PROVIDER | SPRING EDITION One to One Newsletter Blue Cross of Idaho has been busy since the beginning of the year. Much of the information this quarter is important for appropriate coding, getting good information on the online employer portal enhancing patient wellness screenings and managing gaps in care. The information is in categories based on whether the article is Informational (is for education only) or Action (requires action on your part). Topics in this edition of the Provider Newsletter include: Informational • Qualified Health Plan Risk Adjustment Scorecards and Reports • Provider Web Portal Improvements: Claims Status Application Upgrade • Medical Drug Prior Authorization Changes • Blue Cross of Idaho Member Outreach Campaign • Eye Health and Your Patients with Diabetes • Medical Policy Update • New Medicare ID Cards • Obesity and Protein-Calorie Malnutrition: Related Risk Adjustment Coding, Member Resources and Benefits Action • Are Your Patients Up to Date? • 2018 MMCP Seminars Thank you, Provider Operations
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P R O V I D E R | S P R I N G E D I T I O N
One to One Newsletter
Blue Cross of Idaho has been busy since the beginning of the year. Much of the information this quarter is important for appropriate coding, getting good information on the online employer portal enhancing patient wellness screenings and managing gaps in care.
The information is in categories based on whether the article is Informational (is for education only) or Action (requires action on your part).
Topics in this edition of the Provider Newsletter include:
Informational• Qualified Health Plan Risk Adjustment
Scorecards and Reports
• Provider Web Portal Improvements: Claims Status Application Upgrade
• Medical Drug Prior Authorization Changes
• Blue Cross of Idaho Member Outreach Campaign
• Eye Health and Your Patients with Diabetes
• Medical Policy Update
• New Medicare ID Cards
• Obesity and Protein-Calorie Malnutrition: Related Risk Adjustment Coding, Member Resources and Benefits
Action• Are Your Patients Up to Date?
• 2018 MMCP Seminars
Thank you,
Provider Operations
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Now Available: Qualified Health Plan (QHP) Provider Risk Adjustment Scorecards and ReportsBlue Cross of Idaho is excited to announce that initial Qualified Health Plan (QHP) Risk Adjustment Scorecards and reports are now available!
What is a Risk Adjustment Scorecard?
Scorecards provide an overall summary view of a group and/or individual provider’s respective membership, including:
• Membership totals for your specific group and/or provider
• Average age of this membership
• Risk Score
• Percentage of membership without visits
• Number of recaptured conditions
• Members with captured conditions
• Members with suspected conditions
• Members without captured or suspected conditions
• Chronic Condition Prevalence
What Risk Adjustment reports are available?
Three different risk adjustment reports are generated for a group and/or individual practitioner:
1. Patients with a suspected chronic condition and no current year visit
2. Patients with suspected chronic condition with a current year visit
3. Patients with a suspected chronic condition not previously coded
How will this information help you?
Many times, providers are limited to health information available within their own group or to what other providers offer, potentially leaving them uninformed of their patients’ care in other settings.
As a health plan, we receive a wide range of information about our members through claims data, lab data, pharmacy data and retrospective chart reviews.
These scorecards and reports give us the opportunity to share this valuable information. This information can assist groups and providers to:
• Identify and stratify risks within defined populations
• Track and monitor members with existing conditions
• Identify potential new conditions sooner
• Assist with comprehensive planning before visits
Our goal is to work collaboratively with our valued providers in support of Hierarchical Condition Category (HCC) risk adjustment efforts. We hope information sharing opportunities like this will complement the quality care you already provide for our members.
To get a copy of your groups’ and/or individual provider’s respective scorecards and reports, please contact a member of our Risk Adjustment Provider Engagement team at 866-283-5723.
Informational
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Claims Status Application UpgradeOn April 27, Blue Cross of Idaho released an updated Claims Status search tool. The tool has a new look and functionality that will make it easier to use. The tool displays all claims processed by Blue Cross of Idaho including commercial, Medicare Advantage and the Federal Employee Program (FEP).
The Claims Status search tool is available to providers who register on our secure provider website at providers.bcidaho.com.
• Select Eligibility & Claims
• Select Claims Status
Here are some of the updates:
• FEP claim information
• Ability to email FEP claim questions directly from the claim
• Dental detail matches the remittance advice
• Dental tooth numbers
• Dental Print Remit provides individual patient remittances for submission to secondary insurance if required
• Claims in process when medical records are requested
• What was requested and who is the requester
• More efficient search by provider
• Ability to search by entity (clinic/facility) or claim number
• Additional sort functions on claim results
• Hyperlinks to the remittance advice and electronic funds transfer (EFT) tools on the claims detail page
Soon, our automated phone system will also include FEP claim information.
Training on this new functionality is available each Tuesday. Registration is not required. To attend, please have your Blue Cross of Idaho username and password available.
• Log on to providers.bcidaho.com
• Under Important Announcements, select Webinar Schedule
• Review the details for the session tailored to your practice type and the date and time that fits your schedule
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Medical Drug Prior Authorization ChangesBlue Cross of Idaho is implementing a new process for getting prior authorization.
Beginning date of service July 1, 2018, you will use the CVS Caremark powered by NovoLogix Online Prior Authorization system to request prior authorizations for certain medications. You can access the authorization system through your login on the Blue Cross of Idaho secure provider website.
Please refer to the list for the medicines that are part of the Prior Authorization program. A list of medications requiring prior authorization is available by logging on to our secure provider portal at providers.bcidaho.com.
1. Select Forms & Resources
2. Select Pharmacy
3. Select Prior authorizations & step therapy
The CVS Caremark powered by NovoLogix Online Prior Authorization system provides a streamlined process for your medicines through online prior authorization management services, including:
• Efficient intake process through the utilization of an online authorization system
• Real-time status updates
Blue Cross of Idaho is offering online training through WebEx as well as an on-demand training video and instructional guide. The sessions provide information on how to request prior authorization and review the status of authorized services.
Questions about prior authorization? Call the CVS Case Review Unit toll-free at 844-345-2803 from 6:30 a.m. - 8 p.m. CT, Monday - Friday.
We look forward to working with you to coordinate the best care for your patients.
Blue Cross of Idaho’s Member Outreach CampaignBlue Cross of Idaho is partnering with Optum for our 2018 Member Outreach Campaign. This service helps to improve member participation in annual wellness visits and preventive screenings, such as mammograms, diabetic eye exams and colorectal cancer screenings.
In mid-April 2018, targeted members will be mailed a postcard to remind them that they are due for their annual wellness visit and/or a preventive screening. Members will then be contacted by phone and an Optum representative will assist them in scheduling services directly with their primary care provider (PCP) and/or specialist. Members will be offered reminder calls prior to their scheduled appointments if they wish to receive them.
This program helps PCPs assess and review a patient’s Health Effectiveness Data and Information Set (HEDIS) gaps in quality. Providers may also have patient assessment forms (PAF) sent to them to assist in addressing a member’s specific quality gaps or suspected conditions during a member’s scheduled visit(s).
This program is scheduled to be completed in September 2018. For questions, please contact the provider engagement specialist assigned to your region, or send an email to [email protected].
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Eye Health and Diabetic Patients with DiabetesAccording the American Diabetes Association, diabetic retinopathy, the neurovascular complication of both Type 1 and Type 2 diabetes is the most frequent cause of new cases of blindness among adults age 20-74. Glaucoma, cataracts and other eye disorders may occur earlier or more frequently in a patient with diabetes. Factors that increase the risk of retinopathy include chronic hyperglycemia, nephropathy, hypertension and dyslipidemia. Intensive diabetes management can prevent or delay the progression of diabetic retinopathy.
Early diagnosis and timely treatment can prevent diabetes related blindness. Many patients are not aware of this diabetic complication. A yearly dilated eye exam is recommended for patients with diabetes. Studies show* that diabetic patients who do not get eye exams have financial and knowledge barriers. Financial barriers may include the cost of insulin, coinsurance and copays. There is also a lack of understanding regarding the reason for exams and what retinopathy is. Fear also may contribute.
As a healthcare provider, you are a valued member of your patient’s diabetic treatment team and have a perfect opportunity to discuss the importance of this exam with your patients to educate, decrease fears and ensure their care is coordinated with the appropriate eye care professional.
* AJMC, “Overcoming Barriers to Eye Examinations Among Patients with Diabetes,” March 31, 2016
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New Policies
Policy # Title Summary of changes to policy statement
1.01.30Artificial Pancreas Device Systems
Blue Cross of Idaho added policy to the Medical Policy Library, effective April 1, 2018.
7.01.160Synthetic Cartilage Implants for Joint Pain
Blue Cross of Idaho added policy to the Medical Policy Library, effective April 1, 2018.
Revised Policies
Policy # Title Summary of changes to policy statement
2.04.10Identification of Microorganisms Using Nucleic Acid Probes
Investigational policy statement added for central nervous system pathogen panel, effective March 1, 2018. New CPT code added (87493).
2.04.62Multimarker Serum Testing Related to Ovarian Cancer
Investigational policy statement changed with addition of the Overa test, effective March 1, 2018.
2.04.78Molecular Markers in Fine Needle Aspirates of the Thyroid
Policy statements revised to add medical necessity statements for ThyGenX, combined genetic variant analysis and microRNA gene expression classifier (i.e., ThyGenX/ThyraMIR), Afirma BRAF after Afirma Gene Expression Classifier, effective March 1, 2018.
6.01.23Diagnosis and Treatment of Sacroiliac Joint Pain
SIJ fusion/stabilization with a titanium triangular implant is considered medically necessary under the specific conditions outlined by NASS, effective April 1, 2018.
7.01.48Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Matrix-induced autologous chondrocyte implantation of the patella is considered medically necessary, effective March 1, 2018.
7.01.149Amniotic Membrane and Amniotic Fluid Injections
Specific indications added to investigational policy statements for clarity purposes only, effective February 26, 2018.
7.01.151 Prostatic Urethral Lift
Use of prostatic urethral lift in individuals with moderate to severe lower urinary tract obstruction due to benign prostatic hyperplasia maybe considered medically necessary when all of the specified criteria are met, effective March 1, 2018
8.01.01 Adoptive Immunotherapy Kymriah and Yescarta added to policy statement, effective April 30, 2018.
Updated Policies
Policy # Title Summary of changes to policy statement
1.01.01Durable Medical Equipment Guidelines
Added weighted blankets and posture enhancement garments under items used for comfort, convenience and/or personal hygiene, effective April 30, 2018.
5.01.15 Infliximab Added nonpreferred drug, Renflexis to policy, effective April 30, 2018.
5.01.93 Specialty Drugs
Updated cost-effective Gaucher Disease Agents, Cerezyme (imiglucerase for injection), effective, March 1, 2018.
Added cost-effective treatment for Monoclonal Antibody Therapy for Multiple Sclerosis, Tysabri, effective March 15, 2018.
Archived Policies
Policy # Title Summary of changes to policy statement
2.01.101Multispectral Digital Skin
Lesion AnalysisAs of January 30, 2018, policy will no longer be used and was archived from the Blue Cross of Idaho Medical Policy Library.
8.02.02 Plasma ExchangeAs of January 30, 2018, policy will no longer be used and was archived from the Blue Cross of Idaho Medical Policy Library.
* This summary of changes to medical policies is for informational purposes only. The list does not replace medical policies and it is not used to determine benefits.
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Tips to Help You Prepare for New Medicare ID CardsThe Centers for Medicare and Medicaid Services (CMS) will replace Social Security numbers on red, white and blue Medicare cards with unique ID numbers in an effort to reduce the risk of fraud and identity theft. CMS will issue new cards to Medicare enrollees across several different phases between April 2018 and April 2019.
The new Medicare ID number, called a Medicare Beneficiary Identifier (MBI), will be alphanumeric. In addition to removing the Social Security number, CMS will remove the member’s gender and signature from the new Medicare cards.
• A sample of the new Medicare card:
Tips to Help Your Patients Understand the Change
• Although CMS is calling the new number format an MBI, it may be easier for patients to understand if you continue to refer to it as their Medicare number or Medicare ID number when talking to them.
• Let them know the reason for the change is to help protect their identity.
• Know that the new Medicare cards will not replace Blue Cross of Idaho Medicare Advantage (True Blue and Secure Blue) member ID cards. Medicare members should keep their new red, white and blue Medicare card in a safe place and continue to use their Blue Cross of Idaho member ID card for medical and/or prescription drug services.
• Direct your patients to the medicare.gov website for more information.
Get Your Systems Ready to Accept the New ID Number Format
• Educate your providers and staff about these upcoming Medicare ID number changes. Idaho Medicare enrollee ID number changes are scheduled to begin in late June 2018.
• Work with your billing vendor to make sure that your practice management system is updated and ready to accept the new MBI number format by April 2018.
• Test your system changes and make sure there will be no eligibility or claim transmission errors.
• Be aware that when checking a Medicare beneficiary’s eligibility, CMS is making system changes and the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System may respond that CMS mailed a beneficiary’s new Medicare card.
• Verify all addresses for your Medicare patients. If a patient’s current address does not match the address on file with Medicare, ask your patient to contact Social Security at ssa.gov to update their address.
• Learn more about this change by visiting the CMS Medicare card website at cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html.
• Sign up for the weekly MLN Connects® newsletter for additional information by visiting the CMS provider website at cms.gov/Medicare. You can also listen to CMS quarterly calls to get more information. You’ll find a schedule for these calls in the MLN Connects® newsletter
New CMS Look-Up Tool
To make this change as easy as possible, CMS is developing a tool that will allow you to search a Medicare enrollee’s MBI at the point of service. CMS will also allow providers to submit claims using either the current health insurance claim number (HICN) or the new MBI for 21 months from April 2018 until January 1, 2020. After January 1, 2020, Medicare claims will be submitted using the MBI. For Medicare Advantage (True Blue and Secure Blue) members, please continue to bill claims to Blue Cross of Idaho using the Blue Cross of Idaho subscriber ID.
Obesity and Protein-Calorie Malnutrition: Related Risk Adjustment Coding, Member Resources and BenefitsAccording to the Centers for Disease Control and Prevention (CDC), more than one-third of adults in the United States have a Body Mass Index (BMI) greater than 30 percent, and are considered obese. Obesity-related conditions, including heart disease, stroke, Type 2 diabetes and certain types of cancer, are some of the leading causes of preventable death. Other health consequences of obesity are hypertension, dyslipidemia, osteoarthritis, reflux disease, gynecological issues (such as abnormal menses or infertility), liver and gallbladder disease, sleep apnea and respiratory problems, low quality of life, mental illness, body pain and difficulty with physical functioning.
• The estimated annual medical cost of obesity in the U.S. is $147 billion to $210 billion. The average medical spend for people who are obese is $1,429 per year higher than those within normal weight ranges.
• Costs for emergency room visits for patients with chest pains are 41 percent higher for severely obese patients, 28 percent higher for obese patients and 22 percent higher for overweight patients than for patients with a healthy weight.
• Reducing obesity by improving nutrition and increasing activity can help lower medical costs through fewer doctor’s office visits, tests, prescription drugs, sick days, emergency room visits and admissions to the hospital. It also lowers the risk for a wide range of diseases.
On the other hand, protein-calorie malnutrition (PCM), which is defined as BMI of less than 18.5, is a significant cause of mortality in the elderly with a BMI of less than 21 percent. PCM can lead to cancer, alcohol abuse, liver disease, chronic kidney disease (CKD), pancreatitis, drug abuse, anemia and end stage renal disease (ESRD). The prevalence of PCM varies depending on the clinical setting:
• 4 percent in the community setting
• 29 percent in subacute care facilities
• 30 – 40 percent in hospital setting
Resources and Programs available to Blue Cross of Idaho Members
At Blue Cross of Idaho we recognize that providers are the cornerstone for the quality care our members receive. We offer various resources, programs and preventative benefits to our members that help promote healthy lifestyle aimed at awareness and reduction of heart disease risk factors.
Members can enroll in wellness workshops using their secure login to the member website. Various workshops are available in the following categories:
• Intensive behavioral therapy (IBT) for cardiovascular disease
• Diabetes screening
• Medical nutrition therapy
• Obesity screening and therapy
• Smoking and tobacco use cessation services
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Commercial Plans offer preventative benefits for:
• Chemistry panels
• Cholesterol screening
• Diabetes screening
• EKG screening
• Aortic aneurysm screening ultrasound
• Alcohol misuse assessment
• Lipid disorder screening
• Smoking cessation counseling
• Dietary counseling
• Behavioral counseling for participants who are overweight or obese
*Blue Cross of Idaho may adjust specifically-listed preventive services to coincide with new or revised laws or regulations. Additionally, some services are subject to certain limitations depending on medical necessity and other reasonable medical management techniques.
This information is a reference tool and is not a guarantee of payment. Review member plan for coverage details or call the Blue Cross of Idaho Customer Service Department at the number on the back of the member ID card for assistance.
Risk Adjustment Coding for Obesity and Protein-Calorie Malnutrition
Obesity
Note: Use additional code to identify body mass index (BMI) in adults, if known (Z68.-)
• ICD-10-CM codes:
• E66.01 - Morbid (severe) obesity due to excess calories
• E66.09 - Other obesity due to excess calories
• E66.1 - Drug-induced obesity
• E66.2 - Morbid (severe) obesity with alveolar hypoventilation
• E66.8 - Other obesity
• E66.9 - Obesity, unspecified
• Z68.41 - Body mass index (BMI) 40.0-44.9, adult
• Z68.42 - Body mass index (BMI) 45.0-49.9, adult
• Z68.43 - Body mass index (BMI) 50-59.9, adult
• Z68.44 - Body mass index (BMI) 60.0-69.9, adult
• Z68.45 - Body mass index (BMI) 70 or greater, adult
• Procedure code for obesity
• HCPCS code G0447 (Face-to face behavioral counseling for obesity, 15 minutes) for BMI >30
Protein-Calorie Malnutrition
Note: Use additional code to identify body mass index (BMI) in adult, if known (Z68.-)
• ICD-10-CM codes:• E43 - Unspecified severe protein-calorie
• E64.0 - Sequelae of protein-calorie malnutrition
• R64 - Cachexia• Z68.1 - Body mass index (BMI) 19.9 or less,
adult• Z68.20 - Body mass index (BMI) 20.0-20.9,
adult
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Action
Are Your Patients Up to Date?As a healthcare provider, you play a big part in keeping your patients on track for preventive screenings. According to the American Cancer Society, only 61 percent of adults in Idaho are up to date on colorectal cancer screening, but the goal is to reach 80 percent screened by the year 2020.
A wellness exam is the perfect opportunity to talk to your patients about the several options available:
• Colonoscopy (every 10 years)
• Sigmoidoscopy (every five years)
• DNA Stool Test (every three years)
• gFOBT (yearly)
Some tips to improve the screening process:
1. Address the patient’s fears and barriers. The Journal of Cancer Education* suggests the main barriers to colorectal screening were a patient’s fear of finding out they have cancer and the lack of awareness about screening procedures.
2. Provide your patients with screening options.
3. Send patient reminders for timely screenings, especially if you have an electronic medical record and patient portal.
Preventive screenings and early detection can be the first step to a healthier life for your patients.
*Journal of Cancer Education, March 2015, Volume 30, Issue 1
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2018 Annual MMCP SeminarsEach year Blue Cross of Idaho hosts training and informational seminars for our Medicare-Medicaid Coordinated Plan (MMCP) waiver providers. We are pleased to announce that we are hosting these seminars again this June in Coeur d’Alene, Idaho Falls, Twin Falls and Meridian.
During these seminars we will cover:
• Program overview. We will review the MMCP program as well as cover frequently asked questions (FAQ).
• A live website demonstration and training. We will review and provide live demonstration of the tools and resources available to you on our website such as; claims, eligibility, share of cost and authorization information for your clients.
• Annual mandatory training. Each June, new mandatory training is published and completion is a requirement of all MMCP provider contracts. During this annual seminar, we will provide and review this year’s mandatory training materials. Each organization that sends a representative will receive credit for training completion.
Dates, times and venues are being finalized. Please look for your invite by fax or mail soon.
Any Questions?
MEDICAL MANAGEMENTManaged Health Care/Review, Preadmission/Admission Certification, or Individual Benefits Management and Case Management • 208-331-7535 • 800-743-1871 • Voice mail available after office hours and on holidays and weekends
BLUE CROSS OF IDAHO HELP DESKElectronic Billing Errors, Error and Acceptance Reports • 8 a.m. – 5 p.m. MT (Monday – Friday), • Email address: [email protected]
PROVIDER CONTACT CENTER Benefits, Coverage and Authorization • 7 a.m. – 7 p.m. MT, Monday – Friday, EXCEPT closed 2-3 p.m. Thursday • 208-286-3656 or 866-482-2250 For post-service claim questions, log on to our secure website at providers.bcidaho.com and select Contact Us.
PROVIDER RELATIONS REPRESENTATIVE Questions regarding coding, contracting or need website training, you may contact one of the following provider relations representatives. • 866-283-5723 or 208-286-3602
