Inside this edition

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

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This publication contains articles previously published on our Provider News Center.December 2018 Recap

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Administrative ● Reminder: New EFT requirement ● Introducing the new ePASS® Next Platform

● Required lead time when updating your provider information

● Will you receive payment for services provided to your Independence CHIP members?

● Important information about the Medicare Outpatient Observation Notice

● Updated Provider Services call center holiday hours

BlueCard®

● Reminder: New medical records retrieval vendor

Billing & Reimbursement ● Billing guidelines for coverage of intrauterine devices (IUDs)

● Reminder: Enhanced claim edits to support correct coding principles and important information about self-funded groups

● Update: BCBSA high-dollar prepayment claims review policy

Health & Wellness ● Prescribe fitness to help your Medicare Advantage patients prevent or control type 2 diabetes in effect

Medical ● Reminder: Updates to the medical benefit specialty drug cost-sharing list

● Updated credentialing requirements for CRNPs and PAs

Medical (continued) ● Reminder: Updates to the list of specialty drugs that will require precertification

● Outbreak of life-threatening coagulopathy associated with synthetic cannabinoids use

● Reminder: New acupuncture benefit and network

● Introducing a new palliative care program

● View up-to-date policy activity on our Medical Policy Portal

● New policy on pediatric intensive day feeding program

Pharmacy ● Our prescription drug program and safe prescribing procedures

● Reminder: Online PreCheck MyScript tool provides insight into member pharmacy benefits

● Medicare seven-day supply limit for first time opioid fills

Products ● Identifying Preferred PCPs and the required copayments

● New coverage option for FEP members

Quality Management ● Improving lead testing and developmental screening among CHIP members

● Reminder: New accreditation requirement for office-based varicose vein procedures

● 2018-2019 Clinical Practice Guideline Summary now available

Inside this edition

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

Professional Facility Ancillary

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IVE Reminder: New EFT requirement

Published December 3, 2018

As previously communicated, Independence will be implementing a new electronic funds transfer (EFT) requirement effective January 1, 2019. All participating providers must register for and maintain EFT capability for the payment of claims, capitation, and incentive-based programs. EFT registration enables a direct electronic payment from Independence to your bank account versus mailed check payments that can be lost or take several days to reach you.

Note: This new requirement will be reflected in the Provider Manual for Participating Professional Providers and the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers once the EFT requirement becomes effective.

Registration detailsRegistration for EFT must be completed no later than January 1, 2019, through the NaviNet® web portal by an individual who is authorized to access and maintain banking information for your organization. Note: This individual will be required to attest as the designated responsible party when first accessing the EFT registration screen.

We encourage you to begin the registration process early so that you are compliant by January 1, 2019. You may choose an alternative effective date, but that date may not be later than January 1, 2019.

Please review the detailed EFT Attestation and Registration Guide, which is available in the NaviNet Resources section.

If you currently do not have an account with NaviNet, please call us at 215-640-7410.

Learn moreFor more information on this requirement, please review the EFT requirement: Frequently Asked Questions (FAQ) document, which can also be found in the Frequently Asked Questions archive on Independence NaviNet Plan Central. Note: The FAQ will be updated as more information becomes available.

If you have additional questions or need help with the registration process, please contact the eBusiness Hotline at 215-640-7410.

Updates on this EFT requirement will be communicated in future Partners in Health UpdateSM articles.

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

The benefits of EFTThere are several benefits of using EFT over conventional paper-based methods, including:

● higher security ● faster access to funds ● reduced administrative processing time

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IVE Introducing the new ePASS® Next Platform

Published December 10, 2018

Over the last several years, Independence has worked together with Inovalon, an independent company, to support the ePASS® online platform across our Medicare Advantage and Commercial HIX (ACA) networks. This program has helped our network providers to enhance the quality and completeness of patient documentation.

We have often received feedback from users asking for a more accessible, streamlined, and reliable tool. We are excited to announce that in 2019 Inovalon will release the ePASS® Next platform. The ePASS® Next platform has been designed to bring a better experience to our provider community. ePASS® Next will go live February 1, 2019.

Platform enhancementsWe are pleased to share a few of the enhancements, which include:

● Increased accessibility − No additional software is required. Microsoft Silverlight is no longer needed. − The tool is browser agnostic. Complete ePASS® assessments through any type of web browser.

● Increased reliability − Enhancements minimize the possibilities of system crashes. − Auto-save features have been added to ensure that no work is lost due to timeouts. − Linkage logic is improved to ensure that both patients and providers are attributed to the correct office.

● Streamlined workflow − Assessments can be completed through a single page. − Smart Logic detects diagnostic and medication information entered into the ePASS® SOAP Note and

automatically prepares future sections of the assessment. ● Floating save and submit buttons have been added for easy updates.

Training available for new platformWith these enhancements the look and feel of the ePASS® platform will change. Independence has multiple training options and guides available on how to use the updated platform. These resources will help get providers off the ground and running with ePASS® Next:

● webex training – provided by both Inovalon and Independence ● embedded video on the homepage to provide a high-level overview of the ePASS® Next platform ● on-site trainings and hard copy materials ● access to the ePASS support team via supplementalprograms@ibx.com ● Inovalon service desk

For more informationePASS® Next will be live starting February 1, 2019. If you have questions or would like more information about the platform or training opportunities, please contact us via email at supplementalprograms@ibx.com.

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IVE Required lead time when updating your provider

informationPublished December 17, 2018

Independence would like to remind you that submitting changes in a timely manner helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories. In accordance with your Provider Agreement (Agreement), the Provider Manual for Participating Professional Providers (Provider Manual) and/or the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual), as applicable, you are required to notify Independence whenever key provider demographic information changes.

Professional providersAs outlined in the Administrative Procedures section of the Provider Manual, Independence requires 30 days advance written notice to process most updates, with the exceptions noted below:

● 30-day notice. Independence requires 30 days advance written notice for the following changes/updates to your practice information:

− updates to address, office hours, total hours, phone number, or fax number;

− changes in selection of capitated providers (HMO primary care physicians [PCP] only);

− addition of new providers to your group (either newly credentialed or participating);

− changes to hospital affiliation; − changes that affect availability to patients (e.g., opening

your panel to new patients). ● 60-day notice. Independence requires 60 days advance

written notice for closure of a PCP practice or panel to additional patients.

● 90-day notice. Independence requires 90 days advance written notice for resignation and/or termination from our network.

Submitting updates and/or changes*Professional providers can use the Provider File Management transaction on the NaviNet® web portal to submit specific updates to their Independence provider record. These updates include:

● Add/Delete a participating practitioner to/from an existing practice ● Add/Delete an address (i.e., doing business as [DBA], check, mailing, main, or practice) ● Add/Delete contact name, title, or communication device type/number ● Add/Delete office hours ● Update “Walk-in” acceptance status ● Update Patient and Appointment Options (i.e., accepting new patients) ● Update General Practice Availability (i.e., Urgent, Routine Visits, etc.) ● Update Member Access number (i.e., the telephone number that appears on the member’s identification card –

which must be the location-specific telephone number for a patient to make an appointment) ● Update Electronic Medical Records (EMR) status ● Update the availability of other clinical staff (i.e., midwife, nurse practitioner, etc.) ● Update office accessibility and services (i.e., handicapped, parking, and communication and language

services)

Important information on updating your provider recordProviders are strongly encouraged to use the Provider File Management transaction to update provider records. If Independence receives provider record updates that can be submitted using the Provider File Management transaction, a member of our eBusiness team may contact that provider to assist them in using the transaction to make the necessary updates. This will allow our team to receive user feedback on the transaction and help improve the overall user experience for our network.

A Provider File Management Guide is available to assist you in navigating this transaction and ensure accurate submissions. The guide is available in the NaviNet Resources section. If you have any further questions on this transaction, please contact the eBusiness Hotline at 215-640-7410.

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The Provider File Management transaction is not intended for use by facilities, skilled nursing facilities, ancillary providers, or providers contracted with Magellan Healthcare, Inc. (Magellan), an independent company.

If your request is not eligible to be completed through the Provider File Management transaction, please submit a Provider Change Form. Please be sure to print clearly, provide complete information, and attach additional documentation as necessary. Mail your completed Provider Change Form to:

Independence Blue Cross Attn: Network Administration P.O. Box 41431 Philadelphia, PA 19101-1431

You can also fax the completed form to Network Administration at 215-238-2275. Please be sure to keep a confirmation of your fax.

Note: The Provider Change Form cannot be used if you are closing your practice or terminating from the network. Refer to “Resignation/termination from the Independence network” in the Administrative Procedures section of the Provider Manual for more information regarding these policies and procedures.

Facility and ancillary providersAs outlined in the Administrative Procedures section of the Hospital Manual, Independence requires 30 days advance written notice to process updates to address, phone number, or fax number, as well as change in ownership.

Submitting updates and/or changes*Notice of all changes must be submitted in writing to our contracting and legal departments at the following addresses, or as provided in your Agreement:

Independence Blue Cross Attn: Vice President, Total Value Contracting and Reimbursement 1901 Market Street, 27th Floor Philadelphia, PA 19103

Independence Blue Cross Attn: Deputy General Counsel, Managed Care 1901 Market Street, 43rd Floor Philadelphia, PA 19103

Authorizing signature and W-9 FormsUpdates resulting in a change on your W-9 Form (e.g., changes to a provider’s name, tax ID number, billing vendor or “pay to” address, or ownership) require the following signatures:

● For professional providers: − Group practices: A signature from a legally authorized representative (e.g., physician or other person who

signed the Agreement or one who is legally authorized to bind the group practice) of the practice is required. − Solo practitioners: A signature from the individual practitioner is required.

● For facility and ancillary providers: Written notification on company letterhead is required.

An updated copy of your W-9 Form reflecting these changes must also be included to ensure that we provide you with a correct 1099 Form for your tax purposes. If you do not submit a copy of your new W-9 Form, your change will not be processed.

Independence will not be responsible for changes not processed due to lack of proper notice. Failure to provide proper advanced written notice to Independence may delay or otherwise affect provider payment.

If you have questions related to updating your provider information, please email us at provider_communications@ibx.com.

*To ensure appropriate setup in Independence systems, the same time frames also apply to behavioral health providers contracted with Magellan. Behavioral health providers must submit any changes to their practice information to Magellan via their online Provider Data Change form by selecting the “Display/Edit Practice Info” link.

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

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.

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IVE Will you receive payment for services provided to your

Independence CHIP members?Published December 20, 2018

Over the past several months, we have published articles in Partners in Health UpdateSM informing you that the Pennsylvania Department of Human Services (Department) requires all providers in the Children’s Health Insurance Program (CHIP) network to have a PROMISeTM ID for each location at which they treat CHIP members. A PROMISe ID is a Department-issued Provider Reimbursement and Operations Management Information System identification number. It is required for you to receive payment for services rendered to CHIP members.

If you have a PROMISe ID, we encourage you to confirm that your office information, including address, is up-to-date. For more information on this requirement, please read our previously published article, Reminder: Important information regarding obtaining a PROMISe ID to render services to CHIP members.

Act now!If you have not yet enrolled with the Department for your PROMISe ID, there is still time to register. Please visit the Pennsylvania Department of Human Services website to access the application, requirements, and step-by-step instructions related to the enrollment process. Providers are encouraged to enroll electronically.

Important information about the Medicare Outpatient Observation NoticePublished December 10, 2018

The Centers for Medicare & Medicaid Services (CMS) requires that all hospitals and critical access hospitals (CAH) provide the Medicare Outpatient Observation Notice (MOON) to beneficiaries in Original Medicare (fee-for-service) and Medicare Advantage enrollees who receive observation services as an outpatient for more than 24 hours.

The hospital or CAH must issue the MOON no later than 36 hours after observation services as an outpatient begin. This also applies to beneficiaries in the following circumstances:

● beneficiaries who do not have Part B coverage (as noted on the MOON, observation stays are covered under Medicare Part B);

● beneficiaries who are subsequently admitted as an inpatient prior to the required delivery of the MOON; ● beneficiaries for whom Medicare is either the primary or secondary payer.

To access the MOON and completion instructions, please visit the CMS website.

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IVE Updated Provider Services call center holiday hours

Published December 20, 2018

The Provider Services call center will be adjusting its hours to allow our representatives to balance time with their families and continue to serve our provider network.

Updated hoursThe Provider Services call center will be adjusting its regular Monday through Friday hours of 8 a.m. – 5 p.m., on the following dates:● Monday, December 24, 2018: 8 a.m. – 6 p.m.● Tuesday, December 25, 2018: Closed● Monday, December 31, 2018: 8 a.m. – 6 p.m.● Tuesday, January 1, 2019: Closed

Thank you for your understanding and have a safe holiday season.

Reminder: New medical records retrieval vendorPublished December 26, 2018

As previously announced, effective January 1, 2018, Inovalon, an independent company, was selected by the Blue Cross® Blue Shield Association® to retrieve medical records for out-of-area Blue members. Inovalon will coordinate medical record requests from Blue Cross® and Blue Shield® companies across the country and help reduce multiple requests for patient data. This arrangement supports Healthcare Effectiveness Data and Information Set (HEDIS®), risk adjustment, and government-required programs related to the Affordable Care Act (ACA).

Requests for medical recordsAs outlined in your provider agreement with Independence, you are required to respond to requests in support of risk adjustment, HEDIS, and other government-required activities within the requested time frame. This includes requests from Inovalon on our behalf. Independence is working diligently to make this process as simple as possible.

For your convenience, medical records may be submitted to Inovalon using any of the following methods:● Fax. Fax medical records to 1-877-221-0604.● FedEx®. For further instruction on returning medical records via FedEx, please call 1-800-463-3339.● Email. Send medical records via secure email to EMRService@inovalon.com.

If you have questions on delivery options and methods, call Inovalon at 1-844-682-9764.

HIPAA and privacyInovalon is contractually bound to preserve the confidentiality of health plan members’ protected health information (PHI) obtained from medical records, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulations. Please note that patient-authorization is not required for you to comply with these requests for medical records.

Providers are permitted to disclose PHI to health plans without authorization from the patient when both the provider and health plan have a relationship with the patient and the information relates to the relationship.

For more information regarding the HIPAA privacy rule, please visit the U.S. Department of Health & Human Services website.

Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

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ENT Billing guidelines for coverage of intrauterine devices (IUDs)

Published December 6, 2018

Intrauterine devices (IUDs) are a form of long-term contraception used to prevent pregnancy. Certain IUDs have non-contraceptive uses, for example in the treatment of medical conditions that result in heavy menstrual bleeding.

The Affordable Care Act (ACA) requires that IUDs used for contraceptive purposes be covered as a preventive service by healthcare plans. The devices are eligible for coverage under plans that offer contraceptive coverage/family planning benefits with no cost-share.

Independence coverage policies are consistent with the requirements of the ACA. The appropriate procedure and diagnosis codes must be reported to distinguish when IUDs are used for contraceptive purposes rather than non-contraceptive treatment of medical conditions.

Providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal to confirm individual member benefits. Please refer to the table below for details on coverage positions and billing guidelines for IUDs that may be used for contraceptive and non-contraceptive indications.

* Providers should confirm individual member benefits using the Eligibility and Benefits Inquiry transaction on NaviNet.

Learn moreFor more information, refer to the following Independence medical policies:

To view these policies, visit our Medical Policy Portal, select Accept and Go to Medical Policy Online, then select Commercial or Medicare Advantage, depending on which version of the policy you would like to view, and then type the policy name or number in the Search field. NaviNet is a registered trademark of NaviNet, Inc., an independent company.

IUD HCPCS codes Is this covered for contraceptive use? Is this covered for

non-contraceptive* use?

Kyleena® J7296

Yes – This is covered for contraceptive use with zero cost-share to the member as a preventive service when billed with the following ICD-10 diagnosis codes: Z01.411, Z01.419, Z30.011, Z30.012, Z30.013, Z30.014, Z30.015, Z30.016, Z30.017, Z30.018, Z30.019, Z30.02, Z30.09, Z30.2, Z30.40, Z30.41, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.44, Z30.45, Z30.46, Z30.49, Z30.8, and Z30.9.

No – This is considered experimental/investigational and therefore is not covered for non-contraceptive use.

Liletta® J7297

Yes – This is covered for contraceptive use with zero cost-share to the member as a preventive service when billed with the following ICD-10 diagnosis codes: Z01.411, Z01.419, Z30.011, Z30.012, Z30.013, Z30.014, Z30.015, Z30.016, Z30.017, Z30.018, Z30.019, Z30.02, Z30.09, Z30.2, Z30.40, Z30.41, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.44, Z30.45, Z30.46, Z30.49, Z30.8, and Z30.9.

No – This is considered experimental/investigational and therefore is not covered for non-contraceptive use

Mirena® J7298Yes – This is covered for contraceptive use with zero cost-share to the member as a preventive service when billed without the following ICD-10 diagnosis codes: N92.0, N92.1, N92.4, and Z79.890.

Yes – Mirena is covered for non-contraceptive use and will be subjected to a cost-share based on the member’s benefits when billed with the following ICD-10 diagnosis codes: N92.0, N92.1, N92.4, and Z79.890.

Skyla® J7301

Yes – This is covered for contraceptive use with zero cost-share to the member as a preventive service when billed with the following ICD-10 diagnosis codes: Z01.411, Z01.419, Z30.011, Z30.012, Z30.013, Z30.014, Z30.015, Z30.016, Z30.017, Z30.018, Z30.019, Z30.02, Z30.09, Z30.2, Z30.40, Z30.41, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.44, Z30.45, Z30.46, Z30.49, Z30.8, and Z30.9

No – This is considered experimental/investigational and therefore is not covered for non-contraceptive use.

Commercial Medicare Advantage ● #07.10.05k: Noncontraceptive Use of the

Levonorgestrel-Releasing Intrauterine System ● #MA07.025d: Intrauterine Systems (IUSs)

(e.g., Mirena®, Skyla®, Liletta®, Kyleena®) ● #00.06.02w: Preventive Care Services ● #MA00.003i: Preventive Care Services

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Reminder: Enhanced claim edits to support correct coding principles and important information about self-funded groupsPublished December 14, 2018

As a reminder, claims received by Independence on or after June 10, 2018, are subject to a claim editing process during prepayment review to ensure compliance with current industry standards and support the automated application of correct national coding principles.* By applying these principles, we will be consistent with other payers in the region and will apply claim payment principles that are national in scope, simple to understand, and continue to comply with industry standard sources, including:

● Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines

● American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines

● CMS HCPCS LEVEL II Manual coding guidelines ● ICD-10 Instruction Manual coding guidelines

Please be advised that as guidelines from these sources are updated, our claim edits will be reviewed and changes to our claim edits will be implemented as applicable.

* Self-funded groups have the option to not participate in the enhanced claim edits; therefore, your outcomes may vary by health plan. See below for more information about self-funded groups.

Areas of focusIndependence's correct coding principles will continue to focus on areas such as:

● National bundling edits, including the Correct Coding Initiative (CCI)

● Modifier usage including, but not limited to, the following:

− 26 − 59 − 77 − 78 − TC

● Global surgery period ● Add-on code usage

With the implementation of these claim edits, claims submitted with inappropriate coding will be returned or denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim return or denial. Any returned claims must be corrected prior to resubmission.

These changes should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.

Claim review requestsWe recognize there may be times when you have questions regarding the outcome of a claim edit. As with all claim review requests, these questions should be submitted using the Claim Investigation transaction on the NaviNet® web portal. Claim lines that have gone through the editor can be identified by the alpha-numeric codes and messages beginning with E8 on your Provider EOB or Provider Remittance. Refer to the box below for more information.

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Important information about self-funded groupsEffective January 1, 2019, a large amount of self-funded employer groups will renew their health plans. While self-funded groups have an option to not participate in the enhanced claim edits, Independence believes many self-funded groups will participate in the enhanced claim edits.

As a result, if correct coding rules based on the industry standards referenced in this document are not being followed, you may see an increase in the E8 claim denials, which you may have already been experiencing since the enhanced claim edit implementation in June of 2018.

Identifying claims that went through the new claim editor processIf your claim was affected by one of the new claim edits, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. Should your claim line contain an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen in NaviNet. To view, hover your mouse over the service line and select View Additional Detail. If you see an E8XXX code/message, the line went through an edit. Only E8XXX codes/messages are part of the enhanced claim editor. All other codes/messages are unrelated to the enhanced claim editor.

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For more informationFor questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found on Independence NaviNet Plan Central in the Frequently Asked Questions section under Administrative Tools & Resources. Note: The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please send an email to claimeditquestions@ibx.com.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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

Automated claim editsHere are some examples of claim edits included in the new claim editing process:

ICD-10 coding ● Excludes1 Notes: Claim lines reported with

mutually exclusive code combinations according to the ICD-10-CM Excludes1 Notes will be denied.

− When a code from range H73.0 – H73.099 (Acute myringitis) is associated to the same claim line as a code in either the range H65H – 65.93 (Nonsuppurative otitis media) or the range H66 – H66.93 (Suppurative and unspecified otitis media), then the claim line will be denied.

● Laterality: The Diagnosis-to-Modifier comparison assesses the lateral diagnosis associated to the claim line to determine if the procedure modifier matches the lateral diagnosis. If it does not match, the claim line will be denied.

− DIAG1: H60.332 (Swimmer's ear, left ear) − CPT: 69000 (Drainage external ear, abscess, or

hematoma; simple) − MOD: RT

● Primary diagnosis code reporting: Certain diagnosis codes cannot be reported as the only or primary diagnosis code on a claim. If one of the following codes is reported as the only or primary diagnosis, then the claim line will be denied:

− Manifestation codes − External causes (i.e., "V – Y" codes) − Secondary codes (e.g., Z33.1)

Evaluation and Management services ● Only one new patient visit will be allowed to the

same group practice and specialty within three years.

● Only one initial inpatient hospital visit and inpatient hospital discharge will be allowed per hospital stay.

● Accurate reporting of initial, subsequent, and observation discharge care.

Surgical services ● Accurate reporting of modifiers for the billing

of surgical services rendered by one or more providers.

● Primary surgeon should not also report as the assistant surgeon.

Code combinations ● Vaccine toxoid must be reported on the same day

as a vaccine administration. ● Ambulance mileage must be reported on the same

day as an ambulance transport.

Procedure/Diagnosis vs. Age consistency Certain procedure and diagnosis codes are limited to a specific age group. The age groups recognized within our edits are as follows:

● Newborn/Neonatal: < 29 days ● Infant: < 1 year (includes newborn/neonatal) ● Child: 1 – 11 years ● Adolescent: 12 – 17 years ● Pediatric: 0 – 17 years (includes newborn/neonatal,

infant, child, and adolescent) ● Adult: 15 years and older ● Maternity: 12 – 55 years ● Geriatric: 70 years and older

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ENT Update: BCBSA high-dollar prepayment claims review

policyPublished December 26, 2018

As previously communicated, effective January 1, 2019, the Blue Cross Blue Shield Association (BCBSA) will require all Blue plans to obtain an itemized hospital bill up front, in order to process certain BlueCard® claims for out-of-area members. Providers need to submit an itemized bill when they receive a code on an electronic remittance report (835) and/or paper Provider Remittance as identified below.

In order to comply with the BCBSA mandate, when hospitals participating in Independence’s network treat out-of-area members of another Blue plan, Independence will require the submission of an itemized bill from the participating hospital in order to process claims when each of the following criteria is met:

● Inpatient institutional (acute-care) claims; and ● Claims with an estimated allowed amount of $250,000 or greater; and ● Pricing methodologies except for the following claims pricing models that do not incorporate individual services

or charges due to global pricing methodology: − Per-diem − Flat-fee case rate − DRG rate

Note: Claims for members in a Medicare Supplement/Medigap plan or traditional Medicaid are excluded from this prepayment review.

If an itemized bill is not received for claims requiring special treatment in connection with this BCBSA mandate, then the claim may be denied. Providers need to submit an itemized bill when they receive a code on an electronic remittance report (835) and/or paper Provider Remittance as identified below.

Identifying a claim affected by this mandateIf you have a claim affected by this BCBSA mandate, you will see the following codes displayed on your electronic remittance report (835) and/or paper Provider Remittance with the following messages:

● CARC 252 – An attachment/other documentation is required to adjudicate this claim/service. ● RARC N26 – Missing itemized bill/statement

Invoice submission instructionsIf your claim has been denied, you will need to submit an itemized bill. Please submit itemized bills via email at OOAHighDollarReview@ibx.com. Note: Use this e-mail address for itemized bill submissions only.

More informationIf you have additional questions regarding a claim denied as a result of the BCBSA mandate, please email us at providerauditinquiries@ibx.com. Please include BCBSA high-dollar prepayment claims in the subject line.

The Blue Cross and Blue Shield Association (BCBSA) is an association of independent Blue Cross and Blue Shield Plans.

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SPrescribe fitness to help your Medicare Advantage patients prevent or control type 2 diabetesPublished December 28, 2018

More than 25 percent of Americans age 65 and older have type 2 diabetes — that’s 12 million people.1 An additional 23.1 million have prediabetes,2 increasing their risk for type 2 diabetes, as well as other health problems such as heart disease and stroke.3 Chances are, many of your older patients fall into those statistics. Now you can “prescribe” an award-winning fitness program to help them feel better, have more energy, stay independent, and reduce their risk for or manage type 2 diabetes.

SilverSneakers works. In fact, 93 percent of SilverSneakers participants report good, very good, or excellent health. Exercise can have a positive impact on many health conditions, including diabetes. Only 18 percent of SilverSneakers participants responding to our survey said they have diabetes, compared to 28 percent of seniors nationwide. Of those surveyed, 68 percent reported an improvement in their condition after participating in SilverSneakers.4

Research shows that people who are physically active on a regular basis can help prevent or manage type 2 diabetes. Encourage your Independence Medicare Advantage patients to start using their free SilverSneakers benefit to gain the benefits of an active lifestyle.

Getting Started Getting started is quick and easy. Your Independence Medicare Advantage patients can simply visit SilverSneakers.com/StartHere or call 1-888-423-4632 (TTY: 711) Monday through Friday, 8 a.m. to 8 p.m. EST, to get their SilverSneakers ID number, find the participating locations they’d like to visit, and then show up! It’s that simple. 1 American Diabetes Association. “Statistics About Diabetes.” 2018. Available from: http://www.diabetes.org/diabetes-basics/statistics/.2 National Institute of Diabetes and Digestive and Kidney Diseases. “Diabetes Statistics.” 2017. Available from: https://www.niddk.nih.gov/health-information/health-statistics/diabetes-statistics.

3 National Institute of Diabetes and Digestive and Kidney Diseases. “Prediabetes Fact Sheet.” 2017. Available from: https://www.niddk.nih.gov/-/media/Files/Health-Information/HF_Factsheet_Prediabetes_EN_SP_RF508_FINAL_508.pdf.

4 2017 SilverSneakers Annual Member Survey. * Membership includes SilverSneakers instructor-led group fitness classes. Some locations offer members additional classes. Classes vary by location.

† Participating locations (PL) are not owned or operated by Tivity Health, Inc. or its affiliates. Use of PL facilities and amenities is limited to terms and conditions of PL basic membership. Facilities and amenities vary by PL.

SilverSneakers and the SilverSneakers shoe logotype are registered trademarks of Tivity Health, Inc. Tivity Health, SilverSneakers On-Demand and SilverSneakers GO are trademarks of Tivity Health, Inc. © 2018 Tivity Health, Inc. All rights reserved.

SilverSneakers®

SilverSneakers is the nation’s leading fitness program for seniors and is free to our Independence Medicare Advantage members. SilverSneakers membership includes:

● trained instructors who specialize in senior fitness; ● group classes designed for all levels and abilities;* ● fitness articles, recipes and meal plans; ● an active and supportive online community; ● access to thousands of fitness locations nationwide;†

● weights, pools, cardio-equipment access (varies by location);

● SilverSneakers On-Demand™ workout videos plus health and nutrition tips;

● the SilverSneakers GO™ app with adjustable workouts, reminders and more.

December 2018 | Partners in Health UpdateSM 14 www.ibx.com/pnc

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Reminder: Updates to the medical benefit specialty drug cost-sharing listPublished December 5, 2018

As a reminder, effective January 1, 2019, Independence will update its list of specialty drugs that require member cost-sharing (e.g., copayment, deductible, and coinsurance). Cost-sharing applies to select medical benefit specialty drugs for members who are enrolled in Commercial FLEX products and other select plans. The member’s cost-sharing amount is based on the terms of the member’s benefit contract. In accordance with your Provider Agreement, it is the provider’s responsibility to verify a member’s individual benefits and cost-share requirements.

The list will be expanded to include 161 drugs, including additions of the following: ● brexanolone* ● FulphilaTM (pegfilgrastim-jmdb)†

● Ilaris® (canakinumab) ● Jivi® (recombinant PEGylated-aucl) ● OnpattroTM (patisiran) ● ravulizumab* ● Triptodur® (triptorelin)

In addition, all specialty drugs that are classified by Independence as Gene Therapy (e.g., LuxturnaTM [voretigene neparvovec-rzyl]) will require member cost-sharing.

The comprehensive list of specialty drugs with cost-sharing is now available on our website.

*Pending approval from the U.S. Food and Drug Administration (FDA).†Cost-sharing applies to all FDA-approved biosimilars to pegfilgrastim.

Updated credentialing requirements for CRNPs and PAsPublished December 12, 2018

Effective June 1, 2019, all certified registered nurse practitioners (CRNP) and physician assistants (PA) will be required to be credentialed to provide independent, unsupervised services to Independence members.

Note: These updated requirements only affect CRNPs and PAs who want to see an Independence member on their own without physician supervision. These new requirements would also not allow a CRNP or PA to see a member for an initial visit, because that requires a physician.

Becoming a credentialed CRNP or PAIn order to make this new requirement as seamless as possible, Independence will accept requests for participation in our network as a CRNP or PA beginning January 1, 2019, through April 1, 2019. Applications received after April 1, 2019, may not be processed prior to June 1, 2019. CRNPs and PAs not credentialed by June 1, 2019, will not be able to render services to Independence members. Please allow up to 45 business days to process applications.

For more information on our network credentialing process and credentialing criteria, please visit our Professional Provider Credentialing webpage. CRNPs and PAs should apply for credentialing by completing the Practitioner Participation Form.

Any professional provider interested in participating in our network must complete a Practitioner Participation Form. You can simplify this process by using the Council for Affordable Quality Healthcare’s (CAQH) online credentialing application: CAQH ProView™.

Note: If you have already been credentialed, there is no need to resubmit a credentialing application.

More informationWe will publish more information about this requirement in future Partners in Health UpdateSM articles.

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Reminder: Updates to the list of specialty drugs that will require precertificationPublished December 5, 2018

As a reminder, effective January 1, 2019, the following specialty drugs, which are eligible for coverage under the medical benefit for Independence commercial and Medicare Advantage HMO and PPO members, will require precertification:

● Azedra® (ultratrace iobenguane I-131)* – Antineoplastic Agents ● Gamifant® (emapalumab-lzsg) – Miscellaneous Therapeutic Agents ● Ilaris® (canakinumab) – Miscellaneous Therapeutic Agents ● Jivi® (recombinant PEGylated-aucl) – Hemophilia/Coagulation Factors ● Krystexxa® (pegloticase) – Miscellaneous Therapeutic Agents ● LumoxitiTM (moxetumomab pasudotox-tdfk) – Antineoplastic Agents ● Panzyga® (immunoglobulin intravenous [human]) – IVIG/SCIG ● Poteligeo® (mogamulizumab-kpkc) – Antineoplastic Agents ● RevcoviTM (elapegademase-lvlr) – Enzyme Replacement Agents ● TruximaTM (rituximab-abbs) – Antineoplastic Agents

In addition, the following drugs are currently pending approval from the U.S. Food and Drug Administration (FDA) and will require precertification for Independence members once they receive FDA approval in 2019, or as of January 1, 2019, for any drug approved in 2018:

● ElzonrisTM (tagraxofusp) – Antineoplastic Agents ● ravulizumab – Miscellaneous Therapeutic Agents ● sacituzumab govitecan – Antineoplastic Agents

Lastly, all drugs that are classified by Independence as Gene Therapy (e.g., LuxturnaTM [voretigene neparvovec-rzyl]) will require precertification as of January 1, 2019.

These changes are reflected in an updated precertification requirement list, which has been posted to our website.

* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. Precertification review benefit varies based on decision by member’s employer group.

Outbreak of life-threatening coagulopathy associated with synthetic cannabinoids usePublished December 14, 2018

The Centers for Disease Control and Prevention (CDC) has provided information on a multistate outbreak of coagulopathy from exposure to synthetic cannabinoids products containing a vitamin K-epoxide cycle antagonist, brodifacoum. To learn more about this outbreak, and what you can do to help your patients who may be affected by it, please refer to the CDC’s alert.

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Reminder: New acupuncture benefit and networkPublished December 6, 2018

As a reminder, effective January 1, 2019, Independence will offer an acupuncture benefit to commercial group members. To accommodate this benefit and better serve our members, we will be expanding our network to include acupuncture providers.

Benefit detailsAcupuncture will be considered medically necessary for certain conditions, limited to:

● Headache (migraine and tension) ● Post-operative and chemotherapy-induced

nausea and vomiting ● Nausea of pregnancy ● Low back pain ● Pain from osteoarthritis of the knee and

hip ● Chronic neck pain

The use of acupuncture for other conditions will be considered experimental/investigational and will not be covered.

Providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal to confirm member benefits.

Acupuncture networkIf you are licensed to practice acupuncture in your state and would like to provide acupuncture for the conditions outlined above, you may submit a request to join the Independence Blue Cross network. For information on our network credentialing process and credentialing criteria, please visit our website. You can apply by completing the online Practitioner Participation Form.

Note: The licensing rules for acupuncturists differ by state. Providers should refer to their state’s licensing board for guidelines.

If you meet the criteria to join our network, your information will be displayed in our Find a Doctor tool. We ask that you submit your application early to allow Independence time to review and process your credentialing request for the January 1, 2019, effective date.

If you have questions about the network or the credentialing process, please email us at specialistsrequests@ibx.com.

Updated policyMedical Policy #12.00.01f: Acupuncture was expanded to capture information related to this new benefit. The updated policy was posted as a Notification on October 2, 2018, and will go into effect January 1, 2019.

To view the Notification for this policy, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Active Notifications.

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

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Introducing a new palliative care programPublished December 20, 2018

Effective January 1, 2019, Independence will enter into an agreement with Aspire Health, Inc. (Aspire), an independent company, to provide our Medicare Advantage members with advanced illnesses and/or with severe symptoms from a chronic illness with additional support in their home at no cost.

What is the palliative care program?Aspire, the nation's largest provider of home-based non-hospice, community-based palliative care services, provides individualized support to our members who are facing issues associated with advanced life-threatening illnesses. A palliative care support team of doctors, nurse practitioners, registered nurses, and social workers provides coordination of the member's care between the member’s treating physician and the Aspire palliative care physician. The program is covered at 100 percent by Independence for Medicare Advantage members.

You will be notified by mail if one of your Independence patients has been identified as a potential candidate for this program. In addition, you may be contacted by a representative from the Aspire clinical team to further discuss the member's care plan and how best to coordinate the member’s care with you.

Note: Independence members who are eligible for the Comprehensive Care Program or Tandigm Care Solutions should receive palliative care services through those programs.

For more informationIf you have questions about this program, please review the Aspire website. If you cannot find the information you are looking for here and have further questions, please email us at palliativecare@ibx.com. Information can also be found on our website for this program at www.ibx.com/aspirepalliativecare.com.

Program benefits include: ● A palliative care clinical team that:

− is available 24 hours a day, 7 days a week; − is available to visit the member in his or her home and prescribe medicine when necessary to manage

symptoms such as fatigue, nausea, shortness of breath, difficulty sleeping, or pain; − works closely with the member's existing providers to coordinate care.

● Enhanced communication through a palliative care support team that works directly with the member and his or her family or caregiver to identify health care goals. The palliative care support team also helps keep the member's providers and caregivers informed of changes in his or her condition.

● Education for members and their families about the illness, plan of care, medications, available treatment options, and much more.

Members enrolled in this program also continue treatment with their primary care physician and other specialists.

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View up-to-date policy activity on our Medical Policy PortalPublished December 19, 2018

Changes to Independence medical and claim payment policies for our commercial and Medicare Advantage Benefit Programs occur in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity section of our Medical Policy Portal to stay up to date with changes to our policies.

The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics include:

● Notifications ● New Policies ● Updated Policies ● Reissued Policies ● Coding Updates ● Archived Policies

For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference.

To access the Site Activity section, go to our Medical Policy Portal and select Accept and Go to Medical Policy Online. From there you can select Commercial or Medicare Advantage under Site Activity to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage tab from the top of the page. To access policies from Independence NaviNet® Plan Central, select Medical Policy Portal under Quick Links in the right-hand column.

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

New policy on pediatric intensive day feeding programPublished December 28, 2018

Independence will issue a new medical policy to communicate the coverage criteria for precertification of pediatric intensive day feeding programs. Medical Policy #10.00.03: Pediatric Intensive Day Feeding Program was posted as a Notification on December 28, 2018 and will go into effect January 28, 2019.

Policy detailsPediatric intensive day feeding programs for treatment of a feeding disorder are offered in an outpatient setting. These programs are provided when the individual requires the intensity of acute inpatient rehabilitation but does not require 24-hour-a-day medical and nursing supervision provided in that setting. Treatment of a feeding disorder occurs during each weekday; the individual returns home each evening and for the entire weekend.

Treatment of a feeding disorder in a pediatric intensive day feeding program involves multiple therapeutic services overseen by a physician who is part of a multidisciplinary professional team. The team may be comprised of a combination of behavioral therapist, occupational therapist, physician, registered dietitian, and speech language pathologist/therapist. A component of pediatric intensive day feeding programs may include other medical services such as psychological therapy, nursing, and case management.

Feeding disorder treatment in an outpatient pediatric intensive day feeding program is considered medically necessary and, therefore is covered when the criteria outlined in the medical policy are met.

To obtain precertification, providers should call Clinical Services at 1-800-ASK-BLUE and select Authorizations from the menu. Initial authorizations for pediatric intensive day feeding cannot be submitted through the NaviNet® web portal at this time.

More informationTo view the Notification for this policy, visit our Medical Policy Portal select Accept and Go to Medical Policy Online, and then select Commercial under Active Notifications.

If you have additional questions, please contact Provider Services at 1-800-ASK-BLUE.

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

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Y Our prescription drug program and safe prescribing proceduresPublished December 5, 2018

Independence is committed to providing our members with high-quality, comprehensive, cost-effective prescription drug coverage. The prescription drug coverage includes a formulary feature, which is a list of drugs approved by the U.S. Food and Drug Administration (FDA) and selected by the Independence Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. The formulary drugs are selected based on their reported medical effectiveness, safety, and value.

FutureScripts® manages the administration and claims processing of Independence’s prescription drug programs. FutureScripts works with the community, mail-order, and specialty pharmacies to provide medications and customer service to our members and providers. The effectiveness and safety of drugs and drug-prescribing patterns are monitored by FutureScripts.

Select Drug Program®

The Select Drug Program is an open formulary managed by Independence. The formulary is organized by cost-share tiers. The non-preferred tier on the formulary is generally associated with a higher cost-sharing than the preferred brand or the generic tiers. Usually, when a brand-name drug has a generic equivalent, the brand-name drug is covered at the non-preferred level of cost-sharing while the generic equivalent is covered at the lowest level of cost-sharing.

● Tier 1 – Generic: Includes most generic medications. Drugs are covered at the lowest formulary level of cost-sharing.

● Tier 2 – Preferred Brand: Includes preferred brand-name medications. Drugs are covered at a higher formulary level of cost-sharing.

● Tier 3 – Non-Preferred Drug: Includes non-preferred medications. Drugs are covered at the highest non-formulary level of cost-sharing.

Some brand-name drugs without generic equivalents, authorized generic drugs, and some generic drugs are also covered at the non-preferred level of cost-sharing because there are cost-effective alternatives on the preferred or generic tiers to treat the same condition.

You can download the latest Select Drug Program Formulary or call 1-800-ASK-BLUE to request a printed copy.

Value FormularyThe Value Formulary is a restricted formulary managed by Independence. The organization of the cost-share tiers is similar to that of the Select Drug Program. Drugs not included on the Value Formulary are considered non-formulary. Non-formulary drugs have covered equivalents and/or alternatives used to treat the same condition. New drugs are not included on the Value Formulary until reviewed by the Pharmacy and Therapeutics Committee (P&T). Formulary placement is determined upon review by the P&T Committee.

Non-formulary exceptions for Value Formulary membersProviders may request consideration of formulary coverage of a non-formulary drug when there has been a trial of, or contraindication to, at least three formulary alternatives when available. The provider should complete a non-formulary exception request form to provide details to support use of the non-formulary drug and fax the request to 1-888-671-5285. If the non-formulary exception request is approved, the drug will be covered at the highest applicable level of cost-sharing. Please note that safety edits, such as quantity limits, will still apply. If the request is denied, the member and provider will receive a denial letter which includes appeal rights and instructions.

Coverage for drugs is based on the member’s prescription drug benefits. You can download the latest Value Formulary or call 1-800-ASK-BLUE to request a printed copy.

Mail-order servicesFutureScripts provides mail-order services as an option for Independence members to receive their medications. Most of the time, medication requests are processed upon receipt of a prescription from a provider. However, there may be times when the provider will be contacted by FutureScripts for medication coverage, such as when the requested drug requires prior authorization and/or safety edits apply. To determine if the drug you prescribed requires prior authorization, please refer to the Formulary Lookup tool on ibx.com. To access the tool, go to Drug Formularies, select the member’s formulary and then select Find a Formulary Drug. For Value Formulary members, the provider will also need to select a tier level before accessing the Lookup tool. For information on how to request a prior authorization for a drug please review the “Prescribing safety” section in this article.

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Generic equivalent drugsAccording to the FDA, generic drugs are equivalent to their brand-name originator in active ingredients, dosage, safety, strength, and performance and are held to the same strict standards as their brand-name counterparts. The only noticeable difference between a generic drug form and its brand-name counterpart may be the shape and/or color of the drug. Generic drugs are generally as effective as their brand-name counterparts. However, they may cost up to 70 percent less, which helps to reduce health care costs for members. The generic drug option is generally the lowest cost for the member.

FutureScripts does not determine when a generic drug will be provided at the pharmacy. In accordance with state laws, generic drugs may be provided by the pharmacist at the point of sale, if available, unless the prescriber indicates “dispense as written” or “brand medically necessary” on the prescription. If a brand-name drug is prescribed in place of a generic drug, prior authorization may be needed before the drug is dispensed and the member will be responsible for the higher cost-sharing associated with a brand-name drug.

Therapeutic alternative drugsDrugs that differ chemically but have the same effect are called “therapeutic alternatives.” These drugs will generally be in the same therapeutic class. For example, ibuprofen and naproxen are both non-steroidal anti-inflammatory drugs that can be therapeutically interchanged in most cases.

Examples of therapeutic alternatives are:

Although they are not the exact chemical equivalents of the brand name drugs, therapeutic alternatives treat medical conditions in a similar way.

Specialty drugsSpecialty drugs meet certain criteria, including, but not limited to drugs used to treat rare, complex, or chronic disease, drugs that have complex storage and/or shipping requirements, and drugs that require comprehensive patient monitoring and/or education. Specialty drugs covered under the pharmacy benefit may be managed by FutureScripts. Benefits may vary, and many plans cover specialty drugs on a specialty tier with higher cost-sharing.

Formulary tier exceptionsProviders may request an exception for a non-preferred drug to be covered at a preferred level of cost-sharing when there has been a trial of, or contraindications to, at least three formulary alternatives. This option is available based on benefit design for both Select Drug Program and Value Formulary members. The following restrictions apply:

● Drugs on the generic, preferred brand, and the specialty tiers are not eligible for a change to cost-share.

● Non-formulary drugs on the Value Formulary are not eligible for change to a lower cost-share. If approved for non-formulary exception, the members will pay the highest level of cost-sharing for these drugs.

● For cost-sharing purposes, authorized generic drugs are treated as brand-name drugs and are not eligible for coverage on the generic tier(s). For example, the authorized generic oxycodone ER is technically a brand-name drug, not a generic of Oxycontin. Brand-name drugs are not eligible for coverage on the generic tier. The lowest tier an authorized generic can fall on is the preferred brand tier.

The provider should complete the formulary exception form, providing details to support the request and fax it to FutureScripts at 1-888-671-5285. The request form can be found on the FutureScripts website. If the tier exception request is approved, the provider will receive a fax notification and the drug will be processed at the appropriate formulary level of cost-sharing. If the request is denied, the provider and member will receive a denial letter.

Prescribing safetyAs part of formulary management, Independence implements safe prescribing procedures that are designed to optimize the member’s prescription drug benefits by promoting appropriate utilization. These procedures are based on FDA guidelines, and the approval criteria were developed by Independence’s Pharmacy and Therapeutics Committee. FutureScripts continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures, such as prior authorization and safety edits, have been established to support safe prescribing patterns and to promote optimal pharmacotherapy outcome for the members.

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Brand name drug Therapeutic alternative(s)

Dulera® Advair® Diskus, Symbicort®

OxyContin® morphine sulfate ER, Xtampza® ER

Lyrica® gabapentin

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Prior authorizationPrior authorization is required for certain covered drugs to ensure medical appropriateness and necessity. The approval criteria for these medications may include a trial of a different drug, such as a generic equivalent drug or a therapeutic alternative. Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s provider, and the member’s available prescription drug therapy history. The evaluation may include a review of potential drug-drug interactions or contraindications, appropriate dosing and length of therapy, and utilization of other drug therapies.

Note: Coverage of certain drugs on the formulary, with or without prior authorization (e.g., weight loss drugs, fertility drugs), may be limited based on the member’s prescription drug benefit design.

The prior authorization process may take up to two business days once complete information from the prescriber has been received. The prescriber will be notified if an approval has a defined time frame, such as 12 months. Once the approval time period expires, the provider will need to request consideration for a new prior authorization.

Providers can access platforms such as CoverMyMeds® and SureScriptsTM that support electronic prior authorization (ePA) to submit a prior authorization request. Alternatively, the provider can complete a prior authorization form and fax all supporting medical information to FutureScripts at 1-888-671-5285. Prior authorization forms are available on the FutureScripts website.

Prior authorization requirements for selected drugsPrior authorization requirements for selected drugs are in place for certain medications. This expedites the review process at the pharmacy by using information available in the member’s pharmacy benefit claim history to determine coverage for the requested medication. For example, Flovent® HFA is a medication that requires previous trial of either of the preferred medications Asmanex® or Qvar®. With the prior authorization requirements for selected drugs, a member will be able to receive coverage immediately for Flovent® HFA if the claim history shows a previous paid claim for either Asmanex® or Qvar®. A manual prior authorization request will not be needed. If the claim history does not contain a previous paid claim of either drug, then a prior authorization request will be needed in accordance with the standard prior authorization process.

Safety editsSafety edits are applied to prescription medications to promote safe and appropriate use of drugs. They are designed to align with clinical practice guidelines and FDA approved use(s) outlined in the manufacturer package insert. There are different types of safety edits, some of which will prompt member counseling at the point-of-sale, others will require prior authorization review. Examples of safety edits are age limits, quantity limits, morphine milligram equivalent (MME) limits, and concurrent drug utilization review (cDUR).

Age limitsAge limits are designed to prevent potential harm to members and to promote appropriate use of the drug. Age groups are identified through the FDA drug approval process. Age limits are generally noted when safety and efficacy has not been established. If the member’s prescription falls outside of the FDA guidelines, it may not be covered until prior authorization is obtained. In addition, an age limit may be applied when certain drugs are more likely to be used in certain age groups. For example, drugs used to treat Alzheimer’s disease may require prior authorization for use in young adults. The provider may request coverage for drugs outside of the age limit when medically necessary. If a member’s prescription falls outside the FDA guidelines, it may not be covered until prior authorization is obtained.

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Quantity limitsQuantity limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses, standard dosing, and/or length of therapy of a drug. There are several different types of quantity limits to promote safe and appropriate utilization. If a member requires more than the limit, the provider will need to submit a prior authorization request.

Morphine milligram equivalent (MME) limitsIndependence applies additional safety measures to opioid products by limiting the total daily dose. This limit accounts for all the different opioid products through a measurement called the morphine milligram equivalent (MME) dose. The MME is a number that is used to determine and compare the potency of opioid medications and it helps to identify when additional caution is needed. The daily limit is calculated based on the number of opioid drugs, their potencies and the duration of therapy. Prior authorization is required for opioid doses that exceed 90 MME per day.

Concurrent drug utilization review (cDUR)Concurrent drug utilization reviews (cDURs) are built into the pharmacy claim adjudication system to review a member’s prescription history for possible drug-related problems including drug-drug interactions and drug therapy duplications. Drugs may reject at the point-of-sale and/or generate a message to the dispensing pharmacist when there is a safety concern. The dispensing pharmacist can review the issue with the provider and override the rejection if appropriate for most edits.

For more informationVisit the Pharmacy section of our website for additional information on pharmacy policies and programs.

FutureScripts is an independent company that provides pharmacy benefits management services.

Limits Description ExampleQuantity over time

This limit is based on dosing guidelines over a rolling time period.

Sumatriptan (Imitrex®) 50mg, limit 18 tablets per 30 days

Maximum daily dose

This limit is based on the maximum daily dose approved by the FDA.

Guanfacine Extended Release 24-hour, limit 1 tablet per day

Refill too soon

This limit is in place to minimize stockpiling of prescription medications. A prescription drug can be refilled after 75% utilization of its previous fill.

A 30 days’ supply of atorvastatin tablets filled on 1/1/19 can be refilled again on or after 1/24/19.

Day supply limit

This limit is based on day supply and not the quantity. However, quantity limits may apply as well

Opioids containing cough and cold products such as hydrocodone/homatropine, limit 5 days’ supply per 30 days and 30 ml per 1 day. The max quantity allowed without prior authorization is 150 ml every 30 days.

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Y Reminder: Online PreCheck MyScript tool provides insight into member pharmacy benefitsPublished December 10, 2018

As previously communicated, Independence is committed to transforming the delivery and affordability of health care. PreCheck MyScript is an online tool powered by FutureScripts®, our pharmacy benefits manager, and embedded directly in electronic medical record (EMR) platforms. The tool gives doctors a real-time, seamless view of a member’s prescription cost-share amount based on the member’s specific health plan benefits.

These real-time details help improve patients’ experience and health by: ● enabling providers to have more constructive conversations with their patients; ● providing the information, comfort and insight the provider needs to make more informed prescribing decisions

related to the pharmacy benefit; ● giving providers more time to spend with their patients by auto-sorting through prescription drug lists and prior

authorization processes; ● and minimizing prescription delays, dispensing of unnecessarily higher-cost medications and other barriers that

could lead to medication non-compliance.

PreCheck MyScript also gives the provider insight into whether their patients’ medication requires a prior authorization. If prior authorization is required, doctors can request approval immediately through the tool. Independence has seen an increase in prior authorizations initiated electronically since August 1, 2018, when the tool was made available.

We want our members and their doctors to feel confident in the health care decisions they make. Knowing that the right medications are being prescribed at the most affordable cost and without unnecessary delays is an important part of ensuring that confidence.

For more informationIf you want more information on accessing the PreCheck MyScript online tool, please contact your EMR vendor for connection support.

FutureScripts is an independent company that manages pharmacy care services.

Medicare seven-day supply limit for first time opioid fillsPublished December 3, 2018

Independence's opioid management policy will be updated to align with the most up-to-date Centers for Medicare & Medicaid Services (CMS) requirements. By updating our policy, we hope to help promote safe and appropriate opioid use.

CMS Guidelines for prescribing opioidsEffective January 1, 2019, Medicare Part D plans are required to limit opioid prescription fills to a seven-day supply for those members who are either filling an opioid medication for the first time or who do not regularly take opioid medications that do not require prior authorization. A prior authorization will be required for members who are requesting more than a seven-day supply. For opioid prescriptions that require prior authorization, there is no seven-day grace fill without a prior authorization.

To support efficient processing of prior authorizations, please ensure that your office staff and on-call services are available to respond to pharmacist and health plan calls. There are several exclusions to the prior authorization requirement, including, prescriptions for members who are identified as being enrolled in hospice or long-term-care (LTC), or those undergoing cancer treatment based on prescription claims data.

For more informationIf you have any questions concerning the prior authorization process, please contact FutureScripts® at 1-888-678-7012.

FutureScripts is an independent company that provides pharmacy benefits management services.

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Identifying Preferred PCPs and the required copaymentsPublished December 20, 2018

As previously communicated, Independence is offering Keystone 65 Basic HMO, Keystone 65 Focus HMO-POS, Keystone 65 Preferred HMO, and Keystone 65 Select HMO individual members a new Preferred primary care physician (PCP) benefit in 2019. This new benefit will allow members to visit one of the hundreds of Preferred PCPs in our network and pay nothing out of pocket.

Our Medicare Advantage HMO and HMO-POS network PCPs have been categorized into one of two benefit tiers: ● Preferred. Members will pay $0 cost-sharing for PCP visits. ● Standard. Members will pay the same cost-sharing for PCP visits as 2018.

Note: Capitation payments are higher for members who have $0 copay to compensate for what would have been collected with higher copays.

Independence sent letters to practices identified as Preferred PCPs to notify them of the distinction. This article walks through how your practice will appear in the Find a Doctor tool, and how to identify the required copayments on the NaviNet® web portal.

Preferred PCP designationOur Find a Doctor tool for Medicare Advantage members has been updated to include your practice’s tier. Simply type your name in the search field next to All Categories and hit the magnifying glass to begin the search. Below is an example of how a Preferred PCP will appear.

In addition, the following message appears at the top of the page to remind you that Independence individual Medicare Advantage HMO members have a $0 copayment:

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Identifying copayments using NaviNetIf a member has chosen the new Preferred PCP benefit, the NaviNet Eligibility and Benefits Inquiry transaction will return one of the two new informational messages on the Eligibility & Benefits Detail screen advising you of the member’s PCP benefit tier.

You can also view the PCP copay amount by selecting Additional Benefit Provisions link from the right-hand side of the screen and then select Professional Services from the prompt.

More informationWe have updated the Eligibility and Benefits Inquiry Guide to include this new information, which can be found in the NaviNet Resources section. If you have additional questions on the Eligibility and Benefits Inquiry transaction, please call the eBusiness Hotline at 215-640-7410.

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

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New coverage option for FEP membersPublished December 20, 2018

In 2019, Federal Employee Program (FEP) members will have a new coverage option – FEP Blue Focus. In addition to offering coverage for in-network medical services, the plan also includes coverage for preferred drugs. Members will be subject to an in-network deductible and out-of-pocket maximum for preferred providers.

The FEP Blue Focus plan is available effective January 1, 2019. Members will be issued new ID cards to present to providers:

Member eligibility and benefit detailsTo review FEP member eligibility and benefits, providers can access the Eligibility and Benefits Inquiry transaction in the BlueExchange® Out of Area Workflows menu option through the NaviNet® web portal.

For more information If you have any questions regarding FEP Blue Focus, please contact FEP Customer Service at 215-241-4400.

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

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ENT Improving lead testing and developmental screening

among CHIP membersPublished December 11, 2018

The Pennsylvania Department of Human Services (Commonwealth) and Healthcare Effectiveness Data and Information Set (HEDIS®) specifications state that all children enrolled in Pennsylvania's Children's Health Insurance Program (CHIP) should receive testing for elevated blood lead levels (EBLL) and developmental screening as recommended below.

Lead testing and developmental screening recommendationsPractitioners are encouraged to follow the Medicaid and Bright FuturesTM guidelines for lead testing and developmental screening. A lead blood test should be completed at ages 9 to 12 months and again before age 24 months. Formal screening for developmental disorders using a standardized tool, such as the Ages and Stages questionnaire (CPT® 96110), should be completed for children who turn 1, 2, or 3 years of age or when surveillance yields concern. This is especially important for children enrolled in CHIP because of the higher incidence of developmental delay among certain pediatric populations enrolled in government sponsored programs when compared to children enrolled in privately insured plans.

CHIP members should meet the Medicaid guidelines for lead testing and developmental screening regardless of risk level. We know many provider practices have already performed these tests, and we thank you and your staff for the care you provide to our pediatric and CHIP members.

What your practice can doTo help ensure your members receive the required testing, your practice can do the following:

● Screen children for EBLL by performing a risk assessment at 6 months, 9 months, 18 months, and then annually from ages 3 – 6 with testing as appropriate.

● Perform developmental surveillance at each well-child visit and document the use of a standardized developmental screening tool for children who turn 1, 2, or 3 years of age or when surveillance yields concern.

● Discuss recommendations for lead testing and developmental screening with the parents/guardians of your CHIP patients.

Identifying CHIP membersTo help your practice easily identify CHIP members, we include the identifying words “PA Kids” on the front of Independence ID cards, as shown in the sample CHIP ID card below.

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Reminder: PROMISeTM ID required to render services to CHIP membersThe state of Pennsylvania requires a Provider Reimbursement and Operations Management Information System (PROMISe) ID for all providers who render services to CHIP members. There are a few important things about PROMISe IDs to keep in mind:

● DHS implemented the Affordable Care Act provision that requires all providers who render services to CHIP members be enrolled with DHS as a CHIP provider.

● Upon enrollment, DHS will issue providers a PROMISe identification number. ● The deadline for CHIP providers to enroll with DHS was December 31, 2017. However, you may still enroll. ● Remember, registering as a CHIP-only provider does not mean providers must accept Medical Assistance

beneficiaries. ● In the near future, a PROMISe ID will be required to receive payment from Independence for services rendered

to CHIP members. This date will be communicated once determined by the Office of CHIP. ● As of the determined date, claims submitted to Keystone Health Plan East by a non-enrolled provider (i.e., one

without a PROMISe ID) will not receive payment. ● Visit the DHS website to access the application, requirements, and step-by-step instructions related to the

enrollment process.

Resources The following resources provide additional information regarding lead testing recommendations:

● Centers for Disease Control and Prevention (CDC): Childhood Lead Poisoning Prevention Program ● Philadelphia Department of Public Health: 215-685-2788 (Philadelphia residents) ● National Lead Information Center: 1-800-424-LEAD (non-Philadelphia residents) ● American Academy of Pediatrics: “Identifying Infants and Young Children with Developmental Disorders in

the Medical Home: An Algorithm for Developmental Surveillance and Screening.” Pediatrics. 2006; 405-420. Available from: http://pediatrics.aappublications.org/content/118/1/405

● CDC’s Child Developmental Screening ● Independence website

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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ENT Reminder: New accreditation requirement for office-based

varicose vein proceduresPublished December 14, 2018

As previously communicated in Partners in Health UpdateSM, effective April 1, 2019, all network offices that perform varicose vein procedures will need to obtain office-level accreditation from the Intersocietal Accreditation Commission (IAC) Vein Center. This new accreditation requirement will help ensure that offices in the Independence network meet current standards of care for these procedures.

All network offices that plan to perform or would like to continue performing varicose vein procedures must appear on the IAC-approved list for Vein Center Accreditation by April 1, 2019, indicating that they have met the IAC standards. Those offices that fail to meet the requirements by this date will no longer be reimbursed for varicose vein procedures.

Accreditation processOffices seeking accreditation through the IAC should prepare and submit their applications using the IAC online accreditation portal. The application process for accreditation takes time and requires proper planning, organization, attention to detail, and resources.

Offices that wish to participate in the IAC Standards for Vein Center accreditation process are encouraged to first view the current IAC Standards for Vein Center Accreditation: Superficial Venous Evaluation and Management document.

More informationTo learn more about the IAC Vein Center accreditation program, please visit the IAC website or call 1-800-838-2110.

Note: Independence commercial and Medicare Advantage policies will be updated to reflect this new accreditation requirement.

We will publish more information about this requirement in future Partners in Health Update articles. If you have additional questions, please email us at qualitymanagement@ibx.com. Be sure to include your name, contact number, and provider ID number in your email.

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ENT 2018-2019 Clinical Practice Guideline Summary now

availablePublished December 14, 2018

We recently posted the 2018-2019 Clinical Practice Guideline Summary, which replaces the previous version on the Independence website. The revised summary includes a listing of all Clinical Practice Guidelines adopted by Independence that are considered the accepted minimum standard of care in the medical profession. Adherence to these guidelines may lead to improved patient outcomes.

Guidelines are available for the following medical and behavioral health conditions: ● asthma ● autism spectrum disorders ● chronic obstructive pulmonary disease (COPD) ● depression ● diabetes ● heart disease ● obesity ● substance abuse disorders

Changes in the 2018-2019 Clinical Practice Guideline Summary include updates to the current guidelines, as well as the addition of the following guidelines:

● Heart Disease. − Cardiac Rehabilitation: Improving Function and Reducing Risk. 2016. − The Care of Children with Congenital Heart Disease in Their Primary Medical Home. 2017.

● Obesity. − Algorithm for the Assessment and Management of Childhood Obesity in Patients 2 Years and Older. 2015.

In addition, the following guidelines were removed: ● Heart Disease.

− 2013 AHA/ACC Guideline of Lifestyle Management to Reduce Cardiovascular Risk. ● Diabetes.

− Management of Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents.

Individual clinical decisions should be tailored to specific patient medical and psychosocial needs. As national guideline recommendations evolve, please update your practice accordingly. The summary provides the reference for each condition and links directly to the guidelines.

We update the guidelines annually based on changes made to nationally recognized sources. Changes are reviewed by internal and external consultants, as appropriate, and by the Independence Quality Committee, which is comprised of network physicians.

You can access the 2018-2019 Clinical Practice Guideline Summary on our website. Paper copies can be ordered by submitting an online request.

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Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (Independence) created to provide valuable information to the Independence-participating provider community that provides Covered Services to Independence members. 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 Independence. Refer to the Provider News Center to stay up to date on news and information from Independence.

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2016 www.dreamstime.com. All rights reserved.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 Independence exercises no control, and accordingly, Independence 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 ResourcesNaviNet is our secure, online provider portal that gives you and office staff access to critical administrative and clinical data. To help you navigate the portal and various transactions, we have created a central location for a variety of NaviNet resources, including user guides, webinars, and a communications archive.

NaviNet Resources

Utilization ManagementCertain utilization review activities are delegated to different entities. Here you will find detailed information on our utilization management programs and common resources used among them.

Utilization Management

Opioid AwarenessWe have created a repository of tools and resources to assist you in managing your patients who are prescribed opioid medications.

Opioid Awareness Resources

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Contact numbersPlease visit the Contact Information section of the Providers section of our website for a complete list of important telephone numbers.

Websites

Provider CommunicationsIndependence Blue Cross

1901 Market Street 28th Floor

Philadelphia, PA 19103

provider_communications@ibx.com