PROVIDER NEWS For participating physicians, dentists, other health care professionals, facilities and their office staff

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1 ISSUE 1 FEBRUARY 2014 PROVIDER NEWS For participating physicians, dentists, other health care professionals, facilities and their office staff WHAT S INSIDE Our products and networks... 2 Contact us member benefit booklets... 2 Administrative Manual updates... 2 EDI news... 3 Risk adjustment reminder... 4 Grace period requirements... 4 ICD-10 remediation and testing... 5 Physical Medicine Program... 6 Sleep Medicine Program... 7 Radiology Quality Initiative... 8 Pre-authorization List updates... 9 Vitamin D policy change Investigational and medical necessity reviews Modifier -50 policy update...14 Drug screening qualitative policy update...14 Welcome to BridgeSpan Health Welcome to our provider network and our first issue of Provider News. Our newsletter includes important information for you and your office staff, including updates to our policies. We will publish six issues of our provider newsletter each year by the first business day of the following months: February, April, June, August, October and December. For your convenience, you can receive notifications when new issues of our newsletter are available. We strongly encourage you to complete the subscription form today by visiting the Library section of our website at ABOUT US BridgeSpan Health offers consumers a new kind of individual health insurance experience and choices to fit their life. We believe that individuals and families deserve a stronger voice in their health care. The BridgeSpan Health portfolio of health benefit plans is available online through health insurance exchange marketplaces in Idaho, Oregon, Utah and Washington. BridgeSpan Health is an affiliate of Cambia Health Solutions. We welcome you as a participating provider and look forward to working with you. BridgeSpan Health Company is a Qualified Health Plan issuer on Washington Healthplanfinder, Cover Oregon, Your Health Idaho, and the Utah Individual Marketplace BridgeSpan Health Company /

2 2014 member benefit booklets delayed LEARN ABOUT OUR PRODUCTS AND NETWORKS Visit the Products and Networks section of our website to learn about our products and verify if you are in our provider network. You can also view sample member cards and search for other participating providers. In addition, this section of our website includes a link to the Availity Web Portal which you should use to verify member benefits and view claims information. Contact us Our Customer Service team is dedicated to helping you and can be reached at 1 (855) As a participating provider, you also have access to our Provider Relations team who will assist you and your staff with questions and claims issues. Visit the Contact Us section of our website for a complete list of phone numbers and addresses. Printing of our 2014 member contract and benefit booklets will be delayed until April. Please access the Availity Web Portal at to obtain the most up-to-date member benefits and eligibility information. Administrative Manual updates The Appeals sections for all Idaho and all Oregon providers in our Administrative Manual will be updated March 1, The time period to submit an appeal will be changed from 18 months to 12 months. Our manual is available to view and print in the Library section of our provider website. 2

3 EDI news CLAIMS SUBMISSION All participating providers and facilities and any non-participating providers or facilities located in our Idaho, Oregon and Utah service areas must submit their medical and dental claims electronically. (Note to Washington providers: Electronic submission of medical claims will be required in the future. We encourage you to register now and begin submitting your medical claims to us electronically. We will notify you 90 days in advance of when this requirement will go into effect.) Electronic claims may be submitted through many types of practice management software systems or via Internet file transfer protocol (FTP). You can key and submit single electronic claims or submit multiple claims via electronic batch transactions. Contact your billing service/ clearinghouse or register and submit them via the Availity Web Portal at physician-practice-solutions/. Electronic claims should be routed to Availity using Payer ID: BRIDG. Note to Oregon and Washington providers: Access the Availity Web Portal via OneHealthPort using a secure, single sign-on. VIEWING YOUR ERAS Did you know that you can use Availity s Remittance Viewer in their web portal to view your 835 Electronic Remittance Advice (ERA)? In the Claims Management section, select Remittance Viewer. If your organization is not set up to access ERA data in Remittance Viewer, you will need to perform a one-time validation as follows: 1. From the list of payers that store their ERA data in Remittance Viewer, select a payer from whom you have received a check/eft 2. Enter the check/eft information: Payee Tax Identification (ID) Check/EFT Trace Number Check/EFT Amount (Check date must be within six months of the current date) 3. If your organization is set up to access ERA data in Remittance Viewer, you can select Manage My Access to perform the following functions: Get access to your organization s ERA data stored or delivered to another organization on your behalf. Grant other organizations, such as billing services, access to your organization s ERA data. View your organization s current access. Revoke access you have granted to others. ELECTRONIC FUNDS TRANSFER (EFT) REQUIRED We require providers to receive claims payments from us via EFT. If you are not already receiving payments via EFT, please complete a registration form now. The form is available on the Receiving payment page in the Claims and payment section of our website. If you have already submitted a registration form or if you currently receive payments for your BridgeSpan patients via EFT, no additional action is necessary EFT CHANGES Effective January 1, 2014, in compliance with National Automated Clearing House Association (NACHA) rules, the following now appears on your Corporate Credit or Debit (CCD) entry: HCCLAIMPMT will be used as the specific identifier for health care EFT transaction. Information about how to reconcile payments using your EFTs and ERAs is available in the Claims and payment section of our provider website, under Receiving payment. 3

4 Risk adjustment reminder At the beginning of each year, risk scores for members are reset. We would like to remind you to document and review each patient s chronic and acute conditions during the course of each office visit. We appreciate your efforts to ensure all relevant diagnosis codes are reported in a claim for each patient every year. We are currently able to receive a maximum of 12 diagnosis codes on each outpatient claim. Additional diagnosis codes may be submitted via an additional claim with a CPT code and a $0.00 charge. For accurate risk scores, CPT level II codes are especially helpful in providing information to us that supports Healthcare Effectiveness Data and Information Set (HEDIS ) reporting. CPT level II codes: Offer descriptive clinical data, such as lab values, and are billed with a $0.00 charge Are billed in the procedure code field of your professional claim just as CPT procedure codes are billed Can ease the administrative burden of medical record requests and help you monitor your internal performance for key measures Learn more about risk adjustment in the Programs section of our website. Exchange individual grace period requirements Under the rules of the Affordable Care Act (ACA), a patient on an exchange product who receives a premium subsidy from the government has a grace period of up to three months to pay premiums before their coverage is cancelled. During this grace period, insurers may not disenroll members. However, insurers are not obligated to pay claims incurred during the second and third month if a member s premium is unpaid. We are required to notify providers in the second and third month of the grace period about the possibility that claims may be denied in the event that the member s premium is not paid. Our notifications will meet state and federal requirements and include the claim number, name of plan, and explanation of the three-month grace period, the purpose of the notice and Customer Service phone numbers. If the member s outstanding premium is paid in full by the end of the grace period, any pended claims will be processed in accordance with the terms of the contract. 4

5 ICD-10 remediation and testing update BridgeSpan Health has completed approximately 85% of internal system remediation in support of ICD-10. We will continue program-level testing activities through September 2014 and will then transition to monitoring and measurement. We have successfully established connectivity through a primary trading partner, Availity, and are engaged with a few providers in further validation of this connectivity. Similar efforts are underway with our other trading partners, including but not limited to, Office Ally and Utah Health Information Network (UHIN). This type of connectivity testing has typically included small data sets that are partially adjudicated and the results are reported to our partner providers. In middle or late March, we expect to be providing deeper analysis of adjudication and pricing results. Manual testing that does not rely on EDI formats and clearinghouse connectivity has also occurred via spreadsheets exchanged with a limited number of our providers. Transactional reporting on any test claims submitted by our selected provider partners will continue to be manual for the foreseeable future. EDI 835 transactions cannot be returned to the providers due to limitations in the test environments, though the detail can be accessed directly from the Availity Web Portal by any provider wishing to query their claims. Additional testing opportunities will become available as our remediation work finalizes and as our clearinghouses continue their efforts to ensure connectivity between all parties. We will continue to update you in future articles regarding new semi-automated testing via our vendor portal (in construction), and specifications for clinical scenarios as well as the volume and types of transactions we can accept. Learn more about our Readiness under Claims Submission in the Claims and Payment section of our provider website. 5

6 Physical Medicine Program required The Physical Medicine Program, a component of our overall Utilization Management Program and administered by CareCore National, LLC (CCN), is a requirement effective for dates of service on or after February 1. If you have not yet registered with CCN, it is critical that you register now at PHYSICAL MEDICINE AND THERAPIES REQUIREMENTS All practice specialties billing therapy and manipulation CPT codes listed in the Physical Medicine and Therapy CPT Codes list must submit a notification to CCN within seven days of the start of treatment in order to obtain a notification number. No clinical information is required. You do not need to wait to schedule or treat the patient. This requirement applies to: Massage treatment Acupuncture treatment Manipulation treatments Physical, occupational and speech therapy treatments SPINAL SURGERY REQUIREMENTS CCN manages our inpatient and outpatient spinal surgery services for dates of service on or after February 1, for all codes listed in the Spinal Surgery CPT Codes list. Please note: Spine interventional pain procedures are not currently part of this program. It is recommended that you consult the Spinal Surgery Code list to determine if your proposed procedure will require authorization. CCN will also conduct post service pre-payment claims review to include medical necessity determination and site of service appropriateness. ADDITIONAL INFORMATION Critical information about our Program, including the items listed below, can be found on our provider website in the Physical Medicine section under Programs: Treatment Request Guides Authorizations Quick Reference Guide Spinal Surgery Frequently Asked Questions Physical Medicine muculoskeletal management criteria List of members included and excluded in this program Physical Medicine and Therapy Frequently Asked Questions The notification and the notification number authorizes payment for the initial evaluation and any other services provided on that date. Failure to obtain notification for required services by the servicing provider will result in claim nonpayment and a provider liability. Utilization Management Program Guide Physical Medicine and Therapy Physical Medicine and Therapy CPT Code and Spinal Surgery CPT Code lists 6

7 Sleep Medicine Management Program launch We are implementing a Sleep Medicine Management Program as an extension to our existing Utilization Management program that will launch on March 10, The Program, administered by AIM Specialty Health SM (AIM), is designed to manage testing and therapy services for sleep disorders including: Titration study Home sleep testing (HST) Oral appliances for sleep therapy In-lab sleep study (Polysomnography [PSG]) Initial treatment order (Automatic Positive Airway Pressure [APAP], Continuous Positive Airway Pressure [CPAP], Bilevel Positive Airway Pressure [BPAP]) Ongoing treatment order (APAP, CPAP, BPAP) PROVIDERS ORDERING SLEEP STUDIES OR DURABLE MEDICAL EQUIPMENT (DME) SERVICES Beginning March 10, physicians and other health care professionals ordering services listed must first contact AIM to request an order number prior to services being rendered. This applies to procedures performed in the following settings: Free-standing sleep center Outpatient hospital setting Outpatient basis in a physician office HOW TO REGISTER WITH AIM TO ORDER SLEEP STUDIES OR DME SERVICES Providers currently using AIM s website for radiology authorizations DO NOT need to re-register. All other providers who will require access to the AIM website to obtain authorization or check on authorization status must register. You can register with AIM by going to com/gowebsleep. For large group practices, AIM can offer assistance with the registration process. FACILITIES SLEEP LABORATORIES, AND DME PROVIDERS You must complete an online OptiNet assessment by March 7 to be included in the AIM OptiNet directory when the program starts on March 10. Complete the online assessment by going to www. aimspecialtyhealth.com/gowebsleep. If you have not registered previously with AIM, you need to register. After registering, you can complete the online assessment. Select BridgeSpan from the drop-down menu, and proceed with the assessment. You do not need to complete the survey if you only read sleep testing results and do not perform the technical and/or global component of these services. Learn more about the Program on our provider website in the Programs section. 7

8 Radiology Quality Initiative expansion reminder We are changing our current Radiology Quality Initiative (RQI) program administered by AIM Specialty Health SM (AIM). Effective March 1, 2014 we will launch full utilization management for the following hightech imaging procedures: Please note: If it is determined by AIM that the service does not meet medical necessity criteria, the requested procedure will be denied and an order number will not be provided. Nuclear cardiology Stress echocardiography (SE) Transesophageal echocardiography (TEE) Resting transthoracic echocardiography (TTE) Positron emission tomography (PET) If an imaging provider performs the procedure without an approved order number, the procedure will be considered a provider write-off and cannot be billed to the member. The above program changes apply to all our members unless they are receiving care outside of the BridgeSpan service area. Magnetic resonance imaging (MRI) / Magnetic resonance angiography (MRA) Computed tomography (CT) / Computed tomographic angiography (CTA) Currently, we require you to obtain an order number through AIM for specified radiology procedures. As long as you have obtained an order number, the service is paid in accordance with the member s benefits. Beginning March 1, order number requests will be reviewed under the full utilization management program. 8

9 Pre-authorization List updates We have made updates to our Pre-authorization List, located under Pre-authorization on our provider website, as outlined below: PROCEDURE CODES POLICY DETERMINATION USED Aqueous Shunts and Stents for Glaucoma (Surgery #164) Microwave Tumor Ablation (Surgery 189) Coverage of Treatments Provided in a Clinical Trial (Medicine #150) In Vivo Analysis of Colorectal Polyps (Medicine #104) Genetic Testing for Inherited Susceptibility to Colon Cancer (Genetic Testing #06) Effective February 1, 2014, all spinal surgeries/procedures as noted on the Spinal Surgery CPT code list now require pre-authorization through CareCore National (CCN). Adding the following codes effective March 1: CPT HCPCS 0191T, 0192T, 0253T changed from investigational to preauthorization required The following codes are effective February 1: CPT 32998, 47382, 50592, Archived Research Urgent Treatments medical policy and replaced with Medicine #150 policy Added the following code effective January 1: HCPCS S9988 Adding the following code effective February 1: CPT Adding the following code effective February 1: CPT Codes are located in the Spinal Surgery CPT code list. BridgeSpan Medical Policy BridgeSpan Medical Policy BridgeSpan Medical Policy BridgeSpan Medical Policy BridgeSpan Medical Policy BridgeSpan Medical Policy or CCN criteria located at www. carecorenational.com View the Spinal Surgery CPT code list and other spinal surgery requirements on our provider website in the Programs section under Physical Medicine. 9

10 Vitamin D policy change Implementation of our Vitamin D Testing (Laboratory #52) medical policy is being revised effective May 1, 2014 to better support the intent of this policy. Our medical policies are located in our Library section under Policies and guidelines on our provider website. We have reviewed the administration of this existing policy and are implementing the changes indicated below to better support the original intent of the policy. These changes will be effective for dates of service on or after May 1, We consider CPT Vitamin D; 1, 25-dihydroxy, includes fraction(s), if performed, to be medically necessary ONLY when billed with the following diagnosis codes: Note: We added ICD and to our existing list. ICD-9-CM DESCRIPTION 135 Sarcoidosis Hyperparathyroidism, range Hypoparathyroidism Rickets, active Rickets, late effect Osteomalacia, unspecified Fanconi syndrome Uric acid nephrolithiasis Familial hypophosphatemia Unspecified disorder of calcium metabolism Hypocalcemia Hypercalcemia Other disorders of calcium metabolism Secondary hyperparathyroidism (of renal origin) Calculus of kidney Calculus of ureter Urinary calculus, unspecified Hypocalcemia and hypomagnesemia of newborn continued on next page 10

11 Effective May 1, we will consider CPT Vitamin D; 1, 25-dihydroxy, includes fraction(s), if performed, to be medically necessary ONLY when billed with the following diagnosis codes: ICD-9-CM DESCRIPTION Blind loop syndrome Calculus of kidney Calculus of ureter Celiac disease Chronic kidney disease , 572, Chronic liver disease Disorder of calcium metabolism Disorders of phosphorus metabolism End stage renal disease Hypercalcemia Hypercalciuria Hypervitaminosis D Hypocalcemia Hypocalcemia and hypomagnesemia of newborn Intestinal malabsorption 576.2, Obstructive jaundice Osteomalacia Osteoporosis Osteosclerosis/petrosis Pancreatic Steatorrhea , Parathyroid disorders 262; Protein-calorie malnutrition 268.0, Rickets See above codes Vitamin D deficiency when on replacement therapy related to a condition listed above, to monitor the efficacy of treatment 11

12 Investigational and medical necessity reviews Listed below are summaries of recent changes to our medical policies. View all detailed policies in the Medical Policy Manual in the Library section under Policies and guidelines on our provider website. NEW OR UPDATED INVESTIGATIONAL OR MEDICAL NECESSITY POLICY CRITERIA ALLIED HEALTH Administrative Guidelines to Determine Dental versus Medical Services (#35) DURABLE MEDICAL EQUIPMENT Functional Neuromuscular Electrical Stimulation (#83.04) GENETIC TESTING Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) (#56) Evaluating the Utility of Genetic Panels (#64) Genetic Testing for Hereditary Breast and/or Ovarian Cancer (#02) Genetic Testing for Inherited Susceptibility to Colon Cancer (#06) Multigene Expression Assays for Predicting Recurrence in Colon Cancer (#22) MEDICINE Coverage of Treatments Provided in a Clinical Trial (#150) Hyperbaric Oxygen Pressurization (HBO) (#14) New and Emerging Medical Technologies and Procedures (#149) Orthopedic Applications of Stem Cell Therapy (#142) New policy. Clarification added to the investigational criteria regarding congenital disorders. Addition of drug afatinib (GILOTRIF ) to medical necessity criteria. New policy on January 1. Addition of new panel test YouScript personalized prescribing system on February 1. Modified medical necessity criteria based on NCCN guideline updates. Addition of BART testing to criteria for clarification purposes. Added new criterion for BRAF V600E or MLH1 promoter methylation and clarification to EPCAM testing criteria. Addition of 4-gene expression profile (GEP) tests. New policy. Added bisphosphonate-related osteonecrosis of the jaw, herpes zoster, depression, hepatitis, and stroke-related motor dysfunction to list of investigational indications. New investigational procedures added to the policy. Investigational criteria added regarding allograft bone products, such as demineralized bone matrix, for orthopedic application. continued on next page 12

13 NEW OR UPDATED INVESTIGATIONAL OR MEDICAL NECESSITY POLICY CRITERIA CONTINUED RADIOLOGY Computed Tomography (CT) Perfusion Imaging of the Brain (#54) Added clarification that policy criteria are specific to the brain. SURGERY Femoroacetabular Impingement Surgery (#160) Microwave Tumor Ablation (#189) TRANSPLANTS Hematopoietic Stem-Cell Transplantation (HSCT) for Acute Lymphoblastic Leukemia (#45.36) Removed criterion requiring patients to be young enough to be considered inappropriate candidates for hip arthroplasty of other reconstruction. New policy. Changed allogeneic HSCT from investigational to medically necessary for relapsing ALL after a prior autologous Stem-Cell Transplantation (SCT). UTILIZATION MANAGEMENT Supplement to MCG Discharge Criteria for Residential Treatment (#14) New policy supplements MCG discharge criteria for behavioral health residential treatment settings. Hyperbaric Oxygen Pressurization (HBO) (#14) Added bisphosphonate-related osteonecrosis of the jaw, herpes zoster, depression, hepatitis, and stroke-related motor dysfunction to list of investigational indications. NEW OR UPDATED INVESTIGATIONAL OR MEDICAL NECESSITY POLICY CRITERIA EFFECTIVE MARCH 1, 2014 SURGERY Aqueous Shunts and Stents for Glaucoma (#164) Criteria changed to consider the istent Micro-Bypass medically necessary when criteria are met. NEW OR UPDATED INVESTIGATIONAL OR MEDICAL NECESSITY POLICY CRITERIA EFFECTIVE MAY 1, 2014 LABORATORY Vitamin D Testing (#52) Medical necessity criteria clarified and policy appendices updated to include additional covered indications. 13

14 Modifier -50 reimbursement policy update We have updated our Modifier -50 Bilateral Procedure (Modifiers #108) reimbursement policy effective January 1, 2014, to reflect that in the event there is a conflict between CMS and the American Medical Association (AMA), the AMA guidelines will take precedence. When using Modifier -50 to report a bilateral procedure do not bill with multiple units of service as your claim will not be processed correctly. This issue was recently brought to our attention as it relates to CPT code In view of the 2014 changes of the descriptors on CPT code from 1 or both ears to unilateral, and the AMA specific instructions to bill CPT code with Modifier -50 when performed bilaterally, we have modified our claim system to accept CPT code as a valid HCPCS modifier combination for appropriate reimbursement. Drug screening qualitative reimbursement policy update. Our Drug Screening Qualitative (Medicine #106) reimbursement policy has been updated to add some minor clarifications. Our reimbursement policies are located in our Library section under Policies and guidelines on our provider website. 14

15 Learn more Our website, includes information for individuals and families, members, producers and providers. The first time you visit our site, you will need to identify yourself as a provider and enter your ZIP code. On future visits, you will automatically be directed to the provider home page for your location. The provider portion of our website includes important information for you and your office staff, including: Pre-authorization requirements and reminders Radiology Quality Initiative, Physical Medicine Program and Sleep Medicine Management Program requirements In addition, our website includes information about our products and networks, including sample member cards and our Provider Search tool. Our Customer Service team is dedicated to helping you and can be reached at 1 (855) As a participating provider, you also have access to our Provider Relations team who will assist you and your staff with questions and claims issues. Visit the Contact Us section of our website for a complete list of phone numbers and addresses. 15