Inside this edition · 2019. 10. 11. · IBC has introduced a new approach to health coaching for our members, called the Primary Health Coach model. The new Primary Health Coach

May 2013www.ibx.com/providers

► Articles designated with an orange arrow include notice of changes or clarifications to administrative policies and procedures.

BUSINESS TRANSFORMATION ● New Primary Health Coach model ● Enrollment changes for Baby BluePrints® to begin

this month

CONSUMERISM ● New release of IBX App features helpful Doctor’s

Visit Assistant

ADMINISTRATIVE ► An updated Hospital Manual coming soon

● Save the date: QIPS High-Performing Office Summit on June 19

BILLING ► Updated payer ID grids now available

BLUECARD®

► Spring 2013 edition of Inside IPP now available

MEDICAL ► Updated policy for artificial intervertebral disc insertion

► Changes to preferred products to treat osteoarthritis of the knee

● In-home assessments of high-risk members ► No member cost-sharing for breast pumps ► Policy notifications posted as of April 26, 2013

NAVINET®

► NaviNet Claim INFO Adjustment requirement now in effect

ICD-10 ► Putting ICD-10 into Practice: Coding exercises and scenarios

HEALTH AND WELLNESS ● May is Mental Health Awareness month ● New screening resources available for primary care

physicians

Updated policy for artificial intervertebral disc insertion page 10

Inside this edition

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Models are used for illustrative purposes only. Some illustrations in this publication copyright 2013 www.dreamstime.com. All rights reserved.Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

The Blue Cross and Blue Shield names and symbols, BlueCard, and Baby BluePrints are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.

The third-party websites mentioned in this publication are maintained by organizations over which IBC exercises no control, and accordingly, IBC disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.

FutureScripts® and FutureScripts® Secure are independent companies that provide pharmacy benefits management services.

CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (IBC), created to provide valuable information to the IBC-participating provider community. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with IBC. This publication is the primary method for communicating such general changes. Suggestions are welcome.

Contact information:

Provider CommunicationsIndependence Blue Cross1901 Market Street 27th FloorPhiladelphia, PA 19103

[email protected]

Personal Choice®, Keystone 65 HMO, and Personal Choice 65SM PPO have an accreditation status of Excellent from the National Committee for Quality Assurance (NCQA).

Keystone Health Plan East has an accreditation status of Commendable from NCQA.

For articles specific to your area of interest, look for the appropriate icon:

Professional

Facility

Ancillary

The Provider News Center — a provider-dedicated website located at www.ibx.com/pnc — features up-to-date news and information of interest to providers and the health care community. Bookmark this site to ensure that IBC news and information remains only a click away.

Finding information that you needThe Provider News Center has a user-friendly interface that allows you to easily find the latest news and information of interest to you and your office:

● Latest News. All provider news published within the previous month is listed conveniently on the home page.

● Spotlight. Promotional banners located along the top of the home page highlight the most important news.

● Dedicated News. The home page features dedicated sections for important topics (e.g., ICD-10) with significant impact to our network providers.

● Sortability & Searchability. All news is grouped into convenient categories (such as Billing & Reimbursement, NaviNet®, and Products) and broken out by provider type (Professional, Facility, or Ancillary) so you can quickly find news that’s relevant to you and your office staff. You can also conduct keyword searches to pinpoint specific content.

Additionally, the Provider News Center includes a Quick Links section that provides easy access to our traditional IBC resources such as Inside IPP (the Inter-plan programs publication), IBC forms, the IBC Medical Policy portal, the NaviNet web portal, and our annually published provider publication indices.

We welcome your feedback. Please email us at [email protected] to share your thoughts.

Visit the Provider News Center

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Business TransformaTion

At IBC, we’re 75 years strong and still changing the game — enhancing the health and wellness of the people and communities we serve. Serving our members well means offering the right technology, tools, and processes, which is why we decided to migrate to a new operating platform.

The new operating platform will offer greater capabilities, increased flexibility in benefit design, and enhanced functionalities to improve the customer experience. This business transformation and migration to the new platform will occur throughout 2014 and into 2015.

IBC is committed to ensuring a seamless transition for our customers and other stakeholders through communication and tools to guide you through the migration process and dedicated teams of IBC associates who will work together to deliver integrated end-to-end solutions.

For more information about this transformation and how it may affect health care providers, please visit our dedicated site. Go to www.ibx.com/pnc and select Business Transformation from the top menu.

Changing the way we do business with you

May 2013 | Partners in Health UpdateSM 3 www.ibx.com/providers

New Primary Health Coach modelIBC has introduced a new approach to health coaching for our members, called the Primary Health Coach model. The new Primary Health Coach model gives members a single point of contact for all issues and concerns related to disease/condition and case management (this combination is called care management).

The following table describes our former care management programs and the changes that have been made as a result of this transition to the Primary Health Coach model:

Program description

Former programChanges for new model

ConnectionsSM Health Management Program

Disease/condition management that offers eligible members 24/7/365 access to a Health Coach by calling 1-800-ASK-BLUE

Program was administered by Health Dialog, an independent company

Program is administered by IBC Health Coaches

ConnectionsSM Complex Care Management Program

Supports eligible members who have one or more of 16 complex, chronic conditions

Support was provided by IBC care management nurses

Program name has been discontinued, but support continues to be provided by IBC Health Coaches

Case management

Provides members with extra support when dealing with an acute illness, chronic condition, or multiple comorbidities

Support was provided by IBC care management nurses

Support continues to be provided by IBC nurses, who are called Health Coaches

Fully insured commercial and Medicare Advantage HMO and PPO members transition to the new Primary Health Coach model on May 6, 2013, and IBC members from self-insured groups will transition on January 1, 2014.

continued on the next page

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Benefits of a Primary Health Coach model include:

● The Health Coach remains consistent as members transition across the health care continuum. This consistency ensures patient-centered coaching that is individualized and coordinated.

● The Health Coach and member can develop a trusted relationship, which fosters higher levels of member engagement and helps members reach their health goals.

● A Health Coach will have a 360-degree view of a member’s complete health record using an integrated nurse dashboard, which puts information at the Health Coach’s fingertips. This display features information about the member’s condition, prescription drugs, recent diagnostic or therapeutic activities, and patterns of treatment and procedures. Such complete data review allows our Health Coaches to have a more meaningful interaction with a member and improves the customer experience.

What providers need to knowProviders should now refer IBC patients for disease/condition and case management by submitting an online physician referral form, available at www.ibx.com/providerforms. A link to this form is also available on NaviNet® Plan Central in the Administrative Tools & Resources section. Providers who wish to refer their patients via telephone should call 1-800-ASK-BLUE.

Note: Providers should no longer call the Provider Support Line (1-866-866-4694) to make patient referrals.

The ConnectionsSM Provider Portal has been discontinued, and providers will no longer receive the SMART® Registry. Instead, providers continue to have access to similar information for their patients through our Clinical Alerts and the Clinical Care Report, both available on the NaviNet web portal through the Eligibility and Benefits Inquiry transaction.

Please note that, with the discontinuation of the SMART Registry, the SMART Registry CD Access Code transaction will be removed from NaviNet later this year.

What members need to knowMembers who currently use the disease/condition management program and who have a Health Coach under the current program have been transitioned to a new Health Coach at IBC. These members were notified of this change by mail and were assigned to a new IBC Health Coach.

Members should continue to call the same number (1-800-ASK-BLUE) to reach a Health Coach. Once they indicate that they would like to speak to a Health Coach, their call will be routed to a Health Coach at IBC. Members continue to have 24/7/365 access to a Health Coach and online educational tools.

If you or one of your IBC patients has any questions about this change, please call Customer Service at 1-800-ASK-BLUE.

New Primary Health Coach model (continued)

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Enrollment changes for Baby BluePrints® to begin this monthBeginning May 6, 2013, changes to the way IBC members are enrolled in our Baby BluePrints maternity program will be effective. The overall goal of the Baby BluePrints program — to reach out to members who have been identified as having risk factors within their first trimester of pregnancy — has not changed.

When IBC maternity members come in for their first prenatal visit, they no longer need to complete the Initial Maternity Patient Questionnaire (IMPQ). Instead, we ask that you let them know about the Baby BluePrints program and encourage them to call our toll-free number, 1-800-598-BABY, to self-enroll. Upon calling, a Health Coach will explain the program to the member and ask her a series of questions to complete the enrollment process.

Once enrolled in the program, members will receive a welcome letter that includes information on how to access educational materials on our secure member website, ibxpress.com, and the 1-800-598-BABY phone number for questions and support during pregnancy. In addition, high-risk members will be given the name and contact information for their Health Coach.

If in subsequent prenatal visits you discover that a maternity member has not yet self-enrolled in Baby BluePrints, or you feel that she may benefit from case management due to a high-risk pregnancy, you can refer the member to the program by completing an online physician referral form, which is available at www.ibx.com/providerforms. When you submit the online referral form, we will make certain that members who need additional support are enrolled in case management. You can also call 1-800-ASK-BLUE to refer a high-risk maternity member for case management.

Member resource availableA flyer is available upon request to place in the member’s chart and distribute at the first prenatal visit to encourage her to enroll in the Baby BluePrints program. To order flyers, please submit an online request at www.ibx.com/providersupplyline or call the Provider Supply Line at 1-800-858-4728.

Changes in the prenotification processWith the discontinuation of the IMPQ, a prenotification number will no longer be generated. Therefore, as of May 6, 2013, you will no longer need to obtain prenotification or notify IBC of the delivery, as claim payment is not dependent on prenotification.

Note: Providers must continue to inform IBC of any OB antepartum admissions, any babies admitted to the neonatal intensive care unit (NICU), and any detained babies.

If you have any questions about these changes, please call Customer Service at 1-800-ASK-BLUE.

Reminder: The last day to submit IMPQs is Friday, May 3, 2013.


www.ibx.com/providerswww.ibx.com/providersupplylinewww.ibx.com/providerforms

Figure 1 - Referrals Figure 2 - ID Cards Figure 3 - Medicine Cabinet

Consumerism

New release of IBX App features helpful Doctor’s Visit AssistantWe recently released an enhanced version of our mobile app — IBX App. It features a vibrant new look, easier navigation, and both new and improved tools, including the new Doctor’s Visit Assistant. These improvements can help members manage their health care more effectively, providing access to health information on the go, 24 hours a day, 7 days a week.

Highlights of the Doctor’s Visit AssistantWe anticipate that our members will increasingly make use of the Doctor’s Visit Assistant. To help ensure that you and your office are prepared, we are providing screen shots of each tool.

One of the most anticipated features of the Doctor’s Visit Assistant is the Referrals tracker. Members will no longer need to call your office to verify that a referral has been submitted, processed, or approved. Instead, a member can use the Doctor’s Visit Assistant to check the status of referrals (as well as claims), the specialist type, and the relevant dates (see Figure 1).

With the ID Cards tool, members can present a digital copy of their ID card (showing both the front and back sides) to your office. Additionally, members can send an email or fax a copy of the card to your office with the simple tap of a button (see Figure 2).

The Medicine Cabinet gives members important information about their prescribed medicine. Each drug that appears in the cabinet includes the official name, the dispense date, and a helpful picture of the drug’s container. Additional information about each drug is available by selecting the drug name (see Figure 3).

Doctor’s Visit Assistant toolsOur new Doctor’s Visit Assistant provides members with access to six helpful tools, each designed to streamline visits and empower members. They include:

● Referrals. Track open referrals. ● ID Cards. View images of the front and back of the member’s ID card. ● Medicine Cabinet. Retrieve information regarding prescribed medications. ● Drug Prices. Display costs and the nearest locations of participating pharmacies. ● Personal Health Record. Access a history of visits, immunizations, etc. ● Notes. Prepare questions, jot down reminders, record instructions, etc.

May 2013 | Partners in Health UpdateSM 6 www.ibx.com/providerscontinued on the next page



Consumerism

New release of IBX App features helpful Doctor’s Visit Assistant (continued)

The Drug Prices tool provides a cost estimate for any available drug. Additionally, the tool allows the member to see the nearest available participating pharmacy or change the ZIP code to find a pharmacy in another location (see Figure 4). Note: Costs are based on quantity and the days supply.

The Personal Health Record tool provides members with a mobile-friendly version of the health information traditionally accessible through our secure member website, ibxpress.com. A complete record of conditions, medications, allergies, visits, procedures, immunizations, and tests can be accessed — an invaluable tool for new members visiting your office for the first time or for members who have recently received care from other health care providers (see Figure 5).

Finally, the Notes feature enables members to prepare questions, jot down notes, and record specific instructions before, during, and after their visit with you. Additionally, the tool enables users to upload photos, allowing members to capture symptoms that may aid you in their care (see Figure 6).

Other enhancementsThe IBX App features expanded provider search capabilities, including participating Patient-Centered Medical Homes, urgent care providers, hospitals, and pharmacies. The app also features access to benefits information, deductible and medical spending account balances, contact information, improved login/password management, and an updated user interface that makes it easier for members to manage their health on the go.

Encourage IBC patients to download the IBX AppWe hope you will recommend this app to your IBC patients, especially those who may need assistance in taking notes on conditions or managing their prescriptions. The IBX App works with both iPhone and Android-powered devices. To download the IBX App, members can visit www.ibx.com/mobile or search for “IBX” in the Apple or Android store.

Note: To access this mobile app, members must read and accept the IBC and third-party vendors’ respective Privacy Policy/Terms and Conditions of Access.

Figure 4 - Drug Prices Figure 5 - Personal Health Record Figure 6 - Notes

www.ibx.com/providerswww.ibx.com/mobile


adminisTraTive

An updated Hospital Manual coming soonThe latest revision of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual) will be available soon through the NaviNet® web portal. The Hospital Manual is located in the Current Publications section of IBC NaviNet Plan Central. Please note that going forward, the Hospital Manual will be updated monthly, as needed, to reflect changes to important information regarding our policies, procedures, and programs that were communicated through Partners in Health Update and Provider Bulletins.

The Hospital Manual is available as easy-to-navigate PDFs that are organized into color-coded sections. Within each section are links to important information, such as forms and reference materials.

If you do not have access to NaviNet, please register by going to www.navinet.net and selecting Sign Up from the top right. Paper copies of the Hospital Manual will be available by submitting an online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

IBC will be hosting a meeting for all practices that are eligible for the Quality Incentive Payment System (QIPS) program.

When: Wednesday, June 19, 2013Time: 6:30 p.m. – 8:30 p.m.Where: G. Fred DiBona Building, 1901 Market Street, Philadelphia

Physicians from high-performing QIPS offices will share the processes and procedures that have enabled them to excel in QIPS, specifically with the Professional & Outpatient Cost Management incentive.

To register for the meeting, please send an email to [email protected] by Friday, June 14 that includes the following information:

● practice name ● individual physician name ● email address of each person attending

If you have any questions, please call Dayna Bersh at 215-241-2079.

About the QIPS programThe QIPS program offers incentives for high-quality, accessible, and cost-effective care. The Professional & Outpatient Cost Management incentive rewards those practices that are active in the coordinated care of their patients, our members.

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www.ibx.com/providersmailto: [email protected]/providersupplyline


Billing

Updated payer ID grids now availableThe professional and facility payer ID grids were recently updated to reflect a new alpha prefix for account-specific BlueCard® PPO members.

Please be sure to use the most current version of the payer ID grids, which are available on our website at www.ibx.com/edi or on our NaviNet® Plan Central page under Administrative Tools & Resources.

The Spring 2013 edition of Inside IPP, an inter-plan programs publication, is now available and features the following articles:

● Correct paid or denied claims using the Claim INFO Adjustment Submission transaction

● Submit claims for Blue Cross® Blue Shield® Medicare Advantage PPO members to IBC

● Use NaviNet® to get eligibility information for out-of-area members

● Updated payer ID grids now available

Go to www.ibx.com/insideipp to read this edition. You can also find a complete archive of past editions there. Printed copies of Inside IPP are available by submitting an online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

Inside IPP is a newsletter intended to increase awareness of and satisfaction with the BlueCard® Program. It highlights BlueCard-specific initiatives and plans for improvement.

Spring 2013 edition of Inside IPP now available

BlueCard®

Submit claims for Blue Cross® Blue Shield® Medicare Advantage PPO members to IBCUnderstand the process for submitting claims to IBC for these members

Use NaviNet® to get eligibility information for out-of-area membersLearn how to easily and efficiently obtain eligibility information using the BlueExchange® Out of Area transaction in NaviNet

Updated payer ID grids now availableDownload the updated payer ID grids for the most current information

I N S I D E T H I S E D I T I O N

2

S P R I N G 2 0 1 3


3

Correct paid or denied claims using the Claim INFO Adjustment Submission transactionTo correct an existing claim in a paid or denied status, use the Claim INFO Adjustment Submission transaction on the NaviNet® web portal. Please do not resubmit a paper claim to correct an existing claim.

Using the Claim INFO Adjustment Submission transaction, providers can submit claim adjustments for claims in a paid or denied status for a period of up to 18 months following the initial date of service. To review the status of submitted requests, providers should use the Claim INFO Adjustment Inquiry transaction.For more informationStep-by-step instructions on how to navigate through these two transactions are available in the Administrative Tools & Resources section of IBC NaviNet Plan Central under the “User Guides” category. These guides were recently updated.If you have any questions or need assistance with a NaviNet transaction, please call NaviNet Customer Care at 1-888-482-8057 or our eBusiness Provider Hotline at 215-640-7410.Note: The Claims INFO Adjustment transactions are available only for users who have the proper INFO permissions. v

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mediCal

Updated policy for artificial intervertebral disc insertion

Changes to preferred products to treat osteoarthritis of the knee

Effective May 17, 2013, IBC’s medical policy on artificial intervertebral disc insertion will be updated to include artificial intervertebral disc insertion in the cervical spine when medically necessary as an alternative surgical treatment to preserve range of motion for a select population.

Previously, artificial intervertebral disc insertion in the cervical spine was considered experimental and investigational. However, based on the current available peer-reviewed literature and clinical input, artificial intervertebral disc insertion in the cervical spine will be considered medically necessary in a select population.

About artificial intervertebral disc insertion Artificial intervertebral disc insertion is a technology intended for use in the cervical or lumbar spine to treat degenerative disc disease (DDD). DDD is a common cause of neck and/or low back pain. Spinal fusion is considered the established treatment for DDD for the resolution of pain and neurologic symptoms. However, artificial intervertebral disc insertion has been proposed as an alternative surgical treatment.

The current evidence suggests that in a select population, artificial intervertebral disc insertion in the cervical spine may offer lower re-operation rates and preserve range of motion. Additionally, mid-term results suggest that cervical artificial intervertebral disc insertion is not inferior to spinal fusion.

The available peer-reviewed literature and clinical input suggests that the current evidence for artificial intervertebral disc insertion in the lumbar spine remains limited and insufficient to permit conclusions regarding long-term safety and effectiveness. Therefore, artificial intervertebral disc insertion in the lumbar spine remains experimental and investigational.

Visit www.ibx.com/medpolicy after May 17, 2013, to review the revised Medical Policy #11.14.19g: Artificial Intervertebral Disc Insertion in its entirety.

Currently, there are seven hyaluronate acid products that have been approved by the U.S. Food and Drug Administration (FDA) to treat osteoarthritis of the knee: Euflexxa®, Gel-One®, Hyalgan®, Orthovisc®, Supartz®, Synvisc®, and Synvisc-One®. These products have demonstrated equivalent therapeutic results when used for this indication.

Effective April 1, 2013, IBC has designated Orthovisc®, Synvisc®, and Synvisc-One® as our preferred hyaluronate acid products for the treatment of osteoarthritis of the knee. These preferred products were selected based on their demonstrated cost-effectiveness. Choosing one of these preferred products does not affect the member’s cost- sharing for the drug.

We encourage providers to choose one of the three preferred products when treating members who have osteoarthritis of the knee.

At this time, we will continue to cover all seven hyaluronate acid products in accordance with the criteria listed in the Medical Policy #11.14.07i: Intra-articular Injection of Hyaluronan for the Treatment of Osteoarthritis.

For more details about the medical policy on hyaluronate acid products, go to www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, and then type the policy name or number in the Search box.

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mediCal

In-home assessments of high-risk membersIBC has partnered with Inovalon, Inc., an independent company, to conduct face-to-face assessments of high-risk Medicare Advantage HMO and PPO members. This outreach initiative began in 2012 and will continue throughout 2013. The purpose of these assessments is to gather member-specific documentation and provide the member’s primary care physician (PCP) with accurate health information to help support ongoing patient care.

Members are contacted by telephone or letter to schedule an appointment. Assessments are completed by a nurse practitioner from Inovalon in the member’s residence, whether in their own home or the skilled nursing facility in which the member resides. During the assessment, the nurse practitioner uses ePASS®, a decision-support tool that is prepopulated with the member’s medical history. It also addresses specific questions targeting gaps in documentation, assessment, and quality improvement. Each assessment is completed electronically and then shared with the member’s PCP as well as IBC.

If you or your IBC patients have any questions about these assessments, please call Customer Service at 1-800-ASK-BLUE.

The Patient Protection and Affordable Care Act requires that group health plans and health plan insurers cover designated preventive services, including certain women’s preventive health services, for members at 100 percent (i.e., $0 cost-sharing). These services include breastfeeding support, supplies, and counseling from in-network providers during pregnancy and/or in the postpartum period.

Recently the government made clarifications regarding the terms of this coverage to include both the rental and purchase of breast pumps. Therefore, as of April 1, 2013, members can purchase one portable manual or electric breast pump, plus supplies, per pregnancy from a participating in-network durable medical equipment (DME) provider with no member cost-sharing.

Note: The rental of hospital-grade breast pumps requires approval for medical necessity. Rentals are available at no cost-sharing only for those members who require the use of a hospital-grade pump. If approval is obtained for medical necessity, member cost-sharing will not be applied when the member rents the breast pump from an in-network DME provider.

If you or your IBC patients have any questions about this coverage, please call Customer Service at 1-800-ASK-BLUE.


No member cost-sharing for breast pumps



mediCal

Policy notifications posted as of April 26, 2013All policies are posted prior to their effective date. Below is a listing of the policy notifications that we have posted to our website as of April 26, 2013.

Policy effective date Policy No. Notification titleNotification issue date

May 10, 2013 05.00.67h Wheelchair Options and Accessories April 10, 2013

May 11, 2013 11.14.25a Total Ankle Arthroplasty/Replacement March 13, 2013

July 1, 2013 00.01.14kReporting and Documentation Requirements for Anesthesia Services April 2, 2013

July 9, 2013 05.00.30gNoninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices

April 10, 2013

To view the policy notifications, go to www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, and click on the Policy Notifications box. You can also view policy notifications using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Once these policies are in effect, they will be available by using the Search box on the Medical Policy homepage. Be sure to check back often, as the site is updated frequently.

NaviNet Claim INFO Adjustment requirement now in effectProviders who call Customer Service to question claim payments or to request a claim adjustment will now be directed to submit the request via the NaviNet web portal. This requirement includes those contracted with Magellan Behavioral Health, Inc. for PPO business. NaviNet offers the Claim INFO Adjustment transactions to ensure that your claim adjustment requests are addressed in the most efficient manner available.

Using the Claim INFO Adjustment Submission transactionThe Claim INFO Adjustment Submission transaction allows ancillary, facility, and professional providers to submit adjustment requests or question claim payments for paid or denied claims for a period of up to 18 months after adjudication of the original claim or as required by applicable law. Each submission is assigned a unique adjustment identification (ID) number.

To access the Claim INFO Adjustment Submission transaction, select Claim Inquiry and Maintenance from the Plan Transactions menu. You can access IBC’s response within ten business days through the Claim INFO Adjustment Inquiry transaction. If you do not receive a response within ten business days of the submission, please call Customer Service and have your adjustment ID number available.

Detailed user guides for both of these transactions are available on our Plan Central page under Administrative Tools & Resources.

Note: Your office location was required to register for NaviNet by April 1, 2013. If you have not yet done so, visit www.navinet.net and select Sign Up from the top right. If your office is currently NaviNet-enabled but would like training on how to submit a claim adjustment or retrieve a response to a submitted request through NaviNet, please contact our eBusiness Provider Hotline at 215-640-7410.

Magellan Behavioral Health, Inc., an independent company, manages mental health and substance abuse benefits for most IBC members.

navineT®

www.ibx.com/providerswww.navinet.netwww.ibx.com/medpolicy

May 2013 | Partners in Health UpdateSM 13 www.ibx.com/providersMay 2013 | Partners in Health UpdateSM 13 www.ibx.com/providers

Putting ICD-10 into Practice: Coding exercises and scenarios

continued on the next page

Answers to coding exercises:

1) H54.11 2) I95.2, T50.2x5A 3) K56.41 4) K58.0 5) K59.00 6) L23.81 7) L29.9 8) M06.311, M06.312 9) N18.6, Z99.2 10) N18.6, Z91.15

Answer to coding scenario:

ICD-10: K52.2, L27.2, Y92.511

ICD-9: 558.3, 693.1, 787.91, E849.6

The coding exercises and scenario in this section are designed to help you put the new ICD-10 guidelines and conventions into practice. An answer key is provided below so you can verify if your answers are correct. In addition, code narratives are included on the next page to describe each ICD-10 code used in the exercises and scenario.

If needed, use the ICD-10 Spotlight: Know the codes booklet for assistance with these exercises. It is available at www.ibx.com/icd10.

Coding exercises Code the following conditions according to ICD-10 coding conventions and guidelines:

1. Blindness (right eye), low vision (left eye)

2. Hypotension due to drugs (diuretics), initial encounter

3. Fecal impaction

4. Irritable colon with diarrhea

5. Constipation

6. Allergy from cat hair

7. Itch

8. Rheumatoid nodule, both shoulders

9. Kidney disease requiring chronic dialysis

10. Kidney disease requiring chronic dialysis, non-compliant patient

Coding scenarioCode the following scenario according to both ICD-9 and ICD-10 coding conventions and guidelines:

Tim and Susan celebrated their wedding anniversary by making reservations at the restaurant where they had their first date. They both decided to order something they have never tried before. The meal was delicious, but later that evening Tim broke out in a rash and experienced abdominal cramping and diarrhea. Susan suspected it must have been something he ate and advised him to see his doctor. The physician confirmed Susan’s suspicion.

www.ibx.com/providerswww.ibx.com/icd10

May 2013 | Partners in Health UpdateSM 14 www.ibx.com/providersMay 2013 | Partners in Health UpdateSM 14 www.ibx.com/providers

Putting ICD-10 into Practice: Coding exercises and scenarios (continued)

NarrativesThe following are the corresponding code narratives for each of the codes in the answer key:

ICD-10 code Code narrative

Exercises

H54.11 Blindness, right eye, low vision left eye

I95.2 Hypotension due to drugs

T50.2x5A Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides, and other diuretics, initial encounter

K56.41 Fecal impaction

K58.0 Irritable bowel syndrome with diarrhea

K59.00 Constipation, unspecified

L23.81 Allergic contact dermatitis due to animal (cat) (dog) dander

L29.9 Pruritus, unspecified

M06.311 Rheumatoid nodule, right shoulder

M06.312 Rheumatoid nodule, left shoulder

N18.6 End stage renal disease

Z99.2 Dependence on renal dialysis

Z91.15 Patient’s noncompliance with renal dialysis

Scenario — ICD-10

K52.2 Allergic and dietetic gastroenteritis and colitis

L27.2 Dermatitis due to ingested food

Y92.511 Restaurant or cafe as the place of occurrence of the external cause

Scenario — ICD-9

558.3 Gastroenteritis and colitis, allergic

693.1 Dermatitis due to food taken internally

787.91 Diarrhea

E849.6 Place of occurrence, public building

For additional information related to the IBC transition to ICD-10, please visit www.ibx.com/icd10. On this site you will find examples of how ICD-9 codes will translate to ICD-10 codes in the ICD-10 Spotlight: Know the codes booklet. In addition, you will find examples of ICD-10 coding exercises and scenarios in the Putting ICD-10 into Practice: Coding exercises and scenarios booklet.

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May is Mental Health Awareness month

New screening resources available for primary care physicians

IBC encourages providers to improve communication between mental health care providers and primary care providers in an effort to promote a cohesive plan of care for patients.

While communication between primary care providers and mental health providers is slowly improving, there continues to be a large percentage of providers, both medical and mental health, who do not communicate concerning patient care. Information that you may find helpful when you contact your patients’ mental health care provider includes:

● How is he/she responding to counseling or medication treatment? ● How is this affecting any medical complaints? If there is a chronic illness, does he/she have increased symptoms during times of stress?

● Are there any special considerations regarding medication interactions? Has the patient had any side effects from medications?

● How can you coordinate appropriate tests to be ordered and results monitored?

Physicians must obtain patient consent to exchange patients’ personal information and discuss mental health care. Please discuss the importance of having this information for your patients’ health and safety. When possible, provide your patients with a consent form they can sign, so they are informed of the information that will be shared and are able to express their written consent.

To obtain a copy of the PCP to Behavioral Health Provider Communication Form, as well as other tools and resources, go to www.ibx.com/providers/resources/worksheets.

We recently created three handouts designed to give primary care physicians additional information and screening techniques, as well as links to resources that can be used when discussing alcohol use, depression, and smoking cessation with IBC patients:

● Alcohol Screening in Primary Care ● Depression and Primary Care ● Smoking Cessation

These handouts can be downloaded from our website at www.ibx.com/resources in the Worksheets, Forms, and Guides section. You can also request a printed copy of these documents by submitting an online request at www.ibx.com/providersupplyline or by calling our Provider Supply Line at 1-800-858-4728.


HealTH and Wellness

For informational purposes only – 2013 Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield – independent licensees of the Blue Cross and Blue Shield Association.

Smoking Cessation 450,000 individuals die each year of smoking-related, and therefore preventable diseases.1

Only 48% of smokers who saw a physician were advised to quit smoking. Most smokers say they want to quit smoking. Clinician advice to stop smoking prompts smokers to make quit attempts and increases quit rates.

Smoking cessation rates combining pharmacotherapy and counseling range from 16% – 24%.

Systemic identification of smoking status increases clinician’s delivery of advice and counseling.

Addressing tobacco use in health care settings has a strong evidence base. Cessation rates increase with increasing counseling intensity. Meaningful use criteria now includes assessment of smoking status.

Five As of smoking cessation2

Ask all patients about smoking Advise all smokers to stop smoking Assess readiness to quit Assist quitting Arrange follow-up

Resources

1-800-QUIT NOW (1-800-784-8669) All Pennsylvania residents can receive free nicotine replacement products and up to five counseling sessions. (The kit includes a four-week supply of nicotine patches as well as other information to help make the quit attempt successful. Those who qualify must be willing to enroll in the Quitline coaching program and set an actual quit date.)

Community-based Quit Smoking Programs The following community-based quit smoking programs provide group counseling and one-on-one support. All programs offer free nicotine replacement therapies to eligible adult enrollees.

Council of Spanish Speaking Organizations (CONCILIO) – provides a Spanish-language quit smoking program for the adult (18+) Latino population in Philadelphia. Call 215-627-3100. Health Federation of Philadelphia – offers group and individual quit smoking services at eight City Health Centers and at many Federally Qualified Health Centers located city-wide. Call 215-246-5584.

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Depression and Primary Care Two-thirds of people with mental illness do not receive treatment.1

Depression second highest cause of disability and premature death worldwide by 20202 $83.1 billion in direct and indirect costs3 majority of people with depression turn to primary care providers for help

Screening improves the accurate identification of depressed patients in primary care settings: 1/100 patients screened will have clinical depression treatment with antidepressants, psychotherapy, or both decreases clinical morbidity programs combining depression screening and feedback with staff-assisted depression

care supports improved clinical outcomes in adults and older adults

For initial screening, asking the following TWO simple questions about mood and anhedonia are effective in helping to determine whether a patient is depressed.4

“Over the past two weeks, have you felt down, depressed, or hopeless?” “Over the past two weeks, have you felt little interest or pleasure in doing things?”

As a next step, the nine-question PHQ-9 depression scale is an easy tool for assisting primary care providers in diagnosing depression, as well as selecting and monitoring treatment.5

When you choose to refer a patient, you can call the Mental Health/Substance Abuse telephone number printed on the back of his or her health insurance ID card.

References 1USPSTF recommendation statements and evidence reviews – www.uspreventiveservicestaskforce.org 2World Health Organization – www.who.int 3National Institutes of Health – www.ncbi.nlm.nih.gov/pubmed/21155203 4The MacArthur Initiative on depression & Primary Care - Depression Tool Kit (includes PHQ-9) – www.depression-primarycare.org/clinicians/toolkits/

5Magellan Behavioral Health, Inc. Clinical Practice Guidelines – https://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/clin_prac_guidelines/index.asp

This information is provided by Independence Blue Cross and its affiliates (IBC) for IBC-participating primary care providers for informational purposes only. This is not a statement of benefits and should not be construed as medical advice. Benefits may vary based on state requirements, Benefits Programs (HMO, PPO, Indemnity, etc.), and/or employer groups. Providers should call Customer Service for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.

Magellan Behavioral Health, Inc., an independent company, manages mental health and substance abuse benefits for most IBC members.


Alcohol Screening in Primary Care

At-risk alcohol use 20% of males and 10% of females are at risk, dependent, or addicted to alcohol based on the following weekly consumption of alcholol1:

>14 drinks per week for males >7 drinks per week for females ETOH and concurrent prescription drug

abuse and/or illicit drug use

Reported decrease in total medical costs for at-risk alcohol use related to treatment over $1,000 for a brief intervention in those at risk in the first year.2

CAGE survey to ask patients 1. Have you ever felt that you should Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt Guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a

hangover (Eye Opener)?

If the answer to any one of the CAGE questions is positive: Step 1. Assessment and Direct Feedback As your physician I am concerned about how much you drink and how it is affecting your

health. Less than 10 percent of patients drink as much as you do. You are drinking alcohol at a level that puts you at serious risk for a number of alcohol-

related problems.

Step 2. Negotiation and Goal Setting You need to reduce your drinking. What do you think about cutting down to one or two drinks two to three times per week? Can you reduce your alcohol use for the next month?

Step 3. Behavioral Modification Techniques Here is a list of situations when people drink and sometimes lose control of their

drinking. Let’s talk about ways you can avoid these situations. Can you identify a family member or a friend who can help you? What are the things you like about drinking? What are some of the things you don’t like about your alcohol use?

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One drink = 12-ounce beer or wine cooler = 5-ounce glass of wine = 1.5-ounces of distilled spirits

www.ibx.com/resourceswww.ibx.com/providersupplylinewww.ibx.com/providers/resources/worksheetswww.ibx.com/providers

I m p o r t a n t r e s o u r c e s

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Mail order program toll-free fax 1-877-228-6162

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FutureScripts® Secure (Medicare Part D) 1-888-678-7015

Formulary updates www.ibxmedicare.com

Mail order program toll-free fax 1-877-344-1318

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NaviNet® portal registration www.navinet.net

Provider Supply Line 1-800-858-4728

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PARTNERS IN HEALTH UPDATE - MAY 2013INSIDE FRONT COVERVisit the Provider News Center

BUSINESS TRANSFORMATIONNew Primary Health Coach model

Enrollment changes for Baby BluePrints® to begin this month

CONSUMERISMNew release of IBX App features helpful Doctor’s Visit Assistant

ADMINISTRATIVEAn updated Hospital Manual coming soon Save the date: QIPS High-Performing Office Summit on June 19

BILLINGUpdated payer ID grids now available

BLUECARD®Spring 2013 edition of Inside IPP now available

MEDICALUpdated policy for artificial intervertebral disc insertion Changes to preferred products to treat osteoarthritis of the knee

In-home assessments of high-risk members No member cost-sharing for breast pumps Policy notifications posted as of April 26, 2013

NAVINET®NaviNet Claim INFO Adjustment requirement now in effect

ICD-10Putting ICD-10 into Practice: Coding exercises and scenarios

HEALTH AND WELLNESSMay is Mental Health Awareness month

New screening resources available for primary care physicians

IMPORTANT RESOURCES

Documents

Inside this edition · 2019. 10. 11. · IBC has introduced a new approach to health coaching for our members, called the Primary Health Coach model. The new Primary Health Coach