BLUE REVIEW - Health Insurance Montana · a newsletter for montana health care providers second quarter 2016 blue review sm please contact your ... extension 6100 or at [email protected]

VISIT OUR WEBSITE AT BCBSMT.COM 1

A NEWSLETTER FOR MONTANA HEALTH CARE PROVIDERS SECOND QUARTER 2016

BLUE REVIEWSM

PLEASE CONTACT YOUR PROVIDER NETWORK REPRESENTATIVE IF YOU HAVE ANY QUESTIONS AND/OR IF YOU NEED ADDITIONAL INFORMATION.

Western Region:

Christy McCauley, 406-437-6068, [email protected]

Leah Martin, 406-437-6162, [email protected]

Central Region:

Floyd Khumalo, 406-437-5248, [email protected]

Eastern Region:

Susan Lasich, 406-437-6223, [email protected]

Troy Smith, 406-437-5214, [email protected]

Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationBlue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 352628.0516

INSIDE THIS ISSUEProvider Network Representative Contact Information . . . . . . . . . . . . . . . . . . . . . . .1

The 2015 Social Responsibility Report Is Live Online. . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Corrected Claim Request Alert: Changes Effective July 11, 2016 . . . . . . . . . . . . . . . . . . . . .3

Electronic Option to Replace Duplicate Provider Claim Summary Requests. . . . . . . . . . . .3

Blue Distinction® . . . . . . . . . . . . . . . . . . . . . . . . .4

Air Ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . .5

HELP Plan Update . . . . . . . . . . . . . . . . . . . . . . . . .6 • NDC • Rural Health Centers (RHC)/ Federally Qualified Health Center (FQHC) Claims

Insurers Now Required by CMS to Conduct Audit for ACA’s Risk Adjustment Program . . . . . .8

Update your Information . . . . . . . . . . . . . . . . . . .8

2016 New Product for BCBSMT – Blue Focus POSSM . . . . . . . . . . . . . . . . . . . . . . . . .9

Getting on the Same Page for Quality Health Care. . . . . . . . . . . . . . . . . . . . .9

Alpha Prefix Reference Guide . . . . . . . . . . . . . .10

Administrative Service Group Tables . . . . . . . . .10

A Message from the Special Investigations Department Regarding Massage Therapy Services . . . . . . . . . . . . . . . . . . . . . . . .11

Annual Medical Record Data Collection for Quality Reporting begins Feb. 1, 2016 . . . . .11

ClaimsXtenTM 2nd Quarter 2016 Updates and New Specialty Pharmacy Rule Notification . . . .12

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2016 . . . . .13

News from DPHHS: . . . . . . . . . . . . . . . . . . . . . .16 • FFY 2014 PERM Medical Review findings • Hepatitis C Prior Authorization Request Form • Health in the 406

The 2015 Social Responsibility Report Is Live Online

I invite you to review our 2015 Social Responsibility Report and share it with your colleagues and employees. Through videos, graphics and member stories, you’ll see how our company and employees are making a difference http://bcbsmt2015srr.com/ a-message-from-the-president/ in the health and well-being of our communities.

Mike Frank, PresidentBlue Cross and Blue Shield of Montana

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http://www.bcbsmt.com

http://bcbsmt2015srr.com/a-message-from-the-president/



BCBSMT celebrated its 75th birthday in 2015

600 Montana-basedemployees

3,500 vaccinesadministered throughour Care Van

More than 7,000 hours of volunteer service

$830,000 invested in Montana communities

450 providers participating in our Patient-Centered Medical Home program

3,433 employer groups with whom we partner to provide health care coverage

38,000 Montanans who enrolled in new Montana HELP Plan Medicaid Expansion

575 children participated in the new Governor’s Cup Kids Marathon program

Our 2015 Social Responsibility Report, now available online, demonstrates through stories, photos and videos how our employees across five states and the company are giving back to improve the lives of people in the communities we serve.

AGAIN THIS YEAR, WE’VE HAD AN IMPRESSIVE IMPACT:

• Increased employee volunteerism by 53 percent, with nearly 220 employees volunteering more than 7,000 hours

• Set a new milestone of over $11,500 in matching funds for nine organizations• Provided over 3,000 immunizations to more than 2,500 individuals via the Care Van®, as

part of our Healthy Kids, Healthy Families initiative, which focuses on nutrition, physical activity, disease prevention and management, and supporting safe environments

• Hear from members as they share personal impressions:• Martha, a first-time mom who turned to the 24/7 Nurseline when she needed immediate

advice on caring for her newborn• Maricruz, who credits an email about wellness for leading to life-saving treatment• Mike, facing multiple weight-related health issues, made dramatic lifestyle changes

HIGHLIGHTS

The report shows how we live our commitment to social responsibility through corporate and employee giving, diversity and inclusion, sustainability, ethics and compliance, and promoting wellness. And it demonstrates how we align our community investments with our business objectives, partnering with community organizations to serve at-risk communities and address chronic health disparities.

The infographic to the right highlights a few of the accomplishments showcased in our 2015 Social Responsibility Report. We invite you to review the report, share it with your business and personal networks and promote it through the social media links provided. You can copy and paste this image into an email to bring the report to life when you email your contacts.

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Electronic Option to Replace Duplicate Provider Claim Summary RequestsEffective July 11, 2016, duplicate copies of paper Provider Claim Summaries (PCSs) may no longer be requested by calling Provider Customer Service and duplicate PCSs will no longer be provided by our Customer Advocates.

Providers who currently receive paper PCSs via U.S. Mail are strongly encouraged to enroll to receive the 835 Electronic Remittance Advice (ERA) from Blue Cross and Blue Shield of Montana (BCBSMT). The 835 ERA is a HIPAA-compliant method of receiving claim payment and remittance details, which can be automatically posted to your patient accounting system, if available. In addition, you may retrieve duplicate remittances through electronic channels. To learn more about ERA enrollment, refer to the Claims & Eligibility section of our website at bcbsmt.com/provider.

Corrected Claim Request Alert: Changes Effective July 11, 2016Effective July 11, 2016, corrected claim requests for previously submitted electronic and paper claims can no longer be initiated by calling Provider Customer Service. Additionally, these requests will not be accepted via the Claim Inquiry Resolution option in our Electronic Refund Management (eRM) tool.

ELECTRONIC SUBMITTERS

The Blue Cross and Blue Shield of Montana (BCBSMT) claim system recognizes claim submission types based on claim frequency code submitted on professional (837P) and institutional (837I) electronic claims. Replacement claims (sometimes referred to as corrected claims) submitted electronically are identified by using claim frequency code 7; voided or canceled claims are identified by using claim frequency code 8. Please note that the electronic replacement claim will replace the entire previously processed claim. Therefore, when submitting a correction, send the claim with all changes exactly how the claim should be processed.

PAPER SUBMITTERS

More than 98% of the claims received from our providers are submitted electronically. BCBSMT encourages our providers to consider the web as the primary resources for administrative inquiry channel. There are several multi-payer web vendors available to our providers or they can visit www.hewedi.com to register.

BCBSMT requires “corrected claim” to be indicated on the claim form or on the Claim Review Form when submitting corrections on a paper claim. Effective July 11, 2016, any changes to a claim that are indicated only on the Claim Review Form or via a letter will be returned with a notice advising resubmission on the appropriate professional (CMS-1500) or institutional (UB-04) paper claim form. The Claim Review Form is available in the Education and Reference/Documents section of our Provider website, under Corrected Claim or Claim Review Request Form. Refer to the form for additional instructions.

Additional information will be included in upcoming issues of the Blue Review, as well as the News and Updates on our website at bcbsmt.com/provider.


https://www.bcbsmt.com/provider



Blue Distinction For more than 75 years, Blue Cross and Blue Shield (BCBS) has been an integral leader in healthcare delivery and benefit design across communities nationwide. BCBS Plans offer unmatched experience and insight gained from insuring nearly 105 million members to deliver substantial value to employers and their employees.

Healthcare delivery is rapidly changing, and a renewed focus on delivering value—a combination of quality and cost—is critical. With a deep local presence, unprecedented national scale and the largest provider networks in the industry, no one is better positioned—or more committed—to drive value than BCBS.

Through Blue Distinction, BCBS Plans offer a suite of flexible national solutions that makes it simple to identify high-performance providers and design benefits tailored to meet employers’ specific objectives. The Blue Distinction suite includes two programs:

• Blue Distinction® Specialty Care recognizes healthcare facilities that demonstrate proven expertise in delivering safe, effective and cost-efficient care for select specialty areas. The program targets procedures and episodes of care in areas of high or increasing demand with variation in quality and cost across facilities.

• Blue Distinction® Total Care recognizes physicians, group practices and hospitals participating in locally tailored programs (Patient-Centered Medical Homes, Accountable Care Organizations or similar programs) designed to lower cost trend through better coordinated care and performance-based payment.

The Blue Distinction Specialty Care Program relies on objective, nationally consistent quality and affordability criteria, enabling BCBS Plans to recognize facilities in their service areas that demonstrate expertise in delivering quality specialty care—safely, effectively and cost-efficiently. The foundation of the Blue Distinction Specialty Care Program is the quality-focused Blue Distinction® Center (BDC) designation. An additional and more select value-based designation, Blue Distinction® Center+ (BDC+), further distinguishes facilities delivering quality, cost-efficient specialty care.

Facility/Organization Name Program Type Designation Type

Benefis Healthcare Hospital Knee and Hip Replacement BDC

Benefis Healthcare Hospital Maternity Care BDC+

Benefis Healthcare Hospital Spine Surgery BDC+

Billings Clinic Cardiac Care BDC

Billings Clinic Knee and Hip Replacement BDC

Billings Clinic Maternity Care BDC+

Bozeman Health Knee and Hip Replacement BDC

Bozeman Health Maternity Care BDC+

Community Medical Center Hospital Knee and Hip Replacement BDC

Community Medical Center Hospital Maternity Care BDC+

Kalispell Regional Hospital Knee and Hip Replacement BDC

Kalispell Regional Hospital Maternity Care BDC+

Kalispell Regional Hospital Spine Surgery BDC

Providence St Patrick Hospital Maternity Care BDC

Quality is keyOnly those facilities that first meet Blue Distinction Centers’ objective, nationally consistent quality criteria will be considered for designation as a Blue Distinction Center+.

Blue Distinction Centers and Blue Distinction Centers+ help employers encourage employees to select quality facilities and control costs. Easy-to-use tools such as the Blue Distinction® Center Finder and National Doctor and Hospital FinderSM help employees, and referring physicians, make better informed decisions and locate designated facilities that will meet their needs.



Air Ambulance Services Blue Cross and Blue Shield of Montana (BCBSMT) partners with our network hospitals and providers in the state to mitigate the impact of the health care costs that continue to reach unprecedented levels for Montanans. The use of out-of-network providers can create avoidable financial hardships for our members. To address that issue, BCBSMT is currently focusing on the immediate concerns with air ambulance services by creating a directory of our participating air ambulance providers to assist our members and your patients in seeking quality, affordable care.

To ensure our members receive the full air ambulance benefits of their BCBSMT health care plan, we urge you to transport our members via in-network air ambulance providers whenever possible, potentially saving your patients thousands of dollars.

Thank you for all you do to ensure the health and well-being of our members, and we appreciate your further collaboration to ensure that your patients continue to receive the best care possible without the adverse impacts of out-of-network costs.

Should you have any questions about this communication, please contact us at 1-800-447-7828, Extension 6100 or at [email protected].

Blue Cross and Blue Shield of Montana (BCBSMT) Air Ambulance Network

Provider Phone Number Rotor Fixed Wing

Benefis Healthcare Mercy Flight Communication Center at 1-800-972-4000 • •

Billings Clinic Hospital 1-800-325-1774 •

Kalispell Regional Hospital 1-866-302-9767 • •

MT Medical Transport 406-457-8205 •

NE Montana Stat Air STAT Air Dispatch Line: 1-800-992-7828 (Montana toll-free); 406-228-3500 (Out of State)

•

St Vincent’s Healthcare 1-800-JET-HELP ( 1-800-538-4357) • •

Disclaimer: A provider’s participation status may change. Contact Customer Service using the phone number on the back of the members health plan ID card to obtain the most up to date information.



HELP Plan UpdateDuring the 2015 Legislative session, the Montana Legislature enacted the Montana Health and Economic Livelihood Partnership (HELP) Act which expands health care coverage for state residents between the ages of 19 and 64, whose household income is 138% or less of the federal poverty level (HELP Plan). The HELP Plan creates affordable health plan coverage and access to providers for this segment of the state’s population. BCBSMT was selected as the third party administrator (TPA) for the HELP Plan.

For general information on member eligibility, benefits, coverage and claims processing, please refer to the BCBSMT.com website/Providers/NetworkParticipation/TheHELP Plan. A slide presentation is also available on this site, in the Updates section.

The HELP Plan Provider Manual is now located under the Resources section of the HELP Plan page.

MONTANA HEALTHCARE PROGRAMS NOTICE Effective ImmediatelyOutpatient Hospital, Emergency Room, Podiatrist, Physician, Mid-Level Practitioner, Independent Diagnostic Testing Facility (IDTF), Birthing Center, Laboratory and X-Ray, Pharmacy, Public Health Clinic, Psychiatrist, and Ambulatory Surgery Center NATIONAL DRUG CODE (NDC) BILLING REQUIREMENTS

The Federal Deficit Reduction Act of 2005 mandates that all State Medicaid Programs require the submission of National Drug Codes (NDCs) on claims submitted with certain procedure codes for physician-administered drugs. This mandate affects all providers who submit claims for procedure-coded drugs both electronically and manually.

The HELP Plan requires all claims submitted for physician administered drugs to include the NDCs, the corresponding CPT/HCPCS codes, and the units administered for each code. The HELP Plan reimburses only in the case where a drug is manufactured by companies that have a signed rebate agreement with the Centers for Medicare and Medicaid Services (CMS).

A list of drug manufacturers who have a rebate agreement is on the Provider Information website at http://medicaidprovider.mt.gov/Portals/68/docs/current/labelersrebatecurrent.pdf.

When a procedure code requires an NDC, the HELP Plan covers only those NDCs that are rebateable.

An NDC is considered rebateable only if all of the following conditions are met:

• The drug is a HELP Plan covered drug.• The dispensed NDC is valid.• The drug dispensed is not terminated.• The drug is a product of an eligible manufacturer.• The DESI indicator is not 5 or 6.

The NDC on the claim must be the NDC that was dispensed to the member.


https://www.bcbsmt.com/provider/network-participation/the-help-plan


Rural Health Centers (RHC)/ Federally Qualified Health Center (FQHC) ClaimsSubmit claims for clinic services provided at an RHC or FQHC to DPHHS/XEROX on a UB-04 form with Type of Bill 711 for RHC and 771 for FQHC, and revenue code 521 for medical clinic services and 900 for mental health clinic services.

Submit claims electronically with the standard payor id billed for the Montana HELP Plan and the participant’s HELP Plan identification number on the ID Card with the YDM alpha prefix, or submit hard copy claims to:

Claims Processing Unit P. O. Box 8000 Helena, MT 59604

Bill inpatient, outpatient and Emergency Room services provided at an RHC/FQHC to BCBSMT on a CMS-1500 form, with places of services 21, 22 or 23, including the rendering provider, with the standard payor id billed for the Montana HELP Plan, and the participant’s HELP Plan identification number on the ID Card with the YDM alpha prefix, or submit hard copy claims to:

BCBSMT HELP Medicaid Claims Correspondence c/o Claims Processing P.O. Box 3387 Scranton, PA 18505 Fax: 855-206-9202

Contact InformationIf you have any questions regarding the Physician-Administered Drug Rebate Program, please contact your Provider Network Representative at 1-800-447-7828, extension 6100.

For claims questions or additional information, contact Provider Customer Service at 1-877-296-8206 (toll-free, in/out of state).

NDC FormattingWhen billing the HELP Plan, the required NDC is 11 digits. The NDC should be structured in the 5-4-2 format. Some manufacturers omit leading zeros in one of the three positions. This results in a 10 digit number, which is invalid. To ensure proper payment, the provider must add the appropriate leading zero to the affected segment of the format.

The table below indicates where the leading zero should be placed in three separate examples.

NDC Example Conversion: 10-Digit to 11-Digit Format

Leading Zero Location 10-Digit Examples Add Zero

5-digit segment XXXX-XXXX-XX 0XXXX-XXXX-XX

4-digit segment XXXXX-XXX-XX XXXXX-0XXX-XX

2-digit segment XXXXX-XXXX-X XXXXX-XXXX-0X



Insurers Now Required by CMS to Conduct Audit for ACA’s Risk Adjustment ProgramStarting in 2016, the Centers for Medicare and Medicaid Services (CMS) requires an annual Initial Validation Audit (IVA) to ensure high quality data is used when assessing the payment transfers for the Affordable Care Act’s (ACA) Risk Adjustment (RA) program. Therefore to comply, Blue Cross and Blue Shield of Montana (BCBSMT) is asking for your cooperation and participation in the required Initial Validation Audit (IVA).

Since insurers are required to hire an independent auditor to perform the requirements of the IVA, BCBSMT will be working with Tactical Management Incorporated (TMI) to retrieve medical records. The audit is expected to begin in July 2016. The RA program applies to all ACA compliant individual and small group plans, both on-and-off the exchange and conducts a calculation based on enrollee risk. As you are aware; enrollee risk is calculated based on the diagnosis codes submitted on a claim, as well as through supplemental code capture through medical record review. As BCBSMT providers, you may be asked to provide medical records directly to the auditor in order to validate all of the diagnosis codes used in the RA calculation within the time frame requested. The IVA requires medical records in order to validate the claims data to CMS on an annual basis. It is of utmost importance that you respond to these requests timely.

The IVA will be performed on a sample of enrollees enrolled in ACA compliant plans. Again, this includes individual and small group plans, both on-and off-the exchange. The IVA auditor will validate medical claims of the sampled enrollees from the previous year. For example, this audit will be conducted in 2016, but will review mainly claims with dates of service in 2015. Please be aware some of these claims may have been paid in 2016 and are likely to be included in the sample.

We understand that this is a very busy time; however, in an effort to complete the audit, we appreciate your full support and cooperation as you receive requests from TMI and delivery of the medical record(s) in a timely manner. We want to ensure that the valuable care that you provide to your patients every day is accurately reflected in the data that you provide to auditors for CMS records.

Additional information will be provided in the upcoming months.

Update Your InformationThe Centers for Medicare & Medicaid Services is placing a renewed focus on Medicare Advantage plan provider networks, with emphasis on both online provider directories and network adequacy. This process was further updated with the release of a November 13, 2015 memo.

Pursuant to the CMS memo, effective immediately, “Medicare Advantage Organizations and Medicare-Medicaid Plans should proactively conduct at least quarterly communications with contracted providers to ensure that the required information in the directory is accurate. Additionally, to be consistent with Marketplace rules, we are defining the previous requirement that online directories be updated in real time to mean within 30 days.”

“Required information” is defined in section 100.4 of the Medicare Marketing Guidelines as:

• Provider Name and Title• Accepting New Patients• Email Address• Practice location • Tax ID• City/State/ZIP• Phone number /Appointment number• Office Fax Number• Office Hours• Specialty – Primary and Secondary• Street address

To ensure network adequacy, having accurate provider data is critical for your practice to ensure our members, your patients, are able to find you in our provider directory. Please notify us promptly of any changes by going to our website bcbsmt.com/provider, under Education and Resources, Forms and Documents.




2016 New Product for BCBSMT – Blue Focus Point of Service (POS) BCBSMT introduced a new product for individuals and families in the Billings and Missoula areas of the state in 2016 – the Blue Focus POS plan. This new product offering, available on and off the Marketplace, includes a limited number of professional providers and facilities in seven counties:

• Lake• Missoula

• Yellowstone• Carbon

• Stillwater• Musselshell

• Sweet Grass

For a list of the participating providers, please go to bcbsmt.com, Doctor or Hospital provider finder. You can recognize these members by the YDR or YDN alpha prefix on their ID card. If you are not participating in this network, please let your patients know prior to the time of service so they are not surprised by out-of-network costs.

Blue Focus POS offers members a lower premium and better benefits when accessing an in-network provider. The member can access a broader provider network but those services will be subject to out-of-network benefits. Under the Blue Focus POS product, members will select a primary care physician (PCP), but referrals are not required. However, pre-authorizations are required for certain services in order to receive in-network cost-sharing benefits. The inclusion of POS plans provides our members with an additional plan option to fit their individual needs while allowing BCBSMT to remain competitive on the market. It is important to make sure doctors and hospitals are in a member’s network when referring them for additional medical services. By staying in-network, members may reduce or even avoid additional out-of-pocket expenses. If you have questions, please call your BCBSMT provider representative. BCBSMT members can call the toll-free Customer Service number listed on the back of their ID card.

A POS gives members access to a select group of contracted doctors and hospitals.

When a member signs up, they must select a primary care physician (PCP). If you are a PCP, you are the patient’s first point of contact for most of their basic health care needs.

In POS patient needs special tests or needs to see a specialist, preauthorization may be required.

Remind patients that hospital emergency departments are the right place to go when they have an emergency illness or serious injury ... but they’re not designed to provide routine health care or treat minor problems.

Getting on the Same Page for Quality Health Care

How can we define specific metrics that measure the quality of health care? Learn about a new collaborative

that addresses that issue in the latest Huffington Post column from our Chief Medical Officer Dr. Stephen Ondra.

Measuring the cost of care is a bit simpler than defining metrics that measure quality. The latter is very complex, requiring coordination by many stakeholders and lots of data. In Dr. Stephen Ondra’s latest Huffington Post column, Getting on the Same Page for Quality Health Care, he talks about the Core Quality Measures Collaborative. This unprecedented effort brings together major provider organizations, employers and consumers, and a group of health care payers, including the Centers for Medicare and Medicaid Services, that collectively provide coverage for over 70 percent of insured Americans.

Dr. Ondra is senior vice president and enterprise chief medical officer of our health insurance Plans in Illinois, Montana, New Mexico, Oklahoma and Texas. He said, “The effort strikes at the heart of a key question in health care: how do we measure where we are, where we wish to go and how well we are progressing towards achieving higher quality while also managing costs?”

Learn about the key goals of this collaborative in Dr. Ondra’s latest article. Watch for future HuffPost articles from Dr. Ondra in this newsletter, and follow him on Twitter at @StephenOndra where he tweets about his work and the future of health care.

Remind your patient to use

ER for emergencies only

EMERGENCY

Help your patient stayin-network

Remind your patient to

go to their PCP

Help your patient get

pre-authorization




Alpha-prefix ReferenceTo accommodate for our increasing lines of business, BCBSMT has adopted several new alpha-prefixes as part of the member identification numbers. For more information, contact your Network Provider Representative or call 406-437-6100. The listing of alpha-prefixes is also posted to our provider portal under “Forms and Documents”.

Individual And Small Group Business

YDF Small group PPO plans purchased on the Health Care Exchange

YDG Individual PPO plan purchased on the Health Care Exchange

YDK Individual PPO plan purchased through BCBSMT

YDI Multi-State PPO Plan

YDR Blue Focus POS purchased on the Health Care Exchange

YDN Blue Focus POS purchased through BCBSMT

YDM Health and Economic Livelihood Partnership (HELP) plan

YDJ Medicare Advantage PPO Plan

YDL Medicare Advantage HMO

YDU Medicare Supplement

Group Business

BCH Billings Clinic

BHX Benefis Health System

GBA Glacier Bancorp, Inc.

MVA Montana University System

NNW Northwestern Energy

PTX Pipe Trades Trust

SSW Stillwater Mining Company

R Federal Employee Program (FEP)

YDT Yellowstone County

YDC Employee Healthlink PPO

YDD Healthlink PPO

YDE Traditional (including HMK)

YDS Blue Preferred PPOSM

Administrative Service Group TablesBCBSMT is now posting Administrative Service Group (ASG) tables on the secure provider web portal under the Compensation tab, and will not be sending hard copies of these tables to providers. The online ASG tables will be updated monthly.

On behalf of nearly 295,000 members of BCBSMT, thank you for your continued participation in our provider networks. Your cooperation and commitment continue to enable BCBSMT and employers to offer valuable and affordable health insurance products and benefits to Montanans. If you have any questions or comments, please contact your Network Management Representative at 1-406-437-6100.



A Message from the Special Investigations Department Regarding Massage Therapy ServicesA common issue frequently addressed by the Blue Cross and Blue Shield of Montana (BCBSMT) Special Investigation Department (SID) involves providers billing for services performed by massage therapists.

Services rendered by a massage therapist cannot be billed under another provider’s name and/or BCBSMT/NPI ID number, regardless of any affiliation or contractual agreement between the two entities. Claims for services provided by a massage therapist should be billed under the massage therapists NPI ID number.

The BCBSMT Provider Manual addresses the billing of services under another provider’s name in Chapter Three of the BCBSMT Provider Manual, which states on page 3-4 that “Providers must submit claims for services under the provider number assigned to them; submitting claims for payment under another provider’s number is considered fraud as defined under Montana Code Annotated 33-1-1202(1).”

Licensed providers should submit claims to BCBSMT under their name and BCBSMT/NPIID number for services they provide a patient. This will ensure correct reimbursement from BCBSMT. In short, do not bill for services you did not provide. To do otherwise may be considered fraud under Montana law.

For assistance in determining a patient’s massage therapy benefits, call the Customer Service number on the back of the member’s ID card.

If you have questions regarding the billing of services provided by a massage therapist in your office, please contact your BCBSMT Provider Network Specialist.

Annual Medical Record Data Collection for Quality Reporting begins Feb. 1, 2016BCBSMT collects performance data using specifications published by the National Committee for Quality Assurance for Healthcare Effectiveness Data and Information Set (HEDIS) and by the U.S. Department of Health and Human Services for the Quality Rating System (QRS). HEDIS is the most widely used and nationally accepted effectiveness of care measurement available and HHS requires reporting of the QRS measures. These activities are considered health care operations under the Health Information Portability and Accountability Act Privacy Rule and patient authorization for release of information is not required.

BCBSMT may be contacting your office or facility in February 2016 to identify a key contact person and to ascertain which data collection method your office or facility prefers (fax, secure email, or onsite or remote EHR access). Appointments for onsite visits will be scheduled with your staff, if applicable. You will then receive a letter outlining the information that is being requested, and the medical record list with the members’ name and the identified measures that will be reviewed. If you receive a request for medical records, we encourage you to reply within 7 to 10 business days.

If you have any questions about medical record requests, please contact the BCBSMT HEDIS Department at 406-437-6462.

HEDIS is a registered trademark of NCQA.



ClaimsXtenTM 2nd Quarter 2016 Updates and New Specialty Pharmacy Rule NotificationBlue Cross and Blue Shield of Montana (BCBSMT) reviews new and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten code auditing tool software by the software vendor and are not considered changes to the software version. BCBSMT will normally load this additional data to the BCBSMT claim processing system within 60 to 90 days after receipt from the software vendor and will confirm the effective date via the News and Updates section of the BCBSMT Provider website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) also will be posted on the BCBSMT Provider website.

Beginning on or after July 18, 2016, BCBSMT will enhance the ClaimsXten code auditing tool by adding the second quarter 2016 codes and bundling logic into our claim processing system. BCBSMT will also implement a new Specialty Pharmacy Knowledge Pack rule into our claim processing system. This new rule will apply to professional and outpatient facility claims with dates of service on or after July 18, 2016. The new rule is summarized below:

The Specialty Pharmacy Knowledge Pack rule will audit professional and outpatient facility claims involving specialty pharmaceuticals utilizing the following parameters:

• HCPCS J-code and diagnosis as defined by the U.S. Food and Drug Administration (FDA) labeling

• HCPCS J-code and maximum billable units • HCPCS J-code and age • HCPCS J-code and gender • HCPCS J-code and place of service • HCPCS J-code with any combination of the elements listed above

This rule will deny claim lines found not payable according to guidelines provided by the FDA and National Comprehensive Cancer Network.

For more information, including answers to frequently asked questions refer to the ClaimsXten page in the Claims & Eligibility section of our Provider website. Information also may be published in upcoming issues of the Blue Review.

ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.

CPT copyright 2015 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.



BRAND MEDICATIONS MOVED TO A HIGHER OUT-OF-POCKET PAYMENT LEVEL ON THE STANDARD DRUG LIST, EFFECTIVE APRIL 1, 2016

Non-Preferred Brand1,2 Condition Used For Generic Preferred Alternative(s)2 Preferred Brand Alternative(s)1,2

Aptivus Aniviral/HIV N/A Prezista, Kaletra

Complera Aniviral/HIV Nevirapine ER Sustiva, Atripla, Intelence, Viramune

Crixivan Aniviral/HIV N/A Prezista, Kaletra

Egrifta Aniviral/HIV N/A N/A

Emtriva Aniviral/HIVAbacavir, Abacavir/Lamivudine/

Zidovudine, Didanosine CR, Lamivudine, Stavudine, Zidovudine

Videx Pediatric, Truvada, Viread

Fuzeon Aniviral/HIV N/A N/A

Invirase Aniviral/HIV N/A Prezista, Kaletra

Lexiva Aniviral/HIV N/A Prezista, Kaletra

Norvir capsule Aniviral/HIV N/A Norvir tablet

Rescriptor Aniviral/HIV Nevirapine ER Sustiva, Atripla, Intelence, Viramune

Reyataz Aniviral/HIV N/A Prezista, Kaletra

Selzentry Aniviral/HIV N/A N/A

Tybost Aniviral/HIV N/A Norvir tablet

Viracept Aniviral/HIV N/A Prezista, Kaletra

Vitekta Aniviral/HIV N/A Tivicay, Isentress

BRAND MEDICATIONS ADDED TO THE STANDARD AND GENERICS PLUS DRUG LISTS, EFFECTIVE APRIL 1, 2016

Preferred Brand1 Drug Class/Condition Used For

Nuwig Hemophilia

Serevent Asthma/COPD

Strensiq Hypophosphatasia (HPP)

BRAND MEDICATIONS ADDED TO THE STANDARD DRUG LIST, EFFECTIVE APRIL 1, 2016

Preferred Brand1 Drug Class/Condition Used For

Cotellic Cancer

Synjardy Diabetes

Tresiba Diabetes

Zarxio Neutropenia

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2016DRUG LIST (FORMULARY) CHANGESBased on the availability of new prescription medications and the Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions were made to the BCBSMT standard drug list and generics plus drug list effective April 1, 2016.




DISPENSING LIMIT CHANGES

The BCBSMT standard and generics plus prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on U.S. Food and Drug Administration (FDA) approved dosage regimens and product labeling.

EFFECTIVE APRIL 1, 2016, DISPENSING LIMITS FOR THE FOLLOWING DRUGS WERE ADDED TO THE STANDARD LIST:

Drug Class and Medication1 Dispensing Limit

Addyi

Addyi (flibanserin) tablets 30 tablets per 30 days

Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker

Corlanor (ivabridine) tablets 60 tablets per 30 days

Natpara

Natpara (parathyroid hormone) 28 cartridges per 28 days

Neprolysin Inhibitors

Entresto (sacubitril/valsartan) tablets 60 tablets per 30 days

Topical NSAIDs

Flector (diclofenac patch) 60 patches per 30 days

Pennsaid (diclofenac solution) 1.5% 2 bottles per 30 days

Pennsaid (diclofenac solution) 2% 2 pumps per 28 days

Voltaren Gel 10 tubes per 30 days

UTILIZATION MANAGEMENT PROGRAM CHANGES

Effective April 1, 2016, several drug categories and/or targeted medications were added to the current Prior Authorization (PA) and Step Therapy (ST) programs for standard pharmacy benefit plans.

DRUG CATEGORIES ADDED TO THE PHARMACY PA STANDARD PROGRAMS, EFFECTIVE APRIL 1, 2016

Drug Category Targeted Medication(s)1, 2

Non-Specialty Programs

Addyi Addyi

Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker Corlanor

Neprilysin Inhibitor Entresto

Opioid Induced Constipation Movantik, Relistor

Therapeutic AlternativesAbsorica, Amrix, Ativan, Bupap, Cambia, Carac/Fluorouracil, Cuprimine,

Daraprim, Dexpak, Durlaza, Fortamet, generic diclofenac gel, Glumetza, Pandel, Primlev, Rayos, Solaraze, Vivlodex

Specialty Programs

Natpara Natpara





DRUG CATEGORIES ADDED TO THE PHARMACY PA STANDARD PROGRAMS, EFFECTIVE APRIL 1, 2016


Non-Specialty Programs

Addyi Addyi

Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker Corlanor

Neprilysin Inhibitor Entresto

Opioid Induced Constipation Movantik, Relistor

Therapeutic AlternativesAbsorica, Amrix, Ativan, Bupap, Cambia, Carac/Fluorouracil, Cuprimine,

Daraprim, Dexpak, Durlaza, Fortamet, generic diclofenac gel, Glumetza, Pandel, Primlev, Rayos, Solaraze, Vivlodex

Specialty Programs

Natpara Natpara

TARGETED DRUGS ADDED TO CURRENT PHARMACY PA STANDARD PROGRAMS, EFFECTIVE APRIL 1, 2016


Kalydeco Orkambi

Pulmonary Arterial Hypertension (PAH) Uptravi

Self-administered Oncology Alecensa, Cotellic, Ninlaro, Tagrisso

DRUG CATEGORIES ADDED TO THE PHARMACY ST STANDARD PROGRAMS, EFFECTIVE APRIL 1, 20163


Topical Non-Steroidal Anti-Inflammatory Drug Flector, Pennsaid, Voltaren

TARGETED DRUGS ADDED TO CURRENT PHARMACY ST STANDARD PROGRAMS, EFFECTIVE APRIL 1, 20163


Infertility Bravelle

Targeted mailings were sent to members affected by formulary change, dispensing limit and prior authorization program changes per our usual process of member notification prior to implementation. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our website at bcbsmt.com/provider.

1Third party brand names are the property of their respective owners2These lists are not all inclusive. Other medications may be available in this drug class.

3Members on a current drug regimen will be grandfathered from participation in the ST program.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSMT contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSMT, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.





NEWS FROM DPHHS:FFY 2014 PERM Medical Review findingsThe Payment Error Rate Measurement (PERM) is a federally mandated audit that occurs every three years. PERM reviews medical payments for Medicaid and CHIP programs. Montana’s FFY2014 PERM audit found few Medical Record Review Errors. The errors were: number of units billed incorrectly; missing pharmacy signature log (ARM 37.86.1102); missing documentation in medical records; and date of service in medical record not matching billed date of service. Providers are encouraged to review their claims for accuracy to avoid future errors.

DPHHS would like to thank providers for their response to the PERM Medical Record requests and timely submission of records. Additionally, we would like to thank all our providers for the excellent services you provide to Montana families. Montana’s next PERM cycle will begin in October 2016. Providers can expect to see Medical Record Requests beginning August 2017. Please review newsletters for future PERM updates.

Please contact Heather Smith with DPHHS Program Compliance Bureau for any PERM questions, 406-444-4171, [email protected]

Providers may also visit the CMS provider web page at any time to become familiar with the entire PERM Process.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/Providers.html

In case you missed it…..In January, DPHHS launched a new series of public health messages called the Health in the 406.

The new series of health messages (they are only three short bullet points with links to more info) focus on various public health topics designed to raise awareness and help Montanans live healthier lives.

To sign up to receive these short email messages, go to healthinthe406.mt.gov

• Fill in email and name and hit ‘subscribe’.

• You will receive a message from healthinthe406 Confirmation.

• Click the link within the message. The message “Your membership has been confirmed” will display.

• Once the confirmation steps are complete you will receive the next scheduled Health in the 406 message.

We are also turning many of the messages into news releases, and partnering with local providers (local physicians, dentists, etc) to help get our messages out to the general public. As one example, TV reporters in Butte, Bozeman and Helena all recently interviewed dentists/dental hygienists and parents on the topic of oral health.




http://www.healthinthe406.mt.gov


Montana Healthcare Programs NoticeThe Montana Medicaid Pharmacy Program has streamlined the prior authorization request form for the Hepatitis C treatment. The newly updated Montana Medicaid Prior Authorization Request for Hepatitis C Treatment can be found under the Forms P-Z section of the Montana Medicaid Provider webpage (http://medicaidprovider.mt.gov/forms). Instead of having a separate form for each Hepatitis C drug available, there is now one all-inclusive Hepatitis prior authorization form that requests all needed information and should be used for all Hepatitis C prior authorization requests.

IMPORTANT NOTES

• The criteria for Hepatitis C treatment has not changed.• Montana Medicaid will not accept forms completed by the providing pharmacy.

All Hepatitis C treatment prior authorization forms must be completed by the prescribing office.

CONTACT INFORMATION

Drug Prior Authorization Unit Mountain-Pacific Quality Health 3404 Cooney Drive Helena, MT 59602 406-443-6002 or 1-800-395-7961 (Phone) 406-513-1928 or 1-800-294-1340 (Fax)

If you have any questions regarding this provider notice, please contact Dave Campana, R.Ph. at 406.444.5951 or [email protected], or Katie Hawkins at 406.444.2738 or [email protected].

For claims questions or additional information, contact Provider Relations at 1-800-624-3958 (toll-free, in/out of state) or (406) 442-1837 (Helena) or via e-mail at [email protected].

Visit the Provider Information website at http://medicaidprovider.mt.gov.

Xerox State Healthcare, LLC P.O. Box 4936 Helena, MT 59604

Blue Review is a quarterly newsletter published for institutional and professional providers contracting with Blue Cross and Blue Shield of Montana. We encourage you to share the content of this newsletter with your staff. Blue Review is located on our website at bcbsmt.com/provider.

The editors and staff of Blue Review welcome letters to the editor. Address letters to:

BLUE REVIEWBlue Cross and Blue Shield of MontanaAttn: Julie Sakaguchi P.O. Box 4309 Helena, MT 59604 Email: [email protected] Website: bcbsmt.com

BCBSMT makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions regarding any of the products or services mentioned in this periodical, you should contact the vendor directly.



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