BlueLink - February 2019On Feb.1, we launched our prior authorization for genetic testing program. To make requesting a prior authorization easier, we have created a . step-by-step

Bluelink Family of health care plans Medical News & Updates February 2019 I Volume 21 I Issue 1

What’s Happening? • Horizon Foundation’s Speak(easy) Howard Campaign Offers Free Webinar Series

• BlueLink Tip — Requesting Prior Authorizations for Genetic Tests

• Save The Date for The CareFirst Pediatric Conference

• Effective March 1— Both CPT® Code 99050 and 99051 Available for Reimbursement

Health Care Policy • Effective Dates, CPT Codes and Policy Updates for February

• New Medical Technology Updates for February

Claims and Billing • Provider Reminder — An Inquiry vs. An Appeal How to Properly Submit Both

Provider Reminders • Care Management Updates — Effective Jan. 1

• Are You Up to Date on Best Practices and Quality Standards?

In Case You Missed It • Take Action Before Ordering Genetic Tests. See Details on the Genetic Testing Prior

Authorization Program

• CareFirst is Changing its Discharge Process

• BlueCard Member Claims Will Require Itemized Bills for Some Services

For more information, visit carefirst.com/bluelink

Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA by: First Care, Inc.). First Care, Inc., CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.

CareFirst of Maryland, Inc. and The Dental Network underwrite products in Maryland only.

http://www.carefirst.com/bluelinkhttps://provider.carefirst.com/providers/news/2019/02/take-action-before-ordering-genetic-tests/https://provider.carefirst.com/providers/news/2019/02/take-action-before-ordering-genetic-tests/https://provider.carefirst.com/providers/news/2019/01/carefirst-changing-discharge-process/https://provider.carefirst.com/providers/news/2019/01/bluecard-member-claims-will-require-itemized-bills/

BlueLink

What’s Happening?

Horizon Foundation’s Speak(easy) Howard Campaign Offers Free Webinar Series

The Horizon Foundation is partnering with the Institute for Healthcare Improvement and The Conversation Project to offer a free 6-week webinar series on incorporating advance care planning into health care settings. Details on the series can be found here.

The weekly series will begin mid-March and include six sessions, each lasting 1 to 1.5 hours. Health care providers (primary care, hospital-based, palliative care, elder care, nursing home, long-term care, skilled nursing facility or hospice care), health system leaders, social workers, chaplains and other clinical staff are all invited to participate and learn tools to address advance care planning in their role. Physicians, nurses and pharmacists can earn up to 6.5 CEU credits. To learn more or register, email [email protected].

BlueLink Tip — Requesting Prior Authorizations for Genetic Tests

On Feb.1, we launched our prior authorization for genetic testing program. To make requesting a prior authorization easier, we have created a step-by-step video and tip sheet to walk you through the process. You can register for one of two upcoming webinars to help guide you through the process:

Training Date Time Register

CareFirst BCBS Genetic Testing Provider Portal Experience

3/7/2019 2 p.m. Register

CareFirst BCBS Genetic Testing Provider Portal Experience

3/14/2019 12 p.m. Register

You may also want to review the provider overview and FAQs that appeared in the Feb. 4 Provider News & Updates.

As always, we appreciate your feedback and questions, just contact your provider representative.

Save The Date for The CareFirst Pediatric Conference

Pediatricians, family practitioners, nurse practitioners and physician assistants are encouraged to attend to hear leading experts share their knowledge about:

• What’s new in pediatric dermatology

2 February 2019 I Volume 21 I Issue 1

https://www.thehorizonfoundation.org/speakeasy-howard-free-webinar-series-on-advance-care-planning-in-health-care/https://carefirst.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=36f71d76-2abd-43c5-8a04-a9e401427082http://media.campaigner.com/media/57/573995/All%20BlueLink/BlueLink%202019/Issue%201%20-%20February%202019/CUT0561-1N%202-19_tip%20sheet.pdfhttps://aimspecialtyhealth.webex.com/mw3300/mywebex/default.do?service=1&siteurl=aimspecialtyhealth&nomenu=true&main_url=%2Fmc3300%2Fe.do%3Fsiteurl%3Daimspecialtyhealth%26AT%3DMI%26EventID%3D775583792%26UID%3D0%26Host%3DQUhTSwAAAARYWwunKAbAr48texjySVuaSm1-sR0Bxpd4CW58d6AbGf7x8Uq9lFILNsAHpYzJlLUgY_WvgfvPXzz8m_N5jN120%26FrameSet%3D2%26MTID%3Dmcb5049fbc793b78706b33fb4f1b97f6dhttps://aimspecialtyhealth.webex.com/mw3300/mywebex/default.do?service=1&siteurl=aimspecialtyhealth&nomenu=true&main_url=%2Fmc3300%2Fe.do%3Fsiteurl%3Daimspecialtyhealth%26AT%3DMI%26EventID%3D775583792%26UID%3D0%26Host%3DQUhTSwAAAARYWwunKAbAr48texjySVuaSm1-sR0Bxpd4CW58d6AbGf7x8Uq9lFILNsAHpYzJlLUgY_WvgfvPXzz8m_N5jN120%26FrameSet%3D2%26MTID%3Dmcb5049fbc793b78706b33fb4f1b97f6dhttps://aimspecialtyhealth.webex.com/mw3300/mywebex/default.do?service=1&siteurl=aimspecialtyhealth&nomenu=true&main_url=%2Fmc3300%2Fe.do%3Fsiteurl%3Daimspecialtyhealth%26AT%3DMI%26EventID%3D775583792%26UID%3D0%26Host%3DQUhTSwAAAARYWwunKAbAr48texjySVuaSm1-sR0Bxpd4CW58d6AbGf7x8Uq9lFILNsAHpYzJlLUgY_WvgfvPXzz8m_N5jN120%26FrameSet%3D2%26MTID%3Dmcb5049fbc793b78706b33fb4f1b97f6dhttps://aimspecialtyhealth.webex.com/mw3300/mywebex/default.do?service=1&siteurl=aimspecialtyhealth&nomenu=true&main_url=%2Fmc3300%2Fe.do%3Fsiteurl%3Daimspecialtyhealth%26AT%3DMI%26EventID%3D775583467%26UID%3D0%26Host%3DQUhTSwAAAATnVjoTz1mjBt943X8q9O8afkAHWqxcojSLF-7e9TwcjR1ghyXJoEgiSTUepUWpLRRbu0ByfJVzt6MfVl3LckMF0%26FrameSet%3D2%26MTID%3Dmc4ebd8658172d5379747b0f1a9b185bbhttps://aimspecialtyhealth.webex.com/mw3300/mywebex/default.do?service=1&siteurl=aimspecialtyhealth&nomenu=true&main_url=%2Fmc3300%2Fe.do%3Fsiteurl%3Daimspecialtyhealth%26AT%3DMI%26EventID%3D775583467%26UID%3D0%26Host%3DQUhTSwAAAATnVjoTz1mjBt943X8q9O8afkAHWqxcojSLF-7e9TwcjR1ghyXJoEgiSTUepUWpLRRbu0ByfJVzt6MfVl3LckMF0%26FrameSet%3D2%26MTID%3Dmc4ebd8658172d5379747b0f1a9b185bbhttps://aimspecialtyhealth.webex.com/mw3300/mywebex/default.do?service=1&siteurl=aimspecialtyhealth&nomenu=true&main_url=%2Fmc3300%2Fe.do%3Fsiteurl%3Daimspecialtyhealth%26AT%3DMI%26EventID%3D775583467%26UID%3D0%26Host%3DQUhTSwAAAATnVjoTz1mjBt943X8q9O8afkAHWqxcojSLF-7e9TwcjR1ghyXJoEgiSTUepUWpLRRbu0ByfJVzt6MfVl3LckMF0%26FrameSet%3D2%26MTID%3Dmc4ebd8658172d5379747b0f1a9b185bbhttps://provider.carefirst.com/providers/news/2019/02/take-action-before-ordering-genetic-tests/https://provider.carefirst.com/providers/news/2019/02/take-action-before-ordering-genetic-tests/http://www.carefirst.com/providerrepmailto:[email protected]

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• The emerging field of pediatric genetics • The latest clinical information about acute flaccid myelitis • How clinicians can better care for transgender patients and patients with gender dysphoria • The recent upsurge in cases of HPV-related oropharyngeal cancers • How clinicians can help adolescents with substance use disorders

Pediatric Conference details are as follows:

Friday, September 13, 2019 8 a.m. – 2:30 p.m. (Registration begins at 7 a.m.) CareFirst Conference Center 1501 S. Clinton Street, Baltimore, MD 21224

Check upcoming issues of BlueLink to receive information about registration or visit carefirst.com/pedsconference.

Effective March 1— Both CPT Codes 99050 and 99051 Available for Reimbursement

Starting March 1, you should use either Current Procedural Terminology (CPT) Code 99050 or 99051 accordingly for services provided as described. Previously, you could only use CPT code 99051 if your patient was enrolled in Federal Employee Plan (FEP) benefits. You will now be able to use CPT Code 99050 and CPT Code 99051 according to their description for all members.

As a reminder, use CPT Code 99050 when the patient is seen when the office is closed. Do not use CPT Code 99050 if the patient has an appointment during business hours but is not seen until later because the office is behind or if the office is open for emergency appointments. Only use CPT Code 99051 when service is provided during regularly scheduled evening hours, weekends or holidays.

Health Care Policy

Effective Dates, CPT Codes and Policy Updates for February

Our Health Care Policy department continuously reviews medical policies and operating procedures as new, evidence-based information becomes available regarding advances on new or emerging technologies, as well as current technologies, procedures and services.


http://www.carefirst.com/pedsconference

BlueLink

The table below is designed to provide updates on changes to existing or new local policies and procedures during our review process. Each local policy or procedure listed includes a brief description of its status, select reporting instructions and effective dates. Policies from non-local accounts, such as NASCO and Federal Employee Program (FEP), may differ from our local determinations. Please verify member eligibility and benefits prior to rendering service through CareFirst on Call (Professional and Institutional) or CareFirst Direct.

Note: The effective dates for the policies listed below represent claims with date of service processed on and after that date.

Medical Policy and/or Actions, Comments, and Reporting Guidelines Policy Procedure Status and

Effective Date

2.01.001 Under Policy Guidelines, added updated 2018 rationale

Periodic review and

Idiopathic Environmental statement. Report service using appropriate category I update Intolerances CPT code. Refer to policy for details.

Effective 11/19/18

2.01.010

Quantitative Electroencephalogram /Topographic Brain Mapping

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 11/19/18

2.01.031 Under Policy Guidelines, added experimental / Periodic investigational criteria and updated 2018 rationale review and

Surface Electromyography statement. Report service using appropriate HCPCS update code. Refer to policy for details.

Effective 11/19/18


https://provider.carefirst.com/carefirst-resources/provider/pdf/carefirst-on-call-reference-card-professional-pcm1034.pdfhttps://provider.carefirst.com/carefirst-resources/provider/pdf/carefirst-on-call-reference-card-institutional-pcm1035.pdfhttp://www.carefirst.com/carefirstdirect

BlueLink


Effective Date


Periodic review and

Ultrafiltration for Fluid statement. Report service using appropriate category I update Overload in Decompensated CPT code. Refer to policy for details. Heart Failure Effective

11/19/18

2.02.011 Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I

Periodic review and

Wearable External CPT code or HCPCS code. Refer to policy for details. update Cardioverter-Defibrillator

Effective 11/19/18

2.03.014

Electric Tumor Treatment Fields

Revised Benefit Applications statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 11/19/18

4.02.008

Recurrent Pregnancy Loss (Recurrent Spontaneous Abortion)

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 11/19/18


BlueLink


Effective Date

2.01.019 Under Policy Guidelines, added experimental / Periodic investigational criteria and updated 2018 rationale review and

Treatments of Tinnitus statement. Report service using appropriate category I update CPT code. Refer to policy for details.

Effective 12/17/18

2.01.043 Periodic Under Policy Guidelines, added updated 2018 rationale review and

Hair Analysis statement. Report service using appropriate category I update CPT code. Refer to policy for details.

Effective 12/17/18


Periodic review and

Electromagnetic and Electrical statement. Report service using appropriate HCPCS update Stimulation for the Care of code. Refer to policy for details. Chronic Wounds Effective

12/17/18

3.01.006

Pervasive Developmental Disorders (e.g. Autism)

Policy placed in archived status. Replaced by new policy 3.01.015. Report service using appropriate category I or category III CPT code. Refer to policy for details.

Revision

Effective 12/31/18

3.01.015

Autism Spectrum Disorders (ASD)

New Policy replacing policy 3.01.006. Autism spectrum disorder (ASD) is characterized by varying degrees of impairments (ranging from mild to severe) in behavioral and social functioning, and communication skills. Applied Behavioral Analysis (ABA) is one of several approaches used to treat ASD. ABA, for the treatment of ASD is considered medically necessary. Other medical services for the treatment of ASD is considered experimental / investigational. Report service using

New Policy

Effective 01/01/19


BlueLink


Effective Date

appropriate category I or category III CPT code. Refer to policy for details.

5.01.039

Lutetium Lu 177 dotatate (Lutathera®)

Lutetium Lu 177 dotatate (Lutathera®), a radiolabeled somatostatin analog, is FDA-approved for the treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs), including foregut, midgut and hindgut neuroendocrine tumors in adults. Lutetium Lu 177 dotatate (Lutathera®), for the treatment of adult patients with somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NET) including foregut, midgut, and hindgut neuroendocrine tumors in adults, is considered medically necessary. Report service using appropriate HCPCS code. Refer to policy for details.

New Policy

Effective 10/01/18

7.01.003 Under Policy Guidelines, added updated 2018 rationale Periodic statement. Report service using appropriate category I review and

Bone-Anchored Hearing Aids CPT code or HCPCS code. Refer to policy for details. update

Effective 12/17/18


Periodic review and

Carotid Artery Angioplasty and CPT code or category llI CPT code. Refer to policy for update

Stenting details. Effective 12/17/18


BlueLink


Effective Date

7.01.096 Under Policy Guidelines, added updated 2018 rationale Periodic statement. Report service using appropriate category I review and

Dynamic Spinal Stabilization CPT code. Refer to policy for details. update

Effective 12/17/18

7.01.123

Gender Reassignment Services

Revised Policy Guidelines. Report service using appropriate category I CPT code. Refer to policy for details.

Revisions

Effective 12/17/18

7.03.002 Under Policy Guidelines, added experimental / investigational criteria and updated 2018 rationale

Periodic review and

High Dose Chemotherapy / statement. Report service using appropriate category I update Radiation Therapy with

CPT code. Refer to policy for details. Autologous Stem Cell Support Effective

12/17/18


Periodic review and

Nonmyeloablative Allogeneic CPT code. Refer to policy for details. update Hemopoietic Stem Cell Transplantation for Effective Hematologic Malignancies 12/17/18

8.01.011A

Habilitative Services (MD and DC Mandates)

Revised Description and Benefit Applications. Report service using appropriate category I or category III CPT code. Refer to policy for details.

Revision

Effective 12/17/18


BlueLink

Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

8.01.014

Lymphedema Therapy (Complex Decongestive Therapy)

Updated Benefits Applications statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 01/01/19

New Medical Technology Updates for February

Our Technology Assessment Unit evaluates new and existing technologies to apply to our local indemnity and managed care benefit plans. The unit relies on current scientific evidence published in peer-reviewed medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst Blue Cross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) criteria for coverage. Policies for non-local accounts like NASCO and FEP may differ from our local determinations.

Please verify member eligibility and benefits prior to rendering services via CareFirst on Call (Professional or Institutional) or CareFirst Direct.

The Technology Assessment Unit recently made the following determinations:

Technology Description CareFirst and CareFirst BlueChoice Determination

The iFuse Triangular Implant System

A triangular-shaped implant designed to stabilize and fuse the sacroiliac joint for low back pain presumed to originate from the sacroiliac joint.

Medically Necessary for patients meeting criteria.

CPT reporting code(s) 22279


https://provider.carefirst.com/carefirst-resources/provider/pdf/carefirst-on-call-reference-card-professional-pcm1034.pdfhttps://provider.carefirst.com/carefirst-resources/provider/pdf/carefirst-on-call-reference-card-institutional-pcm1035.pdfhttp://www.carefirst.com/providerlogin

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Claims and Billing

Provider Reminder — An Inquiry vs. An Appeal How to Properly Submit Both

To prevent delays in the processing of claims, it is important to properly submit an inquiry and an appeal. Here are some valuable tips to help you effectively submit inquires and/or appeals.

Provider Inquiries Inquiries may include issues pertaining to: authorizations, correct frequency, ICD-10, medical records, procedures/codes and referrals.

To properly submit an inquiry, please use the following tips: • Before sending an inquiry, consider submitting a corrected claim that will replace the

original claim submitted • Submit inquiries electronically through CareFirst Direct’s Inquiry Analysis and Control

System function. Please do not submit appeals through this system. • If you cannot access CareFirst Direct to submit an inquiry, please use the provider inquiry

resolution form (PIRF)

Please note, an inquiry must be submitted within 180 days or six months from the date of the explanation of benefits (EOB). Please allow 30 days for a response.

Provider Appeals An appeal is a formal written request to the plan for reconsideration of a medical or contractual adverse decision.

To properly submit an appeal, please use the following tips: • Please submit an appeal via letter on your office letterhead. The letter should describe the

reason for the appeal and the clinical justification/rationale • Do not use a PIRF to submit an appeal • Institutional providers should mail appeals to:

o Clinical Appeals and Analysis Unit (CAU) CareFirst BlueCross BlueShield P.O. Box 17636 Baltimore, MD 21298-9375

• Professional providers should mail appeals to: o Mail Administrator

PO Box 14114 Lexington, KY 40512-4114


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Please note, an appeal must be submitted within 180 days or six months from the date of the EOB. All appeal decisions are answered in writing. Please allow 30 days for a response.

For more information on submitting an inquiry and/or an appeal, visit carefirst.com/inquiriesandappeals

Provider Reminders

Care Management Updates — Effective Jan. 1

CareFirst’s Medical Directors and a panel of regional practitioners met on Dec. 6, 2018 for the Annual Criteria Review. The panel, which included primary care physicians and multiple specialist, reviewed and approved the following:

• Modified Appropriateness Evaluation Protocol (AEP) Criteria

• Apollo Managed Care Physical Therapy, Occupational Therapy, Rehabilitation Care and Pain Management Criteria

• CareFirst Medical Policy Reference Manual

• MCG Behavioral Health Care Guidelines 22nd Edition • The Dental Criteria Guidelines

CareFirst makes physician reviewers available to discuss utilization management (UM) decisions. Physicians may call 410-528-7041 or 1-800-367-3387 x 7041 to speak with a physician reviewer or to obtain a copy of any of the above-mentioned criteria. All cases are reviewed on an individual basis.

Important Note: CareFirst affirms that all UM decision making is based only on appropriateness of care and service. Practitioners and/or other individuals are not rewarded for conducting utilization review for denials of coverage or service. Additionally, financial incentives for UM decision makers do not encourage denials of coverage or service.

Are You Up to Date on Best Practices and Quality Standards? From recommending preventive care options to your patients or managing day-to-day office operations, the clinical resources on our provider website can be valuable, time-saving tools to help support your treatment plan for patients with chronic diseases.


http://www.carefirst.com/inquiriesandappeals

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BlueLink

CareFirst’s Quality Improvement Council annually reviews the clinical resources and adopts nationally recognized guidelines and best practices to make sure you are informed when information changes.

Click on the links below for details on topics that can help you improve the care you provide to patients in your practice.

Quality Standards and Best Practices

General Guidelines and Survey Results Topic Website Link PDF Available CareFirst’s Quality Improvement Program Includes processes, goals and outcomes.

carefirst.com/qualityimprovement

Clinical Practice Guidelines Includes evidence-based clinical practice guidelines for medical and behavioral conditions.

carefirst.com/clinicalresources

Preventive Health Guidelines Includes evidence-based preventive health guidelines for perinatal care, children, adolescents and adults.


Accessibility and Availability of Appointments Includes medical and behavioral health accessibility and availability standards for routine care appointments, urgent care appointments and after-hours care.


Care Coordination Programs Topic Website Link PDF Available Access to Complex Care Coordination Includes instructions for making referrals for both medical and behavioral health; or call 800-245-7013.

carefirst.com/providermanualsandguides


https://member.carefirst.com/members/mandates-policies/quality-improvement-program.pagehttps://provider.carefirst.com/providers/care-management/clinical-resources.page?https://provider.carefirst.com/providers/care-management/clinical-resources.page?https://provider.carefirst.com/providers/care-management/clinical-resources.page?https://provider.carefirst.com/providers/resources/manuals-and-guides.pagehttps://member.carefirst.com/members/mandates-policies/quality-improvement-program.pagehttps://provider.carefirst.com/providers/care-management/clinical-practice-guidelines.page?https://provider.carefirst.com/carefirst-resources/provider/pdf/practitioner-office-standards-performance-measures-bok5130.pdfhttps://provider.carefirst.com/carefirst-resources/provider/pdf/professional-provider-manual.pdf#page=24http://carefirst.staywellsolutionsonline.com/HealthyLiving/ServicesGuidelines/

--BlueLink

Practitioner Referrals for Disease Management Includes information on how to use the services, how a member becomes eligible and how to opt in or opt out.


Pharmaceutical Management Topic Website Link PDF Available Pharmaceutical Management Includes the formulary, restrictions/ preferences, guidelines/policies and procedures.

carefirst.com/rx

Utilization Procedures Topic Website Link PDF Available Utilization Management Criteria Includes information on how to obtain utilization management criteria for both medical and behavioral health.

carefirst.com/bluelink > February 2018

Physician Reviewer Includes instructions on how to obtain a physician reviewer to discuss utilization management decisions for both medical and behavioral health.


Decisions about Medical and Mental Health, and Pharmacy Includes affirmative statement for anyone making decisions regarding utilization management.


Member Related Resources Topic Website Link PDF Available Quality of Care Complaints Includes policies and procedures for complaints involving medical issues or services given by a provider in our network.

carefirst.com/qoc


https://provider.carefirst.com/providers/care-management/clinical-resources.page?http://www.carefirst.com/rxhttps://provider.carefirst.com/carefirst-resources/provider/newsletters/bluelink-2018-feb.pdfhttps://provider.carefirst.com/carefirst-resources/provider/newsletters/bluelink-2018-feb.pdfhttps://provider.carefirst.com/carefirst-resources/provider/newsletters/bluelink-2018-feb.pdfhttp://www.carefirst.com/qochttps://provider.carefirst.com/providers/care-management/disease-management.page?https://www.member.carefirst.com/members/drug-pharmacy-information/drug-coverage-your-prescription-drug-plan.page?https://provider.carefirst.com/carefirst-resources/provider/newsletters/bluelink-2018-feb.pdfhttps://provider.carefirst.com/carefirst-resources/provider/newsletters/bluelink-2018-feb.pdfhttps://provider.carefirst.com/carefirst-resources/provider/newsletters/bluelink-2018-feb.pdfhttps://member.carefirst.com/members/contact-us/contact-us.page?

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BlueLink

How to File an Appeal Includes policies and procedures for members to request an appeal of a claim payment decision.

carefirst.com/appeals

Member’s Privacy Policy Includes a description of our privacy policy and how we protect our members health information.

carefirst.com/privacy

Member’s Rights and Responsibilities Statement Outlines responsibilities to our members.

carefirst.com/myrights

To request a paper copy of any documents listed above, please call (800) 842-5975.

In Case You Missed It

Feb. 4, 2019 — Take Action Before Ordering Genetic Tests. See Details on the Genetic Testing Prior Authorization Program

Jan. 30, 2019 — CareFirst is Changing its Discharge Process

Jan. 22, 2019 — BlueCard Member Claims Will Require Itemized Bills for Some Services


http://www.carefirst.com/appealshttp://www.carefirst.com/privacyhttp://www.carefirst.com/myrightshttps://provider.carefirst.com/providers/news/2019/02/take-action-before-ordering-genetic-tests/https://provider.carefirst.com/providers/news/2019/02/take-action-before-ordering-genetic-tests/https://provider.carefirst.com/providers/news/2019/01/carefirst-changing-discharge-process/https://provider.carefirst.com/providers/news/2019/01/bluecard-member-claims-will-require-itemized-bills/https://member.carefirst.com/members/contact-us/appeal-claim.page?https://member.carefirst.com/members/mandates-policies/members-privacy-policy.page?https://member.carefirst.com/members/mandates-policies/rights-and-responsibilities.page?

What’s Happening? Horizon Foundation’s Speak(easy) Howard Campaign Offers Free Webinar Series BlueLink Tip — Requesting Prior Authorizations for Genetic Tests Save The Date for The CareFirst Pediatric Conference Effective March 1— Both CPT® Code 99050 and 99051 Available for ReimbursementHealth Care Policy Effective Dates, CPT Codes and Policy Updates for February New Medical Technology Updates for FebruaryClaims and Billing Provider Reminder — An Inquiry vs. An Appeal How to Properly Submit BothProvider Reminders Care Management Updates — Effective Jan. 1 Are You Up to Date on Best Practices and Quality Standards?In Case You Missed It Take Action Before Ordering Genetic Tests. See Details on the Genetic Testing Prior Authorization Program CareFirst is Changing its Discharge Process BlueCard Member Claims Will Require Itemized Bills for Some ServicesWhat’s Happening?Horizon Foundation’s Speak(easy) Howard Campaign Offers Free Webinar SeriesThe Horizon Foundation is partnering with the Institute for Healthcare Improvement and The Conversation Project to offer a free 6-week webinar series on incorporating advance care planning into health care settings. Details on the series can be found ...The weekly series will begin mid-March and include six sessions, each lasting 1 to 1.5 hours. Health care providers (primary care, hospital-based, palliative care, elder care, nursing home, long-term care, skilled nursing facility or hospice care), he...BlueLink Tip — Requesting Prior Authorizations for Genetic TestsSave The Date for The CareFirst Pediatric Conference

What’s new in pediatric dermatology The emerging field of pediatric genetics The latest clinical information about acute flaccid myelitis How clinicians can better care for transgender patients and patients with gender dysphoria The recent upsurge in cases of HPV-related oropharyngeal cancers How clinicians can help adolescents with substance use disordersEffective March 1— Both CPT Codes 99050 and 99051 Available for Reimbursement

Health Care PolicyEffective Dates, CPT Codes and Policy Updates for FebruaryNew Medical Technology Updates for February

Policy Status and Effective DateActions, Comments, and Reporting GuidelinesMedical Policy and/or ProcedureUnder Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.Idiopathic Environmental IntolerancesEffective 11/19/18Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.Effective 11/19/18Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.Revised Benefit Applications statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.Effective 12/17/18Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.Effective 12/17/18Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate HCPCS code. Refer to policy for details.Effective 12/17/18Effective 12/31/18Effective 01/01/19Effective 10/01/18Effective 12/17/18Effective 12/17/18Effective 12/17/18Effective 12/17/18Revised Description and Benefit Applications. Report service using appropriate category I or category III CPT code. Refer to policy for details. Effective 12/17/18Effective 01/01/19Claims and BillingProvider Reminder — An Inquiry vs. An Appeal How to Properly Submit BothTo prevent delays in the processing of claims, it is important to properly submit an inquiry and an appeal. Here are some valuable tips to help you effectively submit inquires and/or appeals.

Before sending an inquiry, consider submitting a corrected claim that will replace the original claim submitted Submit inquiries electronically through CareFirst Direct’s Inquiry Analysis and Control System function. Please do not submit appeals through this system. If you cannot access CareFirst Direct to submit an inquiry, please use the provider inquiry resolution form (PIRF) Please submit an appeal via letter on your office letterhead. The letter should describe the reason for the appeal and the clinical justification/rationale Do not use a PIRF to submit an appeal Institutional providers should mail appeals to:o Clinical Appeals and Analysis Unit (CAU)CareFirst BlueCross BlueShieldP.O. Box 17636Baltimore, MD 21298-9375 Professional providers should mail appeals to:o Mail AdministratorPO Box 14114Lexington, KY 40512-4114Provider RemindersCare Management Updates — Effective Jan. 1CareFirst’s Medical Directors and a panel of regional practitioners met on Dec. 6, 2018 for the Annual Criteria Review. The panel, which included primary care physicians and multiple specialist, reviewed and approved the following: Modified Appropriateness Evaluation Protocol (AEP) Criteria Apollo Managed Care Physical Therapy, Occupational Therapy, Rehabilitation Care and Pain Management Criteria CareFirst Medical Policy Reference Manual MCG Behavioral Health Care Guidelines 22nd Edition The Dental Criteria Guidelines

Are You Up to Date on Best Practices and Quality Standards?Quality Standards and Best PracticesTo request a paper copy of any documents listed above, please call (800) 842-5975.

In Case You Missed ItFeb. 4, 2019 — Take Action Before Ordering Genetic Tests. See Details on the Genetic Testing Prior Authorization ProgramJan. 30, 2019 — CareFirst is Changing its Discharge ProcessJan. 22, 2019 — BlueCard Member Claims Will Require Itemized Bills for Some Services

Documents

BlueLink - February 2019On Feb.1, we launched our prior authorization for genetic testing program. To make requesting a prior authorization easier, we have created a . step-by-step