New CMS 1500 Claim Form

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1 For Participating Medical Pharmacies March 2007 CMS 1500 Claim Form HMSA is able to process paper claims submitted on the new CMS 1500 form. However, providers may continue to submit paper claims on the old CMS 1500 form until their current supply has been used up. HMSA has updated claims filing instructions located in the Provider Resource Center. A version of the new claim form with instructions for each field is available. Click on the TRAINING button on the HMSA Provider Resource Center home page, then click on BASIC CLAIMS FILING THE CMS 1500 CLAIM FORM. The form has a colored number that appears in the upper-left corner of each field. Click on the number to view complete directions about the information that should be entered in that field. HMSA provider identification numbers Providers must continue to include their HMSA provider identification number (HMSA legacy number) on paper claims even though there is a field for the National Provider Identifier (NPI). The information fields on the CMS 1500 claim form do not provide sufficient information to allow HMSA to correctly direct payment without the use of the HMSA-assigned legacy provider number. Inclusion of National Provider Identifier (NPI) on EDI claims Currently, HMSA accepts EDI claims submitted with both the HMSA provider number and the NPI. HMSA tentatively plans to accept EDI claims submitted with the NPI, but without the HMSA provider number, beginning the first week of March We will notify providers when we are ready. We will continue to process claims submitted with both the NPI and HMSA provider number until May 23, s/alerts Online in Provider Resource Center Providers are encouraged to check the NEWS/ALERTS section of the online Provider Resource Center for the latest information on fee changes, HMSA policies, coding, billing and other topics to assist pharmacies in serving their customers and doing business with HMSA. Some of the articles featured in this update were posted in the Provider Resource Center as news alerts. The NEWS/ALERTS section was designed to get information to providers more quickly than periodic mailings allow. Inside this Issue Medical claims system upgrade...2 Member information on Blue Eligibility...2 Immunization fee changes...2 DME fee changes...3 policies...4 Vaccine updates...4 DME forms C Plus updates...5 TENS rentals...6 For all CPT codes used in this Provider Update: CPT only 2006, American Medical Association. All rights reserved.

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3 HMSA Upgrading Claims System for Medical Claims HMSA is piloting a new medical claims processing system and will be phasing in the new system over time. The new medical claims processing system will provide HMSA with a platform for future growth, enable it to do comprehensive data reporting related to quality issues, increase its productivity and flexibility, and ensure it is well able to continue its compliance with federal mandates (e.g., HIPAA, ICD-10). This system is for medical claims only and does not affect the Argus drug claims processing system. Claims for a small number of members (about 5,000) are currently being processed in a controlled-production environment of the new system. HMSA will extend the pilot to include more of its private business members by moving them to the new system shortly and expects to be processing claims for approximately 20,000 members by the end of March. The number of members affected is small when compared to HMSA s total membership of more than 700,000. If the pilot progresses as planned, HMSA expects to incrementally convert additional members throughout the year and will keep providers posted on its progress. Providers whose medical claims are being processed under the new system may notice the following changes: Friday mailing. HMSA has scheduled payments for claims processed under the new system to be mailed on Friday. This may result in some providers receiving an additional RTP for claims processed under the new system. Providers who submit EDI claims should also check their electronic mailboxes, which may contain separate electronic remittances (835 transactions) for pick-up after the Friday payment. Discontinuation of TADs. Under the new system, claims requiring additional information will continue to be reported on the HMSA RTP. If the RTP includes a request for additional information pertaining to a claim processed under the upgraded system, do not wait for a Turnaround Document (TAD). TADs are being discontinued for claims processed under the new system. Please resubmit the claim with the requested information. This change will standardize processes among HMSA s various lines of business and is the process currently used by HMSA s 65C Plus plan. As HMSA implements additional phases of the new system, we will identify changes that may affect providers and communicate them in the Provider Update and on the NEWS/ALERTS page of the online Provider Resource Center. Thank you for your support while HMSA phases in its new claims processing system. HMSA Member Information to be Added to Blue Eligibility Effective March 31, 2007, the Blue Eligibility function of the Hawaii Healthcare Information Network (HHIN) will be enhanced to include benefit information for members of HMSA s commercial plans. Previously, providers could obtain information only for members of out-ofstate Blue Cross Blue Shield plans and the Federal Employee Program (FEP). In addition, the available information will be expanded to include the following items for select HIPAA-compliant service-type codes: Copayment Coinsurance Deductibles Benefit limitations Benefit variations The enhanced plan information will be accessible through both the Blue Eligibility interface on HHIN and HIPAA 270/271 eligibility inquiry and response transactions. Prior to the implementation, the HMSA Trading Partner Manual and the HHIN Getting Started Guide (available in the HHIN Documents section of the Provider Resource Center) will be updated to reflect technical changes related to HIPAA 270/271 transactions. Immunization Fee Changes The maximum allowable charge () for the following CPT codes increased, effective January 12, Providers can find fee changes sooner by regularly checking the NEWS/ALERTS page of the online Provider Resource Center. CPT Description Code Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for $

4 CPT Code Description Rabies vaccine, for $ Typhoid vaccine, live, oral $ Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use Tetanus toxoid adsorbed, for Mumps virus vaccine, live, for subcutaneous use Rubella virus vaccine, live, for subcutaneous use Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to 7 years or older, for intramuscular use $ $ $ $ $ The for the following CPT code will decrease, effective April 15, CPT Description Code Measles virus vaccine, live, for subcutaneous use Durable Medical Equipment (DME) Fee Changes Effective April 15, 2007, the will decrease for the following DME items. HCPCS HCPCS $ E0424 $ E2602 NU $ E0424 RR $ E2602 RR $ E0431 $ E2602 UE $ E0431 RR $ E2603 NU $ E0434 $ E2603 RR $ Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to 7 years or older, for Yellow fever vaccine, live, for subcutaneous use Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for Japanese encephalitis virus vaccine, for subcutaneous use $ $ $ $ $ $ E0434 RR $ E2603 UE $ E0439 $ E2604 NU $ E0439 RR $ E2604 RR $ E0441 $ E2604 UE $ E0441 NU $ E2605 NU $ E0442 $ E2605 RR $ E0442 NU $ E2605 UE $ E0443 NU $ E2606 NU $ E0461 RR $ E2606 RR $ E1010 NU $1, E2606 UE $ E1010 RR $ E2607 NU $ E1010 UE $ E2607 RR $ E1390 RR $ E2607 UE $ E1391 RR $ E2608 NU $ E1405 RR $ E2608 RR $

5 HCPCS HCPCS E1406 RR $ E2608 UE $ E2601 NU $ E2620 NU $ E2601RR $ 6.13 E2620 RR $ E2601 UE $ E2620 UE $ Policy - Abatacept (Orencia) Abatacept (Orencia) is a costimulation blocker, a new class of drugs. It may be used alone or in combination with diseasemodifying antirheumatic drugs (DMARDs). Precertification is required and specific documentation should accompany the request. To review the new policy, including criteria, documentation requirements and precertification guidelines, please refer to the Provider E-Library. Policy - Erythropoietin and Darbepoetin Beginning April 15, 2007, a new policy will be in effect for treatment using recombinant erythropoietin (EPO) or darbepoetin alfa (Aranesp). The policy includes a list of symptoms and diagnoses for which EPO and Aranesp would be prescribed. Precertification is required for treating myelodysplastic syndrome or anemia associated with a chronic disease. To preview the complete policy, please refer to the Provider E-Library. Sodium Hyaluronate (Euflexxa) Recent provider inquiries have prompted this reminder that sodium hyaluronate (Euflexxa) does not require precertification. Ranibizumab (Lucentis) Ranibizumab (Lucentis) is an injectable drug recently approved by the FDA to treat agerelated macular degeneration. Although HMSA does not have a specific medical policy covering ranibizumab, it is a newly FDA-approved biologic that is covered under our policy on biologicals and requires precertification when administered to members of HMSA s private business plans. Please refer to the Biological Therapeutics/ Biopharmaceuticals policy in the Provider E- Library for detailed information. When billing for the drug, use HCPCS code J3590, unclassified biologics, and the NDC number which can be placed on the line above or below the HCPCS code, or in Block 19 of the CMS 1500 claim form. Lucentis packaging indicates that one vial is 0.5 mg/0.05 ml. Therefore, 0.05 should be shown in the days/units column. Herpes Zoster Vaccine The Advisory Committee on Immunization Practices (ACIP) recommended on October 25, 2006 that persons age 60 and older receive the herpes zoster vaccine. Effective October 25, 2006, HMSA s private business plans began to cover the vaccine when billed using CPT code 90736, zoster (shingles) vaccine, live for subcutaneous injection. The for CPT code is $ Measles, Mumps, Rubella vaccine HMSA covers vaccines in accordance with guidelines set by the ACIP. The ACIP guidelines for the measles, mumps and rubella (MMR) vaccine were updated on May 17, 2006, to include a booster for older children. HMSA s private business plans cover MMR boosters that meet ACIP guidelines. To access the MMR guidelines, go to Varicella Vaccine The ACIP issued provisional recommendations for use of live, attenuated varicella-containing vaccines for the prevention of varicella. A routine two-dose varicella vaccination is recommended for children, with a second dose catch-up for 5

6 children, adolescents and adults who previously received only one dose. HMSA s private plans cover vaccinations administered in accordance with the ACIP recommendations. Gardasil Approved for HPV Since June 29, 2006, HMSA s private business plans have covered the HPV vaccination, Gardasil, which is the only FDAapproved HPV vaccine at this time. The ACIP provisional recommendations can be accessed from the ACIP website, or from the index of ACIP statements, where you can click on Provisional ACIP Recommendations: Use of Quadrivalent HPV Vaccine. HMSA will only cover Gardasil for HPV vaccinations. Use CPT code for the vaccine material and ICD-9-CM code V05.8 for the diagnosis The for this vaccine is $135. Coverage for Standard Vaccines Increased Effective January 1, 2007, HMSA s private business plans benefit for standard vaccines increased to 100 percent of eligible charge. No copayment will be applied. Benefit level remains unchanged for highrisk and travel immunizations covered under outpatient injections. This benefit change applies to HMSA s PPO and HMO plans. Some plans have a deductible that must be met before the benefit is applied. In such cases, once the deductible is met, standard immunizations are covered at 100 percent of the remaining eligible charge. CMNs and DIFs for Durable Medical Equipment CMS issued new certificates of medical necessity (CMNs) and DME Information Forms (DIFs) to file with DME claims for dates of service on or after October 1, The new CMNs replace the old CMNs, with the following exceptions: Claims submitted for hospital beds and support surfaces do not require a CMN. Claims submitted for infusion pumps and enteral and parenteral nutrition require a DIF. The new CMNs allow ordering physicians to use an electronic signature or signature stamp on the signature line. The old CMNs only allowed the physician s handwritten signature. While the ordering physician signs a CMN, a DIF is signed by the DME supplier. Please refer to the Medicare Learning Network (MLN) Matters MM4296 for more information by going to the MLN Matters Articles website, clicking on 2006 MLN MATTERS ARTICLES and scrolling to MM C Plus Update Administration covered for Part D Prescription Drug Vaccines Effective January 1, 2007, HMSA s 65C Plus plans began to cover the administration of vaccines covered under the Medicare Part D prescription drug program. This coverage will end December 31, As of January 1, 2008, vaccine administration currently covered under 65C Plus will be covered under Medicare Part D. Please submit claims for vaccine administration services performed in calendar year 2007 using HCPCS code G0377. Deductibles and coinsurance requirements under 65C Plus apply. Zostavax Zoster vaccine live (Zostavax) is a new vaccine administered to prevent herpes zoster, or shingles, in people age 60 and older. About 40 to 50 percent of the estimated one million annual cases of shingles in the United States occur in people age 60 and older. HMSA s 65C Plus Prescription Drug Coverage processes Zostavax at the Tier 4 level, but this vaccine is also eligible for tier lowering (see DRUG TIER EXCEPTION FOR MEDICARE PRESCRIPTION DRUG PLANS in the E-Library for more information). Zostavax should not be administered to patients who: 6

7 Are allergic to any of the ingredients in Zostavax, including allergies to gelatin or neomycin Have a disease or condition that weakens the immune system (e.g., immune deficiencies such as leukemia, lymphoma, HIV/AIDS or taking high doses of steroids) Have active TB that is not being treated Who are or may be pregnant, or who may be in close contact (especially those who are household members) with someone who may be pregnant and hasn t had the chickenpox or been vaccinated against chickenpox Zostavax should be stored frozen at an average temperature of -15 F (+5 ) or colder until it is reconstituted for injection. Once reconstituted, the vaccine should be administered immediately to minimize loss of potency. To review detailed information on Zostavax, go to Transcutaneous Electrical Nerve Stimulators (TENS) Effective January 1, 2007, TENS rentals do not require a CMN. A CMN will still be required for TENS purchases and a new form, CMS-848 (09/05), is available on the Medicare website. An MLN Matters article, MM5107, contains information and links to additional resources and can be referenced at the MLN MATTERS ARTICLES web page /MLNMattersArticles/. If you have questions about information in this Provider Update, please call a Provider Teleservice Representative at on Oahu or 1 (800) from the Neighbor Islands. 7