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Blue Cross of Idaho uses our One-to-One newsletter to notify and highlight upcoming important information or actions that may be required by the provider community.
The information is categorized in three parts: Informational (for education only), actions (requires action on your part) or reminders (notification or reminder of events or deadlines).
Topics in this edition of the provider newsletter include:
Informational• 2020 Education Plan from External
Provider Relations Representatives
• Blue Card Claim Submission Requirements
• BlueCard Medicare Advantage
• Chiropractic Quality Initiatives Program
• ChoiceDocs Program
• Introducing SmartShopper
• New Faces
• Providers Vendors
• Value-Based Care
Action• Introducing Idaho Medicaid Plus
(IMPlus)
• Improve Preventive Cancer Screenings
• Medication Adherence and Cardiovascular Disease
• Provider Matching Logic for Professional Claims
Reminders• Access Plans
• Medical Policy Changes
• Retrospective Chart Audits for Risk-Adjustment Validation
M E D I C A L | W I N T E R E D I T I O N
One-to-One Newsletter
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER2
Informational
2020 Education Plan from External Provider Relations RepresentativesIn 2019, Blue Cross of Idaho added external Provider Relations representatives to its business to cover various regions of the state. The reps completed 1,041 in-office provider trainings, presented specialty-specific workshops and held state-wide meetings to find out how to improve provider digital experience.
The reps will continue these efforts into 2020, as well as visit newly contracted Medicare Advantage and Medicaid providers as required by Centers for Medicare & Medicaid Services.
The reps will exhibit at various conferences throughout the state, including:
Annual Family Caregiver Conference
Boise February 2020
Ada County Medical Society Winter Clinics
McCall February 2020
Idaho Psychiatric Association Annual Conference
Meridian February 2020
Nurse Practitioners of Idaho Winter Conference
Coeur d’Alene February 2020
Idaho Academy of Physician Assistants Annual CME
ConferenceSun Valley April 2020
Southwest Idaho Medical Society
TBD TBD
Idaho Health Care ConferenceNampa, Fort Hall, Coeur
d’AleneMay 2020
Idaho Emergency Medicine Conference
Boise August 2020
Idaho Medical Group Management Association
Annual ConferenceBoise September 2020
Idaho Hospital Association Annual Convention
Sun Valley October 2020
Idaho Medical Association Annual Meeting
Sun Valley October 2020
WINTER 2020 3
The reps offer workshops each quarter for specific specialties or services, including but not limited to:
• Preauthorization
• Billing services
• PCPs
• DME
All external reps are available to answer questions and to visit provider offices. If you would like to schedule a training with an external rep, please email [email protected].
Western Central Idaho Reps: Heather Beard, CPC, CPB, CRC, CEMC, CGIC
Christine Brewster
Counties: Ada, Adams, Blaine, Boise, Camas, Canyon, Elmore, Gem, Gooding, Jerome, Lincoln, Owyhee, Payette, Twin Falls, Valley, Washington and contiguous Oregon counties
Southern Idaho Rep: Nicole Stosich
Counties: Bannock, Bear Lake, Bingham, Bonneville, Butte, Caribou, Cassia, Clark, Custer, Franklin, Fremont, Jefferson, Lemhi, Madison, Minidoka, Oneida, Power, Teton and contiguous Nevada, Utah and Wyoming counties
Northern Idaho Rep: Tammy Fortune
Counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce, Shoshone and contiguous Montana and Washington counties
Formulary changes happen regularly. Please review the appropriate member formulary for the most up-to-date version of the formulary.
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER4
BlueCard Claim Submission RequirementsBlueCard claims are unique and need specific information to be listed on both professional (CMS1500) and facility (UB04) claim forms. The claim submission requirements differ from Blue Cross of Idaho’s claim requirements.
Blue Cross of Idaho has published Provider Administrative Policy (PAP) 801 to inform providers on how to submit claims for BlueCard. PAP 801 outlines how to identify BlueCard members by looking at the insurance card, logos, prefixes and Place of Service (POS) codes. POS codes determine where a claim will be submitted.
Finding our PAP’s are easy. Log in to our website at provider.bcidaho.com and follow these steps:
• Select Policies & Procedures at the top of the page
• Select the line of business under Provider Administrative Policies
• Select Continue on the Use & Disclosure of Data page
• Select the policy needed under the table of contents
Tips for proper BlueCard claim submissionsWhen submitting a BlueCard claim, include the prefix, which is the first three letters/numbers. This prefix tells us which Blue Cross Blue Shield plan holds the benefit policy. If the prefix is missing, we will reject the claim and ask for a corrected claim — with the prefix — to be submitted. Submitting a copy of the member’s insurance card and the full policy number will improve the claims process.
Ensure claims are submitted with accurate member information. Plans will deny claims when the member’s name is spelled wrong, the gender code does not match or the patient’s relationship
to the subscriber is not correct. Verify member information prior to submitting a claim to avoid preventable denials.
The POS submitted will affect where the claim will be submitted. For example, if the member is receiving a Durable Medical Equipment (DME) and the DME is delivered to the member’s home, the POS would then be 12. POS 12 requires the claim to be submitted to the local plan where the member lives — not where the DME supplier is located. If the patient’s home is in Idaho, then the claim would be submitted to an Idaho plan. Each POS code determines the local plan the claim will be submitted to. Below are some examples of POS codes that determine where the claim will be sent.
• Office visit (POS 11)- Submit to the local plan for the service address that is listed in box 32 for CMS1500 and box 1 for UB04 claims.
• DME (POS 12)- Submit to the local plan of where the patient lives.
• Independent Lab (POS 81)- Submit to the local plan of where the referring physician is located or where the specimen was drawn.
For more information on BlueCard, claim submission options and requirements, review PAP 801 and PAP 202. Follow the steps in these PAPs to reduce claim denials. The steps in these PAPs will also help you ensure that you have your member’s current insurance information.
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BlueCard Medicare AdvantageAll Blue Cross of Idaho and Blue Cross Blue Shield (BCBS) Blue Medicare Advantage (MA) PPO Plans in the country are now eligible for network sharing. This means that all Blue MA PPO members get in-network benefits when traveling or living in the service area of another Blue MA PPO Plan when they see an MA PPO-contracted provider.
What does BCBS Medicare Advantage (MA) PPO Network Sharing mean to you? If you are an MA PPO-contracted provider with Blue Cross of Idaho and you see MA PPO members from other Blue Plans, these members will get the same access to care and will be reimbursed according to the negotiated rate in your Blue Cross of Idaho contract. Members will get in-network benefits in line with their member contract.
For more information, please review the FAQs at proivders.bcidaho.com. Select Forms & Resources then BlueCard Medicare Advantage, look to the bottom for Information & FAQs.
Chiropractic Quality Initiatives ProgramDid you know that patient care participation and meeting guidelines may increase your reimbursement?
Blue Cross of Idaho’s outcome-based Chiropractic Quality Initiative works with Alternative Medicine Integration of Idaho (AMI) to measure clinical outcomes. Instead of requesting prior authorization, we use the data to improve our members healthcare by offering guidance on cost-effective solutions for chiropractic care.
To access AMI’s Quality Initiative Program portal, you must be a registered user on our secure provider portal. If you need help registering, contact Provider Relations. Once you are registered, follow these steps:
1. Log on to the providers.bcidaho.com
2. Hover over Tools and Reports
3. Select Chiropractic Management
If you need more training, contact Blue Cross of Idaho’s External Provider Relations Department at [email protected].
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER6
ChoiceDocs ProgramBlue Cross of Idaho continuously works with our providers to lower the cost of healthcare for our members. To help in this effort, we added a new option to our existing PPO network on January 1, 2020 – ChoiceDocs.
We partnered with IBM Watson (formerly known as Truven) to gather clinical-level data to identify cost-efficient providers in our network. The data uses premium-level key performance indicators (KPI) to designate a provider as a Blue Cross of Idaho ChoiceDoc in our PPO provider directory.
This label allows PPO plan members to easily find ChoiceDocs-participating providers. When members visit ChoiceDocs providers, they may pay a lower copay — or even no copayment — based on their plan. Members still have access to any in-network PPO provider, but they may pay a regular-level copay. All benefits will be the same whether a member visits a ChoiceDoc or not.
Your KPI clinic score threshold is stated in Exhibit 1 of your contract and is reviewed and updated
annually. As per your contract, you have 60 days after your fee schedule assignment notification to review and approve your clinic score. If you disagree with your score, you can submit a request for reconsideration within that 60-day timeframe. Submit your request with supporting documentation to your Provider Network Management Specialist. If Blue Cross of Idaho agrees to reconsider, any changes to your score and subsequent fee schedule will be made within 30 days.
We sent an informational video to our members explaining the ChoiceDocs program. Watch the video to familiarize yourself with this program’s educational material.
If you have questions about the ChoiceDocs program, contact Blue Cross of Idaho Provider Relations Department at 866-283-5723 option 4 or email [email protected].
Introducing SmartShopperAt Blue Cross of Idaho, we believe in affordable healthcare. We are taking innovative steps to empower employers and members to make smart choices about their healthcare through lower costs and resources.
Save with SmartShopperSmartShopper allows members to shop around for the care they need while cutting healthcare costs for both members and employers. Using the Cost Advisor cost transparency tool, members can search for care and get an estimated cost based on their plan benefits. At the same time, they can see the SmartShopper cash reward offered for using different facilities. When members select a SmartShopper-eligible location, they’re sent a cash reward.
SmartShopper is available to all fully insured groups at no charge and to self-funded groups as a buy up.
Learn more about SmartShopper here.
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New FacesProvider Information & Credentialing
• Todd Childs, Provider information management
• Lisa Hawkins, Provider information management
• Jessica McCurdy, Provider information management
• LaDonna Morris, Provider information management
Provider Network Management• Carla Adon, Provider contract specialist
Provider Partnerships • Jacquie Watson, Provider network manager
Healthcare Analytics• Kirsten Knutson, Supervisor – Healthcare analytics
• Justin See, Supervisor – Healthcare analytics
Provider VendorsWho’s contacting my office for data? Blue Cross of Idaho contracts with many vendors for different programs. Vendors may reach out to our provider community for data or records. Vendors are also used as a direct connection through our provider portal for programs such as AIM.
We have created a list of our vendors – who may contact your organization – that includes their name, program description and contact information.
To access the vendor list, go to providers.bcidaho.com, select Forms & Resources then Provider Vendors.
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER8
Value-Based CareHistorically, providers have been paid based on a fee-for-service model, which rewards the provider for the volume of patients seen and the number of services provided. This model is not sustainable. Blue Cross of Idaho is collaborating with providers and networks across the state to create payment programs that support a new model: value-based care (VBC). VBC supports the triple aim to lower cost, improve quality and outcomes and improve the member experience. Providers continue to be reimbursed under fee-for-service, but payments are shifting to reward providers for managing the total cost of care and member outcomes.
VBC programs differ based on the experience of the practice and each practice’s tolerance for risk. A practice or network (group) may choose to start their VBC journey with a shared savings model that looks at the total cost of care for a population and sets a reduced cost target. The program typically includes quality metrics, such as cancer screenings, diabetes management, well-child visits and reducing admissions, readmissions and emergency department visits.
For a VBC arrangement to be successful, and to lower costs, groups may introduce processes like care coordination, increased monitoring of chronic conditions, member engagement, medication management and a focus on preventive screenings. If the total cost of care is lower than the cost target, groups may get
a portion of the savings a payer receives. As a group improves processes and gains confidence in their ability to manage the outcomes of a population and control costs, they will enter a shared risk arrangement, which holds the group accountable for keeping the costs below the target. If the group cannot keep costs below the target, the group agrees to cover the difference over the target.
Currently, Blue Cross of Idaho has 25 shared savings/shared risk VBC’s with 11 provider groups or networks throughout Idaho. Providers that have a shared savings VBC handle the total cost of care for Medicare Advantage, Qualified Health Plans (QHP) sold on the Your Health Idaho exchange, self-funded employer groups with directed traffic arrangements and a growing commercial, value-based program population.
Blue Cross of Idaho is partnering with providers to make sure our members get the right care, at the right time and in the right place. VBC will give our members many short and long-term benefits. Members will be able to navigate the complex healthcare system with ease through greater coordination and help them gain a better picture of their health, leading to healthier, longer lives.
WINTER 2020 9
Action
Introducing Idaho Medicaid Plus (IMPlus)Idaho Medicaid has successfully implemented a new managed care program: Idaho Medicaid Plus (IMPlus). This is a mandatory program for Dual- Eligible participants aged 21 years or older who are enrolled in both Medicare (Parts A, B and D) and Enhanced Medicaid. The Idaho Department of Health and Welfare (IDHW) has partnered with Blue Cross of Idaho to manage IMPlus, which covers most Medicaid services. Members are assigned a care specialist who serves as a single point of contact to help participants navigate their Medicaid services. There are no changes to a participant’s Medicare coverage.
IMPlus is a mandatory program in these counties: Twin Falls, Bonner, Bannock, Bonneville, Bingham, Kootenai, Nez Perce, Ada and Canyon.
Changes in 2020 include additional mandatory counties: Boise, Boundary, Cassia, Elmore, Fremont, Gem, Jefferson, Madison, Minidoka, Owyhee, Payette and Power.
Mandatory IMPlus Counties:On January 1, 2020, Dual-Eligible residents in Boise, Boundary, Cassia, Elmore, Fremont, Gem, Jefferson, Madison, Minidoka, Owyhee, Payette and Power counties received a letter from IDHW about their enrollment in IMPlus. Dual-Eligible participants in these counties will have 90 days to let IDHW know which plan they would like to have administer their IMPlus benefits. If a participant does not choose, they will be auto-enrolled in one of the plans on April 1, 2020 (90 days after the January 1, 2020, notice).
Participants will have 90 days from when their coverage begins to make a change to their plan. After this, participants may make a change during the annual Open Enrollment period running October 15 through December 7.
Passive IMPlus Counties:A new enrollment process called passive enrollment was introduced in some counties. On January 1, 2020, Dual-Eligible participants who live in Adams, Benewah, Clark, Gooding, Jerome, Latah, Shoshone, Valley and Washington counties received a letter from the state about their passive enrollment into IMPlus with Blue Cross of Idaho. Dual-Eligible participants will be enrolled on April 1, 90 days after the January 1, notice. Participants can opt out before or after the start date by contacting IDHW. If a participant opts out, their services will remain with Idaho Medicaid.
Medicare-Medicaid Coordinated Plan (MMCP) UpdateAs of January 1, 2020, the MMCP is available in 30 counties in Idaho with Blue Cross of Idaho through the True Blue Special Needs Plan. The plan combines both Medicare and Medicaid services into one coordinated plan. Members also get a care coordinator to be their advocate and point of contact.
If you live in Ada, Adams, Bannock, Benewah, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Clark, Elmore, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Shoshone, Twin Falls, Valley and Washington County, you can select the Blue Cross of Idaho True Blue Special Needs Plan (HMO SNP).
Source: https://healthandwelfare.idaho.gov/Medical/Medicaid/DualEligibleParticipants/IdahoMedicaidPlus/tabid/4653/Default.aspx
Source: https://healthandwelfare.idaho.gov/Medical/Medicaid/DualEligibleParticipants/MMCP/tabid/4656/Default.aspx
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER10
Improve Preventive Cancer ScreeningsAre you encouraging your patients to lead healthy lives? Your advice may help patients lower their cancer risks and inspire them to have life-extending cancer screenings.
The U.S. Preventive Services Task Force advises:
Colorectal cancer screening (for members 50-75 years of age)• Colonoscopy
• Fecal occult blood test
• FIT-DNA
• Flexible sigmoidoscopy
Cervical cancer screening (for women 21-65 years of age)• Cervical cytology in women 21-29 years of age
• Cervical cytology every three years and every five years with high-risk human papillomavirus (hrHPV) testing or every five years with hrHPV testing in combination with cytology (co-testing) in women 30 to 65 years of age
Breast cancer screening (for women 50-74 years of age)• Biannual screening mammogram
In addition to preventive screenings, eating healthy, exercising and using sunscreen are some ways to slow the development of cancerous cells. Encouraging your patients to start healthy habits will not only help them stave off cancer but improve other aspects of their health as well.
Discuss your patients’ medical histories and lifestyles with them to help them understand their health-risk factors and encourage them to get life-extending preventive screenings. Together, providers and Blue Cross of Idaho can encourage members to live healthy, proactive lifestyles.
WINTER 2020 11
Medication Adherence and Cardiovascular DiseaseA startling 96.5 million U.S. patients do not take their medications as prescribed. Poor medication adherence is particularly common among patients with cardiovascular disease. Research suggests that 24 percent of patients who suffer a heart attack do not fill their medications within seven days of discharge. Also, 34 percent of heart attack patients with multiple prescriptions stop taking at least one of them within one month of discharge.
Here are some side effects of medication nonadherence:• About 125,000 preventable deaths a year
• 46,000 deaths may be avoided each year if 70 percent of patients with hypertension received the care they need
• The risk of hospitalization, re-hospitalization and premature death among nonadherent hypertension patients is more than five times higher compared to hypertension patients who adhere to taking their medicine
• Patients with high cholesterol who do not adhere to their medications have a 26 percent greater chance of a cardiovascular-related hospitalization compared to patients who take their prescriptions as instructed
There are a few steps that you can take to help your patients follow their prescription instructions:
• Create a medication regimen that is easy to follow by prescribing medication that can be taken once a day instead of two to three times a day
• Help your patients understand the purpose of the prescription
• Let your patients know that they are putting their health at risk if they neglect their medications
Sources:
https://www.heart.org
https://today.mims.com/how-to-improve-patient-compliance-for-medications
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER12
Provider Matching Logic for Professional ClaimsBlue Cross of Idaho has updated the EDI provider matching logic for claim submissions. This update will make sure that claims are processing to the right tax ID number when submitted while reducing the risk of HIPAA violations.
For the matching logic to work correctly, verify that your claim includes the following information:
• Organizational NPI
• Individual NPI
• Tax ID
For electronic claims: • Enter the performing provider in the 2310B loop, NM108 = XX, NM109 = Performing or
Rendering NPI. If you belong to a clinic, your performing number is different from the billing number.2
• Enter the organizational NPI in the 2010AA loop, NM108 = XX, NM109 = Billing NPI.1,2
For hardcopy claims:• Enter the organizational NPI number of who receives payment in field 33a of the CMS 1500.
• Enter the individual NPI number of the performing provider in field 24J of the CMS 1500.
If your claim is rejected due to an NPI that doesn’t match, contact Provider Relations. We will verify your tax ID number, individual NPI and organizational NPI to see how the claim is being billed and match it to what is in our system.
For more information, see policy PAP203 for professional claim submission number requirements. This policy can be found on the Blue Cross of Idaho Provider Portal.
If you have additional questions, contact Provider Relations at 866-283-5723 option 4.
1If the provider is in a solo practice and does not have an organizational NPI, bill using the individual NPI in field 33a of the CMS 1500 or 2010AA loop, NM108 = XX, NM109 = for electronic claims submission.
2The Tax ID or Employee Identification Number (EIN) needs to be placed in field 25 on the CMS 1500 form or 2010AA loop, REF01, REF02 for electronic claims submission.
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Reminders
Access PlansBlue Cross of Idaho’s new Access Plans are available as of January 1, 2020. These three new plans — Access Secure, Access Safeguard and Access Protector — are available to the individual market, separate from employer-sponsored coverage.
These plans offer low-cost coverage for nearly 125,000 uninsured Idahoans and their families.
You will be able to identify our Access members from their unique member ID cards. Each ID card has an “ISZ” prefix and “ACCESS” printed in the upper right corner. Below is a sample member ID card of one of the three plans.
How Access Plans Will Affect You Access plans include primary care provider (PCP) assignments and referral requirements but use the statewide Blue Cross of Idaho PPO network. PCP referrals are required for any providers, including in- and out-of-state providers, who are not PPO-contracted with Blue Cross of Idaho.
If you are already a PPO-contracted provider with Blue Cross of Idaho, you are considered an in-network provider for this product.
If you have questions about this new product, please contact Blue Cross of Idaho’s Provider Relations Department at 866-283-5723 or at [email protected].
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER14
Medical Policy ChangesChanges to the medical policy library over the last quarter are summarized below. Please see the medical policy referenced for more information.
Blue Cross of Idaho medical policies provide general guidance for Blue Cross of Idaho benefit plans and do not constitute medical advice. Medical policies are designed for informational purposes only and are not an authorization, explanation of benefits or a contract. Any person applying a medical policy must identify member eligibility, the member-specific benefit plan and any related policies or guidelines prior to applying a medical policy. If there is a conflict between a member-specific benefit plan and Blue Cross of Idaho’s standard benefit plan, the member-specific benefit plan supersedes medical policy. Receipt of benefits is subject to satisfaction of all terms and conditions of the member-specific benefit plan coverage. Blue Cross of Idaho reserves the sole discretionary right to modify all its policies and guidelines at any time.
Policy # Title Summary of changes to policy statement
New Policies
5.01.06
Human Growth Hormone Effective 01/30/2020: Recombinant human growth hormone (GH) therapy may be considered medically necessary when criteria are met
5.01.34
Esketamine Nasal Spray for Treatment-Resistant Depression
Effective 01/30/2020: Esketamine nasal spray may be considered medically necessary if all the specified conditions are met. This policy replaces 5.01.655 Spravato (esketamine)
8.01.63
Chimeric Antigen Receptor Therapy (CAR-T) for Hematologic Malignancies
Effective 01/30/2020: CAR-T therapy with tisagenlecleucel intravenous infusion is considered medically necessary for relapsed or refractory patients with B-cell acute lymphoblastic leukemia if they meet all the specified criteria.
9.01.505
Treatment Plans Effective 11/20/2019: Blue Cross of Idaho supports the use of medical, mental health or pharmacy treatment plans for any complex or lengthy course of treatment.
Revised Policies
2.01.501
Gender Reassignment Effective 01/30/2020: Policy revised to align more closely with WPATH and the 2017 Endocrine Society Guidelines. Updated title from Transgender Services.
2.04.08
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Effective 12/30/2019: Policy statements for MMR and EPCAM testing revised to include criteria for individuals with documentation of 5 percent or higher predicted risk of the syndrome on a validated risk-prediction model are eligible for genetic testing.
WINTER 2020 15
Policy # Title Summary of changes to policy statement
2.04.45
Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer
Effective 01/30/2020: New indications for NTRK testing and tumor mutational burden (TMB) testing added to the policy. Medically necessary statement for NTRK testing and investigational statement for TMB testing added.
2.04.643
Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)
Effective 01/30/2020: A medically necessary statement was added for the commercial test for the EGFR variants. Edits made to the EGFR medically necessary statement to be consistent with the medically necessary statement in the closely related policy on tissue-based EGFR testing in NSCLC (2.04.45). Large genetic panels containing tests considered investigational, will remain investigational.
3.01.550
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Effective 10/24/19:
Added clarification regarding rTMS therapy and Deep rTMS therapy. "Supervising physician" updated to state "supervising psychiatrist".
5.01.509
Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension
Effective 01/30/2020: Policy statement added “Combination therapy with tadalafil and ambrisentan as first-line treatment may be considered medically necessary in the treatment of medication-naïve, PAH patients with WHO Functional Class Groups II and III”.
7.01.133
Microwave Tumor Ablation Effective 12/30/2019: Microwave Tumor Ablation (MWA) may now be considered medically necessary for primary or metastatic hepatic or lung tumors under the specified conditions.
7.01.151
Prostatic Urethral Lift Effective 11/20/2019: The medically necessary statement was updated to remove the clause from the fifth criterion: 'Patient does not have prostate-specific antigen level ≥3 ng/mL'.
7.01.572
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
Effective 11/20/2019: Policy number updated from 7.01.72 to 7.01.572. New policy statement: “Intraosseous radiofrequency nerve ablation of basivertebral nerve (e.g., INTRACEPT® Intraosseous Nerve Ablation System) is also considered investigational”.
8.01.01
Adoptive Immunotherapy Effective 01/30/2020: Sections about use of tisagenlecleucel and axicabtagene ciloleucel were removed from this policy and added to new policy 8.01.63 Chimeric Antigen Receptor Therapy (CAR-T) for Hematologic Malignancies. Policy statement revised to “All applications of adoptive immunotherapy evaluated in this policy are considered investigational”.
8.01.505Immunoglobulin Therapy Effective 01/30/2020: Statement referring to
post-transplant use of IVIg removed. Policy number updated from 8.01.05
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER16
Policy # Title Summary of changes to policy statement
8.03.502
Authorization Criteria for Outpatient Physical Therapy
Effective 12/30/2019: Additional criteria added under first policy statement, “services are documented in a written treatment plan that can be reviewed upon request”.
9.02.501
Non-Cosmetic Pediatric Orthodontia Coverage Guidelines
Effective 12/30/19: The terms “medically necessary” and “not medically necessary” added for clarification of “cosmetic” and “non-cosmetic” in the first and last policy statements.
Policy statement added, “When the primary reason for treatment is due to an injury caused by domestic violence, pediatric orthodontia may be considered medically necessary”.
Archived Policies
5.01.655Esketamine Effective 01/30/2020: Policy will be replaced
with 5.01.34 Esketamine Nasal Spray for Treatment-Resistant Depression.
6.01.45Computer-Aided Evaluation as an Adjunct to Magnetic Resonance Imaging of the Breast
Effective 01/30/2020: Policy will no longer be used and was archived from the medical policy library.
WINTER 2020 17
Retrospective Chart Audits for Risk-Adjustment ValidationEach year, Centers for Medicare and Medicaid Services (CMS) requires Blue Cross of Idaho to confirm that medical records support the International Classification of Diseases (ICD)-10 diagnoses codes on claims for risk-adjustment purposes.
Medicare Advantage Risk-Adjustment Data Validation (RADV) AuditBlue Cross of Idaho Care Plus, a Medicare Advantage Organization (MAO), has been selected by CMS for a contract-level RADV audit.
The purpose of this audit is to identify discrepancies in payments made to MAOs by comparing risk-adjustment diagnosis data received on claims filed for 2014 dates of service against medical record documentation.
Federal regulations require providers to submit medical records to validate risk-adjustment diagnosis data (42 CFR § 422.310). Provider contracts require medical records to be submitted within 14 days of receipt of the request — without charge — for federally mandated audits.
Qualified Health Plan Retrospective Chart ReviewBlue Cross of Idaho is conducting risk-adjustment audits for Qualified Health Plan (QHP) members to confirm that medical records support the ICD-10 diagnoses codes that were submitted on claims filed for 2019 dates of service.
The purpose of this audit is to ensure medical records are compliant with Human and Health Services risk-adjustment reporting requirements for QHPs.
Medical Records RequirementsWhen submitting records, ensure they contain:
• Dates of services listed in the request
• Correct member/patient information
• CMS-valid — and legible — provider signature/credentials, preferably dated within 180 days of the service
• CMS-generated attestations will be required if signatures do not meet CMS requirements
• Documentation that supports the diagnosis code billed on the claim and is compliant with ICD-10-CM coding guidelines.
BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER18
Delegated Vendor for Medical Record AcquisitionEpisource LLC is our partner for collecting and reviewing medical records. Episource complies with HIPAA privacy regulations and is bound by federal and state privacy and confidentiality requirements. Prior to each request, we will ensure that the we do not already have the records on file from a past risk-adjustment medical record audit.
We recognize that you receive multiple requests for medical records to comply with federal mandates, and we appreciate your cooperation. If you have any questions, please email our Risk-Adjustment Team at [email protected].
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Any Questions?MEDICAL MANAGEMENT Questions regarding managed health care/review, preadmission/admission certification or individual benefits management and case management:
• Call: 208-331-7535 or 800-743-1871 (voicemail available after office hours and on holidays and weekends)
MEDICAL POLICY Questions regarding medical policy and clinical criteria:
• Email: [email protected]
BLUE CROSS OF IDAHO HELP DESK Questions regarding electronic billing errors, error and acceptance reports:
• Email: [email protected]
PROVIDER CONTACT CENTER Questions regarding benefits, coverage and authorization:
• Call: 208-286-3656 or 866-482-2250 between 7 a.m.-7 p.m. MT Monday-Friday, EXCEPT closed 2-3 p.m. MT Thursday
For post-service claim questions, log on to our secure website at providers.bcidaho.com and select Contact Us.
PROVIDER RELATIONS Questions regarding coding, contracting or need website training:
• Call: 866-283-5723 or 208-286-3602 • Email: [email protected]
MEDICARE-MEDICAID COORDINATED PLAN/IDAHO MEDICAID PLUS
• Call: 208-286-3678 or 866-462-4612• Email: [email protected]
FRAUD, WASTE AND ABUSE We encourage anyone who suspects possible fraudulent activity to report it to us. You have the option to remain anonymous. Call the fraud hotline at 800-682-9095 or email [email protected].
