Now providers can get

4 More Eligibility Information 4 Additional Benefits Information 4 Claim Status and Pend Reason

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more information, more easily, by using Premera’s enhanced Interactive Voice Response (IVR) or automated Customer Service functionality.

Accessed by calling Customer Service, these improvements offer additional eligibility, benefit and claim information.* And now IVR includes speech recognition to help make your experience more efficient and allow for quicker access to information.

You can access information for multiple members in a single call without transfer. You can also obtain eligibility status, access member benefit information, and find out how much of the deductible the member has satisfied.

The enhancements allow you to find out if a claim has been paid, applied to the deductible or is currently being processed. If the claim is pended, now IVR will tell you why.

The new and improved IVR is available 24 hours a day, 7 days a week so you can access information at your convenience.

The new and improved Self Service for providers can be reached by calling Premera customer service at 1-800-722-4714, option 2.

*Blue Card and NASCO member information is not available through Premera’s IVR. Benefit information may be limited for some Premera groups.

Contents

Announcing IVR Enhancements page 1 Medical Policy Update page 2 Claims Update page 3

Updates page 4

Online Update page 5

Providers can get

more information,

more easily, by using

Premera’s enhanced

Interactive Voice

Response (IVR)

November 2006

news

News from Premera Blue Cross Blue Shield of Alaska

N

etwork

M

edical

P

olicy

update

Physicians, Providers and Office Staff

Medical Policy Update

Premera Blue Cross Blue Shield of Alaska medical policies are guides in evaluating the medical necessity of a particular service or treatment. We adopt policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, we reserve the right to review and update our policies as appropriate. When there are differences between the member’s contract and medical policy, the member’s contract prevails. The existence of a medical policy does not guarantee that the member’s contract allows the service.

Medical policies are available on the www.premera.com Web site. Visit the Provider Portal and then the Library. Click on Reference Info and then click on Medical Policies. If you are not able to obtain the policy online and want to request a copy of a particular medical policy, e-mail your request to [email protected] or call 1-800-722-4714.

Note: All policy numbers begin with CP.MP.

The following policy changes are effective for dates of service of August 8, 2006, and later: AR.1.01.01 Air Fluidized Beds. This policy has been

deleted because this item is addressed in policy PR.1.01.520-Hospital Beds and Accessories. PR.1.01.520 Hospital Beds and Accessories. New Policy.

This policy incorporates the information from Air Fluidized Beds, expanding further on benefit coverage for specific home-use hospital beds and accessories. Hospital beds are considered

medically necessary when specific criteria are met.

AR.2.01.13 Human Antihemophiloc Factor (AHF). This policy has been deleted and will no longer be reviewed.

AR.2.01.14 Electroencephalograms. This policy has been

deleted and will no longer be reviewed. BC.2.01.20 Esophageal pH Monitoring. The policy

statement on wireless monitoring changed from investigational to not medically necessary.

AR.2.01.32 Ketogenic Diet as a Treatment of Refractory Epilepsy. This policy has been deleted and will no longer be reviewed.

AR.2.01.37 Canalith Repositioning as a Treatment of Benign Paroxysmal Positional Vertigo (BPPV).

This policy has been deleted and will no longer be reviewed.

AR.2.01.46 Vacuum Therapy as a Treatment of Female Sexual Dysfunction. This policy has been

deleted and will no longer be reviewed. PR.2.02.502 Pulmonary Vein Ablation as a Treatment

of Atrial Fibrillation. The policy statement on pulmonary vein ablation changed from investigational to medically necessary under specific circumstances.

AR.2.04.05 Genetic Testing for Germline Mutations of the RET Proto-Oncogen in Medullary of the Thyroid. This policy has been deleted and will no longer be reviewed.

BC.5.01.09 Treatment of Pulmonary Hypertension with Prostacyclin Analogues or Endothelin Receptor Antagonists. The policy statement was revised to state that sildenafil may be considered

medically necessary.

PR.5.01.605 Medical Necessity Criteria for Pharmacy Edits.

The policy statement was amended to include modafinil as medically necessary for depression when certain criteria are met. Exenatide and thiazolidinediones may also be considered

medically necessary when certain criteria are met.

BC.6.01.10 Sterotactic Radiosurgery of CNS Lesions.

The policy statement was revised to indicate that stereotactic radiosurgery of extracranial sites is

investigational.

BC.7.01.100 Bone Morphogenetic Protein. The policy was revised to remove limitation to single level spinal fusion and the type of carrier system.

BC.8.02.02 Plasma Exchange (Plasmapheresis). The policy statement was amended to include plasmapheresis in the stetting of solid organ transplants as

medically necessary for certain conditions.

New & Improved

Medical Policies Section

We are pleased to announce the successful launch of a new and improved Medical Policies section now available

at www.premera.com. A cross-functional and collaborative

effort by several representatives resulted in a database change to allow increased title size for medical policies. We also improved the user experience by streamlining the Stellent search functionality and the user interface design.

c

laiMs

update

Professional and Facility

Claim Form Updates

The National Uniform Claims Committee (NUCC) and National Uniform Billing Committee (NUBC) are implementing changes to the professional (CMS-1500), and institutional (UB-92) claim forms for national acceptance by health plans, clearinghouses, and vendors. The purpose of these updates is to accommodate the new NPI, and align with the electronic HIPAA 837. The update will also prepare for future implementation of the ICD-10.

Premera Blue Cross Blue Shield of Alaska is currently preparing to accept the revised formats of the CMS-1500 and UB-04 (revised UB-92). Below are effective dates for the revised forms:

Revised CMS 1500 Effective Dates

w Jan. 1, 2007: Providers can start using the new CMS-1500 form w Jan. 1, 2007 – April 2, 2007:

Providers can use either the current or revised CMS 1500 form

w April 2, 2007: The current CMS 1500 form is officially discontinued (by the NUCC)

UB-04 (Revised UB-92) Effective Dates

w Mar. 1, 2007 – May 22, 2007:

Providers can use either the UB-92 or UB-04

w May 23, 2007: The current form (UB-92) is discontinued

Please watch for updates in future PBC Network News articles.

If you would like more information and details about the status of these updates, visit: CMS-1500 http://www.nucc.org/frontpage/Itemid,1/ UB-04 http://www.nubc.org/

TIPS

RSV Claims Update

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory infections in children. We cover Synagis from mid- December through April, but may approve earlier start dates and later end dates if data show significant RSV activity. The FDA-labeled indication for Synagis is prevention of serious lower

respiratory tract disease caused by RSV. We recommend a Benefit Advisory to expedite claims payment, as Synagis is subject to clinical review for medical necessity. For more information about our RSV prevention medical policy, or for a list of drugs and services subject to clinical review, visit www.premera. com/medicalpolicies.

Tips for Timely Payment

w Use the same drug code used for approval of the Benefit Advisory when you submit the claim.

w Use the appropriate Synagis specific drug code.

w Confirm the units match the drug code rather than the NDC when submitting claims,

Specialty Pharmacies Two contracted specialty

pharmacies can provide Synagis, bill Premera for the drug, and facilitate the approval process. Contact Caremark Specialty Pharmacy or Accredo Health Group to get started:

Caremark Specialty Pharmacy 1-800-237-2767

Accredo Health Group 1-877-244-2995

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Pdates

The Refund Request e-form is now available through the Provider portal at

www.premera.com. The e-form can be completed online making it quicker and

simpler to process. It will also enhance clarity for the staff that processes refund requests leading to quicker turnaround times.

Any data entered will not be saved on our template. Executing the “save as” function allows you to maintain an electronic copy of the completed form for your records. To find this form visit www.premera.com, select Provider, then Forms and then scroll down to Miscellaneous.

Please note: Please continue to submit the completed form through the U.S. mail.

R E F U N D R E Q U E S T E - F O R M

Provider Portal Update

You can view new information on Premera’s secure Provider Portal, including: w Member’s out-of-pocket maximum

w Member’s life-time maximum

w Deductible used, deductible yet to be satisfied

The information is displayed with a new, improved layout, featuring a larger font and additional spacing for improved readability. Use Premera’s secure Provider Portal to find quick eligibility, benefits and claims status information, or clinical information and resources. In December you can look forward to an improved user experience when you navigate between a member’s claims, benefits and eligibility. Watch for more information about these enhancements. To access the Portal:

For first-time users: Register with OneHealthPort, a health-care security service that provides a free, secure sign-on. You’ll be given a User ID and password. Once registered, you can use a single sign-on to access most area health plans, including Premera.

Already registered: Enter your OneHealthPort User ID and password to access the secure area of the Provider Portal at www.premera.com.

Avoid Claim Rejections as

of May 23, ‘07

As of November 2006 a total of 3,622 individual and organizational providers have enumerated in the state of Alaska and received their National Provider Identifier (NPI). Nationally 1,411,903 providers have enumerated.

The NPI is the new HIPAA standard for a unique identifier for covered health-care providers*. The NPI will replace all proprietary (payor-issued) provider identifiers, including Medicare ID numbers. It will not replace your TIN or DEA number.

*Covered health-care providers are those that transmit health-care information in an electronic form with HIPAA standard transactions.

The compliance date for NPI is May 23, 2007. As of this date HIPAA electronic claim transactions received without the NPI will be rejected. If you have requested and received your NPI, please include it now in your electronic claim transactions.

To avoid claim rejections as of the compliance date, apply for your NPI now. In addition, we strongly recommend that you contact your systems vendor to ensure that their timelines for addressing NPI will be well within the final

compliance date.

You can view detailed information, a comprehensive question and answer document, and updates regarding NPI (and access the online application site) at www.premera.com.

Apply for your NPI today by accessing: https://cms.hhs.gov/NPPES/ Welcome.do

o

NliNe

update

Online Services

At www.premera.com you can view benefits, claims status and eligibility confirmation

for members on most Premera plans. You also can search for preferred pharmaceuticals by using the electronic formulary. The site features useful tools and information about how to file for an NPI or submit an electronic claim. Here are some additional services and tools we provide online:

Tools

w Search for other providers in our network using the online directory.

w Perform detailed benefit inquiries or eligibility confirmations as you’re scheduling patients, when it’s convenient.*

Library

w The Forms library contains the Credentialing Application for new providers, the Refund Request form, the Corrected Claim form and many other useful forms.

w Check out the latest communications from Premera including the Network News newsletter, News Briefs and EMC Hotline.

w Review reference manuals, medical policies and frequently asked questions to help make your interactions with Premera as smooth as possible.

Of Interest

w Apply for your NPI online and get the information you need in our handy FAQ. w Find resources and links about HIPPA.

* Items with a padlock symbol next to them are secure and require a OneHealthPort user ID and password. For information about how to register with OneHealthPort, visit

Please post or circulate this newsletter in your office

PRESORTED STANDARD U.S. POSTAGE PAID

SEATTLE, WA PERMIT NO. 2944

Premera Blue Cross Blue Shield of Alaska

P.O. Box 327 Seattle, WA 98111

Network News

Back issues of Network News are on our Web site at www.premera.comin the Library on the Provider page under “Communications.”