Inside this edition
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
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August 2019 RecapThis publication contains articles previously published on our Provider News Center.
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Administrative ● Now in effect: A PROMISeTM ID is required to receive payment for services provided to your Independence CHIP members
● Required lead time when updating your provider information
Billing & Reimbursement ● Professional Injectable and Vaccine Fee Schedule updates effective October 1, 2019
● ICD-10 in Action: Chapter-specific guidelines
● Now in effect: Enhanced claim edits to align with industry standard billing rules for DME and P&O billing providers
● Enhanced claim edits to align with industry standard billing rules for injectable drugs and biological agents beginning September 1, 2019
Medical ● New claim payment policies for multiple therapies
● Changes to the Most Cost-Effective Setting Program: Pediatric exception
● View up-to-date policy activity on our Medical Policy Portal
● Changes to the annual Synagis® (palivizumab) distribution program
● Skilled nursing, subacute, and inpatient rehabilitation facility admission guidelines
Pharmacy ● Independence drug program formulary updates
For articles specific to your area of interest, look for the appropriate icon:
Professional Facility Ancillary
Inside this edition
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IVE Now in effect: A PROMISeTM ID is required to receive
payment for services provided to your Independence CHIP membersPublished August 1, 2019
Over the past several months, we have published articles in Partners in Health UpdateSM informing you that the Pennsylvania Department of Human Services (Department) requires all providers in the Children’s Health Insurance Program (CHIP) network to have a PROMISe ID for each location at which they treat CHIP members. A PROMISe ID is a Department-issued Provider Reimbursement and Operations Management Information System (PROMISe) identification number. It is required for you to receive payment for services rendered to CHIP members.
In accordance with Department requirements, all claims submitted for Independence CHIP members for dates of service on or after July 1, 2019, by an in-network Keystone Health Plan East provider who does not have a PROMISe ID that corresponds to the location where the services were rendered, or through which services were ordered, referred, or billed, will be denied. Please be aware that both the practitioner and the group/provider need a PROMISe ID for the claims to process.
Continuity of careContinuity of care options will be available for 60 days for CHIP members who are in an active course of treatment with a physician or provider who does not have a PROMISe ID. Requests for exceptions will be considered when there is an ongoing, active course of treatment for a chronic or acute medical condition and prudent medical practice requires continued care from the same physician. Please be mindful that your contract with Independence limits when providers can bill members for non-covered services other than copayments, coinsurance, and deductibles. The Department requires that members are not billed when claims are rejected due to a provider not having a PROMISe ID.
How to request a PROMISe IDVisit the Department’s website to access the application, requirements, and step-by-step instructions related to the enrollment process. If you have any questions or issues with the enrollment process, contact the Department’s Provider Enrollment Hotline at 1-800-537-8862, select options 2, 4, and finally option 2 to speak to a Department representative. The application and hotline are monitored by the Pennsylvania Department of Human Services, not Independence.
How to confirm the status of your PROMISe IDIf you submitted your application electronically, you can to check the status here. You will need to enter the following information:
● application tracking number (ATN) ● social security (SSN) or federal tax identification number (FEIN) ● site password
If you have questions related to this information, please email us at [email protected].
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Required lead time when updating your provider informationPublished August 21, 2019
Independence would like to remind you that submitting changes in a timely manner helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories.* In accordance with your Provider Agreement, the Provider Manual for Participating Professional Providers, and/or Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, as applicable, you are required to notify Independence whenever key provider demographic information changes.
Please review our dedicated webpage to review the specific lead-time requirements, exceptions, and/or additional information for:● Professional providers● Facility and ancillary providers● Authorizing signature and W-9 Forms
Independence will not be responsible for changes not processed due to lack of proper notice. Failure to provide proper advance written notice to Independence may delay or otherwise affect provider payment.
If you have questions related to updating your provider information after reviewing the webpage, please email us at [email protected].
* Behavioral health providers contracted with Magellan Healthcare, Inc. (Magellan), an independent company, must submit any changes to theirpractice information to Magellan via their online Provider Data Change form by selecting the “Display/Edit Practice Info” link.
Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.
Professional Injectable and Vaccine Fee Schedule updates effective October 1, 2019Published August 26, 2019
Effective October 1, 2019, updates will be made to our Professional Injectable and Vaccine Fee Schedule for all contracted providers. These updates are made quarterly and reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables as well as any modifications to the percentage premium.
Allowance Inquiry transactionProviders can look up the rate for a specific code using the Allowance Inquiry transaction on the NaviNet® web portal (NaviNet Open). To do so, go to Independence NaviNet Open Plan Central, select Claim Inquiry and Maintenance from the Independence Workflows menu, and then select Allowance Inquiry. For step-by-step instructions on how to use this transaction, refer to the Allowance Inquiry Guide, which is available under User guides and webinars in the NaviNet Open section.
Note: The Allowance Inquiry transaction only returns current rates for professional providers. The reimbursement rates that go into effect October 1, 2019, will be available through this transaction on or after this effective date. Provider payment allowances are for informational purposes only and are not a guarantee of payment.
NaviNet® is a registered trademark of NantHealth, an independent company.
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Published August 15, 2019
This Independence series, ICD-10 in Action, features articles to recap some of the ICD-10 diagnosis code changes, introduce new coding scenarios, and/or communicate updates to ICD-10 coding conventions.
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) contains official guidelines for coding and reporting. There are coding conventions, general coding guidelines, and chapter-specific guidelines. These conventions and guidelines are rules and instructions that must be followed to classify and assign the most appropriate code. Understanding these guidelines and conventions are key to selecting the most appropriate code assignment.
● Conventions. A set of rules for use of the classification independent of the guidelines. Coding conventions and instructions of the classification take precedence over guidelines. (e.g., Code First).
● General guidelines. A set of rules and sequencing instructions for using the Tabular List and Alphabetic Index. These guidelines provide rules such as how to locate a code and obtain level of detail.
● Chapter-specific guidelines. A set of rules for specific diagnoses and conditions in a particular classification.
It is necessary to review all three sections of the guidelines to fully understand the rules and instructions needed to code properly. Adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).
Chapter-specific guidelinesIn addition to coding conventions and general coding guidelines, many of the chapters have a specific set of rules for diagnoses and conditions in a particular classification, known as chapter-specific guidelines. Unless otherwise noted, chapter-specific guidelines apply to all health care settings. These guidelines contain additional important information for reaching the most appropriate code assignment and proper sequencing of ICD-10-CM codes.
Additional resourcesFor more information, as well as full set of chapter-specific guidelines for ICD-10-CM, visit the Centers for Medicare & Medicaid Services website.
We will continue to communicate ICD-10-specific information through this article series to review some of the ICD-10 diagnosis code changes. We encourage you to keep up with the latest news and information by visiting the ICD-10 section of our website.
1 Centers for Medicare & Medicaid Services. “ICD-10-CM Official Guidelines for Coding and Reporting FY 2019.” 2019. Available from: www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf.
Chapter-specific guidelines containing sequencing information Examples from Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99)1
3) Status
Z15 Genetic susceptibility to disease
Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease.
Codes from category Z15 should not be used as principal or first-listed codes. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. If the purpose of the encounter is genetic counseling associated with procreative management, code Z31.5, Encounter for genetic counseling, should be assigned as the first-listed code, followed by a code from category Z15. Additional codes should be assigned for any applicable family or personal history.
16) Z Codes That May Only be Principal/ First-Listed Diagnosis
The following Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined:
Z00 Encounter for general examination without complaint, suspected or reported diagnosis
Except: Z00.6
Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
August 2019 | Partners in Health UpdateSM 6 www.ibx.com/pnc
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standard billing rules for DME and P&O billing providersPublished August 5, 2019
As previously communicated in a series of Partners in Health UpdateSM articles, Independence has expanded the enhanced claim editing process to include additional rules specific to durable medical equipment (DME) and prosthetic and orthotic (P&O) billing providers effective for claims processed as of August 1, 2019.
Claims received by Independence on or after June 10, 2018, are subject to an enhanced claim editing process during prepayment review. This process ensures compliance with current industry standards and supports the automated application of correct national and regional coding principles.*
● National and Regional Centers for Medicare & Medicaid Services (CMS) policy ● Durable Medical Equipment Regional Carries (DMERC) Manual ● CMS HCPCS LEVEL II Manual coding guidelines ● Medicare Claims Processing Manual
*Self-funded groups have the option to not participate in the enhanced claim edits; therefore, prepayment review may vary by health plan.
Modifier usage for DME and P&O billing providersIn addition to the above, Independence enforces CMS rules on modifier usage including the following modifiers:
For detailed requirements related to these modifiers, please see this document.
With the implementation of these claim edits, claims submitted with inappropriate coding will be returned or denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim return or denial. Any returned claims must be corrected prior to resubmission. These changes should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.
Claim review requestsWe recognize there may be times when you have questions regarding the outcome of a claim edit. As with all claim review requests, these questions should be submitted using the Claim Investigation transaction on the NaviNet® web portal (NaviNet Open).
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● A1 – A9, GY ● K0 – K4 ● KX, GA, or GZ
● AU, AV, AW, and AX ● K0 – K4 ● NU, UE, and RR
● CG ● KS, KX ● RT/LT
Identifying claims that went through the claim editor processIf you have been submitting claims in accordance with industry standards, you will have no issues with the topics in this article. However, if you have not, please be advised that you may see an increase in claim rejections and/or denials due to the new claim edits. If your claim is affected by one of the new claim edits, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. Should your claim line contain an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen in NaviNet Open. To view, hover your mouse over the service line and select View Additional Detail. If you see an E8XXX code/message, the line went through an edit. Only E8XXX codes/messages are part of the enhanced claim editor. All other codes/messages are unrelated to the enhanced claim editor.
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Learn morePlease review the Partners in Health Update article, Reminder: Enhanced claim edits to support correct coding principles, which was posted December 14, 2018.
For further questions about the enhanced claim editing process, review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on Independence NaviNet Open Plan Central or in the Quick Links menu on the right-hand side of the Independence Provider News Center. The FAQ will be updated as more information becomes available.
If you still have questions after reviewing these resources, please send an email to [email protected].
NaviNet® is a registered trademark of NantHealth, an independent company.
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Enhanced claim edits to align with industry standard billing rules for injectable drugs and biological agents beginning September 1, 2019Published August 5, 2019
As previously communicated in a Partners in Health UpdateSM article, Independence will be expanding the enhanced claim editing process to include additional rules specific to various injectable drugs and biological agents effective for claims processed beginning September 1, 2019.
Claims received by Independence on or after June 10, 2018, are subject to an enhanced claim editing process during prepayment review. This process ensures compliance with current industry standards and supports the automated application of correct national and regional coding principles.*
The industry standard sources specific to injectable drugs and biological agents are: ● The manufacturer’s package insert (primary source: U.S. Food and Drug Administration [FDA]-approved
indications) − Other compendia references include, but not limited to:
○ Thomson Micromedex® (DRUGDEX®, DrugPoints®) ○ National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium®
○ American Hospital Formulary System (AHFS®) Drug Information®
○ Elsevier Gold Standard Clinical Pharmacology ● ICD-10 Instruction Manual coding guidelines ● Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual
* Self-funded groups have the option to not participate in the enhanced claim edits; therefore, prepayment review may vary by health plan.
Areas of focusThe enhanced claim editing process for injectable drugs and biological agents will focus on the following areas:
● The diagnosis code(s) billed are consistent with the FDA-approved indications and approved off-label indications. If the ICD-10 code billed on the claim does not match the approved indication, the claim may reject.
● The diagnosis code(s) billed are consistent with the ICD-10 Instruction Manual coding guidelines. ● The dosage and frequency of administration is appropriate for the diagnosis for which it is being used. ● The administration code(s) and hydration services are appropriately reported.
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With the implementation of these claim edits, claims submitted with inappropriate coding will be returned or denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim return or denial. Any returned claims must be corrected prior to resubmission. These changes should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.
Claim review requestsWe recognize there may be times when you have questions regarding the outcome of a claim edit. As with all claim review requests, these questions should be submitted using the Claim Investigation transaction on the NaviNet® web portal (NaviNet Open).
Learn morePlease review the Partners in Health UpdateSM article, Reminder: Enhanced claim edits to support correct coding principles, which was posted December 14, 2018.
For further questions about the enhanced claim editing process, review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on Independence NaviNet Plan Central or in the Quick Links menu on the right-hand side of the Independence Provider News Center. The FAQ will be updated as more information becomes available.
If you still have questions after reviewing these resources, please send an email to [email protected].
NaviNet® is a registered trademark of NantHealth, an independent company.
Identifying claims that went through the claim editor processIf you have been submitting claims in accordance with industry standards, you will have no issues with the topics in this article. However, if you have not, please be advised that you may see an increase in claim rejections and/or denials due to the new claim edits. If your claim is affected by one of the new claim edits, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. Should your claim line contain an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen in NaviNet. To view, hover your mouse over the service line and select View Additional Detail. If you see an E8XXX code/message, the line went through an edit. Only E8XXX codes/messages are part of the enhanced claim editor. All other codes/messages are unrelated to the enhanced claim editor.
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New claim payment policies for multiple therapiesPublished August 1, 2019
Effective September 1, 2019, Independence will implement new claim payment policies for multiple therapies for outpatient facility providers, specifically to include physical, occupational, and speech therapy services. These claim payment policies apply to specific CPT® and HCPCS codes that are designated by the Centers for Medicare & Medicaid Services (CMS) as “Always Therapy” for these services. Independence will include full payment for the procedure with the highest total allowance and reduced payment as described below for each subsequent procedure.
The following policies were posted to our Medical Policy Portal as Notifications on August 1, 2019, and will go into effect September 1, 2019:
● Commercial: #00.01.68: Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
● Medicare Advantage: #MA00.050: Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
Claims processingFacility outpatient therapy claims when multiple physical, occupational, and speech therapy services are reported by the same provider, for the same member, on the same date of service will be processed as follows:
● The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
● Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.
In addition, multiple procedures may be submitted on one claim or on multiple claims. These claim payment policies for services designated as “Always Therapy” are based on the date of service regardless of the date the claim was submitted or received.
Learn moreTo view the Notifications for these policies, visit our Medical Policy Portal.
Refer to Attachment A of these policy documents to see the list of CPT and HCPCS codes for multiple therapies to which the claim payment policies described above apply.
For further questions about these new claim payment policies, review our New claim payment policy for multiple therapies: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on Independence NaviNet® web portal (NaviNet Open) Plan Central or in the Quick Links menu on the right-hand side of the Independnece Provider News Center. The FAQ will be updated as more information becomes available.
If you still have questions after reviewing these resources, please call 1-800-ASK-BLUE.
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
NaviNet® is a registered trademark of NantHealth, an independent company.
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Changes to the Most Cost-Effective Setting Program: Pediatric exceptionPublished August 27, 2019
Independence wants to ensure that our members receive injectable/infusion therapy drugs in safe, cost-effective settings. Since 2012, as part of our Most Cost-Effective Setting Program, Independence has been reviewing the settings where members enrolled in our commercial products receive certain drugs that are eligible for coverage under the medical benefit.
As a result of the recent expansion of ambulatory (freestanding) infusion suites in our network, effective December 1, 2019, Independence will remove the setting review exception for pediatric members under 18 years of age who receive the following drugs:
● Actemra® (tocilizumab) ● Entyvio® (vedolizumab) ● Inflectra® (infliximab-dyyb) ● Orencia® (abatacept) ● Remicade® (infliximab) ● Renflexis® (infliximab-abda) ● Simponi Aria® (golimumab)
Our expanded network of ambulatory infusion suites gives our members increased access to cost-effective, convenient treatment sites.
How this affects your patientsIn September 2019, Independence will send letters to adult subscribers whose dependents are under 18 years of age and currently receiving any of these drugs in a hospital outpatient facility. Subscribers will be notified about the change in the pediatric exception and informed that their dependent can continue to receive treatment in the hospital outpatient facility until their current precertification approval expires. Decisions about future treatment settings will be made at the next precertification review. Settings that Independence considers to be cost-effective are:
● a physician’s office; ● the member’s home, where the drug is administered
by an in-network home infusion provider; ● an ambulatory (freestanding) infusion suite, not
owned by a hospital or health system in our network.
Effective December 1, 2019, all requests for these drugs will require precertification review for both medical necessity and setting, regardless of the age of the member.
In accordance with our current program guidelines, requests to receive any drug in the Most Cost-Effective Setting Program in a hospital outpatient facility will be considered for certain members, including those who are receiving their initial therapeutic dose or for members whose condition requires the intensive monitoring and care uniquely available in a hospital outpatient facility. Independence requires providers to submit relevant medical records to support requests for ongoing administration of these drugs in a hospital outpatient facility. This information will be reviewed, and a coverage determination on setting will be made.
Medical policy informationProviders can find additional information about these drugs in the following Independence commercial medical policies:
● #08.00.34: Infliximab and Related Biosimilars ● #08.00.62: Abatacept (Orencia®) for Injection for
Intravenous Use ● #08.00.85: Tocilizumab (Actemra®) for Intravenous
Infusion ● #08.01.15: Golimumab (Simponi Aria®) Intravenous
(IV) Injection ● #08.01.18: Vedolizumab (Entyvio®)
To review these medical policies, visit our Medical Policy Portal.
Learn moreFor more information, including a downloadable list of all drugs in the program, visit our Most Cost-Effective Setting Program webpage.
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View up-to-date policy activity on our Medical Policy PortalPublished August 21, 2019
Changes to Independence medical and claim payment policies for our commercial and Medicare Advantage Benefit Programs occur in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity section of our Medical Policy Portal to stay up to date with changes to our policies.
The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics include:
● Notifications ● New Policies ● Updated Policies ● Reissued Policies ● Coding Updates ● Archived Policies
For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference.
To access the Site Activity section, go to our Medical Policy Portal and select Accept and Go to Medical Policy Online. From there you can select Commercial or Medicare Advantage under Site Activity to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage
tab from the top of the page. To access policies from the NaviNet® web portal (NaviNet Open), go to Independence NaviNet Open Plan Central and select Medical Policy Portal under Quick Links in the right-hand column.
NaviNet® is a registered trademark of NantHealth, an independent company.
News & AnnouncementsIn addition to the information posted in our Site Activity section, articles related to our website and medical and claim payment policies are periodically posted within the News & Announcements section. Simply select the appropriate link (Commercial, Medicare Advantage, or MAPPO Host) under the News & Announcements header on the Medical Policy Portal home page to stay informed.
Recently published News & Announcements include:
● Clinical Appropriateness Guidelines for Radiology to be updated for Independence Commercial Members
● Clinical Appropriateness Guidelines for Radiology to be updated for Medicare Advantage Members
Changes to the annual Synagis® (palivizumab) distribution programPublished August 9, 2019
PerformSpecialty®, an independent company, will facilitate delivery of the drug Synagis (palivizumab) through Independence’s Direct Ship Drug Program for the upcoming respiratory syncytial virus (RSV) season, which runs from November 2019 through March 2020.
As a reminder, it is mandatory for all participating providers to obtain Synagis for their patients who are Independence members through our Direct Ship Drug Program.
Over the next few months, we will publish additional Partners in Health UpdateSM articles to provide information like:
● the complete list of recommendations for Synagis from the American Academy of Pediatrics
● information about how to order Synagis through our Direct Ship Drug Program
New order forms branded with the PerformSpecialty logo and contact information will be available on
our Direct Ship Drug Program website in advance of the RSV season. Providers should discard previous copies of the Synagis Direct Ship order forms, as these versions will no longer be accepted by Independence.
Later this month, we will send a letter to providers who have a history of prescribing Synagis to Independence members with more details about this change.
Learn moreProviders can find additional information about Synagis in the Independence Medical Policy #08.00.22m: Immune Prophylaxis for Respiratory Syncytial Virus (RSV). To view this policy, visit our Medical Policy Portal.
If you have questions about the Synagis distribution program, please call Customer Service at 1-800-ASK-BLUE.
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Skilled nursing, subacute, and inpatient rehabilitation facility admission guidelinesPublished August 23, 2019
Independence closely reviews skilled nursing, subacute, and inpatient rehabilitation admissions for medical necessity and to ensure our members are receiving the right level of care and in the most appropriate setting.
As outlined in the Provider Manual for Participating Professional Providers and/or Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, we would like to remind you that Independence follows therapy guidelines set by the Centers for Medicare & Medicaid Services (CMS), and InterQual®, a product of Change Healthcare, an independent company.
According to CMS and InterQual therapy guidelines, the minimum required hours for the following services are: ● Skilled Nursing Facility. At least 1 – 2 hours of direct physical, occupational, or speech therapy per day, at
least 5 days/week. ● Subacute facility. At least 2 hours of direct therapy (physical, occupational, or speech therapy) per day,
at least 6 days/week (i.e., at least 12 hours of direct therapy per week). Member must be physically and cognitively willing and able to participate in, and benefit from, the rehabilitation program.
● Inpatient rehabilitation. At least 3 hours per day direct physical, occupational, or speech therapy per day, at least 5 days/week. Physician intervention at least 3 times/week.
To protect against delays in advancing medical care and service, we will be evaluating the following with each concurrent review:
● follow-up appointments are timely; ● members are receiving appropriate skilled therapy hours and number of days; ● members are discharged timely and discharge plans are continually reviewed and updated to reflect the
members functional status and expectations; ● Notice of Medicare Non-Coverage (NOMNC) is delivered timely.
If you have any questions regarding these guidelines, please contact Sheila Van Daly, Manager, Clinical Services, at [email protected].
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Y Independence drug program formulary updatesPublished August 23, 2019
Effective October 1, 2019, Independence will make changes to its Select Drug Program® Formulary and Value Formulary.
● Select Drug Program Formulary. This formulary-based prescription drug benefit program is available to commercial members. It includes all generic drugs and a defined list of brand-name drugs. All drugs on the formulary have been approved by the U.S. Food and Drug Administration (FDA) and were chosen for formulary coverage based on their medical effectiveness, safety, and value. Independence’s Pharmacy and Therapeutics Committee reviews the formulary periodically to ensure its continued effectiveness.
● Value Formulary. This is a restricted formulary managed by Independence and is available to commercial members. The selection of drugs for inclusion in the Value Formulary is similar to the Select Drug Program Formulary. All drugs on the formulary have been approved by the FDA and were chosen for formulary coverage based on their medical effectiveness, safety, and value. Drugs not included on the formulary (non-formulary drugs) have covered equivalents and/or alternatives used to treat the same condition.
In addition, new and updated prior authorization, morphine milligram equivalent (MME) limit, age limit, and quantity limit requirements will be applied to certain drugs on the formularies.
● Prior Authorization. Prior authorization requirements help ensure that prescribed drugs are medically necessary and are being used appropriately.
● MME Limit. The MME limit is designed to help with safe and appropriate opioid use. ● Age Limit. Age limits help ensure drugs are used in the appropriate age group in furtherance of patient safety. ● Quantity Limit. Quantity limits are designed to allow a sufficient supply of medication based upon the
maximum daily dose and length of therapy approved by the FDA for that drug. This also includes a day supply limit, which is based on the day supply of a prescription and not the quantity.
Please review the Select Drug Program Formulary and Value Formulary changes that go into effect October 1, 2019. For additional information on pharmacy policies and programs, visit our website.
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Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (Independence) created to provide valuable information to the Independence-participating provider community that provides Covered Services to Independence members. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the Covered Services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with Independence. Refer to the Provider News Center to stay up to date on news and information from Independence.
Models are used for illustrative purposes only. Some illustrations in this publication copyright 2016 www.dreamstime.com. All rights reserved.This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.The third-party websites mentioned in this publication are maintained by organizations over which Independence exercises no control, and accordingly, Independence disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.
NaviNet® OpenThe NaviNet web portal (NaviNet Open) is our secure, online provider portal that gives you and office staff access to critical administrative and clinical data. To help you navigate the portal and various transactions, we have created a central location for a variety of NaviNet Open resources, including user guides, webinars, and a communications archive.
NaviNet Open
Utilization ManagementCertain utilization review activities are delegated to different entities. Here you will find detailed information on our utilization management programs and common resources used among them.
Utilization Management
Opioid AwarenessWe have created a repository of tools and resources to assist you in managing your patients who are prescribed opioid medications.
Opioid Awareness Resources
Quick Links ● Bulletins ● Forms ● Frequently Asked Questions ● Medical Policy ● NaviNet Open Login ● Provider Home ● Services that require precertification
− Commercial − Medicare Advantage
Archives ● Partners in Health Update past edition PDFs ● Cumulative Index ● ICD-10 Transition
Email sign up ● Sign up for email from Provider Communications
Contact numbersPlease visit the Contact Information section of the Providers section of our website for a complete list of important telephone numbers.
Websites
Provider CommunicationsIndependence Blue Cross
1901 Market Street 28th Floor
Philadelphia, PA 19103
