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Understanding quality measurement

A key component of our Quality Program is Healthcare Effectiveness Data and Information Set (HEDIS®) reporting. Each year, we are required to report information on the quality of care our Medicare, group and Individual members receive to various sources. We gather information to include in these reports through claims and medical record data.

HEDIS measures and reporting

We will begin our 2015 HEDIS medical record reviews of 2014 services in February, continuing through May. This year, we have contracted with RecordFlow to contact providers and collect medical record data using a HIPAA-compliant process.

We appreciate your help during this process and will make every effort to work with your office to collect the medical records either by fax, mail, onsite abstraction/copying visit and/or through electronic medical record (EMR) access, if applicable for your site.

As a reminder, your agreement requires participation in quality

improvement activities, such as HEDIS, with medical records provided free of charge. A signed release from your patient, our member, is not required for us to obtain these records. Learn more about this year’s review on our website: Programs>Cost and Quality>Quality Program>HEDIS Reporting.

Medicare Star Ratings

There are specific HEDIS measures that affect the Medicare Star Ratings we receive for our Medicare Advantage HMO and PPO plans. We ask that all our providers strive to provide 5-star level service to our members for these measures, which includes ensuring our members have the recommended screenings, receive help controlling chronic conditions and that steps are taken to improve member compliance with their treatment plan. Learn more on our website: Programs>Medicare Star Ratings.

February 2015


Understanding quality measurement ... 1

Newsletter survey results ... 2

Medicare Quality Incentive Program ...3

ICD-10 deadline approaching ...3

Asuris to utilize Regence BlueShield of Idaho’s PPO network ...4

DME vendors, check your inbox ...4

Aperture to conduct recredentialing ...4

Coding Toolkit updates ... 5

Pre-authorization list updates ... 5

Medical and reimbursement policy reviews ... 5

Medical policy updates ... 6

Join our medical policy discussion ... 6

Reimbursement policy updates ...7

Non-reimbursable services...7

Clinical Practice Guidelines review ...7

Infusion therapy site of service ... 8

Medication formulary updates ... 9

Help Medicare Part D members stay adherent ... 9

Medication policy updates ...10-11 Radiology Quality Initiative ... 12-13 Sleep Medicine Program reminders ... 13

Physical Medicine Program changes .... 14

Personalized Care Support reimbursement and resources ... 14

Upcoming member surveys ... 15

Referring to in-network providers saves members money ... 15

Annual update on network accessibility results ... 15

Provider appeals updates ... 16

Electronic claims submission ... 17

ABA therapy services ... 18

Mental illness support available ... 19

Preventive health care coverage ... 20

Well-child visits for FEP members ... 21


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Quality Measures Guide

We know that it can be difficult to know which measures apply to your patients, and what data actually needs to be submitted on a claim and/or documented in the medical record during the year to ensure the care you provide will be captured correctly. We have created a Quality Measures Guide to help you, which is available on our website: Programs>Cost and Quality>Quality Program>HEDIS Reporting or Programs>Medicare Star Ratings.

If you want more detailed information, the National Committee for Quality Assurance (NCQA) has technical specification materials available for purchase on their website at

Understanding quality measurement continued from page 1

Newsletter survey results

Thank you for completing our newsletter survey. The majority of respondents agree that the newsletter is easy to read and navigate. In addition, respondents indicate that the articles are the right length and have the right amount of information. Included below are the key findings.

Most read content

Pre-authorization information was selected most frequently (58%) as being useful to practices, followed by ICD-10 updates, reimbursement policies and new programs that impact the provider community.

Content for specific specialty types

Ancillary, behavioral health and dental providers responded to indicate that they would like to easily identify articles related to their specialties. If we have articles specific to certain specialty types, the articles will be clearly identified in the table of contents.

Email notification

The majority of respondents (nearly 70%) report they currently receive an email when a new edition of the newsletter is available. If you do not currently receive the email notification, simply visit The Connection section on the home page of our website and select subscribe.

Publication schedule

This year, we will continue to publish six issues by the first of the following months: February, April, June, August, October and December.

Stay up to date

In addition to our newsletter, we also publish important information on the home page of our website. Visit our website frequently to stay up to date.

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About The Connection

This publication includes important updates for you and your staff, in addition to information about updates to policies and procedures, and notices we are contractually required to communicate to you. In the table of contents on page 1, this symbol indicates articles that include critical updates: . The Connection includes information for all four of our Regence Plans. In this publication, “Regence”

refers to the following: Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in select counties of Washington). When information does not apply to all of these Plans across the four states, then this publication will identify the Plan(s) or state(s) to which that specific information applies.

Washington providers, in January we published a special edition of our newsletter that included important information about our new product, Regence ActiveCareSM and our Accountable Health Networks. It is posted on our website:

Library>News and Updates>Newsletters.


2015 Medicare Quality Incentive Program

We are pleased to announce the 2015 Medicare Quality Incentive Program for our Medicare Advantage PPO providers. This program rewards providers who work throughout the year to close medical care and risk adjustment diagnosis gaps in documentation. Gaps left open and not properly documented as closed by the end of the year have a negative impact on our Medicare Star Ratings, regardless of whether the service was performed.

This year’s program includes several levels of incentive.

Providers may earn a basic incentive or an enhanced incentive for better condition control for patients with hypertension or diabetes. Providers may also earn a separate incentive for not prescribing medications considered high risk in the elderly.

While participation in the program is voluntary, we

encourage all eligible Medicare Advantage PPO providers to take part. We will begin distributing member rosters in the next few weeks, so you know which of your patients have one or more gaps that can be addressed during office visits with you this year. Please notify us via email at within 30 days of receipt of the roster about any members that should not be on your roster, so they will not be included in your gap report. The first detailed gap reports will be available in April.

Specific details about the incentive program are available on our website: Programs>Medicare Star Ratings.

ICD-10 deadline approaching

On October 1, 2015, health care providers, health plans and health care clearinghouses are to begin using the 10th edition of the International Classification of Diseases (ICD-10) codes for all dates of service on or after that date for medical diagnosis and hospital inpatient procedures.

It is critical that you do not use ICD-10 codes now. We cannot accept them until the compliance date above.

ICD-10 codes submitted on claims at this time will be denied as invalid codes and will slow down the processing of your claim. Please continue to use ICD-9 coding for dates of service through September 30.

Available tools can help your readiness

The Centers for Medicare & Medicaid Services (CMS) has many online tools available, including Road to 10 designed to help small practices jumpstart their ICD-10 transition.

There are also three Medscape Education resources that provide guidance around the transition to ICD-10 that provide continuing medical education (CME) and nursing continuing education (CE) credits, plus a number of fact sheets to help you work through the ICD-10 transition. This information is located at


View our ICD-10 Frequently Asked Questions document to review our readiness and testing efforts towards this fast approaching deadline on our website: Claims and Payment>Claims Submission>ICD-10.


DME vendors, check your inbox

In December, Durable Medical Equipment (DME) vendors received an amendment to their agreement(s) adjusting their reimbursement rates effective April 1, 2015. In addition, the notification indicated that we are introducing a DME Quality Reporting Program this year. Participation in this program will provide DME vendors with the opportunity to qualify for an increased reimbursement rate.

Please check your inbox this month for more information about how to participate in our DME Quality Reporting Program. If you are registered for eContracting, information will be emailed to you. Otherwise you will receive

information via U.S. mail.

Asuris to utilize Regence

BlueShield of Idaho’s PPO network

Asuris Northwest Health has accessed the Regence BlueShield of Idaho Participating provider network for many years. Beginning May 1, 2015, Asuris members will also have access to the Regence BlueShield of Idaho Preferred Provider Organization (Regence PPO) network as supported by your provider agreement with us.

There are no changes to how you submit claims for Asuris members.

If you have questions, please contact our Network Management team in Idaho via email at

Aperture to conduct


We have partnered with Aperture Credentialing, LLC (Aperture) to conduct our recredentialing process. Aperture will complete the following on our behalf:

Receiving recredentialing documents

Contacting providers who have not returned required documents

Conducting primary source verification activities (e.g., license, sanction and board certification verification) Providers who are due for recredentialing will be contacted by Aperture to initiate the process. All credentialed

providers must complete the recredentialing process every three years in order to continue network participation. To make the recredentialing process more efficient, please be sure to keep your office information up to date. This is especially important when physicians or other health care providers join or leave a practice.

Verify your office information using our Find a Doctor tool on our website

Update your office information by completing our Provider Information Update Form available on our website: Library>Forms.


Pre-authorization list updates

With 2015 CPT and HCPCS coding changes effective January 1, 2015, it is important to review our

pre-authorization lists as new 2015 CPT and HCPCS codes may be added and codes no longer valid will be deleted.

New codes added to our lists are indicated in color along with effective dates. We also review and delete codes on a monthly basis and it is important to review our lists for changes each month. Our pre-authorization lists are available in the Pre-authorization and Referrals section of our website. Please review the lists and pre-authorize services accordingly.

We have made the following updates to our Federal Employee Program Pre-authorization List effective January 1, 2015:

Procedure Codes

BRCA Testing Added CPT 81211, 81212, 81213, 81214, 81215, 81216 and 81217 Outpatient intensity-

modulated radiation therapy (IMRT)

Added CPT 77385, 77386, HCPCS G6015 and G6016

Coding Toolkit updates

Our Coding Toolkit is a listing of our clinical edits and includes information specific to Medicare’s National Correct Coding Initiative (NCCI). These coding requirements are updated and posted on a monthly basis in the Clinical Edits by Code List in the Coding Toolkit and apply to claims for our commercial products and BlueCard®.

In addition, our Correct Code Editor (CCE), also located in the Coding Toolkit, has additional CPT® and HCPCS code pair edits that we have identified and are used as a supplement to Medicare’s NCCI. This supplemental list of code groupings in the CCE is updated quarterly in January, April, July and October.

The Coding Toolkit is available on our website: Claims and Payment>Claims Submission>Coding Toolkit.

As a reminder, we perform ongoing 12-month retrospective review on claims that should be processed against our clinical edits. We follow our existing notification and recoupment process when we have overpaid based upon claims processing discrepancies and incorrect application of the clinical edits. View our notification and recoupment process on our website: Claims and Payment>Receiving Payment>Overpayment Recovery.

Please remember to review your current coding

publications for codes that have been added, deleted or changed and to use only valid codes.

Medical and

reimbursement policy reviews

Our medical and reimbursement policies are reviewed due to the following:

⊲ Updates from CMS

⊲ Regularly scheduled review

⊲ Changes in published scientific literature

⊲ Requests from physicians, other health care professionals or facilities

⊲ Addition, deletion or revision of codes published in the CPT, HCPCS and ICD-9-CM manuals View and provide feedback on reimbursement policies currently under review on our website:

Library>News and Updates.


Join our medical policy discussions

We welcome your input and feedback as we draft our medical policies. It’s easy to join our email reviewer list. Simply complete the Contact Medical Policy Staff request form on our website: Library>Policies and Procedures>Medical Policy.

While we prefer to receive input as policies are developed, we also have a formal process that allows providers to submit additional information, such as clinical trial results, that may warrant a policy review.

Listed below are summaries of recent changes to our medical policies. View all detailed policies on our website:

Library>Policies and Guidelines. This list does not include medications or Medicare medical policy exceptions.

New or updated investigational or medical necessity policy criteria Allied Health

Biofeedback (#32) Added investigational indications

Genetic Testing

BRAF Gene Mutation Testing To Select Melanoma Patients

for BRAF Inhibitor Targeted Therapy (#41) Clarified patient diagnosis within criteria

Evaluating the Utility of Genetic Panels (#64) Clarified criteria and added, updated and deleted genetic panel tests

Hereditary Hearing Loss (#36) New policy

Genetic Testing for Inherited Susceptibility to

Colon Cancer (#06) Added criterion regarding comprehensive panel testing

JAK2 and MPL Mutation Analysis in

Myeloproliferative Neoplasms (#59) Added, updated and deleted genetic panel tests;

celeted Prosigna gene expression assay Molecular Analysis for Targeted Therapy of

Non-Small Cell Lung Cancer (NSCLC) (#56) Added criteria for additional genes Medicine

New and Emerging Medical Technologies and

Procedures (#149) CPT 27279 replaced 0334T; CPT 33418-33419 replaced

0343T-0344T; CPT 0377T replaced HCPCS C9735;

CPT 0299T-0300T, 0378T-0379T, 0381T-0391T, 52441, 52442 and 91200 added to the policy

Outpatient Cardiac Telemetry (#135) Clarified criteria Mental Health

Applied Behavior Analysis for the

Treatment of Autism (#18) Updated policy criteria

New or updated investigational or medical necessity policy criteria effective May 1, 2015 Surgery

Sacral Nerve Modulation/Stimulation for

Pelvic Floor Dysfunction (#134) Adding overactive bladder and post rectal surgery to criteria

Note: Policy available for viewing on the website on February 11

Sacroiliac Joint Fusion (#193) New policy with investigational and medical necessity criteria

Medical policy updates


Non-reimbursable services

Our Non-Reimbursable Services (Administrative #107) reimbursement policy, which explains invalid services that are considered to be non-reimbursable, is located on our website: Library>Policies and Guidelines. If billed,

non-reimbursable services are considered not payable, are denied as a provider write-off and cannot be billed to our member.

View specific CPT and HCPCS codes that are considered non-reimburseable services in the Clinical Edits by Code List located on our website: Claims and Payment>Claims Submission>Coding Toolkit.

Clinical Practice Guidelines review

Clinical Practice Guidelines are systematically developed statements on medical and behavioral health practices that help physicians and other health care professionals make decisions about appropriate health care for specific conditions. View these guidelines on our website:

Library>Policies and Guidelines.

Our chronic obstructive pulmonary disease (COPD) practice guideline was recently reviewed and updated to indicate that we continue to endorse the COPD guidelines published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

Reimbursement policy updates

We are updating our Hospital Acquired Conditions and Never Events (Administrative #106) reimbursement policy with minor changes to provide clearer definitions and references.

Effective May 1, 2015

Our Associated Claims (Administrative #119) reimbursement policy, which identifies services that will be denied due to being performed as part of a non-covered service, will be updated for dates of service on or after May 1. Services that may be denied as associated claims include, but are not limited to, services provided or performed as follows:

By the provider performing the service

By any assistant surgeon

By the facility where the service was performed

At the same time or during the same operative session (regardless of whether the service was billed)

Prior to or subsequent to an initial related denied service

During an inpatient stay when the hospital did not provide adequate notice of admission

When a provider fails to obtain required pre-authorization Effective for dates of service on or after May 1, claims from radiologists, pathologists and anesthesiologists will no longer be excluded from this policy. Reimbursement for all claims associated with denied services, includes but is not limited to, investigational, cosmetic, not medically necessary services and administrative denials.

Responsibility for the costs associated with these claims will be assigned to the provider or member depending on the denial type.

The updated reimbursement policies will be available on our website on February 1. View all our reimbursement policies on our website: Library>Policies and

Guidelines>Reimbursement Policy.


Infusion therapy site of service changes

We continually strive to ensure that members have access to and receive the right care for the best value. This includes evaluating new technologies and pharmaceuticals that allow infusion services to be administered safely and effectively outside of the hospital outpatient setting.

As we review our medication policies, we are making changes that allow us to consider the site of service as a factor in determining medical necessity for intravenous (IV) infusion therapy for Idaho, Oregon and Washington group and Individual members. At this time, Utah members are only included in this initiative on a voluntary basis. This focuses on providing our members, your patients, with access to alternative infusion therapy locations as a convenient and less costly solution compared to treatment at an outpatient hospital facility.

We recommend that you always refer your members who need infusion therapy to the site of service that provides the best value, regardless of whether our medication policy criteria require it at the time. This can include provider offices, infusion centers or home infusion, where appropriate and available. We have contracted with infusion therapy providers to deliver in-network services for our members.

You can find in-network providers using the Find a Doctor tool on our website.

As part of the current prior authorization process, we will require you to identify where the medications will be administered in order for the request to be reviewed and processed. Authorization requests missing this information will be considered incomplete and will not be authorized.

Our December 2014 issue of this newsletter notified you of medication policies that are changing as of March 1, 2015.

Please review the Medication Policy Updates article in this issue (see pages 10 and 11) and future issues for

additional changes.

As a reminder, if a medication is determined to be not medically necessary, a prior authorization will not be issued.

The charges for these services are not covered, and both the member and the payer must be held harmless from all charges.

To view all medication policies related to specific prior authorization requirements, please visit

The Medical Prior Authorization Medications List, forms and contact information are available at


Help Medicare Part D members stay adherent

This year, we have made changes to support our Medicare Part D members, helping save them time and money, as well as encouraging adherence to their medication regimen. All pharmacies in the Regence Medicare Part D retail pharmacy network can fill a 90-day supply of medication (specialty medications excluded). This is in addition to the mail order pharmacy options available.

In addition, members can now receive a 90-day supply of generic medications for only two copays, and 90 days of brand name medications for only 2½ copays; rather than one copay for each 30-day supply. This is the same copay that they pay for mail order medications. For patients who are stable on their maintenance medications, consider prescribing a 90-day supply to improve medication adherence and save your patients money.


formulary updates

Effective April 1, 2015, the following inhaled corticosteroid- containing medications will be moving from the preferred brand tier to the non-preferred brand tiers for group and Individual members:

ciclesonide MDI (Alvesco®)

flunisolide MDI (Aerospan®)

fluticasone furoate DPI (Arnuity® Ellipta®)

fluticasone propionate MDI (Flovent® HFA)

fluticasone propionate DPI (Flovent® Diskus®)

fluticasone propionate/salmeterol DPI (Advair Diskus®)

fluticasone propionate/salmeterol MDI (Advair® HFA)

fluticasone furoate/vilanterol DPI (Breo® Ellipta®)

Prior authorization is required for all non-preferred inhaled corticosteroid-containing medications and requires the member to try a preferred medication first. Review the Medication policy updates article on pages 10 and 11 for more information.

The following inhaled corticosteroid-containing medications will be available without prior authorization on the preferred brand tier:

budesonide + formoterol MDI (Symbicort®)

mometasone/ formoterol MDI (Dulera®)

beclomethasone MDI (QVAR®)

budesonide DPI (Pulmicort Flexhaler®)

mometasone DPI (Asmanex Twisthaler®)


Medication policy updates

Listed below is a summary of upcoming changes to our medication policies. View all policies in the Medication Policy Manual, available on our website: Library>Policies and Guidelines. This list does not include other medical policy updates.

The formularies or preferred medication lists for our products are available at

If CMS has designated a medication as product not available (PNA) for ninety days, we consider it a non-reimburseable service (NRS) and not eligible for reimbursement. We review medication codes quarterly and update any drugs with a PNA code status to NRS.

Since medical offices or facilities may have small quantities already in stock, we provide the 90-day timeframe to allow for use of any existing medication supply. View our Non-Reimbursable Services (Administrative #107) reimbursement policy in the Reimbursement Policy Manual available on our website: Library>Policies and Guidelines.

The following medication policy is new as of April 1, 2015

Medication Policy Description of new policy on existing medication Non-preferred inhaled corticosteroid

(ICS)-containing products (Advair®

HFA, Advair® Diskus, Alvesco®, Arnuity®

Ellipta®, Breo® Ellipta®, Flovent® HFA, Flovent® Diskus®) (dru380)

Will allow coverage of non-preferred ICS-containing products when preferred products are ineffective, not tolerated or contraindicated

The following are medication policies that are new as of May 1

Medication Policy Description of new policy on existing medication Alpha-1 proteinase inhibitors: (Aralast

NP, Glassia, Prolastin®-C, Zemaira®) (dru382)

Will cover for patients with a confirmed diagnosis of outflow obstruction (emphysema) due to alpha-1 antitrypsin deficiency (AATD) and limit the approved dose (60 mg/kg/week)

Berinert®, plasma-derived C1 esterase inhibitor (dru374)

Kalbitor®, ecallantide (dru375)

Will confirm the diagnosis of hereditary angioedema (HAE), ensure consistency between medication policies related to HAE, and, for Idaho, Oregon and Washington members, limit administration to non-hospital outpatient settings (e.g., provider’s office, infusion centers, home infusion). Administration in a hospital outpatient setting will be considered not medically necessary.

Soliris®, eculizumab (dru385) Will limit administration to non-hospital outpatient settings (e.g., provider’s office, infusion centers, home infusion) for Idaho, Oregon and Washington members.

Administration in a hospital outpatient setting will be considered not medically necessary.

Vectibix®, panitumumab (dru383) Will encourage the use of panitumumab (Vectibix) in patients who have a diagnosis of advanced (unresectable) or metastatic colorectal cancer when no KRAS mutation is present (for use with KRAS wild type tumors only)

continued on page 11


Medication policy updates continued from page 10

The following medication policies are changing effective May 1

Medication Policy Description of criteria changes to existing policy

Cimzia®, certolizumab (dru160) Ankylosing spondylitis and rheumatoid arthritis (RA) : Will add step therapy requiring failure of two preferred biologics

Psoriatic arthritis: Will add step therapy requiring failure of three preferred biologics

Will specify that vials (covered under the medical benefit) are not medically necessary Entyvio®, vedolizumab (dru0356) Will update step therapy to remove Simponi as a preferred option

Actemra®, tocilizumab, (dru209) For the indication of Juvenile Idiopathic Arthritics: Will add step therapy with oral DMARD to align with policies for alternative biologics

Tysabri®, natalizumab (dru111) Will update criteria to promote utilization of alternatives with the strongest efficacy data, by removing Copaxone as an option that would satisfy the step

therapy requirement

Will limit administration for Idaho, Oregon and Washington members to non-hospital outpatient settings (e.g., provider’s office, infusion centers) that are certified by the Risk Evaluation and Mitigation Strategies (REMS) program. Administration in a hospital outpatient setting will be considered not medically necessary.

Cinryze®, C1 Inhibitor (human) (dru172), Ruconest®, recombinant human C1 esterase inhibitor (dru373), Lemtrada™, alemtuzumab (dru381)

Will limit administration for Idaho, Oregon and Washington members to non-hospital outpatient settings (e.g., provider’s office, infusion centers) that are certified by the REMS program. Administration in a hospital outpatient setting will be considered not medically necessary.

The following medication policies will be updated to limit administration to non-hospital outpatient settings for Idaho, Oregon and Washington members as of the effective dates listed:

Benlysta®, September 1

Nplate®, September 1

Prolia/Xgeva®, October 1

Please read the Infusion therapy site of service changes article on page 8 for more information.



Radiology Quality Initiative updates

Following are radiology program updates:

HCPCS S8032 addition

HCPCS S8032 Low-dose computed tomography for lung cancer screening will be added to the CPT code list and require authorization through AIM Specialty Health (AIM) effective for dates of service on or after May 1, 2015.

Updated AIM clinical

appropriateness guidelines for advanced diagnostic imaging

The following changes to AIM’s Clinical Appropriateness Guidelines for Radiology, Cardiology, and Oncologic PET, available at, will become effective on May 4:

Head and neck appropriate use criteria

Adding new criteria for MRI, MRA, CT and CTA brain for evaluation of tinnitus

Expanding existing criteria for MRI and CT brain for evaluation of sensorineural hearing loss

Adding new criteria for MRI orbit, CT maxillofacial and CT neck (soft tissue) for evaluation of osteonecrosis of the jaw

Expanding criteria for MRI and CT brain to allow for evaluation prior to discontinuation of antiepileptic medications when a patient has not had a prior MRI Chest appropriate use criteria

Infectious and inflammatory criteria for CT chest will be further differentiated at the condition level

Adding several new criteria for CT chest include bronchopleural fistula, complications of pneumonia and paraneoplastic syndrome with unknown primary tumor or origin

Abdomen and pelvis appropriate use criteria

Adding new criteria for CTA abdomen and pelvis for evaluation of visceral artery aneurysms

Adding new criteria for MRI and CT abdomen for evaluation of iron deposition/overload in patients with hemochromatosis when they are candidates for chelation therapy

Musculoskeletal appropriate use criteria

Clarifying criteria for MRI and CT spine when evaluating cord compression

Revising criteria for MRI upper extremity evaluation of nonspecific upper extremity pain

Removing criteria to allow CT cervical and thoracic spine evaluation for MS, myelopathy and spinal cord infarct (Note: These will still be available under MRI.)

Oncologic PET appropriate use criteria

Enhancing clinical criteria for thyroid cancer Cardiology appropriate use criteria

Adding new criteria to allow stress echo and myocardial perfusion imaging (MPI) evaluation of patients awaiting solid organ transplantation

Clarifying criteria for stress echo and MPI evaluation of patients who have undergone percutaneous coronary intervention (PCI) greater than three years ago

Clarifying criteria for stress echo, resting echo, and MPI evaluation for cardiac arrhythmias redefining frequent premature ventricular contractions

Modifying criteria for resting echo reevaluation of patients who have undergone implantation of a bioprosthetic valve to allow imaging seven years after the procedure and then annually thereafter

New pediatric guidelines

In addition to the changes above, AIM has developed a set of radiology guidelines that are specific to pediatric patients. These guidelines include:

Fetal MRI

Pediatric chest

Pediatric head and neck

Pediatric musculoskeletal

Pediatric abdomen and pelvis

The guidelines listed above bring together criteria from AIM's adult guidelines applicable to pediatrics with new criteria specific to pediatric patients.

Contact AIM via email at aim.guidelines@ with questions.

continued on page 13


Radiology Quality Initiative updates continued

Sprint employees now part of AIM

Sprint, in partnership with Blue Cross and Blue Shield of Illinois (BCBSIL) and AIM, recently implemented the Radiology Quality Initiative (RQI) program for all of its employees nationally.

Similar to our Regence program, ordering providers must contact AIM before scheduling the following outpatient advanced diagnostic imaging procedures for Sprint employees. It is necessary for imaging providers to verify that an order number has been obtained before scheduling and performing diagnostic imaging exams. The diagnostic imaging studies covered under this program include the following:




Nuclear Cardiology

Imaging studies performed in conjunction with emergency room services, inpatient hospitalization, outpatient surgery (hospitals and free-standing surgery centers), urgent care centers, or 23-hour observations are excluded from this requirement.

Sprint members participating in the RQI program can be identified by their unique three-character alpha prefixes appearing on their member identification (ID) cards. The unique alpha prefixes are SKL, SXX, SKP, SHM, SPW and SMT.

Physicians ordering diagnostic imaging services for Sprint members need to obtain an order number from AIM by calling 1 (866) 455-8415 or using the ProviderPortalSM at Physicians will need to give AIM the member’s ID number and alpha prefix from the BCBSIL ID card.

Sleep Medicine

Program reminders

We wanted to clarify the following related to our Sleep Medicine Program:

Supplies for APAP, CPAP, BPAP do not require pre-authorization.

Compliance information for APAP, CPAP, BPAP must only be submitted during the rent to purchase time period.

Once the equipment has been purchased, we do not require compliance information.

Cambia Health Solutions (group #6001408) is included in the Sleep Medicine Program effective for dates of service on or after January 1, 2015.


Personalized Care Support reimbursement and resources

Our nationally recognized Personalized Care Support program surrounds patients and families with

comprehensive services during serious health challenges.

Our program supports our members’ and their loved ones’

medical, psychosocial, behavioral and spiritual needs. Our 360-degree approach provides planning, communication and stability for patients and caregivers and facilitates health care needs from wellness all the way through completion of life.

As a participating provider or home health agency, you can be reimbursed for delivering quality care that honors your patients’ wishes for treatment, including:

Palliative care services

Goals of care conversations

Specialized care management

Our website includes the following helpful resources:

Personalized Care Support flyer – This document includes information about the benefits we cover and how to submit claims for the services listed above.

Personalized Care Support poster – This document provides a visual overview of our program and information about our commitment to improving high quality palliative care services across our community.

Palliative Care Payer/Provider Toolkit – This

comprehensive document defines palliative care and provides tools and resources.

Visit our website to learn more: Programs>Personalized Care Support.

Physical Medicine Program changes

Chiropractic authorization requirements eliminated for Medicare Advantage

Effective January 30, 2015, all authorization requirements for chiropractic CPT 98940, 98941, 98942 and 98943 will be removed from our Medicare Advantage Physical Medicine and Therapies CPT Code List.

Physical therapy waiver process

The waiver process will be enhanced effective February 1 in an effort to reduce administrative burden for Tier B and C physical therapists.

Tier B and C physical therapy providers will be eligible for a standard six visit waiver for the first new condition for the calendar year or for a condition previously receiving treatment if there has been a gap in care of more than 60 days.

Tier B providers will also be eligible for a second standard six visit waiver based on qualifying conditions for a new episode of care (new condition or gap in care of more than 60 days). Note: The second standard waiver will not NOT apply to Tier C providers.

Tier B and C providers will be eligible for a dynamic waiver for greater than six additional visits based on qualifying conditions supported by clinical documentation.

Subsequent requests during an existing episode will not be eligible for the standard or dynamic waiver for either Tier B or C providers.

Waiver period length: Effective February 1, we will change the waiver period length from 60 to 30 days as a result of statistical analysis of provider usage of waiver length. A date extension will be available if the waiver needs to be used over a 60 day period.

Functional outcomes collection

Effective February 1, in response to requests to include outcomes information for network categorization, it will now be optional to provide patient reported functional outcomes. This is a pilot to assess viability of using this information for future enhancements.



member surveys

Each year, our members are surveyed on various aspects of their health care experience through the Consumer Assessment of Health Care Providers and Systems (CAHPS®) survey and the Health Outcomes Survey (HOS).

These surveys will be conducted or distributed in the next couple of months.

Members report their perception of care and service delivered in provider offices. You have the ability to make a difference for our members.

Use our Provider Checklist for Member Surveys for more details about items you can review within your office and during patient visits to make a positive impact on the experience your patients have with the health care delivery system. This checklist is available on our website:

Library>Printed Material.

The survey results have an impact on our Medicare Star Ratings for measures relating to patient experience with the care they receive, such as appointment wait times, coordination of care between different providers, fall prevention, follow-up on test results, etc.

Annual update on network

accessibility results

Last fall, we surveyed a sample of family practice, general practice, internal medicine, specific specialties and behavioral health PPO and Medicare Advantage (PPO and HMO) and physician offices. The survey measured provider compliance with our accessibility and availability standards.

The standards included:

After-hours phone coverage

Treatment waiting room times (PPO only)

Advance directives (Medicare Advantage PPO and HMO only)

Appointment wait times for scheduling various types of visits

In general, the majority of our providers are compliant with the standards as expected. However, there is room for improvement in some areas where standards were not fully met, and we have contacted non-compliant offices.

We will also include additional articles in future issues of our newsletter to clarify key standards and expectations of all our participating providers. A summary of our network accessibility and availability findings is available on our website: Programs>Cost and quality>Quality Program>Accessibility and Availability Standards.

All participating providers should review our standards and implement any steps necessary to meet them.

Referring to in-network providers saves members money

As a reminder, except in cases of an emergency, you must refer members to participating

in-network medical and dental providers.

Referrals to non-participating providers should only be made after notifying the member in writing that services may not be covered or may result in higher out-of-pocket costs.

Use the Find a Doctor link on our website to locate in-network providers. Locate providers by name, location or specialty type.


Provider appeals updates

This month, we are making changes to the Appeals section of our provider website and to our appeal form for providers.

We have updated the Appeals page on our website to better define when a provider appeal is appropriate, when another type of dispute is appropriate, who to contact, and when to use the appeal form.

The Appeals page on our website includes information about:

How and where to submit disputes other than provider appeals as seen in the examples listed below:

Claim timely filing denial. Please contact Provider Relations.

Contractual pricing of a claim or claim line. Please contact Provider Relations.

Claim denied as a duplicate and no payment received. Please contact Provider Customer Service.

Claim denied as member’s payment responsibility. There is a member appeal process for this situation.

Claim denied for additional information that you are now submitting (e.g., Incident Report, Coordination of Benefits).

Other additional information requests. Please contact Provider Customer Service.

How and where to submit a provider appeal using the Appeal Form for Provider Billing Dispute and Medical Necessity Denial. Use the appeal form to disagree with our decision that:

Pre-authorization was not obtained

No admission notification was provided

Claim denied for not meeting our medical necessity criteria

National Correct Coding Initiative (NCCI) or Correct Coding Editor (CCE) coding rules apply to a claim or claim line

Claim denied as a duplicate when services were performed more than one time, and payment does not reflect multiple service payment

Note: The form has been updated and we ask that you begin using the new form now and discard any older versions you may have been using.

The form and additional process information will be available on our website by February 6: Claims and Payment>Receiving Payment>Appeals. The form is also available in the Library section under Forms.


Reminder: Electronic claims submission is required

If you are complying with our electronic claims submission requirement, we thank you! Last year, we received

19,631,000 American National Standards Institute (ANSI) 837 health care claim transactions (medical, dental and facility).

We’ve seen a significant reduction in the overall number of paper claims received. However, we continue to receive a high volume of paper claims every week. Avoid having your paper claims returned back to you by submitting them electronically which will save you time and avoid additional delays in claims processing

If you do not currently submit your claims to us electronically, we ask you to sign-up today using one of the options listed below available at no cost to you:

Availity Web Portal:

Dental providers at

Medical providers at and click Get Started under Register Now for Availity Web Portal

Office Ally™ at

Utah providers may also use the Utah Health Information Network (UHIN) at

Electronic claims may be submitted through many types of practice management software systems. If you currently use a vendor to submit your claims, please contact them to confirm that they can/will submit claims to

us electronically.

Note: Single sign-on access to the Availity Web Portal is also available via OneHealthPort for Oregon and Washington providers.

Did you know that claims, including the following, can also be submitted electronically?

Single claims

Corrected claims

Medicare crossover

Coordination of Benefits (COB)

Additional information, including how to submit the above types of claims electronically, is available on our website:

Claims and Payment>Claims Submission and Benefit Coordination.

Reminder: Sending unsolicited attachments can delay the processing of your claim. Please do not send attachments as part of an initial dental or medical claim (except as indicated on our clinical edits by code lists). If additional information is required to process your claim, we will send you a request.


ABA therapy services

Effective January 1, 2015, Applied Behavior Analysis (ABA) for the treatment of autism spectrum disorder is now a covered benefit for Oregon and Washington group and Individual members.

All services are subject to our medical and reimbursement policies including a diagnostic/prescriptive assessment and reviews for medical necessity.

New Oregon coverage for ABA services

The State of Oregon has established a Behavior Analysis Regulatory Board under the Oregon Health Licensing Agency. We will accept licensure from this Board for the credentialing of Board Certified Behavior Analyst (BCBA) network providers. We urge appropriate providers to apply for licensure as soon as possible. Licensure information and application forms are available online at http://www.oregon.

gov/OHLA/BARB/Pages/forms.aspx. Once licensure is complete, providers can begin the process of joining our network(s) by visiting the Contracting and Credentialing section of our website.

Additionally, BCBAs who can document that they were providing services as of August 14, 2013 (State of Oregon defines as “grandfathered providers”) can contact us to provide continued treatment to members. We will verify their status and pay for ABA services provided to our members in advance of completion of licensure if they meet the requirements detailed on our website: Contracting and Credentialing>Credentialing.

New code set for ABA services

The ABA services fee schedule for commercial business, effective January 1, 2015 utilizes the new CPT Category III codes.

New Washington coverage for ABA Services

New code set for ABA services

The ABA services fee schedule for commercial business, effective January 1, utilizes the new CPT Category III codes.

The existing Uniform Medical Plan fee schedule for ABA services remains unchanged. Both schedules, as well as a crosswalk between the code sets, are available on the fee schedules page in the Provider Center.

Medical policy and pre-authorization

Read the related Medical policy updates article on pages 10 and 11. View our ABA therapy medical policy and

pre-authorization requirements on our website:

Pre-authorization and Referrals>Commercial.


If you have questions, please contact your behavioral health provider relations representative. Contact information is available on our website in the Contact Us section.


Mental illness support available

Do you have patients living with mental illness or family members of patients who would benefit from support? The National Alliance on Mental Illness (NAMI) offers education, support and advocacy services at no cost to participants. A national organization, NAMI’s mission is to improve the lives of people living with mental illness, along with the lives of their families and loved ones.

NAMI offers free education classes and support groups taught by individuals with lived experience. NAMI also helps individuals and families navigate the mental health system through advocacy on the state and local levels. Their offerings include:

Family-to-Family: A free 12-week course for family members of individuals living with severe mental illness.

This class discusses the clinical treatment of these illnesses and teaches the knowledge and skills that family members need to care for themselves as well as their loved ones.

Peer-to-Peer: A free course for individuals living with mental illness with a focus on maintaining recovery. Telling their story, relapse prevention planning, and writing an advance directive for psychiatric care are included in this class.

NAMI Connection: A weekly recovery support group program for adults living with mental illness that is expanding in communities throughout the country. These groups provide a place that offers respect, understanding, encouragement and hope.

Family Support Groups: Weekly, drop-in groups for family members and friends who have a loved one living with a mental illness.

NAMI Basics: A new education program for parents and other caregivers of children and adolescents living with mental illness. This free course is taught by teachers who are the parent or caregiver of an individual who developed symptoms of mental illness prior to age 13. This course consists of six, 2 ½ hour classes.

To learn more about what your local NAMI has to offer, or to refer a patient, please contact your local state organization:

Idaho: NAMI Boise, (208) 376-4304,

Oregon: NAMI Oregon, (503) 230-8009,

Utah: (801) 323-9900,

Washington: NAMI Washington, (206) 783-4288,


Preventive health care coverage

We believe that preventive care and early detection are keys to the long-term health and well-being of our members. Our plans cover services that prevent infectious diseases, screen for serious illness and help our members stay well. When our members see participating providers, the preventive care services may be covered with no deductibles, coinsurance or copayment amounts. Please verify your patients’ coverage on the Availity Web Portal.

View our Preventive Health Care Coverage flyer on our website: Library>Printed Materials.

Submitting routine colonoscopy and sigmoidoscopy claims under Federal Reform

Please submit routine colonoscopy and sigmoidoscopy claims to us following these updated Federal Reform guidelines to ensure that these claims are processed and paid correctly.

Routine colonoscopies or sigmoidoscopies and all associated claims for screening (for example, pathology and anesthesia) must be billed with one or more of the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) V

diagnosis codes:

V76.41 Special screening for malignant neoplasms, other sites, rectum

V76.51 Special screening for malignant neoplasms, colon

V16.0 Family history of malignant neoplasm, gastrointestinal tract

V18.51 Family history of colonic polyp

Routine screenings that become diagnostic (i.e., due to detection of a suspected pathology) should be billed with Modifier 33 Preventive Service or Modifier PT Colorectal Cancer Screening test, converted to diagnostic test or other procedure to indicate the original intent of the procedure was for preventative screening. (For example, during a scheduled routine screening colonoscopy several suspicious lesions are discovered and multiple biopsies of the lesions are obtained by the surgeon. The surgeon would bill CPT 45380 PT.)

For members under 50 years of age, the appropriate V diagnosis code should be used in the primary field. If polyps are removed, the V diagnosis code should be used in the primary field and 211.3 diagnosis code should be used in the secondary field. Please refer to page 2 of the MLN Matters® Number: SE0746 and-Education/Medicare-Learning-Network-MLN/


For more information about Modifier PT, please refer to page 3 of the MLN Matters® Number: MM7012 at Learning-Network-MLN/MLNMattersArticles/downloads/


The following will not be paid under Federal Reform and the member will incur cost-sharing amounts according to his or her medical benefits.

Screenings services billed with other diagnoses codes (for example, personal history ICD-9-CM V10-V15) or is outside of the age or frequency guidelines.

A procedure that is diagnostic and not a screening will not be paid at 100%; it will be covered as a regular medical benefit. For example, if a physician orders the procedure due to a medical condition or orders any subsequent diagnostic colonoscopies, these procedures are not routine screenings and will not be paid at the Federal Reform benefit level of 100%.





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