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WHAT’S INSIDE?
REVIEWSM
Medical Policy Updates ����������������������������������������������������������2
Medicare Part D Pharmacy Updates �������������������3
Benefits Value Advisor Available to Members ���������������������������������������������������������������������3
Professional Provider Network Consultant Assignments �������������������������������������4, 5
In the Know: Fighting Fraud and Abuse �������������� 6
Provider Learning Opportunities �������������������������� 6
ClaimsXtenTM Third Quarter 2014 Updates ���������7
Watch for the Annual Physician Surveys ������������ 8
FOR CONTRACTING INSTITUTIONAL AND PROFESSIONAL PROVIDERS
AUGUST 2014
VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER
National Initiative Examines Antipsychotic Drug Use in the ElderlyIn 2012, the Centers for Medicare and Medicaid Services (CMS) developed the CMS National
Partnership to Improve Dementia Care in Nursing Homes. One of the goals set by this program
was to achieve a 15 percent reduction in antipsychotic drug use within nursing homes. The cre-
ation of this goal was due in part to the U.S. Department of Health and Human Services Office
of Inspector General (OIG) report released in 2011, which indicated that in nursing homes:
• Eighty-eight percent of atypical antipsychotic drug claims were for patients with dementia,
an indication with a black box warning.
• Eighty-three percent of atypical antipsychotic drug claims were for non-U.S. Food and Drug
Administration (FDA) labeled indications (off-label indications).
• More than 50 percent of atypical antipsychotic drug claims were improperly billed to
Medicare due to the fact that Medicare does not cover off-label indications which are not
supported by drug compendia.
• Twenty-two percent of atypical antipsychotic drugs claims were not administered in
accordance with CMS standards regarding unnecessary drug use in nursing homes due to
excessive dose, duration, inadequate monitoring or continuation despite adverse effects.1
A separate OIG report released in 2012 indicated that long term care facilities were not in
compliance with federal requirements for the documentation of patient assessments, decision
making, care plan development and care plan implementation in patients receiving antipsychotics.2
RISKS OF ANTIPSYC H OTIC DRUG USE IN TH E ELDER LY
The FDA Black Box Warning for both conventional and atypical antipsychotics outlines the
increased risk of mortality in elderly patients treated for dementia-related psychosis. The FDA
warning is based on a review of 17 placebo-controlled trials studying 5,377 elderly patients with
dementia-related behavioral disorders. The studies reported a 1.6 to 1.7 times greater increase
in death with the use of atypical antipsychotics compared with the placebo group. Additionally,
two large epidemiologic studies with a combined population of 37,241 elderly patients found that
the increased risk of death was similar between conventional and atypical antipsychotics.3
In addition to risks for increased mortality, antipsychotic drug use in the elderly is associated
with an elevated risk of cerebrovascular events, adverse metabolic effects, extrapyramidal
symptoms, falls, cognitive worsening, cardiac arrhythmia and pneumonia. Conventional
antipsychotics may pose an even greater safety risk.4,5
G R ADUAL DOSE R EDUC TION S
Gradual dose reductions are an important tool in minimizing adverse effects of antipsychotic
medications. Tapering of antipsychotics allows medical providers to determine the medication’s
true efficacy, the need to continue the medication and optimal dosing. In nursing homes,
gradual dose reductions should be conducted annually unless clinically contraindicated.4,5
(continued on p. 2)
VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER2
National Initiative Examines Antipsychotic Drug Use in the Elderly (continued from p. 1)
PR E SC RIBIN G OF ANTIPSYC H OTIC DRUGS TO TH E ELDER LY
According to CMS4, antipsychotics prescribed for the elderly in nursing homes should generally be
used only in the treatment of the following conditions as identified by the Diagnostic and Statistical
Manual of Mental Disorders:
Antipsychotics may occasionally be considered for behavioral or psychological symptoms of
dementia (BPSD) if:
• The behavioral symptoms present a danger to the patient or others;
• AND one or both of the following criteria are present:
o The symptoms are identified as being due to mania or psychosis (such as: auditory, visual, or
other hallucinations; delusions, paranoia or grandiosity); OR
o Behavioral interventions have been attempted and included in the plan of care,
except in an emergency.4,5
SUMMARY
Neuropsychiatric symptoms such as agitation and delusions occur commonly in elderly patients
with dementia and often cause significant distress. Data on treatment efficacy are strongest for
atypical antipsychotics, but these agents must be used with great caution. An antipsychotic drug
trial is warranted when non-pharmacological intervention is unsuccessful and neuropsychiatric
symptoms or associated behaviors cause severe distress or pose a significant safety risk. Risks,
benefits and alternatives should be discussed with the patient and, if applicable, the surrogate
decision maker, with an opportunity given to ask questions. Dosages should be the lowest necessary
and metabolic parameters should be regularly monitored. Face-to-face visits are important
to monitor response, tolerance and the need for continued treatment. For patients in whom
neuropsychiatric symptoms have been much improved or have been in remission for 3-6 months,
a discontinuation trial should be considered. Through careful selection of appropriate patients for
treatment, education of patients and caregivers and close monitoring, safety risks can be minimized.
References
1. Department of Health and Human Services-Office of the Inspector General. Medicare Atypical Antipsychotic Drug Claims to Elderly Nursing Home Residents. May 2011. OEI-07-08-00150. https://oig.hhs.gov/oei/reports/oei-07-08-00150.asp
2. Department of Health and Human Services-Office of the Inspector General. Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotic Drugs. July 2012. OEI-07-08-00151. https://oig.hhs.gov/oei/reports /oei-07-08-00151.asp
3. U.S. Food and Drug Administration. Information for Healthcare Professionals: Conventional Antipsychotics. August, 15, 2013. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsand Providers/ucm124830.htm
4. Department of Health and Human Services. Advanced Copy: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309 – Quality of Care and F329 – Unnecessary Drugs.
5. Department of Health and Human Services. CMS Manual System Pub. 100-07 State Operations Provider Certification. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r22soma.pdf
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.
• Delusional disorder
• Hiccups (not induced by other medications)
• Huntington disease
• Mood disorders (e.g., bipolar disorder)
• Medical illnesses with psychotic symptoms
(e.g., neoplastic disease or delirium)
• Nausea and vomiting associated with
cancer or chemotherapy
• Psychosis (in the absence of dementia)
• Schizo-affective disorder
• Schizophrenia
• Schizophreniform disorder
• Treatment related psychosis or mania
(e.g., high-dose steroids)
• Tourette’s Disorder
Medical Policy Updates
The BCBSIL Medical Policies are for informational purposes only and are not a replacement for the independent medical judgment of physicians. Physicians are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policy. Members should contact their local customer services representative for specific coverage information.
Approved, new or revised Blue Cross and Blue Shield of Illinois (BCBSIL) Medical Policies and their effective dates are usually posted on our website the first day of each month. Medical policies, both new and revised, are used as guidelines for benefit determinations in health care benefit programs for most BCBSIL members, unless otherwise indicated. These policies may impact your reimbursement and your patients’ benefits.
Although medical policies can be used as a guide, HMO providers should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual, which is located in the Standards and Requirements section of our website at bcbsil.com/provider.
You may view active, new and revised policies, along with policies pending implementation, by visiting the Standards and Requirements/Medical Policy section of our website at bcbsil.com/provider. Select “View all Active and Pending Medical Policies.” After confirming your agreement with the Medical Policies disclaimer, you will be directed to the Medical Policies Home page.
You may also view draft medical policies that are under development, or are in the process of being revised, by selecting “View and comment on Draft Medical Policies.” After confirming your agreement with the Medical Policies disclaimer, you will be directed to the Draft Medical Policies page. Just click on the title of the draft policy you wish to review, and then select “Comments” to submit your feedback to us.
Please visit the Standards and Requirements/Medical Policy section of our website at bcbsil.com/provider for access to the most complete and up-to-date medical policy information.
JULY 2012 5MARCH 2013 5AUGUST 2014 3
Benefits Value Advisor Available to MembersBCBSIL Benefits Value Advisor (BVA)
service, launched on Jan. 1, 2014,
is available to BCBSIL members to
help them maximize their health
insurance benefits.
BVAs can provide cost comparisons on:
• Imaging services
• Maternity services
• Joint replacement services
• Back surgery
• And many more procedures
BVAs can also help members:
• Understand their benefits
• Find in-network providers
• Schedule appointments
• Request benefit preauthorization
• Access online educational tools
Providing members with more
information may help them make
better decisions about their health
care. Look for more information about
BVAs and the services they provide in
future issues of the Blue Review.
Medicare Part D Pharmacy Updates
First Quarter 2014 Formulary ChangesThe Pharmacy Program/Medicare Part D Updates section of our website at bcbsil.com/provider
includes articles that are intended to help keep you up-to-date on Medicare Part D issues such
as formulary changes, U.S. FDA safety updates, Part D Gap strategies, overlapping coverage
between Part B and Part D drugs and more.
This month, we added the First Quarter 2014, Medicare Part D Formulary Updates to our
online library. This article includes a summary table of some of the more important BCBSIL
Medicare Part D Formulary changes that may be of interest to you.
In addition to viewing a summary of recent formulary changes on the BCBSIL website,
you may follow the instructions below to visit Prime Therapeutics’ “MyPrime” website
for a complete listing, along with other Medicare Part D formulary information for your
BCBSIL patients.
1. Go to hpps://www.myprime.com
2. Click on Continue without sign in
3. Follow directions to
• “Select your Health Plan” – Click on BCBS Illinois
• “Medicare Part D Member?” – Select YES
• “Select Your Health plan type” – Select Blue Cross MedicareRx Value
• Select Continue to MyPrime
• Select Find Medicines
4. From this page you will be able to determine the formulary status and applicable
utilization management programs for individual drugs or access any of the important
databases outlined above.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.
VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER4
BCBSIL contracts with more than
2,000 independent ancillary providers
in Illinois and Northwest Indiana.
Our Ancillary Provider Network
Consultant (PNC) focuses specifically
on the services provided by skilled
nursing facilities, home health
agencies, hospice, home infusion
therapy, durable medical equipment
(DME) suppliers, orthotics and
prosthetics, dialysis centers and private
duty nursing agencies.
The following Ancillary PNC is
available to meet with you and
your staff regarding BCBSIL
policies and procedures, billing
and contractual issues:
• Elaine Williams, 312-653-4305
You may also direct your requests and
inquiries to our general email box at
[email protected], or leave
a message at 312-653-4820.
Meet Your Ancillary Provider Network Consultant
Professional Provider Network Consultant Assignments (Revised July 2014)
Amanda Williams – 217-698-5179
Michelle Brownfield-Nance – 312-653-4727
Roy Pyers – 217-698-2524
Cathy Dismuke – 312-653-2388
Kathleen Barry – 312-653-4247*
Teresa Trumbley – 618-998-2528
Gina Plescia – 312-653-4733
Adam Kwiecien – 312-653-1726
Ramona Espino – 312-653-5032
Ana Hernandez – 312-653-6488
– 217-698-5179
ld-Nance – 312-653-4727
98-2524
12-653-2388
12-653-4247*
-653-4733
312-653-1726
312-653-5032
12-653-6488
21
82
4196 24
93
57
67
78
43 89 1014 56
49
16
4519
718
52
47
99
46
3250
637
98
81
8862
72 102
53
38
9220
74
10
2790
66
4836
94
2955
63
5465
85
75
5 9
84
11
87
1812
23
15
70
58
8669
7
42
31
603
5968
2625
40 17
5180136114
95
7973
28
33 97
3083100
39
35764491
6477
2
22
21
82
4196 24
93
57
67
78
43 89 1014 56
49
16
4519
718
52
47
99
46
3250
637
98
81
8862
72 102
53
38
9220
74
10
2790
66
4836
94
2955
63
5465
85
1
34
75
5 9
84
11
87
1812
23
15
70
58
8669
7
42
31
603
5968
2625
40 17
5180136114
95
7973
28
33 97
3083100
39
35764491
6477
2
22
Code County1 Adams2 Alexander3 Bond4 Boone5 Brown6 Bureau7 Calhoun8 Carroll9 Cass
10 Champaign11 Christian12 Clark13 Clay14 Clinton15 Coles16 Cook17 Crawford18 Cumberland19 DeKalb20 Dewitt21 Douglas22 DuPage23 Edgar24 Edwards25 Effingham26 Fayette27 Ford28 Franklin29 Fulton30 Gallatin31 Greene32 Grundy33 Hamilton34 Hancock35 Hardin36 Henderson37 Henry38 Iroquois39 Jackson40 Jasper41 Jefferson42 Jersey43 JoDaviess
Code County44 Johnson45 Kane46 Kankakee47 Kendall48 Knox50 LaSalle49 Lake51 Lawrence52 Lee53 Livingston54 Logan58 Macon59 Macoupin60 Madison61 Marion62 Marshall63 Mason64 Massac55 McDonough56 McHenry57 McLean65 Menard66 Mercer67 Monroe68 Montgomery69 Morgan70 Moultrie71 Ogle72 Peoria73 Perry74 Piatt75 Pike76 Pope77 Pulaski78 Putnam79 Randolph80 Richland81 Rock Island83 Saline84 Sangamon85 Schuyler86 Scott87 Shelby82 St Clair88 Stark89 Stephenson90 Tazewell91 Union92 Vermilion93 Wabash94 Warren95 Washington96 Wayne97 White98 Whiteside99 Will
100 Williamson101 Winnebago102 Woodford
Vickey Jones – 312-653-6321
Ron Smothers – 312-653-8518
Our PNCs serve as the liaison between BCBSIL and our independently contracted professional provider community, developing and maintaining cooperative working relationships with the contracted professional providers participating in the network throughout Illinois and Northwest Indiana.
Your Professional PNC has extensive knowledge and is available to meet with you to help educate your staff on BCBSIL procedures, help ensure provider contract compliance and work with you to resolve any operational issues.
For the name of your Professional PNC, refer to the Illinois county map on the following page. PNCs for professional providers in Cook and DuPage Counties (Codes 16 and 22) are assigned by either Chicago ZIP code or city, listed below. The Professional Provider Network Consultant List and map are also available in the Education and Reference Center on our website at bcbsil.com/provider.
I LL IN OIS TER RITORY BR E AKDOWN BY COU NT Y CODENorthern (8, 43, 49, 81, 89 and 98) – Gina Plescia
Southern (2, 3, 12, 13, 14, 15, 17, 18, 24, 25, 26, 28, 30, 33, 35, 39, 40, 41, 44, 51, 60, 61, 64, 67, 73, 76, 77, 79, 80, 82, 83, 84, 87, 91, 93, 95, 96, 97 and 100) – Teresa Trumbley
West-Central (1, 5, 7, 9, 11, 29, 31, 34, 36, 42, 55, 59, 63, 65, 66, 68, 69, 75, 85, 86 and 94) – Roy Pyers
East-Central (10, 20, 21, 23, 27, 38, 53, 54, 57, 58, 70, 72, 74, 90, 92 and 102) – Amanda Williams
North Metro (4, 6, 19, 37, 45, 47, 48, 50, 52, 56, 62, 71, 78, 88 and 101) – Cathy Dismuke
South Metro (32, 46 and 99) – Adam Kwiecien
Northwest Indiana – Kathleen Barry
Cook County (16) – See below for Cook and DuPage County Breakdown
DuPage County (22) – See below for Cook and DuPage County Breakdown
COOK AN D DU PAG E COU NT Y BR E AKDOWN BY CIT Y AN D ZIP CODEAdam Kwiecien – City: Lemont
Ana Hernandez – ZIP Codes: 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60610, 60611, 60612, 60614, 60616, 60622, 60634
Cathy Dismuke – Cities: Addison, Bartlett, Bloomingdale, Hanover Park, Hillisburg, Medinah, Roselle, Streamwood, Wayne
Gina Plescia – Cities: Arlington Heights, Elk Grove Village, Hoffman Estates, Schaumburg
Kathleen Barry – Cities: Aurora, Burr Ridge, Calumet City, Chicago Heights, Darien, Dolton, Flossmoor, Ford Heights, Glen Ellyn, Glendale Heights, Glenwood, Homewood, Lansing, Lisle, Lynwood, Matteson, Naperville, Olympia Fields, Park Forest, Richton Park, Riverdale, Sauk Village, South Holland, Steger, Summit, Thornton, Warrenville, Willowbrook, Woodridge
Michelle Brownfield-Nance – Cities: Calumet Park, Carol Stream, Country Club Hills, Countryside, Crestwood, Downers Grove, Harvey, Hazel Crest, Hickory Hills, Homer Glen, Markham, Midlothian, Oak Forest, Orland Hills, Orland Park, Palos Heights, Palos Hills, Palos Park, Posen, Robbins, Tinley Park, West Chicago, Wheaton, Willow Springs, Winfield, Worth
Ramona Espino – Cities: Bensenville, Clarendon Hills, Des Plaines, Elmhurst, Glencoe, Glenview, Golf, Hinsdale, Inverness, Itasca, Kenilworth, Lincolnwood, Lombard, Morton Grove, Mt. Prospect, Neenah, Niles, Northbrook, Northfield, Oak Brook, Oak Brook Terrace, Palatine, Prospect Heights, Rolling Meadows, Rosemont, Skokie, South Barrington, Villa Park, Westmont, Wheeling, Wilmette, Winnetka, Wood Dale
Ron Smothers – City: Evanston; ZIP Codes: 60601, 60602, 60603, 60604, 60608, 60609, 60613, 60615, 60617, 60618, 60619, 60620, 60621, 60623, 60624, 60625, 60626, 60627, 60628, 60629, 60630, 60631, 60632, 60633, 60635, 60636, 60637, 60638, 60639, 60640, 60641, 60642, 60643, 60644, 60645, 60646, 60647, 60648, 60649, 60650, 60651, 60652, 60653, 60654, 60655, 60656, 60657, 60658, 60659, 60660, 60661, 60666, 60668, 60669, 60670, 60673, 60674, 60675, 60676, 60677, 60678, 60680, 60681, 60686, 60689, 60690, 60693, 60694, 60695, 60696
Vickey Jones – Cities: Alsip, Bellwood, Berkeley, Berwyn, Blue Island, Bridgeview, Broadview, Brookfield, Burbank, Chicago Ridge, Cicero, Elmwood Park, Evergreen Park, Forest Park, Franklin Park, Harwood Heights, Hillside, Hines, Hometown, Indian Head Park, Justice, Knoxville, La Grange, La Grange Park, La Grange Highlands, Lyons, Maywood, Melrose Park, Merrionette Park, Norridge, North Riverside, Northlake, Oak Lawn, Oak Park, Park Ridge, River Forest, River Grove, Riverside, Schiller Park, Stone Park, Summit Argo, Westchester, Western Springs
Key: Cook County (16) and DuPage County (22) are split between Ana, Cathy, Gina, Kathleen, Michelle, Ramona, Ron and Vickey.
City of Chicago is split between Ana and Ron.
* NW Indiana is assigned to Kathleen.
As a reminder, if you are an ancillary provider (DME, home infusion therapy, skilled nursing facility, home health, hospice, orthotics/prosthetics, dialysis, private duty nursing), your PNC is Elaine Williams. Elaine can be contacted at 312-653-4305 or [email protected].
Professional Provider Network Consultant Assignments
MARCH 2012 7AUGUST 2014 5
Professional Provider Network Consultant Assignments (Revised July 2014)
Amanda Williams – 217-698-5179
Michelle Brownfield-Nance – 312-653-4727
Roy Pyers – 217-698-2524
Cathy Dismuke – 312-653-2388
Kathleen Barry – 312-653-4247*
Teresa Trumbley – 618-998-2528
Gina Plescia – 312-653-4733
Adam Kwiecien – 312-653-1726
Ramona Espino – 312-653-5032
Ana Hernandez – 312-653-6488
– 217-698-5179
ld-Nance – 312-653-4727
98-2524
12-653-2388
12-653-4247*
-653-4733
312-653-1726
312-653-5032
12-653-6488
21
82
4196 24
93
57
67
78
43 89 1014 56
49
16
4519
718
52
47
99
46
3250
637
98
81
8862
72 102
53
38
9220
74
10
2790
66
4836
94
2955
63
5465
85
75
5 9
84
11
87
1812
23
15
70
58
8669
7
42
31
603
5968
2625
40 17
5180136114
95
7973
28
33 97
3083100
39
35764491
6477
2
22
21
82
4196 24
93
57
67
78
43 89 1014 56
49
16
4519
718
52
47
99
46
3250
637
98
81
8862
72 102
53
38
9220
74
10
2790
66
4836
94
2955
63
5465
85
1
34
75
5 9
84
11
87
1812
23
15
70
58
8669
7
42
31
603
5968
2625
40 17
5180136114
95
7973
28
33 97
3083100
39
35764491
6477
2
22
Code County1 Adams2 Alexander3 Bond4 Boone5 Brown6 Bureau7 Calhoun8 Carroll9 Cass
10 Champaign11 Christian12 Clark13 Clay14 Clinton15 Coles16 Cook17 Crawford18 Cumberland19 DeKalb20 Dewitt21 Douglas22 DuPage23 Edgar24 Edwards25 Effingham26 Fayette27 Ford28 Franklin29 Fulton30 Gallatin31 Greene32 Grundy33 Hamilton34 Hancock35 Hardin36 Henderson37 Henry38 Iroquois39 Jackson40 Jasper41 Jefferson42 Jersey43 JoDaviess
Code County44 Johnson45 Kane46 Kankakee47 Kendall48 Knox50 LaSalle49 Lake51 Lawrence52 Lee53 Livingston54 Logan58 Macon59 Macoupin60 Madison61 Marion62 Marshall63 Mason64 Massac55 McDonough56 McHenry57 McLean65 Menard66 Mercer67 Monroe68 Montgomery69 Morgan70 Moultrie71 Ogle72 Peoria73 Perry74 Piatt75 Pike76 Pope77 Pulaski78 Putnam79 Randolph80 Richland81 Rock Island83 Saline84 Sangamon85 Schuyler86 Scott87 Shelby82 St Clair88 Stark89 Stephenson90 Tazewell91 Union92 Vermilion93 Wabash94 Warren95 Washington96 Wayne97 White98 Whiteside99 Will
100 Williamson101 Winnebago102 Woodford
Vickey Jones – 312-653-6321
Ron Smothers – 312-653-8518
Our PNCs serve as the liaison between BCBSIL and our independently contracted professional provider community, developing and maintaining cooperative working relationships with the contracted professional providers participating in the network throughout Illinois and Northwest Indiana.
Your Professional PNC has extensive knowledge and is available to meet with you to help educate your staff on BCBSIL procedures, help ensure provider contract compliance and work with you to resolve any operational issues.
For the name of your Professional PNC, refer to the Illinois county map on the following page. PNCs for professional providers in Cook and DuPage Counties (Codes 16 and 22) are assigned by either Chicago ZIP code or city, listed below. The Professional Provider Network Consultant List and map are also available in the Education and Reference Center on our website at bcbsil.com/provider.
I LL IN OIS TER RITORY BR E AKDOWN BY COU NT Y CODENorthern (8, 43, 49, 81, 89 and 98) – Gina Plescia
Southern (2, 3, 12, 13, 14, 15, 17, 18, 24, 25, 26, 28, 30, 33, 35, 39, 40, 41, 44, 51, 60, 61, 64, 67, 73, 76, 77, 79, 80, 82, 83, 84, 87, 91, 93, 95, 96, 97 and 100) – Teresa Trumbley
West-Central (1, 5, 7, 9, 11, 29, 31, 34, 36, 42, 55, 59, 63, 65, 66, 68, 69, 75, 85, 86 and 94) – Roy Pyers
East-Central (10, 20, 21, 23, 27, 38, 53, 54, 57, 58, 70, 72, 74, 90, 92 and 102) – Amanda Williams
North Metro (4, 6, 19, 37, 45, 47, 48, 50, 52, 56, 62, 71, 78, 88 and 101) – Cathy Dismuke
South Metro (32, 46 and 99) – Adam Kwiecien
Northwest Indiana – Kathleen Barry
Cook County (16) – See below for Cook and DuPage County Breakdown
DuPage County (22) – See below for Cook and DuPage County Breakdown
COOK AN D DU PAG E COU NT Y BR E AKDOWN BY CIT Y AN D ZIP CODEAdam Kwiecien – City: Lemont
Ana Hernandez – ZIP Codes: 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60610, 60611, 60612, 60614, 60616, 60622, 60634
Cathy Dismuke – Cities: Addison, Bartlett, Bloomingdale, Hanover Park, Hillisburg, Medinah, Roselle, Streamwood, Wayne
Gina Plescia – Cities: Arlington Heights, Elk Grove Village, Hoffman Estates, Schaumburg
Kathleen Barry – Cities: Aurora, Burr Ridge, Calumet City, Chicago Heights, Darien, Dolton, Flossmoor, Ford Heights, Glen Ellyn, Glendale Heights, Glenwood, Homewood, Lansing, Lisle, Lynwood, Matteson, Naperville, Olympia Fields, Park Forest, Richton Park, Riverdale, Sauk Village, South Holland, Steger, Summit, Thornton, Warrenville, Willowbrook, Woodridge
Michelle Brownfield-Nance – Cities: Calumet Park, Carol Stream, Country Club Hills, Countryside, Crestwood, Downers Grove, Harvey, Hazel Crest, Hickory Hills, Homer Glen, Markham, Midlothian, Oak Forest, Orland Hills, Orland Park, Palos Heights, Palos Hills, Palos Park, Posen, Robbins, Tinley Park, West Chicago, Wheaton, Willow Springs, Winfield, Worth
Ramona Espino – Cities: Bensenville, Clarendon Hills, Des Plaines, Elmhurst, Glencoe, Glenview, Golf, Hinsdale, Inverness, Itasca, Kenilworth, Lincolnwood, Lombard, Morton Grove, Mt. Prospect, Neenah, Niles, Northbrook, Northfield, Oak Brook, Oak Brook Terrace, Palatine, Prospect Heights, Rolling Meadows, Rosemont, Skokie, South Barrington, Villa Park, Westmont, Wheeling, Wilmette, Winnetka, Wood Dale
Ron Smothers – City: Evanston; ZIP Codes: 60601, 60602, 60603, 60604, 60608, 60609, 60613, 60615, 60617, 60618, 60619, 60620, 60621, 60623, 60624, 60625, 60626, 60627, 60628, 60629, 60630, 60631, 60632, 60633, 60635, 60636, 60637, 60638, 60639, 60640, 60641, 60642, 60643, 60644, 60645, 60646, 60647, 60648, 60649, 60650, 60651, 60652, 60653, 60654, 60655, 60656, 60657, 60658, 60659, 60660, 60661, 60666, 60668, 60669, 60670, 60673, 60674, 60675, 60676, 60677, 60678, 60680, 60681, 60686, 60689, 60690, 60693, 60694, 60695, 60696
Vickey Jones – Cities: Alsip, Bellwood, Berkeley, Berwyn, Blue Island, Bridgeview, Broadview, Brookfield, Burbank, Chicago Ridge, Cicero, Elmwood Park, Evergreen Park, Forest Park, Franklin Park, Harwood Heights, Hillside, Hines, Hometown, Indian Head Park, Justice, Knoxville, La Grange, La Grange Park, La Grange Highlands, Lyons, Maywood, Melrose Park, Merrionette Park, Norridge, North Riverside, Northlake, Oak Lawn, Oak Park, Park Ridge, River Forest, River Grove, Riverside, Schiller Park, Stone Park, Summit Argo, Westchester, Western Springs
Key: Cook County (16) and DuPage County (22) are split between Ana, Cathy, Gina, Kathleen, Michelle, Ramona, Ron and Vickey.
City of Chicago is split between Ana and Ron.
* NW Indiana is assigned to Kathleen.
As a reminder, if you are an ancillary provider (DME, home infusion therapy, skilled nursing facility, home health, hospice, orthotics/prosthetics, dialysis, private duty nursing), your PNC is Elaine Williams. Elaine can be contacted at 312-653-4305 or [email protected].
WEBINARS
Electronic Provider Access (EPA)EPA is a new tool that will enable providers to
initiate online pre-service reviews for out-of-area Blue Plan members.
Aug. 21, 2014 10 to 11:30 a.m.
Introducing Remittance ViewerThe remittance viewer is an online tool that offers providers and billing services a convenient way to
retrieve, view, save or print claim detail information.
Aug. 20, 2014 11 a.m. to noon
Aug. 27, 2014 1 to 2 p.m.
WORKSHOPS
BCBSIL Professional Provider WorkshopHoliday Inn
7550 E. State StreetRockford, IL 61108
Registration deadline: Aug. 20, 2014. Register online or contact Cathy Dismuke
at [email protected] or 312-653-2388.
Aug. 27, 2014
Registration: 9 to 9:30 a.m.
Session: 9:30 a.m. to noon
BCBSIL Professional Provider Workshop Stoney Creek Hotel & Conference Center
101 18th Street Moline, IL 61265
Registration deadline: Sept. 18, 2014. Register online or contact Gina Plescia
at [email protected] or 312-653-4733.
Sept. 25, 2014
Registration: 9 to 9:30 a.m.
Session: 9:30 a.m. to noon
VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER6
BC BSIL WEBINAR S AN D WOR KSH OPS Below is a list of complimentary training sessions sponsored by BCBSIL. For details and
online registration, visit the Workshops/Webinars page in the Education and Reference
Center of our website at bcbsil.com/provider.
Provider Learning Opportunities
AVAILIT Y TM WEBINAR S Availity also offers free webinars for their registered users. For a current listing of webinar
topics, dates and times, registered Availity users may log on to the secure Availity provider
portal – the Live Webinar Schedule is located under the Free Training tab. Not yet registered
with Availity? Visit their website at availity.com for details; or call Availity Client Services at
800-AVAILITY (282-4548) for assistance.
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
IN THE KNOW✓
BCBSIL considers abusive or
fraudulent billing to include, but
not be limited to, the following
claim practices:
• Misrepresentation of the services
provided to receive payment for a
non-covered service;
• Billing in a manner that results in
reimbursement greater than what
would have been received if the
claim were properly filed; and/or
• Billing for services that were
not rendered.
If BCBSIL determines, in its sole
discretion, that a provider has
engaged in abusive or fraudulent
billing practices, BCBSIL may take
further actions up to and including
termination of the provider from
the network.
Fighting Fraud and Abuse
MARCH 2012 7AUGUST 2014 7
ClaimsXtenTM Third Quarter 2014 UpdatesBCBSIL reviews new and revised Current Procedural Terminology (CPT®) and HCPCS codes on a
quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson
and these changes are not considered changes to the software version. BCBSIL will normally load
this additional data to the BCBSIL claim processing system within 60 to 90 days after receipt from
McKesson and will confirm the effective date on the BCBSIL Provider website. Advance notification
of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will
continue to be posted on the BCBSIL Provider website.
Beginning on or after Sept. 29, 2014, BCBSIL will enhance the ClaimsXten code auditing tool by
adding two new rules into our claim processing system, as follows:
OBSTE TRIC S PAC K AG E RU LE This rule audits claim lines to determine if any global obstetric care codes (defined as containing
antepartum, delivery and postpartum services) were submitted with another global OB care code
or a component code during the average length of time of the typical pregnancy of 280 days and/or
pregnancy plus postpartum period of 322 days.
CONTIN UOUS POSITIVE AIRWAY PR E SSU R E OR BI - LEVEL POSITIVE AIRWAY PR E SSU R E (C PAP/BIPAP) SU PPLY FR EQU EN C Y RU LE This rule audits maximum frequency of PAP supplies based on the recommended replacement
schedule from CMS. Specifically, this rule identifies supply codes associated with CPAP/BiPAP
therapy that are being submitted by all providers for the same member at a frequency that exceeds
the CMS Local Coverage Determination (LCD) policy for PAP supplies. Accessories used with a
CPAP device are covered when the coverage criteria for the device are met. If the coverage criteria
are met, the accessories billed that exceed the maximum number of supplies for the CPAP/BiPAP
item will be disallowed. See below for maximum allowable quantity/frequency guidelines, as
determined by CMS:
PROCEDURE CODE
MAXIMUM QUANTITY
FREQUENCY (number of days)
A4604 1 90
A7027 1 90
A7028 2 30
A7029 2 30
A7030 1 90
A7031 1 30
A7032 2 30
A7033 2 30
A7034 1 90
A7035 1 180
A7036 1 180
A7037 1 90
A7038 2 30
A7039 1 180
A7046 1 180
For details on ClaimsXten including answers to frequently asked questions, refer to the Clear Claim
Connection™ page in the Provider Tools section of our website at bcbsil.com/provider. Additional
information also may be included in upcoming issues of the Blue Review.
ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.
CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Fairness in Contracting
In an effort to comply with fairness
in contracting legislation and help
keep our independently contracted
providers informed, BCBSIL
has designated a column in the
Blue Review to notify you of any
significant changes to the physician
fee schedules. Be sure to review this
area each month.
Effective Nov. 1, 2014, the allowance for J1745 will be updated.
The information above is not
intended to be an exhaustive listing
of all the changes. Annual and
quarterly fee schedule updates can
also be requested by using the Fee
Schedule Request Form. Specific code
changes that are listed above can also
be obtained by downloading the Fee
Schedule Request Form and
specifically requesting the updates on
the codes listed in the Blue Review.
The form is available in the
Education and Reference Center/
Forms section of our Provider
website at bcbsil.com/provider.
Fairness in Contracting
PRSRT STDU.S. POSTAGE
PAIDPERMIT NO. 581
CHICAGO, IL
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
REVIEWFOR CONTRACTING INSTITUTIONAL AND PROFESSIONAL PROVIDERS
00014.0814
Blue Review is a monthly newsletter published for institutional and professional providers contracting with Blue Cross and Blue Shield of Illinois. We encourage you to share the content of this newsletter with your staff. Blue Review is located on our website at bcbsil.com/provider. The editors and staff of Blue Review welcome letters to the editor. Address letters to:
BLUE REVIEWBlue Cross and Blue Shield of Illinois300 E. Randolph Street – 24th FloorChicago, Illinois 60601-5099Email: [email protected]
Website: bcbsil.com/provider
Publisher:Stephen Hamman, Vice President, Network Management
Editor: Wes Chick, Divisional Vice President, Provider Relations
Managing Editor: Jeanne Trumbo, Senior Manager, Provider Communications
Editorial Staff: Margaret O’Toole, Marsha Tallerico, Michael Chaney, Edna Johnson
BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions regarding any of the products or services mentioned in this periodical, you should contact the vendor directly.
Watch for the Annual Physician SurveysThis month, the 2014 Physician Surveys will be sent to HMO Primary Care
Physicians (PCPs) and randomly selected PPO physicians.
These HMO and PPO surveys are conducted annually to help analyze the
physician experience with BCBSIL and with the physician’s primary hospital.
The HMO survey includes questions about operational, service and reporting
activities that are conducted by HMO Medical Group/Independent Practice
Associations (MG/IPAs) and BCBSIL. PCPs contracted with more than
one HMO MG/IPA site will receive a separate survey for each entity with
which they are contracted. The PPO survey includes questions regarding
operational, service and reporting activities conducted by BCBSIL.
The questions in these surveys are primarily directed to physicians. However,
office staff may be more familiar with some activities and may provide
assistance in completing the survey. As some questions may not apply to
all physicians or their office staff, a “no experience” response is always
acceptable, when it applies.
To help maintain the accuracy of survey responses and the confidentially
of all participants, BCBSIL has systems in place to ensure that only one set
of answers is recorded per respondent and that only aggregate results are
reported to BCBSIL operating areas and HMO MG/IPA sites.
WE WANT TO H E AR FROM YOU We would appreciate your participation. Please return all completed surveys
in the postage-paid envelope within 10 business days of receipt.
VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER
