HealthyBlue Dual/Triple Option Provider Manual · HealthyBlue PROVIDER MANUAL HealthyBlue: How it...

>HealthyBlue Dual/Triple Option Provider Manual

HealthyBluePROVIDERMANUAL

TableofContents

Welcome to HealthyBlue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

HealthyBlue: How it Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4HealthandWellnessEvaluationHealthy Action PlanHealthandWellnessRequestforInformationLetterPlanOptions

Membership & Product Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9HealthSavingsAccount(HSA)andHealthReimbursementArrangement(HRA)Plans

HealthyBlue Identification Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Referral Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15PCPReferralProcessSpecialistReferralProcessServicesNotRequiringaReferralExtended(Standing)Referrals

Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ServicesRequiringAuthorizationServicesNotRequiringanAuthorizationIn-NetworkversusOut-of-NetworkProviders

Arranging for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20RoleofthePCPRoutineOfficeVisitsEmergencyRoomServicesHospitalServicesBenefits,ExclusionsandLimitationsAwayFromHomeCareLaboratoryServicesObstetrics&Gynecology

Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Administrative Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ChangeinPrivilegesWebResources

Important Addresses and Telephone/Fax Numbers . . . . . . . . . . . . . . . . . . . . . . . . 48

Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

PerthetermsoftheParticipationAgreement,allprovidersarerequiredtoadheretothepoliciesandprocedurescontainedinthismanual,asapplicabletoeachtypeofprovider.

2


Welcome to HealthyBlue

Astheprimarycareprovider(PCP)*,youknowourmembers’healthcareneedsbetterthananyone.Youarealsointhebestpositiontoprovidecoordinatedcareandmakekeyjudgmentsregardingthemembers’health.CareFirstBlueChoice,Inc.(CareFirstBlueChoice)ispleasedtointroduceHealthyBlue,anewproductwithapositiveapproachtohealthcarethatfostersandrewardshealthylifestylesandpromotesastrong,trustingrelationshipbetweenyouandyourpatients.

HealthyBlueproductsaredesignedtorewardCareFirstBlueChoicememberswhoworkcloselywiththeirproviderstobetterunderstandandmonitortheircare.Withyourguidance,memberswillbegintotakeanactiveroleinmaintainingahealthylifestyleandworktowardimprovedhealth.

ThismanualwillassistyouincaringforCareFirstBlueChoicememberswhoelecttoparticipateinHealthyBlue.Enclosedyouwillfindadministrativeguidelines,sampleformsandmore.

Pleasenote:

● Thismanualwillbeupdatedifproceduralchangesaremadeinourongoingeffortstoimproveourservice.

● Thespecificsofamember’shealthbenefitsvaryandmaydifferfromtheproceduresoutlinedinthismanual.It is important to note that the referral process for HealthyBlue is different than BlueChoice HMO. Please refer to the Referrals section for more information.

IfyouhaveanyquestionsorwouldlikeadditionalinformationaboutHealthyBlue,pleasecallaProviderServicesRepresentativeat202-479-6560 or 800-842-5975.

*TopracticeasanindependentPCP,NPsmustbecertifiedbytheirrelevantapprovedNationalCertificationBoardandmeetalllicensingcertificationguidelinesofthestateinwhichtheNPpractices.NPsmustalsofileanattestationthattheyhaveawrittencollaborativeagreementwithaphysicianofthesamespecialtywhoisingoodstandinginthesameCareFirstprovidernetworks.

3


HealthyBlue: How it Works

FollowingenrollmentintheHealthyBlueproduct,memberswhoelectedtoparticipatewillhavetocompleteaHealthAssessmentandscheduleaPrimaryCareProvider(PCP)visittoconductaHealthandWellnessEvaluationatnoout-of-pocketcostforthemember.

ThefollowingtypesofCareFirstBlueChoicepractitionersarerecognizedasHealthyBlueprimarycareproviders(PCPs):

● FamilyPractice

● GeneralPractice

● InternalMedicine

● Pediatrics

● Geriatrics

Note for OB/GYN physicians: IfyouareaCareFirstBlueChoiceparticipatingOB/GYNwhoagreestoactasPCPforamember,givethememberaletterstatingyourdecisiontoserveasherPCP.ThelettershouldincludeyourCareFirstBlueChoiceprovidernumberandthemember’sidentificationnumber.ThemembershouldsubmitthelettertoCareFirstMemberServicesforprocessing.

4

Health and Wellness EvaluationThroughtheHealthandWellnessEvaluation,anindividual’sbaselinehealthstatusforcertainriskfactorswillbedetermined.YouwillmeasureandrecordeachfactorontheHealthandWellnessEvaluationForm.Youcanobtainacopyoftheformviathefollowing:

● OnlineatCareFirst Direct

● OnourWebsite:www .carefirst .com/providers/forms

● BycallingaProviderServicesRepresentativeat202-479-6560or800-842-5975

ThehealthfactorsmeasuredonthisformaredeterminedbytheAmericanJournalofPreventiveMedicinetobemostindicativeoffuturehealthoutcomes.ConsultthestandardssetinourPreventive Services Guidelinesformoreinformation.

Theseinclude:

● TobaccoUse–notrequiredforchildrenages17andyounger

● BloodPressure–notrequiredforages17andyounger

● Cholesterol–notrequiredforchildrenages17andyounger

● BodyMassIndex(BMI)

● InfluenzaImmunization

● ChildhoodImmunizationstatus–asappropriateforage

● CommonCancerScreenings–asappropriateforageandgender

● Breast(50+women) ● Cervical(18+women) ● Colon(50+menandwomen)

Health and Wellness Evaluation Scheduling

WhenCareFirstBlueChoicememberscalltomakeanappointment,instructyourofficestafftoaskiftheappointmentisforaHealthandWellnessEvaluation.Theofficestaffshouldremindmemberstobringallnecessarypaperworkandinformationtotheofficevisit.ThisincludesacopyoftheHealthandWellnessEvaluationFormandanyapplicablevaccinationdates(forexample,flushots)andtestandscreeningupdates(forexample,breastexamsandcervicalcancerresults).

MembersmustscheduletheirHealthandWellnessEvaluationandanyrequiredtestswithin 90 daysofpolicyeffectivedate.WithHealthyBlue,membershavetheoptiontoseekcarefromanyCareFirstBlueChoicePCP.AlthoughitisidealforthemembertocompletetheHealthandWellnessEvaluationwiththeirselectedPCP,theycanselectanotherparticipatingCareFirstBlueChoicePCPifnecessary,toconducttheHealthandWellnessEvaluation.

Health and Wellness Evaluation Form

ThemembershouldbringaHealthandWellnessEvaluationFormtotheinitialevaluationofficevisit.Wehaveincludedasampleformaboveforyourreference.TheHealthandWellnessEvaluationFormwillserveasarecordto:

● Captureabaselinehealthcarestatus

● Determineareasforimprovement


Section I: Member/Primary Care Provider (PCP) Information – to be completed by member and PCP within 90 days of effective date.

Member Information (Please print) PCP Information (Please print)

Last Name First Name MI PCP Name

Member ID Number (include alpha-numeric prefix) CareFirst BlueChoice PCP Number

Date of Birth(mm/dd/yyyy): / /

Gender (Check one)

Male Female

PCP Phone Number

Group Number (found on ID card)

Effective Date of Coverage (verify in CareFirst Direct)

Section II: Health Measures — Initial Screening completed by PCP at initial visit.

1. Tobacco Use (not required for ages 17 and younger) Must be within 6 months of PCP screening date

2. Blood Pressure (BP) (not required for ages 17 and younger) Must be within 6 months of PCP screening date

GOAL: Non-smoker (never smoked or quit for more than 30 days) GOAL: 120/80

Date of service (mm/dd/yyyy): / /

Non-Smoker Smoker

Alternative Guideline Set: Yes No Waiver: Yes No


BP Reading: / sys / dia


3. Cholesterol (LDL) (not required for ages 17 and younger) Must be within 6 months of PCP Screening date

4. Healthy Weight (required for age 2 and up – list as percentile for child) Must be within 6 months of PCP Screening date

GOAL: Acceptable LDL per guidelines every 5 years GOAL(s): • Adult Body Mass Index (BMI) is in the range 19 to 25 • Child’s BMI percentile range based on age and gender

(5th percentile to less than 85th percentile)

LDL Acceptable LDL Not Acceptable


LDL:



BMI:


5. Screenings and Immunizations (required)

GOAL(s): • PCP has reviewed appropriate cancer screening and immunization schedules with member • Member is up-to-date for Colon Cancer Screening, Cervical Cancer Screening, Breast Cancer Screening and immunizations

Important: • For children 2-17, the childhood immunizations need to be up-to-date based on the PCP’s discretion • For men and women over 50, the Colon Cancer Screening needs to be within 10 years of PCP screening signature date • For women over 21, the Cervical Cancer Screening needs to be within 3 years of PCP screening signature date • For women over 50, the Breast Cancer Screening needs to be within 2 years of PCP screening signature date • For all members, the Influenza Vaccine needs to be within 18 months of PCP screening signature date

Child Immunizations up-to-date: Yes No

Alternative Guideline Set: Yes No

Waiver: Yes NoLast Colon Cancer Exam Date (mm/dd/yyyy): / /


Waiver: Yes No

Last Breast Cancer Exam Date (mm/dd/yyyy): / /


Waiver: Yes No

Last Cervical Cancer Exam Date (mm/dd/yyyy): / /


Waiver: Yes No

Last Influenza Vaccine Date (mm/dd/yyyy): / /


Waiver: Yes No

Initial Screening PCP Comment(s): Healthy Action Plan established: Yes No (please explain)

Section III: By signing below, I verify that I have reviewed the information provided by my PCP and agree with the status indicated. I also agree to follow any recommendations made by my PCP.

Member Initial Screening Signature Date(Parent or guardian must sign if member is 17 or younger)

PCP Initial Screening Signature Date(Note to PCP: Do not sign until all applicable test results have been received)

Health and Wellness Evaluation FormFor Dual/Triple Option Plans Only (XIN or XIM on ID card)

PCPs must submit the completed form by fax to 410-505-6160 or through CareFirst Direct. Members should not submit this form directly to CareFirst.CUT8511-1P (4/12)

When CareFirst

BlueChoice members

call to make an

appointment, instruct

your office staff to ask

if the appointment is for

a Health and Wellness

Evaluation.

5

https://www.carefirst.com/signon/welcome.do


http://www.carefirst.com/providers/forms


http://www.carefirst.com/providers/redirects/CareFirstDirectRedirect.html

www.carefirst.com/providers/forms



http://www.carefirst.com/clinicalresources



● DevelopaHealthyActionPlantopromotehealthylifestyles

IfthememberdoesnotbringtheHealthandWellnessEvaluationFormtotheinitialofficevisit,youcanaccesstheformviathefollowing:

● OnlineatCareFirst Direct

● OnourWebsite:www .carefirst .com/providers/forms

● BycallingaProviderServicesRepresentativeat202-479-6560or800-842-5975

Besuretoconfirmthemember’seffectivedateandeligibilitypriortofillingouttheHealthandWellnessEvaluationForm.Theformmustbecompletedduringyourmember’sevaluationvisitandreturnedtoCareFirstBlueChoicewithin120 daysofthemember’seffectivedate,otherwisethememberwillnotbeeligibletoreceiveanincentive.

Ifthememberhascompletedtherequiredscreenings,immunizationsandhealthmeasureswithintheprevioussix(6)months,youmaydeterminethatanofficevisitisnotnecessarytocompletetheHealthandWellnessEvaluationForm.However,allareasoftheinitialscreeningsectionmustbecompletedandbothyouandthemembermustsigntheformregardlessofwhetheranofficevisitisrequired.

Toavoiddelaysinprocessingthemember’sincentive,besurethattheformisfilledoutinitsentirety–includingsignatures,updatesoncancerscreeningsandchildhoodimmunizations.Signingthisformindicatesthatyouhavereviewedtheresultswiththememberandagreewithwhatisreported.Any form received by CareFirst BlueChoice without proper signatures (provider and member) will be considered incomplete and will be returned.

Initial Evaluation Screening

AsyoucompletetheHealthandWellnessEvaluationForm,recordtheoutcomesofthescreenings,immunizationsandbaselinehealthfactorsintheInitial Screeningsection.Also,besuretomeasureanddiscussthehealthfactorswithmemberstodeterminetheirbaselinehealthstatus.AllfieldsoftheHealthandWellnessEvaluationFormmustbecompleted.

TocomplywiththeHealthInsurancePortabilityandAccountabilityAct(HIPAA)regulationsfora

“bonafidewellnessprogram,”youcanallowforanalternativestandard/guideline(orwaiverofinitialgoal/standard)foranymemberforwhomitisunreasonablydifficultduetoamedicalconditionoritismedicallyinadvisabletosatisfytheinitialstandard/guideline.

Check“Waiver”or“AlternativeGuidelineSet”intheboxesprovidedforeachHealthMeasuretoindicatethatthememberhasmettheacceptableguidelines.Detailsonallwaiversoralternativestandards/guidelinesshouldbeprovidedinthecommentssection(s)oftheform.

● By checking “Waiver”youarereportingthatthememberdoesnothavetomeetalternativestandards/guidelines

● By checking “Alternative Guideline Set” youarerequiredtoprovideanewgoalforthemembertomeetatthetimeofaclinicallyappropriatereevaluation

Examplesofawaiveroralternativestandard/guidelineinclude:

● WaivingaBodyMassIndex(BMI)readingduetopregnancy

● Compliancewithalow-cholesteroldietforindividualswithgeneticallyhighcholesterol

When completing the Health and Wellness Evaluation Form, please remember the following goals as they relate to the member’s cancer screening and immunization health status:

● Memberisup-to-dateforappropriatecancerscreeningsbasedonage/gender

● Memberisup-to-dateforinfluenza

● Memberisup-to-dateonchildimmunizationsbasedonage

● PCPhasreviewedappropriatecancerscreeningandimmunizationscheduleswithmember

ConsultourPreventive Services Guidelinesfordetailsonappropriatestandards.

Note:SubmitCPT® code 99420whenyoufileareimbursementclaimforcompletingtheinitialevaluationscreeningportionoftheHealthandWellnessEvaluationFormanddiscussingtheresultswiththemember,alongwithotherservicesrendered.Thereimbursementiscalculatedinthesamemannerasanofficevisit.

Submit the Health and Wellness Evaluation

6

CareFirst Direct





Form using one of the following methods:

1. UploadtoCareFirst Direct: ● Scantheformandsaveitin.JPG,.PDFor

.TIFFformat ● ClickUploadEvaluationFormtosendthe

documentfromyourcomputerOR

2. Faxto:410-505-6160or800-354-8205

Healthy Action PlanAHealthy Action Planisanagreementbetweenthememberandproviderandshouldbedevelopedifthememberdoesnotmeetthenationalguidelines(identifiedas“Goal”ontheHealthandWellnessEvaluationForm)duringtheinitialscreening.Weencourageyoutoworkwiththemembertodevelopacustomizedplanthatincludesrecommendationsformeasuresthatneedre-evaluationtohelpthemembermeetthegoalsontheHealthandWellnessEvaluationForm.TheHealthy Action Plan servesasaguidetoshowmembershowtoachieveandmaintainhealthy,long-termoutcomes.

TheHealthy Action PlanshouldalsoincludeatimeframeforwhenthememberisexpectedtoreturnforaClinicallyAppropriateRe-Screening.Inordertoqualifyforaprogramincentive,themember’sHealthy Action Planmustbedevelopedandtheclinicallyappropriatere-screeningmusttakeplacepriortotherenewaldate.

Formoreinformationonthehealthmeasuresandinstructionsforprovidingpreventivecare,consultourPreventive Services Guidelines .

Clinically Appropriate Re-Screening

TheClinically Appropriate Re-ScreeningisnecessaryifyoudeterminethatthememberdoesnotmeetorexceedhealthymeasuresbasedonthestandardssetinourPreventive Services Guidelines.Membersmustcompletethisprocesstobeeligibleforprogramincentives.There-screeningwillalsobeusedtocheckthestatusoftheHealthy Action Plan atthetimeageeduponbythePCPandthemember.

Submitting the Form:

● Ifyouconductboththeinitialevaluationscreening,andthere-screening,pleasecomplete,signandsubmitboththeInitialandRe-Screeningsectionsoftheform.

● Youmaydecidetoeithertestonlythosemeasuresforthegoalsthememberdidnotreachorre-testallmeasuresagain.However,youmustbesuretofullycompletebothsectionsoftheHealthandWellnessEvaluationForm.

● Makesureallsectionsoftheform,forboththeinitialscreeningandthere-screeningresults,arecompletedbeforesubmittingtheformviaCareFirst Directorbyfax(410-505-6160or800-354-8205),eveniftherearenochanges.

● Bothyouandthemembermustsignthere-screeningsectionoftheHealthandWellnessEvaluationFormtoindicatethatyoubothreviewedtheformandagreewiththemeasuresrecorded.

● UsetheexistingclaimssubmissionprocesstofileaclaimforreimbursementoftheHealthandWellnessEvaluationFormalongwithotherservicesrendered.

● MembersmayrequestacopyoftheHealthandWellnessEvaluationFormfortheirrecords.

● OnlyaCareFirstBlueChoicePCPcansubmittheformtoCareFirstBlueChoice.

Note:SubmitCPT® code 99420whenyoufileareimbursementclaimforcompletingthere-screeningportionoftheevaluationformanddiscussingtheresultswiththemember,alongwithotherservicesrendered.Thereimbursementiscalculatedinthesamemannerasanofficevisit.

Submit the Health and Wellness Evaluation Form using one of the following methods:


.TIFFformat ● ClickUploadEvaluationFormtosendthe

documentfromyourcomputerOR

2. Faxto:410-505-6160or800-354-8205

For more information

on the health measures

and instructions for

providing preventive

care, click here to view

our Preventive Services

Guidelines .

7









Health and Wellness Request for Information LetterIftheHealthandWellnessEvaluationFormissubmittedwithmissingorinvalidinformation,youwillreceiveaHealthandWellnessRequestforInformationLettertoindicatewhatinformationisneeded.Asampleoftheletterisbelow.

UseyouroriginalcopyoftheHealthandWellnessEvaluationFormtocorrectthearea(s)indicatedontheletterthensubmitthecorrectedformwithin ten (10) business daystoCareFirstBlueChoice.

Followthesestepstoensureefficientprocessing:

1. WriteCORRECTED FORMatthetopoftheHealthandWellnessEvaluationForm


.TIFFformat ● ClickUpload Evaluation Formtoupload

thedocumentfromyourcomputerOR

3. Faxto:410-505-6160or800-354-8205

CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. CareFirst BlueCross BlueShield is an independent licensee of the Blue Cross and Blue Shield Association, providing access to the Preferred Provider Organization Network

only and does not assume any fi nancial risk or obligation with respect to claims. ®Registered trademark of the Blue Cross and Blue Shield Association. ®’Registered trademark of CareFirst of Maryland, Inc.

PRV2607 (8/10)

CareFirstBlueChoiceInc.840FirstStreet,NEWashington,DC20065www.carefi rst.com

MemberName:MemberID#:MemberGroup#:

Re:HealthandWellnessRequestforInformation

DearProviderName

ThankyouforsubmittingtheHealthyBlueHealthandWellnessEvaluationFormforyourpatient.Thisletteristoinformyouthattheformcannotbeprocessedbecauseofmissingorinvalidinformation.

UseyouroriginalcopyoftheHealthandWellnessEvaluationFormtocompleteorcorrectthearea(s)indicatedbelow.Return the form within ten (10) business days fromthedateofthisletter.

Section I: Section II: Section III:MemberName TobaccoUse CancerScreenings MemberSignatureProviderName InfluenzaImmunization Breast ProviderSignatureMemberID# ChildhoodImmunization CervicalProviderID# HealthyWeight Colon

CholesterolControlBloodPressure

Other Required Information:_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Oncecompleted,followthesestepstohelpassureefficientprocessing:1 . Write“CORRECTEDFORM”atthetopoftheform.2 . SubmittheHealthandWellnessEvaluationFormthroughCareFirstDirect. ■ScantheformandsaveitinJPG,PDForTIFFformat. ■Clickon“UploadEvaluationForm”inCareFirstDirect.

-OR-

■ Forwardtheinformationbyfaxto 410-505-6160or1-800-354-8205.

Manager,CustomerService

8



Membership & Product Information

ThefollowingsectionprovidesinformationontheHealthyBluebenefitdesignandincludessamplebenefitchartsforyourreference.Itisimportanttonotethatthechartsarefordescriptivepurposesonlyanddonotrepresentbenefitdesignsacrossplanoptions/jurisdictions.IfmembershavequestionsregardingtheirHealthyBluebenefits,pleaseaskthemtocontactMemberServicesatthenumberlocatedonthebackoftheirHealthyBlueIdentificationCard.

Plan Options Throughpurposefulbenefitdesignsandmemberfinancialincentives,HealthyBlue’svalue-basedthree-optionbenefitstructureshowshowyoucanbestadvisememberstogetthemostcost-effectivecarewhentheyneedit.MemberscanhaveeitheraDualOptionorTripleOptionprogram.Inaddition,membersreceivefullcoverageforcertaingenericdrugsusedtopreventchronicdiseases,includingcholesterol,asthma,depression,hypertensionanddiabetes.

Option 1: Access through a CareFirst BlueChoice PCP:InOption1,amember’scareandreferralsarecoordinatedthroughtheprimarycareprovider(PCP)withintheCareFirstBlueChoiceprovider

network(specialist,hospitalorotherprovider)andalowerout-of-pocketcostisincurredorinthecaseofpreventativeservices,thereisnochargeatall.

Option 2: Access directly to other providers in the CareFirst BlueChoice network without PCP referral:Option2requiresthatthememberreceivescarewithintheCareFirstBlueChoicenetworkbutdoesn’trequirethatthecarebeprovidedorcoordinatedthroughthePCP.Thememberwillpayhigherout-of-pocketcosts,whilestillreceivingpreventiveservicesatnocharge.

Option 3: Access to out-of-network providers anywhere in the United States:Option3providesmemberswiththeflexibilitytoreceivecareoutsideoftheCareFirst

9


BlueChoicenetworkthroughthePreferredProviderOrganization(PPO)NetworkorOut-of-Networkentirely,butwillhavethehighestout-of-pocketcostswiththepreventiveservicesrequiringthedeductiblebemetfirst,withacopay/coinsurance.1

Health Savings Account (HSA) and Health Reimbursement Arrangement (HRA) PlansThosemembersinCareFirstBlueChoice’sHealthyBlueBlueFundorCompatibleHSAhealthplanscanelecttoestablishaHealthSavingsAccount(HSA),whichallowsthemtousetax-freedollarstopayforqualifiedmedicalexpenses.TheHealthReimbursementArrangement(HRA)planisavailabletomembersintheHealthyBlueBlueFundHRAandCompatibleHRAplans.TheHRAallowsmemberstouseemployer-depositedfundsfromaspendingaccounttopayforqualifiedmedicalexpenses.

ThebenefitsummaryontheprecedingpagesisasamplebenefitdesignforanHRAeligibleproduct.AllHSAqualifiedplans(BlueFundandCompatible)andsomeHRAqualifiedplans(BlueFundandCompatible)havethedeductibleapplytoallservices,exceptforpreventiveservicesthatincludepreventiveadultvisits,well-childcare,andcertaincancerscreeningsthatarenocosttothemember.

MemberswhoaccesscareunderOption3mayberesponsibleforhigherdeductiblesandcopays/coinsurance.ForIndividualDualOptionHSAaccountswedonotprovidecoverageforout-of-networkservices,thereforemembersshouldonlyvisitaCareFirstBlueChoiceprovider.

HealthyBlue

Option Option1MemberCostSharing

=$

Option2MemberCostSharing

=$$

Option3MemberCostSharing

=$$$

Network CareFirstBlueChoiceNetwork

CareFirstBlueChoiceNetwork

PreferredProviderOrganization(PPO)

Network(nobalancebilling)

Out-of-Network(possiblebalance

billing)

Referral Required for Specialist?

Yes No No

This chart is for descriptive purposes and does not represent benefits across plan options/jurisdictions.

1InMarylandsmallgroups,thewell-childcarevisitsdonotrequirethedeductibletobemetfirstandonlyhavea$10copay.

10


Sample HealthyBlue Benefit Design*

MEDICAL PRODUCT/PLANHEALTHYBLUE

OPTION 1 OPTION 2 OPTION 3

Program Details

Network BlueChoice BlueChoice RegionalProviderNetworkorOut-ofNetwork(balancebilling)

PCPSelection Yes No No

Referrals Yes No No

Member Liability

IndividualDeductible $500IntegratedwithRx $1,200 $2,000

OOPMax $1,500IntegratedwithRx $3,600 $6,000

Service

RoutineAdultPhysical(IncludingroutineOB/GYNVisits)

NoCharge NoCharge NotCovered

Well-ChildCare(includingexamsandimmunizations)


CancerScreening(Paptest,Mammography,ProstateScreening,andColorectalScreening)


Office Visits, Labs and Testing

OfficeVisitsforIllness PCP:NoChargeSpecialist:$20Copay

PCP:NoChargeSpecialist:Deductible,then$20Copay

Deductible,then$20Copay

OfficeVisitsforPT,OT,ST,Chiropractic

$20Copay Deductible,then$20Copay Deductible,then$20Copay

Diagnostic/LabTests NoCharge NoCharge DeductiblethenNoCharge

X-Ray NoCharge NoCharge DeductiblethenNoCharge

Emergency Care

EmergencyRoom $100Copay(waivedifadmitted) $100Copay(waivedifadmitted) $100Copay(waivedifadmitted)

UrgentCareCenter(Participating) $50Copay $50Copay $50Copay

Ambulance(whenmedicallynecessary)

$50Copay $50Copay $50Copay

Hospitalization

InpatientFacilityServices Deductible,thenNoCharge Deductiblethen$500/dayupto5Days

Deductiblethen$700/dayupto5Days

InpatientPhysicianServices Deductible,then$20Copay Deductible,then$100Copay Deductible,then$150Copay

OutpatientFacilityServices Deductible,then$20Copay Deductible,then$100Copay Deductible,then$150Copay

OutpatientPhysicianServices Deductible,then$20Copay Deductible,then$100Copay Deductible,then$150Copay

Option1:AccessthroughaBlueChoicePCPOption2:AccessdirectlytootherprovidersintheBlueChoicenetworkwithoutPCPreferral.Option3:Accesstoout-of-networkprovidersanytimeintheUnitedStates(CareFirstPPOprovidersnotintheBlueChoicenetworkareconsidered

outofnetworkunderMarylandlaw).HealthyBluewillhaveanintegratedmedicalanddrugdeductibleforOption1andallRxwillbetreatedasaOption1.Additionally,thedeductiblesandout-of-pocketmaximumsineachtierwillcontributetowardsoneanother.

*BenefitdesignbasedonMd. 51+RiskHRAavailableasof6/10/10

11


Sample HealthyBlue Benefit Design*

MEDICAL PRODUCT/PLANHEALTHYBLUE

OPTION 1 OPTION 2 OPTION 3

Additional Nursing Services

SkilledNursing Deductible,then$20Copay Deductible,then$100Copay Deductible,then$150Copay

HomeHealthServices Deductible,then$20Copay Deductible,then$100Copay Deductible,then$150Copay

Hospice Deductible,then$20Copay Deductible,then$100Copay Deductible,then$150Copay

Mental Health and Substance Abuse

InpatientFacilityServices Deductible,thenNoCharge Opt1Deductible,thenNoCharge

Opt.1DeductiblethenNoCharge

InpatientPhysicianServices Deductible,thenNoCharge Opt1Deductible,thenNoCharge

Opt.1DeductiblethenNoCharge

OutpatientFacilityServicesandOutpatientPhysicianServices

$20Copay $20Copay Deductible,then$150Copay

OfficeVisits NoCharge NoCharge Deductible,then$150Copay

Durable Medical Equipment

DME(limitof$7500) Deductible,then$20Copay Deductible,then$100Copay Deductible,then$150Copay

Maternity Services

OfficeVisits(preandpostnatal)

Deductible,then$20Copay Deductible,then$20Copay Deductible,then$20Copay

Delivery Deductible,thenNoCharge Deductible,thenNoCharge Deductiblethen$700/dayupto5Days

AI/IVF

AI Deductible,then50%Coinsurance

Deductible,then50%Coinsurance


IVF Deductible,then50%Coinsurance



Vision

AnnualRoutineEyeExam In-Network:$10membercopaywhenexamreceivedfromDavisproviderOut-of-Network:Davispays$33tomemberwhenexamreceivedfromproviderwhoisnotinDavisnetwork

Eyeglasses/ContactLenses DiscountsatparticipatingVisionCenters

RxBenefit Choice

Deductible,then$4/$45/$65or$10/$25/$45;$0genericcopayforprescriptionsrelatedtoDiabetes,Cholesterol,BloodPressure,AsthmaandDepression(andnotsubjecttodeductible)

Option1:AccessthroughaBlueChoicePCPOption2:AccessdirectlytootherprovidersintheBlueChoicenetworkwithoutPCPreferral.Option3:Accesstoout-of-networkprovidersanytimeintheUnitedStates(CareFirstPPOprovidersnotintheBlueChoicenetworkareconsidered

outofnetworkunderMarylandlaw).HealthyBluewillhaveanintegratedmedicalanddrugdeductibleforOption1andallRxwillbetreatedasaOption1.Additionally,thedeductiblesandout-of-pocketmaximumsineachtierwillcontributetowardsoneanother.

*BenefitdesignbasedonMd. 51+RiskHRAavailableasof6/10/10

12


HealthyBlue Identification Cards

TheHealthyBluemembershipidentification(ID)cardprovidesimportantinformationaboutthemember’sbenefitprogram,includingcopaymentamount,authorizationtelephonenumbersandtheclaimssubmissionaddress.

Sample HealthyBlue Triple Option ID Card

13


Sample HealthyBlue Dual Option ID Card

BelowarethedescriptorcodesontheHealthyBlueIDcards:

DESCRIPTOR CODE NARRATIVES

PCP PrimaryCareProvider

S Specialist

ER EmergencyRoomco-paymentamount

RX PrescriptionDrugPlan

DH HMODentalProgram

DN IndemnityDentalProgram

XIM DualOptionPrefix

XIN TripleOptionPrefix

Important Note:Open AccessisnotwrittenontheHealthyBlueidentificationcards(ID),however,allHealthyBlueproductshavetheOpen Accessfeature.

MemberswhoseekcarewithoutareferralmaydosounderOption2orOption3,whereapplicable.

ThosewhoseekcareusingbenefitsinOption 2aresubjecttohigher deductiblesandcopays/coinsurance.ThoseseekingcareusingOption 3 .benefitsaresubjecttothehighest deductibles andcopays/coinsurance.

Remember to Verify Eligibility

PossessionofamembershipIDcarddoes notguaranteecurrenteligibilityforHealthyBluebenefits.UseCareFirst DirectorcallFirstLineat202-479-6560or800-842-5975toverifyeligibilityandbenefitinformationbeforecareisrendered.

14

http://www.carefirst.com/carefirstdirect


Referral Process

ThefollowingsectionoutlinestheHealthyBlueReferralProcess.ItisimportanttonotethatwithHealthyBlue,thePCPcoordinatestheentirereferralprocess.AnyreferralssubmittedtoCareFirstBlueChoiceonbehalfofHealthyBluemembersmustbedonebythePCP.ThissectionalsoprovidesinformationonservicesthatdonotrequirereferralsundertheHealthyBlueproduct.

PCP Referral ProcessHealthyBluerequiresthePCPtotakethefollowingstepstocoordinatethereferralprocessformembersandspecialists:

● Completethereferral

● SubmitthereferraltoCareFirstBlueChoiceforHealthyBluemembers

● Givethememberacopyofthereferraltotaketothespecialistvisit

WiththeHealthyBlueOption1benefit,areferralisrequiredformemberstoseeaCareFirstBlueChoicespecialist.WiththeOption2benefit,memberswhoseeaCareFirstBlueChoicespecialistwithoutareferralwillbesubjecttohigherdeductiblesandcopays/coinsurance.

MemberswiththeOption3benefitcanutilizethePPOnetworkorseekcarefromanout-of-network,non-participatingproviderwithoutareferral,howevertheseservicesmaybesubjecttothehighestdeductiblesandcopays/coinsurance.

ThePCPmustmailtheoriginalreferralto:

MailAdministratorP.O.Box14116Lexington,Ky.40512-4116

15


Thefollowinginformationshouldbeincludedonthereferralform:

● Member’sname,dateofbirthandmemberIDnumber

● PCP’sname,phonenumberandCareFirstBlueChoiceprovideridentificationnumber

● Thedatethereferralwasissuedandthe“validuntil”date

● Thediagnosisorchiefcomplaint(stating“follow-up”or“evaluation”isnotsufficient)

● Thenumberofvisitsallowed(ifthisisleftblank,thedefaultnumberofvisitswillbethree)

● Thespecialist’snameandCareFirstBlueChoiceprovideridentificationnumber.

Specialist Referral ProcessThePCPmustensurethatthememberunderstandstowhomheorsheisbeingreferred,thenumberofvisitsallowed(limitedtoamaximumofthree(3)visits)andthetimelimit(validfor120daysfromthedateofissuance)toseekspecialistservices.Specialistsshouldonlyperformtheserviceslistedonthereferralform.Thisincludesauthorizingprocedures,testsandothermedicalservices.The specialist may also refer the member to another CareFirst BlueChoice provider specialist for the same condition for which the initial referral was obtained.

Example: APCPrefersamembertoanorthopedicspecialistforanankleinjury.Theorthopedicspecialistmayreferthemembertoaphysicaltherapistforcarebutonlyfortheankleinjury,theconditionforwhichtheoriginalreferralwaswritten.

Important Note: Services for a new or different condition require an additional referral from the PCP.

IfaparticularproviderorspecialistisnotlistedintheCareFirst BlueChoice Provider Directory,callProviderInformation&Credentialingat410-872-3500or877-269-9593todeterminewhethertheproviderorspecialistparticipatesintheCareFirstBlueChoicenetwork.

Services Not Requiring a ReferralThefollowingservicesdonotrequireawrittenreferral:

● Emergencycareorfollow-upcareafteremergencysurgery

● CoveredservicesrenderedbyaCareFirstBlueChoiceMentalHealthandSubstanceAbuseServicesprovider,includinginpatientfacilityservices,inpatientprofessionalservices,medicationmanagementservices,methadonemaintenanceservices,residentialcrisisfacilityservices,residentialcrisisprofessionalservicesandpartialhospitalizationservices

● Coveredservicesprovidedbyafree-standingCareFirstBlueChoiceradiologistoffice

● CoveredservicesprovidedbyaCareFirstBlueChoicelaboratory

● CovereddiagnostictestingrenderedbyaCareFirstBlueChoiceprovider

● ProstateCancerscreening,ColorectalCancerscreening,BreastCancerscreening,ChlamydiascreeningtestsandHumanPapillomavirusscreeningtestsperformedbyCareFirstBlueChoiceproviders

● Well-childcare,adultpreventivecareandimmunizationsperformedbyCareFirstBlueChoiceproviders

● AmbulatorySurgicalCenters(ASC),AmbulatorySurgicalFacilities

● RoutineobstetricandgynecologicalcarewhenperformedbyaCareFirstBlueChoiceproviderinanofficesetting

● CoveredservicesrenderedbyaCareFirstBlueChoiceproviderophthalmologistfordiagnosisandtreatmentofmedicalconditionsoftheeye

● RoutinevisionexamsbyparticipatingDavisVision(800-783-5602)optometrists

● Visitstoanurgentcarecenter

● CoveredservicesrenderedbyCareFirstBlueChoicelimitedservicesimmediatecarecenters

● CertainprostheticsprovidedbyCareFirstBlueChoiceproviders

16

http://www.carefirst.com/redirects/FindaDoctorRedirect.html


● DiabeticsuppliesprovidedbyCareFirstBlueChoiceproviders

● Servicesformembersoverage65,whohaveprimarycoveragethroughMedicarePartBandtheirMedicarebenefitshavenotbeenexhausted

Extended (Standing) Referrals

PCPsmayissueanextended,orstanding,referralforaCareFirstBlueChoicememberwhorequiresspecializedcareoveralongperiodoftime.Membersarealloweduptooneyearofunlimitedspecialistvisitsthroughastandingreferralifallofthefollowingcriteriaaremet:

● Memberhasalife-threatening,degenerative,chronicand/ordisablingconditionordiseaserequiringspecializedmedicalcare

● Afterconsultingwiththespecialist,youdeterminewhetherthememberneedscontinuingspecializedcare

● Specialisthasexpertiseintreatingthemember’sconditionandisaparticipatingpractitioner

Ifnecessary,PCPsmaymodifyastandingreferraltolimitthenumberofvisitsortheperiodoftimeforwhichvisitsareapproved.Inaddition,thereferralmayrequirethespecialisttocommunicateregularlywiththePCPregardingthemember’streatmentandhealthstatus.

CareFirstBlueChoicealsoallowsreferralstoallergists,hematologistsoroncologiststobevalidforuptooneyear.Forotherlife-threatening,degenerative,chronicand/ordisablingconditionordiseasesrequiringspecializedmedicalcare,callCaseManagementat410-605-2623or888-264-8648forauthorization.

Anyfollow-upcareprovidedinthespecialist’sofficefollowingthemember’sdischargefromthehospitalrequiresareferral.

Laboratory/Radiology

LabCorp®requisitionformsthatincludethemember’sidentificationnumbermustbeusedwhenorderinglabtestingordirectingmemberstoadrawingstation.SomeexceptionsmayapplyinWesternMarylandandontheEasternShore.

ReferralsareneverrequiredforLabCorp®.ObtaininglaboratoryservicesfromavendorotherthanLabCorp®willresultincoverageattheOption3benefitlevelformembers.

AcompletelistofparticipatinglaboratoryandradiologyfacilitiescanbefoundintheCareFirst BlueChoice Provider Directory.

17




Authorizations

ThefollowingsectionprovidesimportantinformationabouttheCareFirstBlueChoiceHealthyBlueauthorizationprocess.ItisimportanttonotewhichservicesrequireauthorizationsandhowtosecureauthorizationsbeforerenderingcareundertheHealthyBlueproduct.

Services Requiring AuthorizationCallCareManagementat866-PRE-AUTH(773-2884)toobtainallnecessaryauthorizations.Whentheadmittingprovidercallsthehospitaltoscheduleaninpatientorout-patientprocedure,hemustprovidethehospitalwiththefollowinginformation:

● Thenameandtelephonenumberoftheadmittingproviderorsurgeon

● Adiagnosiscode

● AvalidCPTcodeand/ordescriptionoftheprocedurebeingperformed

Authorizationisrequiredforthefollowingservicespendingverificationofeligibilityrequirementsandcoverageunderthemember’sHealthyBluebenefitplan:

● Anyservicesprovidedinasettingotherthanaprovider’soffice,exceptforCareFirstBlueChoicelabandradiologyfacilities,andfreestandingambulatorysurgery/carecenters

● Allinpatienthospitaladmissionsandhospital-basedoutpatientambulatorycareprocedures

● Alldiagnosticorpreoperativetestinginahospitalsetting

● Chemotherapyorintravenoustherapyinasettingotherthanapractitioner’sofficeandbilledbyaproviderotherthanthepractitioner

18


●

●

●

●

●

●

●

●

●

●

●

Durablemedicalequipment(DME)foradiagnosisotherthanasthmaanddiabeteswhenprovidedbyacontractedvendorotherthanNetworkHealthServices(NHS)/NeighborCare

Follow-upcareprovidedbyanon-participatingpractitionerfollowingdischargefromthehospital,withtheexceptionoffollow-upcarefollowingemergencysurgery

Hemodialysis(unlessperformedinaparticipatingfree-standingfacility)

Homehealthcare,homeinfusioncareandhomehospicecarewhenprovidedbyacontractedvendorotherthanNHS/NeighborCare

Inpatienthospicecare

Nutritionalservices(exceptfordiabetesdiagnosis)

Prostheticsandorthoticswhenbilledbyanancillaryprovider,suchasaDMEorsupplyvendor

Radiationoncology(exceptwhenperformedatcontractedfreestandingcenters)

Skillednursingfacilitycare

Treatmentofinfertility(notavailableinDCandVA)

Habilitativeservicesforchildren(MDandDConly)

Note: AuthorizationfromCareManagementisrequiredfortheaboveservices,evenifthememberhasotherprimaryhealthcoverage,suchascommercialcoverage.

Necessary Information

ThehospitalwillprovidethefollowinginformationtoCareManagementforservicesrequiringauthorization:

● Member’sname,addressandtelephonenumber

● Member’sHealthyBlueidentificationnumber

● Member’sdateofbirthandgender

● Member’srelationshiptosubscriber

● Attendingprovider’sname,provideridentificationnumber,addressandtelephonenumber

● Admissiondateandsurgerydate,ifapplicable

●

●

Admittingdiagnosisandprocedureortreatmentplan

Otherhealthcoverage,ifapplicable

Services Not Requiring an AuthorizationAnyserviceperformedataparticipatingfreestandingambulatorysurgical/carecenterorwhenMedicareistheprimarycoveragedoesnotrequireanauthorization.

● EmergencyRoomvisits

● Outpatientservicesnotperformedinahospitaloutpatientdepartment

● Rehabilitationservices

● Spinalmanipulationservices

● Cardiacrehabilitationservices

● Routinematernityadmissions

● Methadonemaintenancetreatment

● DMEimmediateneedsitems

In-Network versus Out-of-Network ProvidersProvidersandspecialistsintheCareFirstBlueChoicenetworkareconsideredin-networkforHealthyBlueOption1andOption2.Memberswhoseekcarein-networkwillreceivethehighestlevelofbenefitswhileloweringtheirout-of-pocketcosts.

ProvidersandspecialistsinanyCareFirstPreferredProviderOrganization(PPO)networkoranynon-participatingproviderareconsideredout-of-network.Ifmemberschooseanout-of-networkprovidertheywillreceiveOption3benefits,whichcouldresultinthehighestdeductible,copay/coinsurance.MemberswiththeDualOptionHSAproductareonlyeligibleforcoveragewithaCareFirstBlueChoiceprovider.

19


Arranging for Care

Thefollowingsectionprovidesinformationonallaspectsofmembercare,fromofficevisitstobenefitguidelines.

Role of the PCPCareFirstBlueChoicerecognizesthatthereisnoonebettersuitedtocoordinatemembers’carethanthePCP.WhenPCPsandmembershavealongstandingmutuallybeneficialrelationship,membersaremoreinclinedtorelyontheirPCP’scounseltomaintainahealthylifestyle.ThiscollaborativerelationshipisattheheartofHealthyBlueandisessentialtoachievingsuccessful,long-term,healthyresults.

WithHealthyBlue,PCPsareattheforefrontofmembers’care.PCPsareinthebestpositiontomakekeyjudgmentsabouttheirmembers’care,includingwhenspecialistsareneededandwhichparticularspecialiststorefermemberstowhentheyseekadditionalcare.

HealthyBluerecognizespractitionersinthefollowingmedicalspecialtiesasPCPs:

● FamilyPractice

● GeneralPractice

● InternalMedicine

● Pediatrics

● Geriatrics

Note for OB/GYN physicians: IfyouareaCareFirstBlueChoiceparticipatingOB/GYNwhoagreestoactasPCPforamember,givethememberaletterstatingyourdecisiontoserveasherPCP.ThelettershouldincludeyourCareFirstBlueChoiceprovidernumberandthemember’sidentificationnumber.ThemembershouldsubmitthelettertoCareFirstMemberServicesforprocessing.

20


EachHealthyBluememberselectsaCareFirstBlueChoicePCPuponenrollmentinHealthyBlueandreceivesaHealthyBlueidentificationcardwiththePCP’snameonit.

IfaPCPnolongerwishestobeamember’sPCP,theprovidermustverifythatheisthecurrentPCP,andnotifyProviderServicesinwriting,priortonotifyingthemember.Sendcorrespondenceto:


AdditionallythePCPmustgivethemember30daysnoticepriortoreleasinghim/herfromcare.AmemberservicesrepresentativewillhelpthememberselectanewPCP.

IfamemberchoosestochangePCPs,themembermustcalltheselectedprovider’sofficetoconfirmthatthePCPparticipateswithCareFirstBlueChoiceandisacceptingnewpatients.ThemembercannotifyMemberServicesofthechangeatwww .carefirst .com/myaccount.Requestsreceivedonorbeforethe20thofthemonthwillbeeffectiveonthefirstdayofthefollowingmonth.Requestsreceivedafterthe20thwillbeeffectiveonthefirstdayofthesecondmonthfollowingtherequest.

Forexample:ChangesreceivedonorbeforeJanuary20willbeeffectiveFebruary1.ChangesreceivedonJanuary21 willbeeffectiveMarch1.NewcardswillbeissuedafterthePCPchangeisprocessed.

Back-up Coverage

WhenthePCPisnotavailabletoprovideservicetomembers,arrangementsmustbemadeforeffectivecoveragethroughanotherpractitionerwhoisaCareFirstBlueChoicePCP.Thecoveringpractitionermustindicateonthepaperclaimform“coveringfor[Dr.’sname]”whensubmittingtheclaimtoCareFirstBlueChoice.

After Hours Care

ThePCPcoveringphysiciansreferencedabovemustprovidetelephoneaccess24hoursaday,sevendaysaweektorespondappropriatelytomembersandotherprovidersconcerning

afterhourscare.Theuseofrecordedphonemessagesinstructingmemberstoproceedtotheemergencyroomduringoff-hoursisnotanacceptablelevelofcareforCareFirstBlueChoicemembersandshouldnotbeused.

Open/Closed Panel

AsstatedinthePhysicianParticipationAgreement,youmaycloseyourpaneltonewmemberswithatleast60dayspriorwrittennoticetoProviderInformationandCredentialing,providedyourpanelincludesatleast200CareFirstBlueChoicemembers.Anasterisk(*)indicatingaclosedpanelwillbeplacedbesidethePCP’snameinthenextprintingoftheproviderdirectory.

Ifyouwishtoacceptanewmemberintoaclosedpanel,youmustnotifyProviderInformationandCredentialinginwriting.Whenyouelecttoreopenyourpaneltonewmembers,writtennotificationisrequired.RequestsforopeningandclosingapanelcanbefaxedtoProviderInformationandCredentialingonyourletterheadto410-872-4107or866-452-2304.

Routine Office VisitsAnnualhealthexaminations,well-childvisitsandotherservicesforthepreventionanddetectionofdiseasearecoveredbenefits.*TheHealthyBlueproductpromotespreventivehealthservicesandCareFirstBlueChoicehasadoptedpreventivehealthrecommendationsapplicabletoourmembers.Examinationssolelyforthepurposesofemployment,insurancecoverage,schoolentryandsportsorcampadmissionaregenerallynotcoveredandshouldbechargedinfulltothemember.Immunizationsrequiredsolelyforforeigntravelaregenerallynotcovered.

PerthetermsoftheParticipationAgreement,non-symptomaticvisits,suchaspreventivecareorroutinewellness,appointmentsshouldbescheduledwithin4weeks.

Note: TheHealthandWellnessEvaluation,alongwithanynecessarytests,musttakeplacewithin 90 daysofthemember’seffectivedate.Boththeinitialevaluationandtheclinicallyappropriatere-screeningareconsideredpreventivevisitsand

shouldbebilledappropriately.

If a PCP no longer wishes

to be a member’s PCP,

the provider must verify

that he is the current

PCP, and notify Provider

Services in writing, prior

to notifying the member.

Send correspondence to:

Mail Administrator

P.O. Box 14114

Lexington, Ky.

40512-4114

*IfamemberaccessescareinOption3therewillbeout-of-pocketcostsfortheservicesrendered.Certaingenericmedicationswillstillbeatnochargeforthemember

21

http://www.carefirst.com/myaccount

http://www.carefirst.com/myaccount


Emergency Room Services

In-Area Emergencies

Participatingprovidersortheircoveringprovidersarecontractuallyobligatedtobeavailablebytelephone24hoursadaysevendaysaweekshouldCareFirstBlueChoicememberscall911foranylife-threateningemergencies.Membersmaycalltheirprimarycareprovider(PCP),FirstHelp,our24-hourmedicaladvicelineand/orthespecialistinurgentsituations.Membersmayarriveattheemergencyroomoneoffourways:

● PCPorspecialistreferral

● FirstHelpreferral

● Self-referral

● Ambulance

Allmedicallynecessaryemergencyandurgentservicesarecoveredatthesamebenefitlevelregardlessoftheprovider.Priorauthorizationisnotneededforemergencyroomservices.

Referred to Emergency Room by PCP or Specialist

MembersareencouragedtocontacttheirPCPand/orspecialisttoseekguidanceinurgentoremergencymedicalconditions.WhenaPCPorspecialistrefersamembertotheemergencyroom(ER),theERprofessionalswilltriage,treatandbillintheircustomarymanner.AnauthorizationnumberorwrittenreferralfromthePCPorspecialistisnotrequired.

Referred to Emergency Room by FirstHelp

WhenFirstHelp(202-479-6560or800-842-5975)refersamembertotheERfortreatment,theERprofessionalswilltriage,treatandbillintheircustomaryfashion.AnauthorizationnumberorwrittenreferralfromFirstHelpisnotrequired.

Emergency Room Self-Referral

Whenamemberself-referstoanemergencyroom,theprofessionalsshouldtriagethemember.Iftheconditionisdeemedemergent,treatmentisrenderedandtheserviceisbilled.Anauthorizationnumberorwrittenreferralisnotrequired.Pleaserememberthatallsubsequentfollow-upcaremustbeprovidedorcoordinatedbythemember’sPCPorauthorizedbyCareManagement(866-773-2884).

Iftheconditionisdeemedanon-emergency,theemergencyroomprofessionalsshouldencouragethemembertocallhisPCP,specialistorFirstHelpforadviceregardingtreatmentattheappropriatelevelofcare.Professionalservicesshouldbebilledappropriately.

Ambulance

Ifthememberarrivesattheemergencyroombyambulance,theERprofessionalstriage,treatandbillintheircustomarymanner.Anauthorizationnumberorwrittenreferralisnotrequired.

Out-of-Area Emergencies

Itisthemember’sresponsibilitytonotifyCareFirstBlueChoicewithin24hoursafterreceivingout-of-areacare.

Emergency Hospital Admissions

WhenemergencyroomprofessionalsrecommendanemergencyadmissionofaCareFirstBlueChoicemember,theyshouldcontactthemember’sPCPorspecialist,asappropriate.Themember’sprovideristhenexpectedtocommunicatetheappropriatetreatmentforthemember.ThehospitalisrequiredtocontactCareManagementbyfollowingtheEmergencyAdmissionAuthorizationProcesstoverifyand/orsecureauthorization.

In-Area Authorization Process

Thehospitalisresponsibleforinitiatingin-areaauthorizationforallemergencyadmissions.CareManagement(866-773-2884) mustreceivetheauthorizationrequestwithin48hoursafteranemergencyadmissionoronthenextbusinessdayfollowingtheadmission,whicheverislonger.Thisincludesanymedical/surgicalorobstetricaladmissions.

Medicalinformationforacutehospitalcaremustbereceivedbytelephonethenextbusinessdayaftertherequestforauthorizationismade.Ifthememberhasbeendischarged,thehospitalmustprovidemedicalinformationtoCareManagementwithin5businessdays.Failuretoprovidetherequestedinformationmayresultinadenialofauthorizationduetolackofinformation.

22

http://www.carefirst.com/providers/BlueChoiceManual/BlueChoiceManualPhone.html


Out-of-Area Authorization Process

Inthecaseofanout-of-areaemergencyadmission,itisthemember’sresponsibility,ifpossible,tonotifyCareManagementwithin24hoursoftheadmission.

Hospital Services

Authorization Process

Thehospitalisresponsibleforinitiatingallrequestsforauthorizationforinpatientadmissions.However,whentheadmittingproviderscallthehospitaltoscheduleinpatientprocedures,theymustprovidethehospitalwiththefollowinginformation:

● Adiagnosiscode

● AvalidCPTcodeand/ordescriptionoftheprocedurebeingperformed

● Thenameandtelephonenumberoftheadmittingproviderorsurgeon

Theadmittingprovidermustcallthehospitalatleastfivebusinessdayspriortoallelectiveadmissions,exceptwhenitisnotmedicallyfeasibletodelaytreatmentduetothemember’smedicalcondition.CareFirstBlueChoicewillcontacttheadmittingprovider’sofficeifadditionalinformationisneededbeforeapprovingtheauthorization.

Failuretonotifythehospitalwithinthistimeframemayresultinadelayordenialoftheauthorization.

CareManagement(866-773-2884)willobtaintheappropriateinformationfromthehospitalandeitherforwardthecasetotheUtilizationReviewSpecialist(URS)orcertifyaninitiallengthofstayforcertainspecifiedelectiveinpatientsurgicalprocedures.TheURSmustreviewarequestforapreoperativeday.On-sitehospitalreview(concurrentreview)isperformedatselectedhospitalsandonacase-by-casebasis.

Ifthedateforanelectiveadmissionchanges,CareManagementmustbenotifiedbythehospitalassoonaspossible,butnolaterthanonebusinessdaypriortotheadmission.Lackofnotificationmayresultinadenialofauthorization.

Preoperative Testing Services

Preoperativelaboratoryservicesauthorizedinthehospitalsettingareasfollows:

● Typeandcrossmatchingofblood

● Laboratoryservicesforchildrenundertheageofeight

AllotherpreoperativetestingmustbeprocessedbyLabCorp®orperformedatparticipatingfreestandingradiologycenters.SomeexceptionsapplyinWesternMarylandandontheEasternShore.

Hospitalist Services Available

CareFirstBlueChoiceoffersavoluntary,diagnosis-specifichospitalistprogramtomembersinselectedhospitalsthroughanagreementwithMDxL,acompanythatspecializesinemergencyinpatientandoutpatientcare.

InpatientcarerequiresthehospitaltoobtainauthorizationfromCareManagement(866-773-2884).MDxLprovideshospitalistservicestomemberswhoareadmittedtoahospitalthroughtheemergencyroom.Ourprogramisofferedatthefollowinghospitals:

● DoctorsCommunityHospital–Lanham,Md.

● HolyCrossHospital–SilverSpring,Md.

● LaurelRegionalHospital–Laurel,Md.

● MontgomeryGeneralHospital–Olney,Md.

● PrinceGeorge’sHospitalCenter–Cheverly,Md.

● ShadyGroveAdventistHospital–Rockville,Md.

● SouthernMarylandHospitalCenter–Clinton,Md.

● SuburbanHospital–Bethesda,Md.

● WashingtonAdventistHospital–TacomaPark,Md.

Hospitalistscoordinatethemember’stestsandspecialtycare,communicatewiththemember’sPCPandinsuranceprovidersandplanthemember’sdischarge,homecare,hospiceorassistedlivingarrangement.

23


Discharge Planning Process

Thehospitalorattendingproviderisresponsibleforinitiatingadischargeplanasacomponentofthemember’streatmentplan.Thehospital,underthedirectionoftheattendingprovider,shouldcoordinateanddiscussaneffectiveandsafedischargeplanwithCareManagementandeachmemberand/orfamilymemberassoonafteradmissionaspossible.Dischargeneedsshouldbeassessedandadischargeplandevelopedpriortoadmissionforelectiveadmissions.

Referralstohospitalsocialworkers,long-termcareplanners,dischargeplannersorhospitalcasemanagersshouldbemadepromptlyafteradmissionandcoordinatedwithCareManagement.

Anappropriatedischargeplanshouldinclude:

● Fullassessmentofthemember’sclinicalconditionandpsychosocialstatus

● Level,frequencyandtypeofskilledservicecareneeds

● Verificationofmember’scontractualhealthcarebenefits

● ReferraltoaCareFirstBlueChoiceparticipatingprovider,ifneeded

● Alternativefinancialorsupportarrangements,ifbenefitsarenotavailable

Outpatient Hospital Services

Authorizationisrequiredforalloutpatientservices,includinglaboratoryandradiologyperformedinahospitalsetting.Youmustperformorarrangeallpre-operativeservicesforyourmembers.SomeexceptionsmayapplyinWesternMarylandandontheEasternShore.

Notethefollowing:

● Thehospitalisresponsibleforinitiatingallrequestsforauthorizationforoutpatientservices(e.g.,surgery,false-labor/observation).

● Ifauthorizationcriteriaaremet,authorizationwillbeissued.Inaddition,thecallerwillbeinstructedwhetherthememberisaccessingin-networkorout-of-networkbenefits.Therewillbeinstancesinwhichthememberwillbedirectedtoamoreappropriatenetworkproviderforcertainservices(i.e.,laboratory,radiologicalservices).

Iftheadmissiondateforanoutpatientelectiveprocedurechanges,thehospitalmustnotifyCareManagement(866-773-2884)assoonaspossible,butnolaterthanonebusinessdaypriortotheprocedure.Lackofnotificationmayresultintheclaimbeingdenied.

Disease Management

DiseaseManagementprograms,suchasthosefordiabetesandasthma,identifymemberswithpotentiallylong-termconditionsandoffereducationaboutandmanagementoftheirdiseasesthatwillsignificantlyimpacttheirmedicaloutcomeandqualityoflife.

ThefollowingimpactconditionsareapartoftheDiseaseManagementoffering:

● Asthma

● Diabetes

● Heartfailure

● Coronaryarterydisease

● ChronicObstructivePulmonaryDisease(COPD)

CallCaseManagementat410-605-2623or888-264-8648toobtainmoreinformationortoreferamembertotheoncologyprogram.

Case Management Care Coordination

CaseManagementisdesignedtoidentify,asearlyaspossible,memberswhorequiremoreinvolvedcoordinationofcareduetoacatastrophic,chronic,progressiveorhighriskacuteillness.CaseManagementcoordinatestheuseofhealthcarebenefitstocreateaplanofcarethatmaximizesbenefitseffectivelywithoutcompromisingthequalityofcare.Refermemberswhowouldbenefitfromtheseservicesassoonastheyareidentified.

CaseManagementinterventionisappropriateformemberswiththefollowingconditions:

● Catastrophic,progressive,chronicorlife-threateningdiseases

● Continuouscareduetoacatastrophiceventoranacuteexacerbationofachronicillness

● Extendedacutecarehospitalizations

● Repeathospitaladmissionswithinalimitedtimeperiod

TheCaseManagerpreparesandcoordinatesacareplanincollaborationwiththemember,his/

24


herPCP,otherprovidersandfamily.TheCaseManagerwillensurethatthecareplaniswithinthemember’sexistingbenefits.

ContactCaseManagementat410-605-2623or888-264-8648ifyouareinterestedintheirservices,ortoreferamember.

Benefits, Exclusions and Limitations

Covered Services and Benefit Guidelines

CareFirstBlueChoiceexpectsthatallproviderswhoperformlaboratoryorimagingtests,atanysitewillobtainand/ormaintaintheappropriatefederal,state,andlocallicensesandcertifications,training,qualitycontrolsandsafetystandardspertinenttothetestsperformed.

AdditionalinformationaboutcoveredservicesandbenefitsguidelinesisavailableintheMedical Policy Reference Manual,thePolicysectionandtheBasicClaimAdjudicationPolicyConceptssection(pg.15)oftheGeneral Information Manual.Ifyouhaveadditionalquestions,contactaProviderServicesrepresentativeat202-479-6560or800-842-5975.

VisitCareFirst DirectorcallFirstLine(202-479-6560or800-842-5975)todeterminethemember’seligibilityandlevelofcoveragepriortoadministeringthefollowingservices.

Abortion

AnauthorizationfromCareManagementisrequiredtoperformanabortioninahospitalsetting.Itisnotrequiredifperformedinaprovider’soffice.Benefitsforabortionsarenotavailableunderallprograms.

Allergy

Allergyservicesrequireawrittenreferral.Youmayissuealong-standingreferralforallergyservices.Allergyconsultation,injections,testingandserumaregenerallycovered.PCPsmayadministerallergyinjectionsandmustmaintainappropriateemergencydrugsandequipmentonsite.

Alternative Therapies

OptionsandBlue365arediscountprogramsthatoffermembershealthandwellnessinformation,support,andservices,inadditiontospecialsavings.Note:Referralsarenotneededfortheseprograms.

Discountsinclude:

● Acupuncture

● Chiropracticcare

● Eldercareservices

● Fitnesscenters

● Hearingcareservices

● Laservisioncorrection

● Mailordercontactlenses

● Massagetherapy

Ambulance

Ambulanceservicesinvolvetheuseofspecially-designedandequippedvehiclestotransportillorinjuredmembers.Benefitsforambulanceservicesareprovidedformedicallynecessaryambulancetransport.ServicesmustbeauthorizedthroughCareManagement,exceptinemergencysituations.

Emergencyambulanceservicesareconsideredmedicallynecessarywhenthemember’sconditionissuchthatanyotherformoftransportationwouldbemedicallycontraindicatedandendangerthemember’shealth.Formoreinformation,pleaserefertotheadministrativeservicessectionoftheMedical Policy Reference Manual.LookintheTableofContentsforMedicalPolicy 10.01.005,AmbulanceServices.

Anesthesia

CareFirstBlueChoiceprovidesbenefitsforanesthesiachargesrelatedtocoveredsurgicalproceduresandforpainmanagement.Authorizationforanesthesiaduringsurgeryisincludedintheauthorizationforthesurgery.AreferralfromthePCPisrequiredforpainmanagementservicesrenderedinaprovider’soffice.

Formoreinformationaboutreportinganesthesiaservices,refertoanesthesiapoliciesinSection9oftheMedical Policy Reference Manual.

25

http://notesnet.carefirst.com/ecommerce/medicalpolicy.nsf

http://www.carefirst.com/providers/attachments/GeneralInformationManual.pdf



http://www.carefirst.com/membsvcs/html/AlternativeTherapiesLanding.html

http://www.carefirst.com/options/Blue365.htm




Procedure Codes – CardiologyPROCEDURE CODE EFFECTIVE DATE PROCEDURE CODE EFFECTIVE DATE

76825 addedpriorto1/1/08 78469 addedpriorto1/1/08



76828 addedpriorto1/1/08 78478 invalidasof1/1/08




78451 added1/1/08 78491 addedpriorto1/1/08




78455 invalidasof1/1/08 78990 invalidasof1/1/08

78456 addedpriorto1/1/08 A9500 addedpriorto1/1/08

78457 addedpriorto1/1/08 A9501 added1/1/08



78460 invalidasof1/1/08 A9505 addedpriorto1/1/08





78468 addedpriorto1/1/08

Refer to your current

CPT® code book for

descriptions.

Cardiology

Radiologicalservicescoveredunderthemember’smedicalbenefitandperformedinthecardiologist’sofficesettingarelimitedtotheproceduresindicatedinthechartabove.AllotherproceduresmustbeperformedbyaCareFirstBlueChoice—contractedradiologyfacility.

Chemotherapy

HealthyBlueOption1benefitsrequireawrittenreferralforchemotherapyservicesrenderedinaspecialist’soffice.Youmayissuealong-standingreferralforthisservice.RefertotheExtendedReferralprocessintheArrangingforCaresectionofthismanual.ServicesrenderedinahospitalsettingmustbeauthorizedbyCareManagement(866-773-2884).

Chiropractic Services

Chiropracticservicesbenefitsarelimitedtospinalmanipulationforacutemusculoskeletalconditionsofthespineforindividualsovertheageof12.RefertotheSpinalManipulationandRelatedServices,policy8.01.003,intheMedical Policy Reference Manual.Copaymentsforspecialtyofficevisitsapply.Therearelimitationsonnumberofvisits,whichvarybycontract.

Toverifyamember’slevelofcoverage,visitCareFirstDirectorcallFirstLine(202-479-6560or800-842-5975).

SeenextpageforChiropracticprocedurecodeschart.

26




Procedure Codes – ChiropracticPROCEDURE CODE EFFECTIVE DATE

72010 added6/9/08

72020 added6/9/08

72050 added6/9/08

72052 added6/9/08

72069 added6/9/08

72070 added6/9/08

72072 added6/9/08

72074 added6/9/08

72080 added6/9/08

72090 added6/9/08

72100 added6/9/08

72110 added6/9/08

72114 added6/9/08

72120 added6/9/08

72200 added6/9/08

72202 added6/9/08

72220 added6/9/08

Dental Care

Restorativedentalservicesforaccidentalinjuriesthataregenerallycoveredunderthemember’smedicalbenefitarelimitedtorepairingorreplacingsound,naturalteeththathavebeendamagedorlostduetoaninjury.Limitationsapply.UseCareFirstDirectorcallFirstLine(202-479-6500or800-842-5975)toverifyamember’slevelofcoverage.

Durable Medical Equipment, Orthotics and Prosthetics

CareManagement(866-773-2884)mustauthorizeservicesrelatedtoprosthetics,orthotics(excludedunderfully-insuredcontracts),andcertainotherDurableMedicalEquipment(DME)itemsexceptwhenusingNetworkHealthServices(NHS)/NeighborCare.AuthorizationisalsorequiredfromCareManagementwhenthecontractedprovidersuppliesallDMEequipmentandsuppliesfordiagnosesother thanasthmaanddiabetes.Formemberswithasthmaand/ordiabetes,theattendingproviderisresponsibleonlyforawrittenprescriptiontotheparticipatingDMEprovider.

TocontactNHS,call800-707-8520.UseCareFirst DirectorcallFirstLine(202-479-6500or800-842-5975)toverifythemember’slevelofcoverage.

Immediate Needs

Immediateneedssuppliesareitemsthatcanbeprovidedinaprovider’soffice.CareFirstBlueChoicePCPs,physicaltherapists,podiatrists,orthopedistsandchiropractorscanprovidecertainmedicalsuppliesintheirofficewhenthesesupplies/devicesarerenderedinconjunctionwithanofficevisit.Noseparateauthorizationisneeded;however,memberbenefitsmustbeverifiedpriortoprovidingsupplies,asmedicalbenefitlimitations,policiesandproceduresstillapply.

ViewalistofimmediateneedssuppliesintheMedical Policy Reference Manual.Typeimmediateneedsinthesearchwindow.Thepoliciesthathaveimmediateneedsitemswillbedisplayed.Choosetheapplicablepolicyandviewthe“ProviderGuidelines”sectionofthepolicyfordetailedinformationforsupplyinganimmediateneed.

Ifyouchoosenottosupplyan“immediateneeds”itemtoamember,thenyoumustreferthemembertoacontractedDurableMedicalEquipment(DME)supplier.ContractedDMEprovidersmustdistributeallothersuppliesnotconsidered“immediateneeds.”FindalistofcurrentDMEsuppliersinourProvider Directory.

Emergency Services

CareFirstBlueChoicedefinesamedicalemergencyasaseriousillnessorinjurythatintheabsenceofimmediatemedicalattentioncouldreasonablybeexpectedbyaprudentlayperson(onewhopossessesanaverageknowledgeofhealthandmedicine)toresultinanyofthefollowing:

● Placingthemember’shealthinseriousjeopardy

● Seriousimpairmenttobodilyfunctions

● Seriousdysfunctionofanybodilyorganorpart

Advisememberstocall911foralllife-threateningemergencies.CareFirstBlueChoicemembersmaycontacttheirPCPorFirstHelpfor


CPT® code book for

descriptions.

27





http://carefirst.benefitnation.net/(kscpnxumay1uk4b2pqdfyr45)/intro.aspx


instructionsormedicaladvice.Ifthemember’smedicalconditionseemslessserious,theemergencyprovidermayelecttodirectthemembertoreceivecareatoneofthefollowinglocations:

● ThePCP’soffice

● Anotherparticipatingprovider’soffice(writtenreferralmayberequired)

● Anurgentcarecenter

Copaysaregenerallyrequiredforemergencyservices;however,thecopayiswaivedifthememberisadmittedtothehospital.

Youoryourcoveringprovideriscontractuallyobligatedtobeavailablebytelephone24hoursaday,7daysaweekformemberinquiries.Theuseofrecordedphonemessagesinstructingmemberstoproceedtotheemergencyroomduringoff-hoursisnotanacceptablelevelofcareforCareFirstBlueChoicemembersandshouldnotbeused.

Endocrinology

Radiologicalservicescoveredunderamember’smedicalbenefitandperformedintheendocrinologist’sofficesettingarelimitedtotheprocedureslistedbelow.

AllotherradiologicalproceduresmustbeperformedbyaCareFirstBlueChoicecontractedradiologyfacility.SomeexceptionsapplyontheEasternShore.

Verifymembereligibilityandcoveragepriortorenderingservices,asbenefitlimitationsandmedicalpolicyrequirementsstillapply.


CPT® code book for

descriptions.

Procedure Codes – EndocrinologyPROCEDURE CODE EFFECTIVE DATE


77080 Invalidasof1/1/08




88172 9/5/08

Gastroenterology

Laboratoryservicescoveredunderamember’smedicalbenefitandperformedinthegastroenterologist’sofficesettingarelimitedtothefollowingprocedures.AllotherlaboratoryservicesmustbeperformedbyLabCorp®(800-322-3629).SomeexceptionsapplyinWesternMaryland.


Procedure Codes – Gastroenterology

PROCEDURE CODE EFFECTIVE DATE









G0262 invalidasof1/1/08

Away From Home CareTheAwayFromHomeCareprogramissponsoredbytheBlueCrossandBlueShieldAssociation,anassociationofindependentBlueCrossandBlueShieldplans,andallowsCareFirstBlueChoicemembersandtheircovereddependentstoreceivecarefromanyBlueCrossandBlueShieldHMOwhileawayfromhomeforatleast90days.

MembersfromotherBlueCrossandBlueShieldHMOscanenrollinCareFirstBlueChoice,selectaPCPandreceiveastandardIDcard.Benefitsmayvary.CheckCareFirstDirectorcontactaProviderServicesrepresentativeat202-479-6560or800-842-5975toverifycoverage.

ThisprogramdoesnotchangeCareFirstBlueChoiceproviders’normalofficeprocedures.

28



Guest Membership Program

TheguestmembershipprogramissponsoredbytheBlueCrossandBlueShieldAssociation,anassociationofindependentBlueCrossandBlueShieldplans.TheprogramallowsCareFirstBlueChoicemembersandtheircovereddependentstoreceivecarefromanyBlueCrossandBlueShieldHMOwhileawayfromhomeforatleast90days.

MembersfromotherBlueCrossandBlueShieldHMOscanenrollinCareFirstBlueChoice,selectaPCPandreceiveastandardIDcard.Benefitsmayvary;itisimportanttoverifythemember’scoverageatCareFirstDirectorcontactProviderServices.ThisprogramdoesnotchangeCareFirstBlueChoiceproviders’normalofficeprocedures.

Hematology/Oncology

Intravenoustherapyorchemotherapyservicesadministeredinaprovider’sofficewillbereimburseddirectlytotheprovider.ThePCPmayissuealong-standingreferralfortheseservices.PleaserefertotheExtendedReferralprocessfordetails.

Laboratoryservicescoveredunderamember’smedicalbenefitandperformedinthehematologist/oncologist’sofficesettingarelimitedtothefollowingprocedures.AllotherlaboratoryservicesmustbeperformedbyLabCorp®.SomeexceptionsapplyinWesternMaryland.

Hemodialysis

AuthorizationfromCareManagement(866-773-2884)isrequiredforinpatient,outpatientorhomehemodialysisservices,unlesstheservicesareperformedinacontractedfreestandingfacility,inwhichcasetheattendingproviderisresponsibleforawrittenprescriptionororder.

Home Health Services

CareManagementcoordinatesdirectlywiththeproviderand/orhospitaldischargeplanningpersonnelandwillauthorizeandinitiaterequestsforhomehealthserviceswhenappropriate.AuthorizationforHomeHealthServicesfromCareManagementisnotnecessarywhenusingNetworkHealthServices(NHS)/NeighborCare.TocontactNHS,call800-707-8520.

Home Infusion Therapy

CareFirstBlueChoicehascontractedwithdesignatedintravenoustherapyproviders.TheseservicesrequireauthorizationfromCareManagement.AuthorizationforhomeinfusiontherapyfromCareManagementisnotnecessarywhenusingNetworkHealthServices(NHS)/NeighborCare.TocontactNHS,call800-707-8520.

Procedure Codes – Hematology/OnocolgyPROCEDURE CODE EFFECTIVE DATE PROCEDURE CODE EFFECTIVE DATE





85023 invalidasof1/1/08 85097 addedpriorto1/1/08





85032 6/15/03 85585 invalidasof1/1/08



CPT® code book for

descriptions.

29



Hospice Care

Memberswithlifeexpectanciesofsixmonthsorlessmaybeeligibleforhospicecare.CallCareManagementforauthorization.AuthorizationforhospicecarefromCareManagementisnotnecessarywhenusingNetworkHealthServices(NHS)/NeighborCare.TocontactNHS,call800-707-8520.

House Calls

WhenaproviderdeterminesthatahousecallisnecessaryfortreatingaCareFirstBlueChoicemember,copayisrequired.Basedonprovider’sspecialty,collecttheappropriatecopaylistedonthemember’sHealthyBlueIDcard.Areferralisrequiredforaspecialisttovisitthehome.UsetheappropriateEvaluation&Managementhomevisitprocedurecode.

Laboratory ServicesPCPsandspecialistsarerequiredtouseLaboratoryCorporationofAmerica(LabCorp®)foroutpatientlaboratoryservicesthatarenotlistedonthechartbeginningonpage31.Therequiredlaboratoryrequisitionformsmustaccompanylabspecimenscollectedintheprovider’soffice.TherequisitionformmustincludethemembershipIDnumberexactlyasitappearsontheIDcard.Indicatethemember’sinsurancecompanyasCareFirstBlueChoice.PCPsmayalsorefermemberstodesignateddrawingsiteswiththerequiredlaboratoryrequisitionforms.

CallLabCorp®at 800-322-3629toobtaincopiesoftherequisitionform.

RefertotheProvider DirectoryorcallLabCorp®fordesignatedlocations.Laboratoryservicescoveredunderamember’smedicalbenefitandperformedinthePCPorspecialist’sofficesettingarelimitedtotheprocedurecodeslisted.AllotherlaboratoryservicesmustbeperformedbyLabCorp®.SomeexceptionsapplyinWesternMaryland.

WithHealthyBluelaboratoryservicesperformedinanoutpatienthospitalsettingrequirepriorauthorizationwithOption1,butnotinOption2or3.Membersmaybesubjectedtohigherdeductiblesand/orcopaysinOption2.CareFirstmemberswhoseeklaboratoryservicesatafacilityotherthanLabCorp®inOption3maybesubjecttothehighestdeductiblesandcopays/coinsurance.

ProviderswhoperformlaboratoryservicesintheirofficeshouldmaintaintheappropriatelevelofClinicalLaboratoryImprovementAmendmentscertification.FormoreinformationonCLIA,pleasevisithttp://www .fda .gov/cdrh/clia/.


Mental Health/Substance Abuse Services

MagellanBehavioralHealthServices(800-245-7013)administersallmentalhealthandsubstanceabusebenefitsforCareFirstBlueChoicemembers.

30



Procedure Codes – Laboratory ServicesPROCEDURE CODE EFFECTIVE DATE PROCEDURE CODE EFFECTIVE DATE


75731 added4/1/09 76960 invalidasof1/1/08











76003 invalidasof1/1/08 36400 11/1/04

76005 invalidasof1/1/08 36405 11/1/04




76095 invalidasof1/1/08 71090 added4/1/09


76098 addedpriorto1/1/08 72255 added4/1/09













76937 added9/18/09 75600 added4/1/09




76945 added4/1/09 75635 added4/1/09




CPT® code book for

descriptions.

31


Procedure Codes – Laboratory ServicesPROCEDURE CODE EFFECTIVE DATE PROCEDURE CODE EFFECTIVE DATE

























82044 8/1/05 87205 addedpriorto1/1/08




82272 1/6/06 87220 addedpriorto1/1/08

82274 1/6/06 87430 addedpriorto1/1/08


82570 8/1/05 87450 addedpriorto1/1/08






83036 addedpriorto1/1/08 87807 addedeffective4/10/09

83037 3/7/08 87880 addedpriorto1/1/08


CPT® code book for

descriptions.

32


Procedure Codes – Laboratory Services(CONTINUED)


88170 invalidasof1/1/08

87510 added6/15/03



87807 addedeffective4/10/09




88382* 12/4/09














*ApprovalofthiscodeappliesonlytoDermatopathologiststhataretrainedandcertifiedtoperformMohsmicrographicsurgery.

Nephrology

Laboratoryservicescoveredunderamember’smedicalbenefitandperformedinthenephrologist’sofficesettingarelimitedtotheproceduresbelow.AllotherlaboratoryservicesmustbeperformedbyLabCorp®.SomeexceptionsapplyinWesternMaryland.

UseCareFirstDirectorcallFirstLine(202-429-6500or800-842-5975)toverifymembereligibilityandcoveragepriortorenderingcare,asbenefitlimitationsandmedicalpolicyrequirementsstillapply.

Nutritional Services

AuthorizationfornutritionalservicesmustbeissuedbyCareManagementunlessamemberisdiagnosedwithdiabetesandservicesarerenderedinanofficesetting.ThePCPmustprovideawrittenreferraltoaparticipatingprovider,whennutritionalservicesarerenderedinanofficesettingtoamemberdiagnosedwithdiabetes.

Obstetrics & GynecologyObstetricalcaremaybeprovidedbyaparticipatingOB/GYNwithoutawrittenreferralfromthePCP.ThehospitalmustcontactCareManagementthedayofdeliveryorthenextbusinessdaytoobtainthenecessaryauthorizationforthefacility.

Procedure Codes – NephrologyPROCEDURE CODE EFFECTIVE DATE PROCEDURE CODE EFFECTIVE DATE

75710 5/9/2008 75902 5/9/2008

75790 5/9/2008 75978 5/9/2008


75820 5/9/2008 76937 addedpriorto1/1/08

75822 5/9/2008 81001 addedpriorto1/1/08

75825 5/9/2008 81003 addedpriorto1/1/08

75827 5/9/2008 81005 addedpriorto1/1/08

75894 5/9/2008 81007 addedpriorto1/1/08


CPT® code book for

descriptions.

33



Admissionsforpre-termlabororotherobstetricalcomplicationsrequireanadditionalauthorization.Ifthenewbornrequiresadditionalservicesoranextendedstayduetoprematurityoranycomplicationsofbirth,aseparateauthorizationwillberequired.

Reporting for Obstetrical Services

Foradditionalinformationaboutreportingmaternityservices,visitourMedical Policy Reference ManualandconductasearchforGlobal Maternity Care (4.01.06A).YoumayalsofindinformationintheBasicClaimAdjudicationPolicyConceptssection(pg.15)oftheGeneral Information Manual.

Obstetrical Radiology/Laboratory Services

Obstetricalultrasoundscoveredbythemember’smedicalbenefitandperformedintheOB/GYN’sofficesettingarelimitedto:

● OnebaselinefetalultrasoundfordiagnosiscodesV22-V22.2or650

● Anymedicallynecessarydiagnosticfetalultrasound

Otherradiology,laboratoryandothernotedservicescoveredunderthemember’smedicalbenefitandperformedintheOB/GYN’sofficesettingarelimitedtothefollowingprocedures.AllotherradiologyandlaboratoryservicesmustbeperformedbyLabCorp®oraCareFirstBlueChoicecontractedradiologyfacility.SomeexceptionsapplyinwesternMarylandandontheEasternShore.

Foradditionalinformation,refertotheBasicClaimAdjudicationPolicyConceptssection(pg.15)oftheGeneral Information Manual.

Amniocentesis/Chorionic Villus Sampling (CVS)

AnauthorizationfromCareManagementwillberequirediftheamniocentesisisperformedinahospitalsetting.Iftheamniocentesisisperformedintheofficesetting,CareManagementauthorizationisnotnecessary.AllspecimensmustbesubmittedtoLabCorp®forprocessing.

CVSproceduresrequireanauthorizationfromCareManagement,whetherperformedinahospitalorinyouroffice.Allspecimensmustbe

submittedtoLabCorp®forprocessing,unlessprocedureisperformedinahospitalsetting.SomeexceptionsapplyinWesternMaryland.

Genetic Testing/Counseling (excludes Amniocentesis)

Genetictestingandcounselingperformedinaspecialist’sofficerequiresawrittenreferral,unlessthespecialistisanOB/GYN.Genetictestingandcounselingperformedinasettingotherthanaparticipatingprovider’sofficewillrequireanauthorizationfromCareManagement.AlllabworkmustgotoLabCorp®forprocessing.PleasecontactFirstLine(202-479-6560or800-842-5975)oruseCareFirst Directtoverifyamember’slevelofcoverage.SomeexceptionsapplyinWesternMaryland.

Maternal and Child Home Assessment

Apostpartumhomevisitisavailableforamaternalandchildhomeassessmentbyahomehealthnurse.Thehomevisitmaybeperformedafterthemotherandchildaredischargedfromthehospital:

● Lessthan48hoursfollowinganuncomplicatedvaginaldelivery

● Lessthan96hoursfollowinganuncomplicatedC-Section

● Uponproviderrequest

CareManagementmustauthorizethepostpartumhomevisit.Thepostpartumhomevisitwillconsistofacompleteassessmentofthemotherandbaby.Testsforphenylketonuria(PKU)orbilirubinlevelsarealsoincludediforderedbytheprovider.Ifmorevisitsaremedicallyindicated,anadditionalauthorizationfromCareManagementwillberequired.

Infertility Services

Teststhatrelatetoestablishingthediagnosisofinfertility(e.g.,semenanalysis,endometrialbiopsy,postcoitalandHSG-hysterosalpingogram)donotrequireanauthorizationfromCareManagementwhenperformedinanofficesetting.AllspecimensmustgotoLabCorp®forprocessing.SchedulethesetestswithLabCorp®priortorenderingservices.

Treatmentofinfertility(excludedinDCandVA),includingartificialinsemination(AI)and

34









Procedure Codes – Infertility ServicesPROCEDURE CODE EFFECTIVE DATE PROCEDURE CODE EFFECTIVE DATE



59841 addedpriorto1/1/08 84704 1/18/2008




72190, 76645, 76801,76802,76805, 76810,

76811, 76812, 76813, 76814,76815, 76816, 76817, 76818,76819, 76825, 76826, 76827,

76828, 76946, 93325

Limitedtoobstetricalservicessuchasnormaldelivery,abortion,ectopicpregnancy,miscarriageandinfertility.

74740

addedpriorto1/1/08

87660 addedpriorto 9/15/10








10/28/2011 89256 invalidasof1/1/08

76376 9/5/2008 89257 addedpriorto1/1/08

76705, 76830, 76948

Limitedtoobstetricalservicessuchasnormaldelivery,abortion,ectopicpregnancy,miscarriage,infertilityandmedicalservices.

addedpriorto1/1/08






76820, 76821

Limitedtoobstetricalservicessuchasnormaldelivery,abortion,ectopicpregnancy,miscarriageandinfertility.

3/1/2007





89290 addedpriorto 9/15/10

76856, 76857

Limitedtoinfertilityandmedicalservices.

addedpriorto1/1/08








84146, 84443, 89291 Limitedtoinfertilityonly addedpriorto1/1/08


89331 added1/1/08


Refer to your current CPT® code book for descriptions.

35


In-VitroFertilization(IVF)(excludedunderfully-insuredcontracts)requiresauthorizationfromCareManagementinallsettings.Treatmentofinfertilitywhenperformedinaspecialist’sofficerequiresawrittenreferralfromthePCP.Somemembersmaynothaveinfertilitybenefits(foreitherdiagnosisortreatment)aspartoftheirhealthcoverage.CheckCareFirst DirectorcallFirstLine(202-479-6560or800-842-5975)to

verifythemember’seligibility.Ifamemberhasinfertilitybenefits,refertotheMedical Policy Reference Manualforpolicyconsiderations.Insertinfertilityinthesearchbox.

Priorauthorizationmayberequiredforallinfertility/IVFprescriptionmedications.ICOREpharmacymanagementprogramadministersthisprocess.ICOREcreatesacentralpointofcontactforproviders,membersandpharmacies.


CPT® code book for

descriptions.

OB/GYN Services Quick Reference Guide

SERVICES CARE MANAGEMENT AUTHORIZATION REQUIRED? COMMENTS

Abortions Yes,ifperformedinahospitalsetting.No,ifperformedinofficeorfreestandingradiologycenter.

None

Amniocentesis Yes,ifperformedinahospitalsetting. None

ChorionicVillusSampling(CVS) Yes,inanysetting. LabworkmustgotoLabCorp®,unlessperformedinahospitalsetting.*

DilationandCurettage(D&C) Yes,ifperformedinahospitalsetting. AllclaimsforD&Csperformedintheofficemustbesubmittedwithreport.

Depo-Provera® No. Mustbeadministeredintheprovider’soffice.Medicationisavailableforeligiblemembersthroughaprescriptiondrugbenefit.

GeneticTesting No,ifperformedintheoffice.Yes,ifperformedinahospitalsetting.

None

GynecologicSurgicalProcedures

Yes,ifperformedinahospitalsetting. None

Hysteropsalpingogram(HSG) No. Mustbeperformedatacontractedfree-standingradiologycenter.

InfertilityTesting Yes,ifperformedinahospitalsetting. Mustverifythemember’sbenefits.

InfertilityTreatment Yes,inanysetting. Mustverifythemember'sbenefits.

IUD/DiaphragmInsertion No. CostofIUD/diaphragmmaybemember’sfinancialobligation.Diaphragmisavailableforeligiblemembersthroughaprescriptiondrugbenefit.

MaternityServices Yes,ifperformedinahospitalsetting. Mustcalltoauthorizeandtonotifyofactualadmissiondate.

Mammograms No. Mustbeperformedatacontractedfreestandingradiologycenter.**

*Some exceptions apply in western Maryland.**Some exceptions apply on the Eastern Shore.

36






Tobeginthepriorauthorizationprocess,callICOREat866-664-2673,ext.113orfaxtheICOREpriorauthorizationformto866-850-7806.AnICORErepresentativewillthencontactthemembertoreviewherneedsandofferseveralprescriptiondeliveryoptions.Exceptionsmayapplydependingonbenefitplan.

Laboratory,radiologyandothernotedservicescoveredunderamember’smedicalbenefitandperformedintheofficesettingarelimitedtotheproceduresindicatedinthechartatleft.AllotherlaboratoryandradiologyservicesmustbeperformedbyLabCorp®orbyaCareFirstBlueChoicecontractedradiologyfacility.SomeexceptionsmayapplyinwesternMaryland.

Gynecologic Services

CareFirstBlueChoicemembersmayself-refertoparticipatingOB/GYNsforservicesperformedinanofficesetting.IfanursepractitionerisapartoftheOB/GYNpractice,awrittenreferralisnotrequiredifthediagnosisandprocedureisrelatedtoOB/GYNservices.CareManagementauthorizationmayberequiredforgynecologicservicesperformedoutsidetheofficesetting.

Mammograms

AllmammogramsmustbeperformedinaCareFirstBlueChoicecontractedfreestandingradiologicalcenter.SomeexceptionsapplyontheEasternShore.Eitheryouoryourattendingproviderisresponsibleforthewrittenprescription/orderfortheradiologicalcenter.RefertotheProviderDirectoryforfacilities.

Dilation and Curettage

DilationandCurettage(D&C)maybeperformedintheofficeforreasonsotherthanvoluntaryterminationofpregnancy.

Contraceptive ServicesIntrauterine contraceptive Device (IUD)/DiaphragmMemberbenefitsgenerallycoverproviderservicesinconnectionwiththeinsertionofanIUDorfittingofadiaphragm.TheIUDordiaphragmitselfmightnotbeacoveredbenefitforsomemembers,andthemembermaybefinanciallyresponsibleforthiscomponentoftheservice.

Ifcovered,theIUDchargescanbesubmittedtoCareFirstBlueChoice.Thediaphragmcanbeobtainedbythememberataparticipatingpharmacywithaprescriptionfromtheprovider.ThediaphragmisacoveredbenefitonlyforCareFirstBlueChoicememberswithprescriptiondrugbenefitswhosebenefitsdonotincludecontraceptivelimitations.

Depo-Provera®

Depo-Provera®isgenerallycoveredforthepreventionofpregnancywhenadministeredintheprovider’soffice.Depo-Provera®canbeobtainedataparticipatingpharmacywithaprescription.Depo-Provera®isacoveredbenefitonlyformemberswithprescriptiondrugbenefitsthatdonotincludecontraceptivelimitations.RefertothequickreferenceguidebelowregardingOB/GYNservices.CheckCareFirstDirectorcallFirstLine(202-479-6560 or800-842-5975)forinformationortoverifythemember’seligibilityorlevelofcoverage.

Oral Surgery

Radiologicalservicescoveredunderamember’smedicalbenefitandperformedintheoralsurgeon’sofficesettingarelimitedtothefollowingprocedures.AllotherradiologyservicesmustbeperformedbyaCareFirstBlueChoicecontractedradiologyfacility.SomeexceptionsapplyontheEasternShore.

Procedure Codes – Oral Surgery









Oralsurgeonswillbereimbursedfor70300,70310and70320onlyinthecaseofaccidentalinjurytotheteeth.


CPT® code book for

descriptions.

37





Orthopedics

Radiologicalservicescoveredunderamember’smedicalbenefitandperformedintheorthopedist’sofficesettingarelimitedtothe

proceduresbelow.AllotherradiologyservicesmustbeperformedbyaCareFirstBlueChoice-contractedradiologyfacility.SomeexceptionsapplyontheEasternShore.


CPT® code book for

descriptions.

Procedure Codes – OrthopedicsPROCEDURE CODE EFFECTIVE DATE PROCEDURE CODE EFFECTIVE DATE





71120 8/17/2007 73115 addedpriorto1/1/08

71130 8/17/2007 73120 addedpriorto1/1/08


















72220 3/28/2008 73592 addedpriorto1/1/08











38


Physical, Occupational and Speech Therapy

PCPs,neurologists,neurosurgeons,orthopedistsorphysiatristsmustissueawrittenreferraltoaparticipatingtherapistforuptothreevisitsforrehabilitativephysicaltherapy(PT),occupationaltherapy(OT)orspeechtherapy(ST).Afterthefirstvisit,thetherapistshouldsubmithisfindingsfromtheevaluationandatreatmentplantothereferringprovider.

CoverageforrehabilitativePT,OTand/orSTservicesisprovidedtoenableamembertoregainaphysical,speechordailylivingskilllostasaresultofinjuryordisease.

CoverageforhabilitativePT,OTand/orSTservicesisprovidedtoenableamembertodeveloporgainaphysical,speechordailylivingskillthatwouldnothavedevelopedwithouttherapy.

Note:

● Memberscoveredbyself-fundedplansmayrequireauthorizationfromtheOutpatientPre-TreatmentAuthorizationProgram(OPAP)tocontinuetreatmentbeyondthefirstthreevisits.VisitCareFirst DirectorcallFirstLine(202-479-6560or800-842-5975)toidentifymembersthatrequireOPAPauthorization.

● Whenapplicable,habilitativePT,OTandSTmayrequireOPAPauthorization.CallFirstLinetoreachaproviderservicesrepresentativetoidentifymembersthatrequireauthorizationforhabilitativeservices.

Podiatry

Youmustprovideawrittenreferraltothespecialistforpodiatricservices(excludedunderfully-insuredcontracts).Benefitswillonlybeprovidedforroutinefootcareserviceswhendeterminedthatmedicalattentionisneededbecauseofamedicalconditionaffectingthefeet,suchasdiabetes.

Radiologicalservicescoveredunderamember’sbenefitandperformedinthepodiatrist’sofficesettingarelimitedtothefollowingprocedures.AllotherradiologyservicesmustbeperformedbyaCareFirstBlueChoicecontractedradiologyfacility.

Procedure Codes – Podiatry









76881 1/1/11

76882 1/1/11

Oralsurgeonswillbereimbursedfor70300,70310and70320onlyinthecaseofaccidentalinjurytotheteeth.

Prescription Drugs

ArgusHealthSystems(Argus)workswithCareFirstBlueChoicetoadministerprescriptiondrugbenefits.Argusmaintainsmemberdrugrecords,processespaperworkandpaysclaimsrelatedtopharmaceuticalneeds.CallArgusat800-314-2872ifyoucannotfindaparticulardrugorhavedrug-relatedquestions.

CareFirstBlueChoice’sformularyisupdatedregularly.Drugsareplacedontheformularybasedontheirquality,effectiveness,safetyandcost.

Encouragememberstousetheformularytodetermineout-of-pocketexpensesformedication.Theformularyisdividedintothreetiers,orlevels,ofdrugs.Thetierthataprescriptiondrugisondeterminesthelevelofcopay:

● Tier1(lowestcopay)–Genericdrugs

● Tier2(highercopay)–Preferredbrand-namedrugs

● Tier3(highestcopay)–Non-preferredbrand-namedrugs

SomedrugsrequirepriorauthorizationundertheCareFirstBlueChoicePrescriptionProgram.CallArgus(800-314-2872)toobtainanauthorizationformordownloadaformhere.


CPT® code book for

descriptions.

39




http://www.carefirst.com/pharmacy/redirects/redirect_to_drug_formulary.htm

http://notesnet.carefirst.com/formulary/formulary.nsf/vwwebbycategorypa?openview



CPT® code book for

descriptions.

Procedure Codes – Pulmonology


71010 3/6/2006

71015 3/6/2006

71020 3/6/2006

71021 3/6/2006

71022 3/6/2006

71023 3/6/2006

71030 3/6/2006

71034 3/6/2006

71035 3/6/2006







WithHealthyBlue,membershaveaccesstocertaingenericdrugsatnocost.Thisincludesmedicationinthefollowingclasses:

● Asthma

● Depression

● Diabetes

● Highbloodpressure

● Highcholesterol

Alistofgenericdrugsonthepreferreddruglistisavailableatwww .carefirst .com/HealthyBlue.

Pulmonology

Laboratoryservicescoveredunderamember’smedicalbenefitandperformedinthepulmonologist’sofficesettingarelimitedtotheprocedurecodesabove.AllotherlaboratoryservicesshouldbeperformedbyLabCorp®.SomeexceptionsmayapplyinWesternMaryland.

Radiology

OutpatientradiologyproceduresrenderedataparticipatingfreestandingradiologyfacilitydonotrequireawrittenreferralfromthePCP.SomeexceptionsapplyontheEasternShore.

Providersmustprovidethememberwithaprescriptionororder.PleaserefertotheProvider Directoryforanup-to-datelistingofparticipatingfacilities.

Radiologicalservicesandothernotedcodescoveredunderamember’smedicalbenefitandperformedinthePCP’sorspecialist’sofficearelimitedtotheprocedurecodes.AllotherradiologyservicesmustbeperformedbyCareFirstBlueChoicecontractedradiologyfacility.SomeexceptionsapplyontheEasternShore.

CareFirstandCareFirstBlueChoice,Inc.expectsallproviderswhoperformlaboratoryorimagingtests,atanysitetoobtainand/ormaintaintheappropriatefederal,stateandlocallicensesandcertifications,training,qualitycontrols,andsafetystandardspertinenttothetestsperformed.

Multiple Computerized Tomography (CT) Scans, Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRAs)

MultiplemedicallynecessaryCTScans,MRIsandMRAsperformedbyprofessionalprovidersataparticipatingoutpatientfacility(free-standingorhospital-based)willbereimbursedat100percentoftheallowedamount,minusapplicablecopaymentsand/ordeductiblespaidbythemember.

ThisappliestomultipleCTScans,MRIsandMRAsrenderedtothesamememberonthesamedateofservice.

Rheumatology

Radiologicalservicescoveredunderamember’smedicalbenefitandperformedintherheumatologist’sofficesettingarelimitedtotheproceduresonthefollowingpage.AllotherradiologicalproceduresmustbeperformedbyaCareFirstBlueChoicecontractedradiologyfacility.SomeexceptionsapplyontheEasternShore.

40

http://www.carefirst.com/HealthyBlue



Procedure Codes – Rheumatology

PROCEDURE

CODEEFFECTIVE DATE

PROCEDURE

CODEEFFECTIVE DATE

PROCEDURE

CODEEFFECTIVE DATE

71100 8/17/07 73040 7/15/07 73590 7/15/07

71101 8/17/07 73050 7/15/07 73592 7/15/07

71110 8/17/07 73060 7/15/07 73600 7/15/07

71111 8/17/07 73070 7/15/07 73610 7/15/07

71120 8/17/07 73080 7/15/07 73615 7/15/07

71130 8/17/07 73085 7/15/07 73620 7/15/07

72010 8/17/07 73090 7/15/07 73630 7/15/07

72020 8/17/07 73092 7/15/07 73650 7/15/07

72040 8/17/07 73100 7/15/07 73660 7/15/07

72050 8/17/07 73110 7/15/07 76075 invalidasof1/1/08

72052 8/17/07 73115 7/15/07 76880 7/15/08

72069 8/17/07 73120 7/15/07 76881 1/1/11

72070 8/17/07 73130 7/15/07 76882 1/1/11

72072 8/17/07 73140 7/15/07 77080 addedpriorto1/1/08

72074 8/17/07 73500 7/15/07 77081 addedpriorto1/1/08

72080 8/17/07 73510 7/15/07 77082 addedpriorto1/1/08

72090 8/17/07 73520 7/15/07 83872 7/15/07

72100 8/17/07 73525 7/15/07 85652 7/15/07

72110 8/17/07 73530 7/15/07 87075 7/15/07

72114 8/17/07 73540 7/15/07 89051 7/15/07

72120 8/17/07 73542 7/15/07 89060 7/15/07

72170 8/17/07 73550 7/15/07 87510 added6/15/03

72190 8/17/07 73560 7/15/07 87797 addedpriorto1/1/08

73000 7/15/07 73562 7/15/07 87804 addedpriorto1/1/08

73010 7/15/07 73564 7/15/07 87807 addedeffective4/10/09

73020 7/15/07 73565 7/15/07 87880 addedpriorto1/1/08

73030 7/15/07 73580 7/15/07 88170 invalidasof1/1/08


CPT® code book for

descriptions.

41



CPT® code book for

descriptions.

Transplants

TransplantsandrelatedservicesmustbecoordinatedandauthorizedbyCareManagement,dependingonthemember’scontract.Coverageforrelatedmedicationsmaybeavailableundereithertheprescriptiondrugprogramormedicalbenefits.

Urgent Care Services

Amembermayrequireservicesforurgent,butnon-emergent,conditions.Directthemembertoanurgentcarecenter.Awrittenreferralisnotrequired.

Urology

Radiology,laboratoryservicesandothernotedcodescoveredunderamember’smedicalbenefitandperformedintheurologist’sofficesettingarelimitedtothefollowingprocedurecodes.AllotherradiologyandlaboratoryservicesmustbeperformedbyaCareFirstBlueChoicecontractedradiologyfacilityorLabCorp®.SomeexceptionsmayapplyinWesternMaryland.

Procedure Codes – Urology















Procedure Codes – Vision Care


0025T addedpriorto1/1/08









S0830 invalidasof1/1/08

Vision Care

Medical/RadiologyAwrittenreferralfromthemember’sPCPisrequiredforophthalmologicandoptometricservicesrelatedtomedicaldiagnoses.Radiologyservicescoveredunderthemember’smedicalbenefitandperformedintheophthalmologistoroptometrist’sofficearelimitedtotheprocedurecodesabove.AllotherradiologyservicesmustbeperformedbyaCareFirstBlueChoice-contractedradiologyfacility.

Routine Vision and EyewearDavisVision(800-783-5602)isourcontractedvendorforroutinevisioncare.Routinevisionservices,includingrefractionsandeyewear,performedbyDavisVision-contractedprovidersdonotrequireawrittenreferralfromthePCP.

42



Appeals Process

ThissectionprovidesPCPswiththeinformationneededtobetterunderstandtheAppealsProcess.Refertothissectionforinformationonhowtorequestreconsiderationofaclaimsdecision.

Claims Issues

Youmayappealaclaimsdecisioninwritingwithin180daysfromthedateyoureceivedthedenial.UseaProviderInquiryResolutionForm(PIRF),sendaformalletterofmedicalnecessity,oruseCareFirst DirecttosubmitalladministrativeappealstoProviderServices.

ContactaProviderServicesrepresentative(202-479-6560or800-842-5972)regardinganinquiryorappealofaclaimpayment.Yourconcernscanoftenbehandledandresolvedthroughinformaldiscussionsandinformationgathering.Ifyourquestionsorconcernrelatestoourhandlingofaclaimorotheradministrativeaction,callanddiscussthematterwithaCareFirstBlueChoiceProviderServicerepresentative.Inmanyinstances,themattermaybequicklyresolved.

IftheinquirycannotbesatisfiedintheServiceArea,youwillbeinstructedtomaketheappealinwritingandsubmitthisinformation,alongwithyourappealreasonandanypertinentorsupportivemedicalrecords,literatureorclaimsdocumentationtoCareFirstBlueChoice.

Internal Appeal or Grievance Process

Allappealsandgrievancesmustbesubmittedinwritingandfiledwithin180daysfromthedateyoureceivedthenotificationofthedenialofbenefitsorservices.CareFirstBlueChoicemayrequireadditionalinformationfromyouorthebillingand/ortreatmentprovider.Ifyourgrievanceisregardingamedicalnecessity,cosmeticorexperimental/investigationaldenialreason,thegrievancewillbereviewedbyaproviderwhowasnotinvolvedintheinitialdenialdetermination.

43



Writtenappealsshouldbemailedto:


Thereisanemergency/expeditedappealprocessavailabletoyou.Inanexpeditedappealforurgent/emergencycare,theappealorgrievancedecisionwillbemadeassoonaspossible,andnolaterthan24hoursafterCareFirstBlueChoicereceivesthenecessaryinformationtomakeadecision.Theappealorgrievancereviewwillbecompletedbyaproviderinthesameorsimilarspecialtyasthetreatmentunderreviewandnotpartoftheoriginaldenialdecision,asappropriate.Expeditedappealsinvolvecarethathasnotyetoccurredoriscurrentlyoccurring(pre-serviceorconcurrentcare).Allappealandgrievancedecisionsareansweredinwriting.Ifthedecisionremainsadenialoftheoriginalrequest,adetailedexplanationthatreferencestherule,policyorguidelineusedtomakethedecisionwillbeincluded.

Necessary Information

Aletterdescribingthereason(s)fortheappealandtheclinicaljustification/rationaleisrequired,includingthefollowinginformation,ifpossible:

● Member’snameandidentificationnumber

● Provider’snumberortaxidentificationnumber

● Claimnumber

● Admissionanddischargedate(ifapplicable)ordate(s)ofservice

● Provider’sname

● AcopyoftheoriginalclaimorExplanationofBenefit(EOB)denialinformation

● Supportingclinicalnotesormedicalrecords(i.e.pertinentlabreports,x-rays,treatmentplans,progressnotes,etc.)

Contact a Provider

Services representative

(202-479-6560 or 800-

842-5972) regarding

an inquiry or appeal of

a claim payment. Your

concerns can often be

handled and resolved

through informal

discussions and

information gathering.

44


Administrative Functions

Thissectionprovidesinformationaboutouradministrativeprocedures,includingchangesinprivileges,providerreimbursementandimportanttelephonenumbers.

Web ResourcesThefollowinginformationisavailableatwww .carefirst .com:

● ThePrescription DrugssectionincludestheCareFirstformularyandinformationonpriorauthorizationrequirementsandquantitylimits.

● CareFirstMedical Policy Reference Manualhasthemostup-to-datemedicalpolicyinformationandguidelines.

● HealthyBlueseminarsandweb-basedseminarsareavailablethroughtheCenter for Provider Education & Training .

● ClaimsAdjudicationandAssociatedReimbursementPolicyinformation,includingdetailsonbillingandreimbursementguidelinesareavailableintheGeneral Information Manual.

● MedicalForms,includingtheHealthyBlueHealthandWellnessEvaluationFormareavailablefordownloadingandmore.

Change in PrivilegesYourparticipationintheCareFirstBlueChoicenetworkissubjecttothetermsofyourparticipationagreementwithCareFirstBlueChoice.Theagreementspecificallyprovidesfortheenforcementofarangeofsanctionsuptoandincludingterminationofyournetworkparticipationforreasonsrelatedtothequalityofcarerenderedtomembers,aswellasforbreachesoftheparticipationagreementitself.

AfterreviewofrelevantandobjectiveevidencesuppliedtoorobtainedbyCareFirstBlueChoice,aCareFirstBlueChoiceMedicalDirectormayelecttoreduce,suspendorterminateyourprivilegesforcause.Whenapotentialproblemwithqualityofcare,competenceorprofessionalconductisidentifiedandthereisimminentdangertothehealthofCareFirstBlueChoicemembers,theMedicalDirectormayimmediatelyterminateyourparticipation.Actions,otherthanterminationofparticipation,include:

45

http://www.carefirst.com

http://www.carefirst.com/pharmacy/html/PharmacyHome.html


http://www.carefirst.com/providers/CenterForProviderEducation/index.html

http://www.carefirst.com/providers/CenterForProviderEducation/index.html




●

●

●

●

●

Implementationofacorrectiveactionplan

Implementationofamonitoringplanrelativetobillingand/ormembersatisfaction

ClosureofPCPpanels

Suspensionwithnoticetoterminate

SpecialletterofagreementbetweenthepractitionerandCareFirstBlueChoiceoutliningexpectationsand/orlimitationofrangeofservicesthepractitionermaysupplytomembers

Tomakefinaldeterminations,theMedicalDirectorseeksadvicefromtheCredentialingAdvisoryCommittee(CAC)andmayappointotherpractitionersasadhocmemberstotheCACtoofferspecializedexpertiseinthemedicalfieldthatisthesubjectofthecaseorissuepresented.Aspartofitsinvestigation,thecommitteemayuseinformationthatmayincludechartreviewofoutpatientandinpatientcare,complaintsummaries,peer/staffcomplaintsandinterviewswiththepractitioner.

TheMedicalDirectornotifiesyouinwritingofthereason(s)fortheterminationand/orsanction,his/herrighttoappealthedeterminationandtheappealprocess.Thepractitionermayappealthedecisionbysubmittingawrittennoticewithmaterialsrelevanttothedecisionwithin30daysofbeingnotifiedofthedecision.Ifanappealisn’tfiledwithin30days,appealrightsareforfeited.

Pursuanttothelocaljurisdiction’sregulations,CareFirstBlueChoicenotifiestherelevantlicensingboardswithin10dayswhenithaslimited,reducedchangesorterminatedapractitioner’scontractifsuchactionwasforreasonsthatmightbegroundsfordisciplinaryactionbytheparticularlicensingboard.AsaqueryingagentfortheNationalPractitionerDataBank(NPDB),CareFirstBlueChoicecomplieswiththenotificationrequirements.

Quality of Care Terminations

Appealrequestsrelativetoqualityofcareterminationsarereviewedthroughahearingpanel.ThehearingpaneliscomprisedofclinicalmembersoftheCorporateQualityImprovementCommitteewhowerenotpreviouslyinvolvedinthereviewordecisionofthecase,andatleastthreepractitionerswithnoadverseeconomicinterestsconnectedtotheappealingpractitionerandsimilarexperienceintheappealing

practitioner’sexpertise(ifappropriate).

Theappealingpractitionerisnotifiedinwritingofthehearingprocess.Followingthehearing,thepanelwillmakeafinaldecisiontoaffirm,amendorreversethesanctionornetworktermination.TheMedicalDirector,inconsultationwithCareFirstlegalrepresentative(s),notifiesthepractitionerofthedecisioninwriting,providesastatementforthebasisofthedecisionandinformsthepractitionerthatthedecisionisfinalandnotsubjecttofurtherconsiderationwithCareFirstBlueChoice.

All Other Sanctions or Terminations

TheMedicalDirectorwillreconsiderappealsforallothersanctionsorterminationsonthebasisofnewinformationprovidedbythepractitioner.TheMedicalDirectormayseekrecommendationsfromtheCredentialingAdvisoryCommittee(CAC)priortomakingafinaldecision.TheMedicalDirectornotifiesthepractitionerofthedecisioninwriting,providesastatementforthebasisofthedecisionandinformsthepractitionerthatthedecisionisfinalandnotsubjecttofurtherconsiderationwithCareFirstBlueChoice.

Member to be Held Harmless

CareFirstBlueChoicewillmakepaymentstotheprovideronlyforcoveredserviceswhicharerenderedtoeligiblemembersandwhicharedeterminedbyCareFirstBlueChoicetobemedicallynecessary.AnyservicesfoundbyCareFirstBlueChoicetohavenotbeenmedicallynecessary,andineligibleforbenefits,willnotbechargedtothemember.Theprovidermaylooktothememberforpaymentofdeductiblesand/orcopaymentsorforservicesnotcoveredunderthemember’sHealthBenefitPlan.PaymentmaynotbesoughtfromthememberforanybalancesremainingafterCareFirstBlueChoice’spaymentforcoveredservicesorforservicesdeniedduetotheprovider’slackofcontractedcompliance(e.g.,lackofauthorization),unlessitistosatisfythedeductibleorcopaymentrequirementsofthemember’sHealthBenefitPlan.Theprovidershouldnotspecificallycharge,collectadepositfrom,seekcompensation,remunerationorreimbursementfromorhaveanyrecourseagainstmembersorpersonsotherthanCareFirstBlueChoiceorathirdpartypayerforcoveredservicesprovidedaccordingtotheParticipationAgreement.

46


Administrative Services Policy

Providerscannotrequirethepaymentofchargesaboveandbeyondcopaymentsanddeductibles.Tohelpyouevaluateyouroffice’scurrentpractices,ourpolicyisbelow.

● Participatingprovidersshallnotcharge,collectfrom,seekremunerationorreimbursementfromorhaverecourseagainstsubscribersormembersforcoveredservices,includingthosethatareinherentinthedeliveryofcoveredservices.ThepracticeofchargingforofficeadministrationandexpenseisnotinaccordancewiththeParticipationAgreementandParticipatingProviderManual.Suchchargesforadministrativeserviceswouldinclude,bywayofexample,annualorpervisitfeestooffsettheincreaseofofficeadministrativedutiesand/oroverheadexpenses,malpracticecoverageincreases,writingprescriptions,copyingandfaxing,completingreferralformsorotherexpensesrelatedtotheoverallmembermanagementandcompliancewithgovernmentlawsandregulations,requiredofhealthcareproviders.

● Theprovidermaylooktothesubscriberormemberforpaymentofdeductiblesandcopayments,orforprovidingspecifichealthcareservicesnotcoveredunderthemember’sHealthBenefitPlanaswellasfeesforsomeadministrativeservices.Suchfeesforadministrativeservicesmayinclude,bywayofexample,feesforcompletionofcertainformsnotconnectedwiththeprovidingofCoveredServices,missedappointmentfees,andchargesforcopiesofmedicalrecordswhentherecordsarebeingprocessedforthesubscriberormemberdirectly.

● Feesorchargesforadministrativetasks,suchasthoseenumeratedabove,maynotbeassessedagainstallmembersintheformofanofficeadministrativefee,butrathertoonlythosememberswhoutilizetheadministrativeservice.

Participation in Provider Reimbursement

Primary Care Practitioners and Specialists/ProvidersCareFirstBlueChoicePCPsarereimbursedonafee-for-servicebasisforbillableservices,suchasofficevisitsandprocedures.

Physician AssistantsCareFirstBlueChoicedoesnotcontractwithPhysicianAssistants(PA).CoveredservicesrenderedbyaPAareeligibleforreimbursementunderthefollowingcircumstances:

● PAisunderthesupervisionofaphysicianasrequiredbylocallicensingagencies.

● ServicesrenderedbythePAaresubmittedunderthesupervisingphysician’snameandprovidernumber.

HIPAA Compliant Codes

TocomplywiththerequirementsoftheHealthInsurancePortabilityandAccountabilityAct(HIPAA),CareFirstandCareFirstBlueChoicewilladdtheHIPAA-compliantcodesandcorrespondingreimbursementratestoyourfeeschedulewhentheyarereleasedfromAMAorCMS.Theseupdatesaremadeonaquarterlybasisthroughthecalendaryear.

In-Office Injectable Drugs Standard Reimbursement Methodology

In-OfficeInjectabledrugsarereimbursedatapercentageoftheAverageSalesPrice(ASP).In-OfficeInjectabledrugswithoutanASParereimbursedatapercentageofthelowestAverageWholesalePrice(AWP).TheASPiscalculatedbytheCentersforMedicare&MedicaidServices(CMS)andavailableatCMS .gov .TheAWPisbasedonthemostcosteffectiveproductandpackagesizeasreferencedinThomson’sRedBook.

Reimbursementforallin-officeinjectabledrugsisupdatedquarterlyonthefirstofFebruary,May,AugustandNovember.Theratesareineffectfortheentirequarterbutaresubjecttochangeeachquarter.P4OncologyandP4Rheumatologyfeeschedulesarenotincludedinthisreimbursementmethodology.

Collection of Retroactively Denied ClaimsAproviderreimbursementmaybeoffsetagainstaretroactivelydeniedclaimbyanaffiliatedcompanyofCareFirst,Inc.

47

http://cms.gov


ImportantAddressesandTelephone/FaxNumbersPROVIDER CONTACT NUMBER TO CALL SEND CORRESPONDENCE TO

ProviderInformation&Credentialing

410-872-3500 877-269-9593

Fax:410-872-4107 Fax:866-452-2304

CareFirstBlueCrossBlueShield10455MillRunCircleP.O.Box825 MailstopCG41OwingsMills,Md. 21117-0825

ProviderRelations&ProfessionalContracting

410-872-3500 877-269-9593

Fax: 410-505-6900 Fax: 866-452-2306


InstitutionalandVendorContracting

410-872-3500 877-269-9593

Fax:410-872-4106 Fax:866-452-2306


CaseManagement 410-605-2623 888-264-8648

CareFirstBlueCrossBlueShield100SouthCharlesStreet,TowerIIMailstopBALT-72Baltimore,Md.21201

AUTOMATED VOICE RESPONSE UNIT NUMBER TO CALL

FirstLine

NationalCapitolArea(NCA)Region–eligibility,claimandbenefitinquiryforCareFirstBlueChoice,BluePreferred,NCAIndemnityandHealthyBlue

NCARegion–FirstLine

202-479-6560

800-842-5975

FederalEmployeeProgram(FEP)–eligibility,claimandbenefitinquiry 202-488-4900

DOCUMENTS HOW TO SUBMIT NUMBER TO CALL

HealthandWellnessEvaluationForm

UploadtoCareFirst Direct

Fax:410-505-6160 Fax:800-354-8205

202-479-6560

800-842-5975

UseCPT®code99420whenyoufileaclaimforcompletingtheHealthyBlueHealthandWellnessEvaluationFormanddiscussingtheresultswiththemember,alongwithotherservicesrendered.

PROVIDER CONTACTS NUMBER TO CALL

ProviderSeminarRegistration 877-269-2219

Authorization Faxforauthorization:410-528-7027

CareManagement 866-PRE-AUTH(773-2884)

48


ImportantAddressesandTelephone/FaxNumbers(CONT’D)

VENDOR CONTACTS NUMBER TO CALL / WEBSITE

ArgusHealthSystemsPharmacybenefitsmanager 800-314-2872 forpriorauthorizationrequests

Fax:800-315-4025

DavisVision 800-783-5602

Emdeon–enrollmentforelectronicclaimssubmission 866-369-8805

ICOREHealthcare-Supplierofinjectabledrugs 866-522-2470

LaboratoryCorporationofAmerica(LabCorp®)ProvideslaboratoryservicesforCareFirstBlueChoicemembers

800-322-3629

MagellanBehavioralHealth–mentalhealthandsubstanceabuseservices 800-245-7013

NetworkHealthServices(NHS) 800-707-8520

Allscripts–enrollmentforelectronicclaimssubmission 877-623-5706ext.2

RealMed–enrollmentforelectronicclaimssubmission 410-480-7165 or 877-927-8000, ext. 1201

RelayHealth–enrollmentforelectronicclaimssubmission 800-527-8133,option2

WalgreensSpecialtyPharmacy(formerlyMcKessonSpecialty)–Supplierofinjectabledrugs

888-456-7274

49

http://www.emdeon.com/

http://www.payerpath.com/

http://www.realmed.com/

http://www.relayhealth.com/


Frequently Asked Questions

1 . Why is CareFirst BlueChoice offering HealthyBlue?Inanefforttoreducetherisingcostofhealthcareandenhancehealthylifestylesthroughanengagedpatient/providerrelationship,CareFirstBlueChoicedevelopedHealthyBlue.Thisnewproductisaboldapproachtohealthcarethatencouragesprimarycareproviderstoworkcloselywiththeirpatientstominimizehealthrisksinordertoachieveandmaintainhealthyoutcomes.

2. Which provider specialties are considered PCPs?HealthyBluerecognizesthefollowingspecialtiesasprimarycareproviders(PCPs):FamilyPractice,GeneralPractice,InternalMedicine,PediatricsandGeriatrics.

Note:OB/GYNswhowishtoserveasamember’sPCPmustgivethememberaletterexpressingtheirwishtoserveasthePCP.ThememberwillsubmitthelettertoMemberServices.OnceselectedasthePCP,OB/GYNswillhavethesameprivilegesasotherPCPs,includingwritingreferrals.

3. How can I tell whether my patient is eligible for HealthyBlue?Uponreviewofthemember’sHealthyBlueIDcard,useCareFirst Directtoconfirmtheireligibilityandeffectivedateofcoverage.

4. Am I required to schedule appointments within a certain timeframe?HealthyBluerequiresthattheHealthandWellnessEvaluationandapplicablescreeningsandimmunizationstakeplacewithin90daysofthemember’scontracteffectivedate.However,thePCPwillhave120daystosubmittheHealthandWellnessEvaluationFormtoCareFirst

50



BlueChoice.IfyoucannotmeetwiththememberintimetoconducttherequiredhealthscreeningsandfillouttheHealthandWellnessEvaluationForm,themembermayseeanotherCareFirstBlueChoiceprovider.

PerthetermsoftheParticipationAgreement,non-symptomaticvisits,suchaspreventivecareorroutinewellness,appointmentsshouldbescheduledwithin4weeks.

5. Can I verify information about my patient on the Voice Response Unit (VRU)?Yes,youcanaccesstheVRUtoobtainthemember’sbenefitinformation.

6. Where can I find more information about HealthyBlue?AdditionalinformationaboutHealthyBlueisavailableatwww .carefirst .com/healthyblue.

Health & Wellness Evaluation Form

7. What is a Health & Wellness Evaluation Form?TheHealthandWellnessEvaluationFormisusedbyaPCPtorecordtheoutcomesofrequiredhealthscreeningsandimmunizations.Theformservesasarecordtocaptureabaselinehealthstatus,determineareasforimprovement,andpromotehealthylifestylesthroughthedevelopmentofaHealthy Action Planformemberswhoneedit,basedonthegoalsoutlinedintheform.BoththePCPandthemembermustsigntheHealthandWellnessEvaluationFormbeforethePCPsubmitsittoCareFirstBlueChoice.

8. How do I get a copy of the Health & Wellness Evaluation Form?ThemembershouldbringacopyoftheformtotheirHealthandWellnessEvaluationscreening.However,iftheyforget,acopycanbeobtainedfromwww .carefirst .com/providers/forms.

9 . .Will I get reimbursed for completing the Health & Wellness Evaluation Form and submitting it?Yes,useCPT®code99420whenyoufileaclaimforcompletingtheHealthandWellnessEvaluationForm.Theofficevisitshouldbebilledappropriatelyasapreventiveservice.The

reimbursementiscalculatedinthesamemannerasanofficevisit.

10 . .How do I submit the Health & Wellness Evaluation Form for my patient?TheHealthandWellnessEvaluationFormshouldbesubmittedusingoneofthefollowingmethods:

● SubmitthroughCareFirst Direct ● ScanthisformandsaveitinJPG,PDF,or

TIFFformat ● Click“UploadEvaluationForm”

OR

● Faxto410-505-6160or1-800-354-8205

Note: Only a CareFirst BlueChoice PCP can submit the form.

11 . .How do I submit a claim for completing the Health & Wellness Evaluation Form?SubmityourclaimtoCareFirstBlueChoiceasyounormallywouldthroughthestandardclaimssubmissionprocessusingCPT®code99420toreceivereimbursementforcompletingtheHealthandWellnessEvaluationForm.

Note: Do not send the Health & Wellness Evaluation Form with your claim.

12 . .How soon should my patient schedule an appointment to complete the Health & Wellness Evaluation Form?Themembermustscheduleanofficevisitwithyouandhaveanyapplicabletestscompletedwithin90daysoftheircoverageeffectivedatetobeconsideredforprogramincentives.YoumustsubmittheHealthandWellnessEvaluationFormtoCareFirstBlueChoicewithin120daysofthemember’scoverageeffectivedate.

Note: Iftestsarerequired,enterthedatethetestwasperformedtodocumentthatthetestwasdonewithin90daysofthemember’scoverageeffectivedate.

13 . .Where can I find the Preventive Service Guidelines?ThePreventive Service GuidelinesareavailableonourWebsite.

14 . .What is a Healthy Action Plan?AHealthy Action Planisaguidethattheproviderandthememberworktogetherto

51

http://www.carefirst.com/healthyblue



http://www.carefirst.com/providers/html/ClinicalResources.html


developifthememberdoesnotmeetthenationalguidelinesduringtheinitialevaluationscreening.TheHealthy Action Planservesasaguidetoshowmembershowtoachieveandmaintainhealthy,long-termoutcomes.ItshouldalsoincludeatimeframeforwhenthememberisexpectedtoreturnfortheClinicallyAppropriateRe-Screening.TheHealthy Action Planmustbedevelopedandre-measuredpriortothemember’srenewaldate.

15 . .It was necessary to put my patient on a Healthy Action Plan. How do I submit a claim for a re-evaluation if I am treating the patient for a condition?Allservicesshouldbebilledappropriatelyforthetypeofcarerendered(i.e.sick,preventive,etc.).

16 . .Can CPT® code 99420 be processed more than once a year without the claim being rejected?Yes,thecodecanbeprocessedatamaximumoftwiceayear,permember:oncefortheHealthandWellnessEvaluationandonceforthere-screening,ifnecessary.

17 . .Can I charge my patient for another office visit when they return to sign the form?Youwilldetermineifanofficevisitsisrequiredtoreviewthetestresults,finalinformationontheform,orneedtoputthememberonaHealthy Action Plan.Ifthereisnoneedforfollow-upcareorthemembercouldsimplycomeintosigntheformsoitcanbeforwardedtoCareFirstBlueChoiceandnotincuranotherofficevisitcharge.

18 . .I submitted the Health and Wellness Evaluation Form but found there was an error on the form. How do I resubmit form?AcorrectedHealthandWellnessEvaluationFormcanberesubmittedthroughCareFirst Directorfax(410-505-6160or1-800-354-8205).Write“CorrectedCopy”atthetopoftheform.

19 . .What is the difference between a waiver and an alternative standard/guideline?Awaivermeansthatthehealthmeasureisexcluded.Analternativestandard/guidelinemeansthatanewgoalisset.Youmaydeterminethatawaiverisappropriatefor

anygivenhealthmeasure(s).Youmayalsodeterminethatthemembercannotmeettheinitialstandard,andthereisnoappropriatealternativestandard/guidelinethatwillallowthemembertomeetthenationalguidelines.

20 . .How do I document a waiver or alternative standard/guideline?ThereareboxesontheHealthandWellnessEvaluationFormtoindicateifaWaiverorAlternativeGuidelinewasset.Checktheappropriatebox.Provideadditionaldetailsinthe‘Comment’sectionoftheform.

21 . .My patient had another PCP complete the Health and Wellness Evaluation. Can I conduct the re-screening?MemberswillbeencouragedtousethesamePCPtoconductboththeinitialandre-screeningvisitsandcompletetheHealthandWellnessForm.However,iftheyhavechangedPCP’sorhavechosentouseanotherproviderforthere-screening,theymaydoso.Ifpossible,membersshouldprovideyouwithacopyoftheoriginalHealthandWellnessEvaluationFormshowingtheresultsfromtheinitialvisitsoallinformationwillbeononeform.IfthisisnotpossibletheyshouldbringyouablankcopyoftheformoryoucangetacopyfromourWebsiteatwww .carefirst .com/providers/forms.

22 . .The Health and Wellness Evaluation Form was returned to me with a request for additional and/or corrected information. I already submitted my claim for the services. How should I resubmit this form?Maketheadditions/correctionsonyourcopyoftheHealthandWellnessEvaluationForm.NoteCorrected FormatthetopanduploadittoCareFirst Directorfax(410-505-6160or1-800-354-8205).Thereisnoneedtoresubmittheclaim.

23 . .My patients continue to contact me about an incentive and said that what I put on the form impacted the amount they received. Do I need to be involved with this?No,howeveritishelpfultoreviewthemember’sHealthandWellnessEvaluationFormforaccuracyifmembersareallegingthatthereisaclericalerror(comparedtoyourmedicaldocumentation),andtomaintaintimelineswithsubmissiondaterequirements.

52






Yourresponsibilitiesinclude:schedulingatimelyinitialevaluationandscreeningwiththemember,completingtheInitialScreeningsectionontheHealthandWellnessEvaluationFormincludingdocumentationofeachofthehealthmeasuresforthisspecificmember,yourdecisionanddocumentationontheastowhetherornotanalternativestandardorwaiverwillbeallowedasappropriate,reviewoftheformwiththememberandyourssignaturesontheformandsubmissiontoCareFirstBlueChoice.

Referral Process

24 . .As a CareFirst BlueChoice PCP, I never had to submit a referral to CareFirst BlueChoice. Why do I have to do this now?HealthyBlueencouragesyoutocoordinatethemembers’careandrequiresthatyourefermemberstoaCareFirstBlueChoicespecialistinordertohavethelowestout-of-pocketexpenses.Therefore,itisnecessaryforCareFirstBlueChoicetoreceivethereferralfromyoutoensurethatservicesareprocessedappropriatelyformembers.

25 . .How do I submit a referral to CareFirst BlueChoice?Mailreferralsto:


26 . .Should I use the Uniform Consultation Referral Form for submission of a referral for a HealthyBlue member?Yes,youshouldusethesameformasforotherCareFirstBlueChoicereferrals.

27 . .Why must my patient always have a referral?ReferralsfromaCareFirstBlueChoicePCPtoanotherCareFirstBlueChoiceproviderareneededformemberstoreceivethelowestout-of-pocketexpenses.Thosememberswhoseekcarewithoutareferralaresubjecttohigherdeductiblesandcopays/coinsurance.

28 . .I am a specialist with a referral from my patient’s PCP. I must send them to another provider for care on this same condition, but the referral is only for 3 visits and I know it will require more visits than this. Is it necessary for my patient to get another referral from their PCP? WithHealthyBlue,oncethenumberofvisitsexpires,thepatientmustcontactthePCPtogetanadditionalreferralformorevisits,evenifitisforthesameconditionlistedontheoriginalreferral.

29 . .My patients say they do not need a referral to schedule a visit but their membership card does not state Open Access. Can I still render services?Yes,Open AccessisnotwrittenontheHealthyBlueidentificationcards(ID),however,allHealthyBlueproductshavetheOpen Accessfeature.Memberswhoseekcarewithoutareferralmaydosohowever,theymaybesubjecthigherdeductiblesandcopays/coinsurance.

53


Index

AAlternativestandard/guideline6AppealsProcess43Authorizations18

BBenefitDesign11

CClinicallyAppropriateRe-Screening7

DDiseaseManagement24

EEmergencyRoomServices22

H

HealthandWellnessEvaluationForm5HealthAssessment4HealthyActionPlan7HospitalServices23

I

IdentificationCards13InitialEvaluationScreening6

L

LaboratoryServices30

P

PlanOptions9PrimaryCareProvider20

R

ReferralProcess15RoutineOfficeVisits21

S

SampleHealthyBlueBenefitDesign11Specialistservices16

W

WebResources45

54


From the CareFirst BlueCross BlueShield family of health care plans .

More to feel good about.840FirstStreet

Washington,DC 20065

www.carefirst.com/healthyblue

CareFirst is used as a collective reference for CareFirst BlueChoice, Inc. and CareFirst BlueCross BlueShield.

BOK5408-1S (6/12)

CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. CareFirst BlueCross BlueShield is an independent licensee of the Blue Cross and Blue Shield Association, providing access to the Preferred Provider

Organization Network only and does not assume any financial risk or obligation with respect to claims. ®Registered trademark of the Blue Cross and Blue Shield Association. ®’Registered trademark of CareFirst of Maryland, Inc.

55

Date post:	04-Aug-2019
Category:	Documents
Upload:	lamtu
View:	214 times
Download:	0 times

HealthyBlue Dual/Triple Option Provider Manual · HealthyBlue PROVIDER MANUAL HealthyBlue: How it...

Documents