations.
2/1/2014
CG-SURG-34
Diagnostic Infertility Surgery
This guideline addresses the use of hysteroscopy and laparoscopy for diagn ostic work-up of infertility.
2/1/2014
CG-SURG-35
Intracytoplasmic Sperm Injection (ICSI)
This guideline addresses the use of intracytoplasmic sperm injection (ISCI) 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.
REVISIONS TO EXISTING MEDICAL POLICIES OR CLINICAL UM GUIDELINES
10/8/2013
ADMIN.00001
Medical Policy Formation
This policy describes the medical policy formation process.
10/8/2013
ADMIN.00002
Preventive Health Guidelines
This policy provides links to several national organizations' evidence -based guidelines for preventive
services.
10/8/2013
ANC.00009
Cosmetic and Reconstructive Services of the Trunk and Groin
This policy addresses a variety of surgical procedures of the trunk or groin that may be considered medically
necessary, cosmetic or reconstructive in nature.
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10/8/2013
BEH.00004
Behavioral Health Treatments for Autism Spectrum Disorders and Rett Syndrome
This policy addresses pharmacotherapeutic and behavioral health -related treatments and therapies used to
treat Autism Spectrum Disorders (ASDs) and Rett syndrome.
Previously titled: Behavioral Health Treatments for Pervasive Developmental Disorders
10/8/2013
DME.00027
Ultrasound Bone Growth Stimulation
This policy addresses the use of low-intensity pulsed ultrasound devices as a treatment to promote healing
of some fresh fractures and to accelerate healing for nonunion of other fracture sites.
8/12/2013
DRUG.00002
Tumor Necrosis Factor Antagonists
This policy addresses the indications for a class of biologic disease -modifying antirheumatic drugs
(DMARDs) known as tumor necrosis factor (TNF) ant agonists (inhibitors), that target specific pathways of
the immune system and either enhance or inhibit immune response.
8/12/2013
DRUG.00015
Prevention of Respiratory Syncytial Virus Infections
This policy identifies populations at high risk for RSV a nd indications for RSV prophylaxis.
8/12/2013
DRUG.00038
Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
This policy addresses the indications and criteria for the use of bevacizumab in the treatment of oncologic
conditions and other non-ophthalmologic indications.
8/12/2013
DRUG.00043
Tocilizumab (Actemra®)
This policy addresses the use of tocilizumab for the treatment of adults with moderately to severely active
rheumatoid arthritis (RA) and children two years of age and older with active pol yarticular juvenile idiopathic
arthritis (PJIA) or active systemic juvenile idiopathic arthritis (SJIA).
10/8/2013
DRUG.00044
Belimumab (Benlysta®)
This policy addresses the use of belimumab for the treatment of individuals age 18 or older with active,
antibody-positive systemic lupus erythematosus (SLE), and for other indications.
2/1/2014
GENE.00001
Genetic Testing for Cancer Susceptibility
This policy addresses genetic testing for individuals who are at higher than average risk for the development
of cancer.
8/12/2013
MED.00080
Cryopreservation of Oocytes or Ovarian Tissue
This policy addresses oocyte and ovarian tissue cryopreservation which are alternative techniques to
embryo cryopreservation for women who would become infertile due to gonadotoxi c therapies such as,
chemotherapy, radiation therapy or surgery.
10/8/2013
MED.00107
Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett
Syndrome
This policy addresses pharmacotherapeutic, medical, and clini cal rehabilitative treatments and therapies
used to treat Autism Spectrum Disorders (ASDs) and Rett syndrome.
Previously titled: Medical and Other Non-Behavioral Health Related Treatments for Pervasive Developmental
Disorders
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2/1/2014
RAD.00035
Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA),
Coronary Magnetic Resonance Angiography (MRA), and Cardiac Magnetic Resonance Imaging (MRI)
This policy 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.
10/8/2013
SURG.00007
Vagus Nerve Stimulation
This policy addresses the use of an implantable vagal nerve s timulation (VNS) device and the electronic
analysis of the implanted neurostimulator pulse generator system for the treatment of medically and
surgically refractory seizures associated with intractable epilepsy and as a treatment of other conditions.
10/8/2013
SURG.00011
Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue
Grafting
This policy addresses the use of soft tissue (e.g., skin, ligament, cartilage, etc.) substitutes in wound healing
and surgical procedures.
8/12/2013
SURG.00017
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT)
This policy addresses stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) which are
non invasive treatments where high doses of focuse d radiation beams are precisely delivered to intracranial
and extracranial targets, thus sparing adjacent tissue and structure from irradiation.
2/1/2014
SURG.00037
Treatment of Varicose Veins (Lower Extremities)
This policy addresses various modalities for the treatment of valvular incompetence (i.e., reflux) of the
greater or lesser saphenous veins and associated varicose tributaries as well as telangiectatic dermal veins.
10/8/2013
SURG.00049
Mandibular/Maxillary (Orthognathic) Surgery
This policy addresses medically necessary, reconstructive and cosmetic procedures involving the mandible,
maxilla or both, with the exception of orthognathic surgery for the treatment of temporomandibular disorders
or obstructive sleep apnea.
8/12/2013
SURG.00055
Cervical Artificial Intervertebral Discs
This policy addresses the use of U.S. Food & Drug Administration (FDA) approved cervical artificial
intervertebral discs as a treatment for symptomatic cervical disc disease when conservative treatment
options have been unsuccessful.
10/8/2013
SURG.00064
Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator
(CRT/ICD) for the Treatment of Heart Failure
This policy addresses biventricular cardiac pacing to deliver cardiac r esynchronization therapy (CRT) to
alleviate the symptoms of moderate to severe congestive heart failure (HF) associated with left ventricular
dyssynchrony. It also addresses a hybrid device that combines CRT with an implantable cardioverter
defibrillator (ICD).
10/8/2013
SURG.00071
Percutaneous and Endoscopic Spinal Surgery
This policy addresses percutaneous and endoscopic spinal discectomy and disc decompression as well as
image-guided minimally invasive lumbar decompression procedures.
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10/8/2013
SURG.00077
Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
This policy addresses laparoscopic and percutaneous ablative techniques for the treatment of symptomatic
uterine fibroids. Previously titled: Laparoscopic and Percutan eous MRI-Image Guided Techniques for
Myolysis as a Treatment of Uterine Fibroids
10/8/2013
SURG.00117
Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and
Fecal Incontinence; Urinary Retention
This policy addresses sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) in
those with chronic, refractory urinary and fecal incontinence, as well as urinary retention.
8/12/2013
SURG.00122
Venous Angioplasty with or without Stent Placement
This policy addresses the use of venous angioplasty as a treatment modality.
10/8/2013
CG-BEH-01
Assessment for Autism Spectrum Disorders and Rett Syndrome
This guideline addresses various tools used in the screening and assessment of individuals with suspected
Autism Spectrum Disorders (ASDs) and Rett syndrome.
Previously titled: Assessment for Pervasive Developmental Disorders
10/8/2013
CG-DRUG-11
Infertility Drugs
This guideline addresses the use of oral, injectable and topical infertility drugs, including protocols used to
treat women with ovulation disorders, drugs used as part of an Assisted Reproductive Technology (ART)
treatment (most commonly through in vitro fertilization [IVF]), intrauterine insemination, and as treatment of
male infertility with gonadotropins.
10/8/2013
CG-DRUG-28
Alglucosidase alfa (Lumizyme®, Myozyme®)
This guideline addresses alglucosidase alfa products (Lumizyme and Myozyme which are enzyme
replacements used for specific indications as a treatment of Pompe disease.
8/12/2013
CG-MED-26
Neonatal Levels of Care
This guideline addresses therapies and services provided in AAP defined level of care required for the
normal healthy newborn to the critically ill newborn.
10/8/2013
CG-MED-44
Holter Monitors
This guideline addresses the use of the standard external ambulatory Holter monitor.
2/1/2014
CG-MED-49
Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing
Disorders
This guideline addresses auditory brainstem response (ABR) and ev oked otoacoustic emission (OAE) testing
which are noninvasive methods used to detect hearing disorders. Previously titled: Auditory Brainstem
Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Screening and Diagnosis of Hearing
Disorders
10/8/2013
CG-SURG-24
Functional Endoscopic Sinus Surgery (FESS)
This guideline addresses the use of functional endoscopic sinus surgery (FESS), an endoscopic surgical
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procedure used to treat various conditions of the nasal sinuses, including but not limited to chronic sinusitis.
10/8/2013
CG-SURG-27
Gender Reassignment Surgery
This guideline addresses gender reassignment surgery which is one treatment option for extreme cases of
gender dysphoria, a condition in which a person feels a strong and persistent ide ntification with the opposite
gender accompanied with a severe sense of discomfort in their own gender.
REVIEW OF EXISTING MEDICAL POLICIES OR CLINICAL UM GUIDELINES
No change
BEH.00002
to previous
Transcranial Magnetic Stimulation for Depression and Other Neuropsychiatric Disorders
effective
date
This policy addresses transcranial magnetic stimulation (TMS) as a treatment of behavioral health
indications including depression and other neuropsychiatric disorders.
10/1/2013
10/8/2013
GENE.00021
Cytogenomic Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder and
Mental Retardation
This policy addresses cytogenomic microarray analysis (CMA), also known as array comparative genomic
hybridization (aCGH) and cytogenomic constitutional (genome-wide) microarray analysis, which is used as a
diagnostic tool for individuals with unexplained developmental delay (DD), autism spectrum disease (ASD)
and mental retardation (MR). Previously titled: Comparative Genomic Hybridization (CGH) Microarray
Testing for Developmental Delay, Autism Spectrum Disorder and Mental Retardation
10/8/2013
LAB.00027
Antigen Leukocyte Cellular Antibody Test (ALCAT) for Chemical and Food Allergies
This policy addresses ALCAT which measures whole bloo d leukocyte activity to identify allergens which
cause an increase in the leukocyte activity. The ALCAT has been promoted as a diagnostic test for food
allergy or intolerance (chemical sensitivities) and as a tool to establish elimination diets.
No change
LAB.00029
to previous
AmniSure® ROM (Rupture of Membranes) Test
effective
date
12/2/2013
This policy addresses the AmniSure® test which detects PAMG -1 (placental alpha-1 microglobulin) protein
marker of amniotic fluid in vaginal secretions and is inten ded for use by health care professionals as a point of-care service to aid in the detection of rupture of membranes (ROM) in pregnant women with signs,
symptoms or complaints suggestive of ROM.
10/8/2013
MED.00064
Transcatheter Ablation of Arrhythmogeni c Foci in the Pulmonary Veins as a Treatment of Atrial
Fibrillation (Radiofrequency and Cryoablation)
This policy addresses transcatheter radiofrequency ablation and cryoablation of arrhythmogenic foci in the
pulmonary veins for the treatment of atrial fibrillation.
12/2/2013
MED.00112
Autonomic Testing
This document addresses the use of autonomic testing. Autonomic nervous system testing can be grouped
into three categories; sudomotor, cardiovagal innervation, and vasomotor adrenergic innervation. The tests
for sudomotor function can include QSART, TST, SSR, Silasticsweat imprint, and QDIRT. This document
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does not address the use of tilt -table testing.
10/8/2013
RAD.00063
Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imagi ng (MPRAGE
MRI)
This document addresses magnetization-prepared rapid acquisition gradient echo (MPRAGE) MRI for all
indications including the assessment of carotid artery plaque.
10/8/2013
SURG.00047
Transendoscopic Therapy for Gastroesophageal Reflux D isease and Dysphagia
This policy addresses selected transendoscopic therapies for the treatment of gastroesophageal reflux
disease (GERD) and dysphagia. This document does not address procedures which approach the
esophagus through abdominal laparoscopic or open surgical approaches.
10/8/2013
SURG.00066
Percutaneous Neurolysis for Chronic Neck and Back Pain
This policy addresses percutaneous techniques to treat spinal pain identified as being facet in origin.
10/8/2013
SURG.00089
Balloon Sinus Ostial Dilation
This policy 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.
10/8/2013
SURG.00131
Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux
Disease (GERD)
This policy addresses the use of non-endoscopic devices intended for the treatment of gastroesophageal
reflux disease (GERD).
10/8/2013
SURG.00133
Alcohol Septal Ablation for Treatment of Hypertropic Cardiomyopathy
This policy addresses alcohol septal ablation for the treatment of hypertrophic cardiomyopathy (HCM). HCM
has also been referred to in the published literatu re as hypertrophic obstructive cardiomyopathy (HOCM).
10/8/2013
TRANS.00014
Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist
Devices and Artificial Hearts)
This policy addresses ventricular assist devices (VADs), percutaneous ventricular assist devices (pVADs)
and artificial hearts.
10/8/2013
CG-MED-22
Neuropsychological Testing
This guideline addresses the use of neuropsychological testing, also known as psychometric testing, which
refers to a quantitative, comprehensive evaluation of cognitive, motor and behavioral functional abilities
related to developmental, degenerative, and acquired brain disorders.
12/2/2013
CG-MED-46
Ambulatory Electroencephalography
This guideline addresses ambulatory electroencephalography monitoring in the outpatient (home) setting.
This test records continuous and prolonged electrical activity of the brain to assist in the evaluation and
diagnosis of seizure disorders and epilepsy syndromes.
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ANNUAL REVIEW TOPICS
10/8/2013
ADMIN.00004
Medical Necessity Criteria
10/8/2013
ADMIN.00005
Investigational Criteria
10/8/2013
ADMIN.00006
Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical
Policy or Clinical Utilization Management (UM) Guideline
10/8/2013
ANC.00006
Biomagnetic Therapy
10/8/2013
ANC.00007
Cosmetic and Reconstructive Services: Skin Related
10/8/2013
ANC.00008
Cosmetic and Reconstructive Services of the Head and Neck
10/8/2013
DME.00004
Electrical Bone Growth Stimulation
10/8/2013
DME.00024
Transtympanic Micropressure for the Treatment of Meniere's Disease
10/8/2013
DME.00030
Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering
10/8/2013
DRUG.00017
Hyaluronan Injections in Joints Other Than the Knee
10/8/2013
DRUG.00031
Subcutaneous Hormone Replacement Implants
10/8/2013
GENE.00002
Preimplantation Genetic Diagnosis Testing
10/8/2013
GENE.00015
Predictive Genetic Testing for Non-Malignant Diseases
10/8/2013
LAB.00011
Analysis of Proteomic Patterns
10/8/2013
LAB.00016
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
10/8/2013
MED.00081
Cognitive Rehabilitation
10/8/2013
MED.00090
Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
10/8/2013
MED.00098
Hyperoxemic Reperfusion Therapy
10/8/2013
RAD.00019
Magnetic Source Imaging and Magnetoencephalography
10/8/2013
RAD.00023
Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
10/8/2013
RAD.00034
Dynamic Spinal Visualization (Including Digital Motion X -ray and Cineradiography/ Videofluoroscopy)
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10/8/2013
RAD.00042
SPECT/CT Fusion Imaging
10/8/2013
RAD.00045
Cerebral Perfusion Imaging Using Computed Tomography
10/8/2013
RAD.00046
Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging
10/8/2013
RAD.00060
Digital Breast Tomosynthesis
10/8/2013
SURG.00005
Partial Left Ventriculectomy
10/8/2013
SURG.00010
Treatments for Urinary Incontinence
10/8/2013
SURG.00020
Bone-Anchored Hearing Aids
10/8/2013
SURG.00023
Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
10/8/2013
SURG.00048
Panniculectomy and Abdominoplasty
10/8/2013
SURG.00051
Hip Resurfacing
10/8/2013
SURG.00054
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and
Aortic Transection
10/8/2013
SURG.00059
Recombinant Human Bone Morphogenetic Protein
10/8/2013
SURG.00074
Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring
10/8/2013
SURG.00076
Nerve Graft after Prostatectomy
10/8/2013
SURG.00084
Implantable Middle Ear Hearing Aids
10/8/2013
SURG.00085
Mastectomy for Gynecomastia
10/8/2013
SURG.00090
Radiofrequency and Pulsed Radiofrequency Neurolysis for Tr igeminal Neuralgia (TGN)
10/8/2013
SURG.00105
Bicompartmental Knee Arthroplasty
10/8/2013
SURG.00116
High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell
Cancer of the Anus
10/8/2013
SURG.00118
Bronchial Thermoplasty
10/8/2013
SURG.00125
Radiofrequency and Pulsed Radiofrequency Ablation of Trigger Point Pain
10/8/2013
SURG.00126
Ablation of Soft Tissue using Irreversible Electroporation (IRE)
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10/8/2013
SURG.00132
Devices for Maintaining Sinus Ostial Patency Fol lowing Sinus Surgery
10/8/2013
SURG.00134
Interspinous Fixation Devices
10/8/2013
TRANS.00035
Mesenchymal Stem Cell Therapy For Orthopedic Indications
10/8/2013
CG-ANC-03
Acupuncture
10/8/2013
CG-BEH-01
Assessment for Pervasive Developmental Disorders
10/8/2013
CG-DME-03
Neuromuscular Stimulation in the Treatment of Muscle Atrophy
10/8/2013
CG-DME-04
Electrical Nerve Stimulation, Transcutaneous, Percutaneous
10/8/2013
CG-DME-05
Cervical Traction Devices for Home Use
10/8/2013
CG-DME-07
Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
10/8/2013
CG-DME-08
Infant Home Apnea Monitors
10/8/2013
CG-DME-15
Hospital Beds and Accessories
10/8/2013
CG-DRUG-03
Beta Interferons or Glatiramer Acetate for Treatment of Mul tiple Sclerosis
10/8/2013
CG-DRUG-07
Hepatitis C Pegylated Interferon Antiviral Therapy
10/8/2013
CG-DRUG-13
Hepatitis B Interferon Antiviral Therapy
10/8/2013
CG-DRUG-27
Clostridial Collagenase Histolyticum Injection
10/8/2013
CG-MED-05
Ketogenic Diet for Treatment of Intractable Seizures
10/8/2013
CG-MED-23
Home Health
10/8/2013
CG-MED-31
Skilled Nursing Facility Services
10/8/2013
CG-REHAB-03
Pulmonary Rehabilitation
10/8/2013
CG-REHAB-09
Acute Inpatient Rehabilitation
10/8/2013
CG-SURG-05
Maze Procedure
10/8/2013
CG-SURG-07
Vertical Expandable Prosthetic Titanium Rib (VEPTR)
10/8/2013
CG-SURG-08
Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
November 2013
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10/8/2013
CG-SURG-11
Surgical Treatment for Dupuytren's Contracture
10/8/2013
CG-SURG-18
Septoplasty
CODING UPDATES OF EXISTING MEDICAL POLICIES OR CLINICAL UM GUIDELINES EFFECTIVE
2/1/2014
SURG.00113
Artificial Retinal Devices
November 2013
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