updateSM

Reminder of upcoming July NaviNet® release page 6

View up-to-date medical and claim payment policy activity on the Medical Policy Portal page 10

Get ready for the upcoming ICD-10 compliance date page 7

July 2015

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2015 www.dreamstime.com. All rights reserved.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.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 is a registered trademark of NaviNet, Inc., an independent company.FutureScripts and FutureScripts Secure are independent companies that provide pharmacy benefits management services.CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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

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

provider_communications@ibx.com

Inside this edition

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

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

Professional Facility AncillaryKeystone Health Plan East, Personal Choice®, Keystone 65 HMO, and Personal Choice 65SM PPO have an accreditation status of Commendable from NCQA.

Administrative ► Procedures for terminating a patient from a practice

Consumerism ● Independence to roll out new and improved member portal

Billing ► Claims processing requirements for PCPs rendering services to

members in long-term care facilities ► Billing requirement for anesthesia claims

NaviNet®

► Reminder of upcoming July NaviNet® release

ICD-10 ● Get ready for the upcoming ICD-10 compliance date ● Join us for the next What’s Up Wednesday on July 15, 2015

Pharmacy ► New mail-order facility for your patients with FutureScripts®

Secure coverage

Medical ► Obtaining precertification for non-emergent radiation therapy

services through NaviNet®

► View up-to-date medical and claim payment policy activity on the Medical Policy Portal

► Reminder: Use –X{EPSU} modifiers to report separate, distinct, or independent non-E&M services on the same day

► Clarifying member cost-share amounts for medical benefit drugs

Quality Management ● Highlighting HEDIS®: Osteoporosis management in women

who had a fracture

Health and Wellness ● Suicide: A concern for all health care providers:

Part 2 – Embracing your role through screening, assessing, and promoting safety for individuals at risk for suicide

ADMINISTRATIVE

July 2015 | Partners in Health UpdateSM 3 www.ibx.com/providers

Procedures for terminating a patient from a practiceIf a situation arises when a primary care physician (PCP) or other treating physician initiates termination of its physician-patient relationship and needs to release an Independence member from his or her practice, there are some important things to remember. The PCP or treating physician must notify both the member and Independence in writing if terminating a member from his or her practice. To notify Independence, the physician must contact his or her Network Coordinator or Customer Service, or send correspondence to:

Independence Blue Cross Attn: Network Services 1901 Market Street, 28th Floor Philadelphia, PA 19103

The physician must also continue treating the member for current medical conditions for 30 days after ending the physician-patient relationship to allow time for the member to select a different treating physician. During this time, we will assist the member in selecting a different PCP or other treating physician. If the member asks the physician or office staff for assistance in selecting a new PCP or other treating physician, he or she should be referred to Customer Service at 1-800-ASK-BLUE. In the event the member is threatening or violent towards the physician or office staff, the member’s access to the office may be terminated immediately.

Non-discrimination Physicians cannot discriminate against any member on the basis of the member’s coverage under a benefit program, age, sex, race, color, religion, ancestry, national origin, disability, handicap, health status, source or amount of payment, or utilization of medical or mental health services or supplies. Other unlawful reasons for discharging a member, without limitation, include the filing by such member of any complaint, grievance, or legal action against the provider or Independence. Participating physicians are also prohibited from excluding or closing a practice to certain members as a result of the reimbursement (e.g., closing a practice to capitated HMO patients only). Physicians are also not permitted to terminate their relationship with a member who has complicated or expensive medical needs unless the provider has received written approval from Independence that there is good cause for such termination and that such termination is in the member’s best interest.

Medical record requestsWhen a provider initiates termination of the physician-patient relationship with the member, the physician cannot charge members for requests for copies of medical records. The physician must facilitate the sharing of such records among health care providers directly involved with the member’s care.

CONSUMERISM

July 2015 | Partners in Health UpdateSM 4 www.ibx.com/providers

Independence to roll out new and improved member portal In mid-July, Independence will launch a newly enhanced ibxpress member portal and provider finder. The portal will include a more intuitive user interface, improved navigation, and seamless integration across digital and mobile technologies.

New Find a Doctor/Hospital ToolThe updated tool has a new look and feel and can be accessed from both www.ibx.com and www.ibxpress.com. Users will be able to search for their medical, pharmaceutical, vision, and dental providers using one tool, eliminating the need for multiple browser windows and multiple logins. A new smart search enhances the way users search for providers by allowing a streamlined keyword search, resulting in a better user experience.

Additional ibxpress featuresHighlighted features of the new ibxpress include:

● Virtual Assistant. This innovative technology makes it easier for members to ask a question in a dynamic, automated conversation.

● My Alerts. Members can now stay up-to-date on information specific to their plan, including alerts advising members of new claims, referrals, and billing payment reminders.

● Claims & Spending. This unified view of medical and prescription claims allows members to pay claims, submit receipts, and print tax information.

● My Care. This page gives members access to everything they need to manage their family’s care, including doctor’s information, referrals, the Care Cost Estimator, and the Symptom Checker.

In mid-July, members can log on to www.ibxpress.com using their existing login credentials to view the newly enhanced portal.

Note: The new portal will be integrated with our IBX Mobile app in October. This free app allows members to connect directly with Independence through their own secure digital space, making it easier to stay on top of need-to-know personal health information.

BILLING

July 2015 | Partners in Health UpdateSM 5 www.ibx.com/providers

Claims processing requirements for PCPs rendering services to members in long-term care facilitiesThis is a reminder of the requirements for primary care physicians (PCP) when rendering services to members in long-term care (LTC) facilities. It is important to adhere to these requirements when providing such services or your claims may be denied. This information is documented in the Provider Manual for Participating Professional Providers and was previously published in Partners in Health Update.

Member must be on PCP’s LTC panelPlease note the following two requirements related to PCPs and their LTC panel:

● PCPs who provide services to members in an LTC/custodial setting must have a separate LTC provider number established in our system. This separate provider number must be used when submitting claims for services rendered to members residing in an LTC facility (custodial members). If you do not have a separate LTC provider number and you are seeing Independence members residing in an LTC/custodial setting, please contact your Network Coordinator to establish an LTC provider number.

● The members you provide care to in the LTC setting must be on your LTC panel or the claim will be denied. Please remind your Independence LTC patients who are not included on your panel that they, or their legal representative, need to contact Customer Service to select your LTC location. You may also want to consult with the administrative staff of the LTC facility to assist with educating the members and/or their legal representative of the need to be on the PCP’s LTC panel.

Note: Members who are on your office panel but now reside in an LTC facility must contact Customer Service in order to be moved to your LTC panel.

Referral requirements for members in LTCPCPs with an LTC panel must issue a referral to an in-network provider for any professional service or consultation for an LTC-panel member in LTC. This requirement includes:

● podiatry, physical therapy, and radiology services ● consultation or follow-up with a specialist ● ancillary services

Note: LTC-panel members do not have capitation requirements for laboratory, physical therapy, or radiology services. Also, the services listed above do not require precertification.

PCPs should submit referrals for LTC-panel members in advance of the service being provided. Referrals can be submitted by using the NaviNet® web portal, and they should be submitted in a timely manner to allow for appropriate claims processing. Claims will not be authorized for payment without a referral on file. In addition, consultants and ancillary providers are encouraged to provide the referral information with the claim to assist in processing.

Billing requirements for members in an LTC facilityServices for members in custodial care are to be billed with Place of Service code 32.

If you have any questions about LTC services, please contact your Network Coordinator.

BILLING

July 2015 | Partners in Health UpdateSM 6 www.ibx.com/providers

Billing requirement for anesthesia claims Our new operating platform has requirements that differ from our previous claims processing system, including for anesthesia claims.

The new platform requires anesthesiologists to report the surgery or service performed that relates to the anesthesia service being provided. When submitting anesthesia claims electronically, there are three fields in which providers can report the related surgery/service performed:

● Anesthesia Surg Proc CD ● Claim Note Note ● NOC Desc

Any claims that are submitted using ASA (American Society of Anesthesiologists) codes that do not indicate the related surgery or service performed in one of the aforementioned fields will deny with the following rejection code:

E5488: The description of the surgery or service reported that relates to the anesthesia service performed is not valid or is not reported.

If you have any questions about this billing requirement, please contact your Network Coordinator.

NAVINET®

Reminder of upcoming July NaviNet® release As previously communicated, we will be introducing the following changes to the NaviNet web portal on July 10:

● Cash Management. This new transaction will give you a weekly summation of estimated payments and offsets by the health plan, as well as provide a summary of payments for the current six-month period. The designated NaviNet Security Officer within your office will initially receive access to this new transaction, and he or she will manage permissions for individual associates.

● EFT Registration. An enhanced transaction will be introduced to assist providers with managing electronic funds transfer (EFT) registrations and changes. The designated NaviNet Security Officer within your office will initially receive access to this new transaction, and he or she will manage permissions for individual associates.

New user guides are available in the NaviNet Resources section of the Provider News Center at www.ibx.com/pnc to help you better understand the changes to these transactions. If you have any questions, please call the eBusiness Hotline at 215-640-7410.

ICD-10

July 2015 | Partners in Health UpdateSM 7 www.ibx.com/providers

Get ready for the upcoming ICD-10 compliance date With the October 1, 2015, compliance deadline for ICD-10 only three months away, Independence would like to make sure that all provider offices are taking the necessary steps to get ready for ICD-10.

Compliance deadlineIndependence would like to remind providers that we will not accept ICD-9 codes on any referrals, authorizations, or claims for dates of service on or after October 1, 2015. If your office submits an ICD-9 code after the compliance date, your referral, authorization, or claim will be denied and sent back to you for proper coding. Providers should work with their trading partners, clearinghouses, and billing vendors/billing software companies to ensure ICD-10 compliance and avoid claims rejections and processing delays.

Ensure successful claims payment In order for your claims to process correctly, all providers must bill with ICD-10 codes for all dates of service on or after October 1, 2015. Any claims submitted for dates of service on or after October 1, 2015, with ICD-9 codes will be denied.

If the dates of service span the compliance date, the claim will need to be split. ICD-9 codes should be used for dates of service prior to October 1, 2015, and ICD-10 codes should be used for dates of service on or after October 1, 2015. Note: You cannot submit both ICD-9 and ICD-10 codes on a single claim.

As a reminder, all network providers are required to use the Health Insurance Portability and Accountability Act (HIPAA) 5010 electronic format and CMS-1500 (02/12) paper format in order to avoid denials.

Keeping you informedIndependence maintains a dedicated ICD-10 web page at www.ibx.com/icd10. There you can find up-to-date information, including updates on external testing, frequently asked questions, and dial-in information for the monthly What’s Up Wednesday teleconference calls.

We have also published ICD-10 information in Partners in Health Update, including the following recent articles: ● External testing updates and tips for a successful conversion (April 2015 edition) ● Clarification: Independence’s guidelines for submitting authorizations and referrals (June 2015 edition)

We will continue to provide ICD-10 updates in future editions of Partners in Health Update.

Additional resourcesThe Centers for Medicare & Medicaid Services (CMS) ICD-10 web page at www.cms.gov/Medicare/Coding/ICD10 offers a plethora of resources for your use, including:

● Road to 10: The Small Physician Practice’s Route to ICD-10: www.roadto10.org ● ICD-10 Resources flyer: www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ResourcesFlyer20141105.pdf ● Video tutorials:

- Introduction to ICD-10 Coding: www.youtube.com/watch?v=NNbTcMwrop8&feature=youtu.be - Road to 10: The Small Physician Practice’s Route to ICD-10: www.youtube.com/watch?v=_

pLwSh09sGo&feature=youtu.be ● CMS ICD-10 Industry Email Updates: www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.html

We encourage providers to use these resources as they prepare for ICD-10.

ICD-10

July 2015 | Partners in Health UpdateSM 8 www.ibx.com/providers

Join us for the next What’s Up Wednesday on July 15, 2015 What’s Up Wednesday is a monthly teleconference hosted by Pennsylvania’s Blue Plans to help prepare health care professionals for the ICD-10 transition on October 1, 2015. What’s Up Wednesday features special guest speakers and ICD-10 experts who will lead discussions to help you get ready for the compliance date. All providers, clearinghouses, information trading partners, and information networks are encouraged to participate.

How to participateNo registration is required. Prior to the call, visit the What’s Up Wednesday web page at www.ibx.com/providers/claims_and_billing/icd_10/whatsupweds.html to access and download the presentation materials. On the day of the call, dial 1-800-882-3610 and enter pass code 5411307 when prompted. Please dial in five minutes prior to the start of the call.

QuestionsIf you have specific ICD-10-related questions during the call, please email them to ICD10ProviderCommunication@capbluecross.com.

Call details

Date: Wednesday, July 15, 2015Time: 2 – 3 p.m. ETPhone number: 1-800-882-3610Pass code: 5411307

New mail-order facility for your patients with FutureScripts® Secure coverage Effective July 1, 2015, the FutureScripts Secure mail-order facility has changed. Therefore, your Independence patients who have prescription drug coverage with FutureScripts Secure may need your assistance in obtaining their medications. Recently, these patients received a letter explaining that they would need to request that their provider write a new prescription for certain non-transferrable prescriptions (i.e., expired prescriptions, prescriptions with no remaining refills, future-fill prescriptions, or prescriptions for controlled-substances).

If you receive a request for a new prescription due to this change, please write the prescription for up to a 90-day supply of medication plus refills of up to one year, where appropriate. The new address is:

FutureScripts SecureP.O. Box 409013Ft. Lauderdale, FL 33340-9013Fax: 1-877-762-9551

To obtain copies of the order form that must accompany the written prescription, members with FutureScripts Secure coverage can call 1-888-678-7015 (TTY: 711). Representatives are available 24 hours a day, 7 days a week.

PHARMACY

MEDICAL

July 2015 | Partners in Health UpdateSM 9 www.ibx.com/providers

Providers are required to obtain precertification through CareCore National, LLC d/b/a eviCore healthcare (eviCore) for non-emergent outpatient radiation therapy services for all commercial and Medicare Advantage HMO, POS, and PPO members. We use eviCore Radiation Therapy Utilization Management Criteria when reviewing requests for radiation therapy services. For members younger than 19, services requested will be automatically approved; however, precertification through eviCore is still required to ensure accurate and timely claims payment.

Obtaining precertification for non-emergent radiation therapy services through NaviNet®

CareCore changes name to eviCore

In June, as a result of their recent merger with MedSolutions, CareCore National, LLC, launched a new name and brand: eviCore healthcare (eviCore). We will work as quickly as possible to revise provider resources, including NaviNet, the Medical Policy Portal, and our manuals, to reflect this new name. All phone numbers and contact information will remain the same for eviCore.

NaviNet currently offers direct access to eviCore’s provider portal to streamline the process of obtaining precertification. Providers can select eviCore/CareCore from the Authorizations transaction and a new window will open that sends providers directly to eviCore’s provider portal and allows initiation of the precertification process.

Once on the eviCore provider portal, select the Request a clinical certification/procedure option. Within the Clinical Certification section, providers can identify themselves by using either their National Provider Identifier (NPI) or tax ID number (TIN) and their last name, city, and ZIP code. The search will return any referring provider associated with the information entered. Simply select the appropriate provider/address to proceed with the remainder of the precertification process.

Providers can also initiate precertification for non-emergent outpatient radiation therapy by calling eviCore directly at 1-866-686-2649.

MEDICAL

July 2015 | Partners in Health UpdateSM 10 www.ibx.com/providers

View up-to-date medical and claim payment policy activity on the Medical Policy Portal Changes to our medical and claim payment policies occur frequently — sometimes daily — for our commercial and Medicare Advantage benefit programs. In order to keep you up to date with changes to our policies, we have enhanced the information available in the Site Activity section of our Medical Policy Portal.

Updated Site Activity section The Site Activity section now includes a snapshot of all activity that occurred within a given month, including:

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

The Site Activity section is updated in real time as changes are made to the Medical Policy Portal. Since the enhancements allow you access to up-to-the-minute medical and claim payment policy activity, we will no longer include a separate supplementary list of changes with Partners in Health Update. For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference.

Accessing policy informationTo access the updated Site Activity section, go to our Medical Policy Portal at www.ibx.com/medpolicy and select Accept and Go to Medical Policy Online. From here 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. You can also get to our Medical Policy Portal through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

We hope these changes allow you to stay better informed of our medical and claim payment policy activity.

MEDICAL

July 2015 | Partners in Health UpdateSM 11 www.ibx.com/providers

Reminder: Use –X{EPSU} modifiers to report separate, distinct, or independent non-E&M services on the same day As a reminder, effective January 1, 2015, providers should be reporting services that are separate, distinct, or independent from other non-evaluation and management (E&M) services and performed on the same day with the following codes:

● Modifier XE: Separate Encounter ● Modifier XP: Separate Practitioner ● Modifier XS: Separate Structure ● Modifier XU: Unusual Non-Overlapping Service ● Modifier 59: Distinct Procedural Service (only to be used when the service cannot be more accurately reported with one of the four –X{EPSU} modifiers listed above)

For guidelines on how to report these modifiers, including appropriate and inappropriate uses, refer to the following claim payment policies:

● Commercial: #03.00.08d: Modifiers XE, XS, XP, XU, 59 (previously Modifier 59: Distinct Procedural Service) ● Medicare Advantage: #MA03.005a: Modifiers XE, XS, XP, XU, 59 (previously Modifier 59: Distinct Procedural Service)

Providers should use the more specific –X{EPSU} modifiers to accurately represent the circumstances that render non-E&M services as separate, distinct, or independent. However, modifier 59 can still be reported if the service cannot be more accurately reported with one of the four specific modifiers. Providers cannot append more than one of these modifiers (i.e., XE, XP, XS, XU, or 59) to a single procedure code. Claims submitted with any of these modifiers may be subject to retrospective review and audit if it is determined that providers are not using them in accordance with the billing requirements in our claim payment policies.

For more information on the use of modifier 59 and the –X{EPSU} modifiers, go to www.ibx.com/medpolicy and select Accept and Go to Medical Policy Online. Then select either the Commercial or Medicare Advantage tab, depending on the version of the policy you’d like to view, and type the policy name or number in the Search field.

MEDICAL

July 2015 | Partners in Health UpdateSM 12 www.ibx.com/providers

Clarifying member cost-share amounts for medical benefit drugs Providers and members often have questions about how medical drugs are covered by Independence, how drug benefits are structured, and how much their drugs will cost. It is important that providers and their office staff remember that member benefits may vary, particularly in terms of cost-sharing amounts (e.g., copayment, deductible, coinsurance) associated with certain drugs. Therefore, member benefits should always be verified prior to rendering services.

Each member’s benefit plan dictates the terms under which Independence provides drug coverage. There are different cost-sharing responsibilities based on how Independence classifies each drug. The terms of the benefit plan also vary based on the type of product in which the member is enrolled (e.g., HMO v. PPO; commercial v. Medicare Advantage).

We offer a variety of online tools to assist you in identifying the terms, requirements, and cost-sharing amounts associated with our benefit plans.

Verifying cost-sharing amounts Many of our plans require members to pay a portion of the cost toward their treatment. The cost-sharing amount is dictated by the terms of each member’s benefit plan. For members enrolled in Flex products and select customized plans, the cost-sharing amount typically applies to certain high-cost specialty drugs, sometimes referred to as “biotech drugs.” For a complete list of drugs that Independence designates as biotech drugs, view the Specialty Drugs with Cost-Sharing document at www.ibx.com/preapproval. This list is subject to change.

For members enrolled in a Keystone HMO Proactive plan, Medicare Advantage plan, high deductible health plan, or other self-funded customer tiered network programs, cost-sharing may apply for all medical drugs, including the high-cost specialty biotech drugs mentioned above.

For drugs that are part of a multiple-dose regimen, the member is responsible for the cost-sharing amount for each date of service that he or she receives the injection from the health care provider. To determine if a provider should collect cost-sharing from a member for these drugs, providers may use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal.

Step 1: From the Eligibility and Benefits Details screen, select the <Product Name> Provisions link to confirm any applicable Deductible and/or Coinsurance for which the member is responsible.

continued on the next page

MEDICAL

July 2015 | Partners in Health UpdateSM 13 www.ibx.com/providers

Step 2: Return to the Eligibility and Benefits Details screen and select the Professional Services link. Scroll down the screen to Other Services to view the member’s benefits for Injections.

When the “Injections” benefit displays as “Coverage = Yes” and there is no other copayment or coinsurance information listed, and the Biotech/Specialty Injections does not appear separately, then the In-Network Deductible and/or Coinsurance would apply to both Biotech/Specialty Injections and Standard Injections.

Note: If the plan has a deductible but the deductible does not apply to the specific service, “Deductible = No” will be displayed.

Medicare Advantage membersUnlike commercial coverage, you will not find the detailed coinsurance for Medicare Part B drugs listed under Injections. The Injections benefit will be listed as “Coverage = Yes”; however, you will find the coinsurance listed under a separate Prescription Drugs benefit within the Professional Services screen.

Precertification requirementsIndependence requires our providers to obtain precertification approval for certain drugs prior to members receiving them. Precertification approval is required for members enrolled in all Independence products. The current list of drugs that require precertification approval from Independence is located on page 3 of the Preapproval/Precertification list available at www.ibx.com/preapproval.

continued from the previous page

QUALITY MANAGEMENT

July 2015 | Partners in Health UpdateSM 14 www.ibx.com/providers

This article series is a monthly tool to help physicians maximize patient health outcomes in accordance with NCQA’s* HEDIS®† measurements for high quality care on important dimensions of services. Go to www.ibx.com/providers/resources/hedis.html to view previously published Highlighting HEDIS® topics. If you have feedback or would like to request a topic, email us at provider_communications@ibx.com.

Highlighting HEDIS®: Osteoporosis management in women who had a fracture

HEDIS® definitionOsteoporosis management in women who had a fracture: The percentage of women ages 67 – 85 who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.

Why this measure is importantThis measure assesses how well the organization manages women who are at high risk for a second fracture. It studies whether female members who suffered a fracture had evidence of either a BMD test or prescription for a drug to treat osteoporosis in the six months after the fracture date.

Morbidity and mortality related to osteoporotic fractures are major health issues. Ten million Americans have osteoporosis, and another 18 million are at risk due to low bone mass. Eighty percent of people with osteoporosis are women. Women who suffer a fracture are at increased risk of suffering additional injuries.

Treatment of osteoporotic fractures is estimated at $10 – $15 billion annually in the U.S. The aging U.S. population is likely to increase the future financial cost of osteoporosis care. — NCQA, HEDIS 2015 V1

* The National Committee for Quality Assurance (NCQA) is the most widely recognized accreditation program in the U.S.

† The Healthcare Effectiveness Data and Information Set (HEDIS®) is an NCQA tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care.

‡ QIPS is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care.

§ Stars is a program developed by the Centers for Medicare & Medicaid Services to measure quality health care. Ratings are published annually to help educate consumers prior to enrollment decisions.

New incentive opportunityIndependence is offering an incentive opportunity through a new program for Medicare Advantage HMO and PPO members who have been identified to be at-risk for osteoporosis to receive a BMD test. We will mail a list of identified members to affected providers, and incentives can be earned if the member:

● receives a DEXA scan at the provider’s capitated (HMO) or any in-network (PPO) radiology site;

● receives a quantitative ultrasound BMD study in his or her home through Mobile Medical Examination Services, Inc. (MedXM), an independent company.

In addition, each member will receive an incentive for the completed test. If you have questions or concerns about this program, please email Independence at starsinitiative@ibx.com.

National averageThe chart below displays the national average for HMO and PPO performance in this measure from 2009 – 2013.

Source: 2014 State of Health Quality

QIPS‡ and Stars§ alertOsteoporosis management in women who had a fracture is a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers and is also a Medicare Stars measure.

HEALTH AND WELLNESS

July 2015 | Partners in Health UpdateSM 15 www.ibx.com/providers

Suicide: A concern for all health care providers We are pleased to introduce the second in a short series of articles in Partners in Health Update, “Suicide: A concern for all health care providers,” that is designed to provide you with information on suicide and the importance of your role in assessing your patients who may be at risk.

Part 2 – Embracing your role through screening, assessing, and promoting safety for individuals at risk for suicide In part one of this series, we addressed your role as a health care provider in assessing the risk of suicide. Here we are offering information on how you can screen and intervene when you believe a patient is suicidal. For primary care physicians (PCP), OB/GYNs, and Behavioral Health providers (BHP), the use of screening tools can promote safety. An advantage to using screening tools is the common language that PCPs, OB/GYNs, and BHPs need to effectively communicate.1 Below are three of the many tools you can explore for use in your practice:

● PHQ-9. One of the more familiar screening tools for depression is the PHQ-9. This tool gives vital information about depression, which is a significant contributor to an increase in the risk for suicide. Although this tool has only one question that directly addresses thoughts of suicide, it could help show that the patient is at risk. In addition, there are specific suicide screening tools available that, when used in conjunction with the PHQ-9, can explore the issue of suicidality more fully.

● SAFE-T. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers several tools on their website at www.samhsa.gov, and many of them can be used without cost. One of these is the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) tool, which identifies risk and protective factors, inquires about suicidal thoughts, determines risk levels, and makes recommendations for intervention and follow-up. In addition to the SAFE-T tool, you can find information on SAMHSA’s website regarding the SAFE-T suicide prevention app for mobile devices.2

● Columbia Suicide Severity Rating Scale. The National Action Alliance for Suicide Prevention supports Zero Suicide and wants health care providers to see suicide as preventable. Through the Zero Suicide website at www.zerosuicide.com, you can obtain information and education about another valid and reliable tool, the Columbia Suicide Severity Rating Scale.3 This tool can be used for screening and referral/triage by PCPs and OB/GYNs as well as a more intense assessment of suicidal ideation and suicidal behavior by BHPs.

While these and other organizations may differ on recommendations of suicide rating scales, they all reinforce that suicide is preventable and that the health care system must address it. These organizations also reinforce that healthy connectedness is a protective factor and set an expectation that health care providers communicate and collaborate on the care of individuals at risk for suicide.

The National Suicide Prevention Lifeline, 1-800-273-TALK (8255), is available for any of your patients who may be at risk.

1Crosby AE, Ortega L, Melanson C. Self-directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2011.2http://store.samhsa.gov/apps/suicidesafe3Posner, K., et al. The Columbia-Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings From Three Multisite Studies With Adolescents and Adults, American Journal of Psychiatry, 2011; 168:1266-1277.

Visit our Provider News Center: www.ibx.com/pnc

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Hotline 1-866-282-2707 or www.ibx.com/antifraud

Care Management and Coordination

Baby BluePrints® 215-241-2198 / 1-800-598-BABY (2229)*

Case Management 1-800-313-8628

Condition Management Program 1-800-313-8628

Credentialing

Credentialing Violation Hotline 215-988-1413 or www.ibx.com/credentials

Customer Service

Provider Services 1-800-ASK-BLUE (1-800-275-2583)

Provider Services user guide www.ibx.com/providerautomatedsystem

Electronic Data Interchange (EDI)

Highmark EDI Operations 1-800-992-0246

FutureScripts® (commercial pharmacy benefits)

Prescription drug prior authorization 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.ibx.com/rx

FutureScripts® Secure (Medicare Part D pharmacy benefits)

FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.ibxmedicare.com

NaviNet® web portal

Independence eBusiness Hotline 215-640-7410

Registration www.navinet.net

Other frequently used phone numbers and websites

Independence Direct Ship Drug Program (medical benefits) www.ibx.com/directship

Medical Policy www.ibx.com/medpolicy

Provider Supply Line 1-800-858-4728 or www.ibx.com/providersupplyline