CONSULT Newsletter. Volume 22 Second Quarter, Member ID Cards Get a Makeover. We've given our member identification (ID) cards a fresh look.

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1 Notice If a website link within this document does not direct you to the appropriate information or website location, please contact Provider Services by telephone. The Provider Services directory is located on the last page of this document.

2 CONSULT Newsletter Volume 22 Second Quarter, 2009 Member ID Cards Get a Makeover We've given our member identification (ID) cards a fresh look. Inside This Issue Member ID Cards Get a Makeover... 1 Cancer Information Available in Spanish... 2 New Tool for Providers: Formulary Search Function... 3 Provider Call Center Hours of Operations... 3 Why Screen for Chlamydia... 4 Member Rights and Responsibilities... 4 A Message from the Pesticide Poisoning Registry... 4 Medical Services Protocol Updates Quality Improvement Program Overview... 8 Quest Diagnostics Service Reminds Patients to Schedule Upcoming Tests Continuity and Coordination of Care Projects Physical Accessibility of Provider Sites for People with Mobility Impairment Provider Telephone and Web Site Reference Guide In our ongoing effort to improve our members' health care experiences, BlueCross BlueShield of Western New York is introducing a new ID card that will make it easier for you and your staff to find the information you need when you service our members. These format changes are also being implemented by other BlueCross BlueShield Association plans to help simplify the claim submission process when a member seeks care in another Blue plan's service area. Please be aware that member benefits are not affected by the slight change in format. Claims should always be submitted to the local BlueCross and/or BlueShield plan. The local plan logo will always appear in the upper left-hand corner of the ID card. New ID Card Delivery We will begin distributing the new cards June 1, 2009, when a member renews, changes plans/benefits or asks for a replacement card. All members will have the new cards by December, 2010, per Association requirements. Both the current and the new ID card designs will be valid throughout the entire transition process to ensure that there is no disruption in member service. Members with High Deductible Health Plans may eventually receive an ID card that lists their deductible amounts and specific copay amounts. (continued on page 2) Page B 2025 WNY CC 5510

3 (continued from page 1) Member ID Card Sample Card Front The left side of the front of the card contains member names, ID number and dependent information (if applicable). The right side shows plan type and claim processing details. This includes: Group Number RX Group Plan Type and Name Selected Copay Amounts Deductible and Coinsurance Information (when applicable, including for High Deductible Health Plans) Card Back The back of the card refers to plan documents (a member guide or contract) for more information about services covered by the member s plan. Our web address and customer service phone number are shown on the right side of the card. We also list the customer service phone numbers for any vendors that may manage selected services that are covered by the plan. If the plan includes prescription drug coverage, the logo for our pharmacy benefit manager, Medco, will always appear at the bottom of the card. The member s pharmacy network will be listed to the right. Cancer Information Available in Spanish The information from the Centers for Disease Control and Prevention (CDC) and the Agency for Health Care Research (AHRQ) for Spanish-speaking people has been greatly expanded. They provide details for many different forms of cancer along with numerous other health care topics. Go to their web sites at and Page 2

4 New Tool for Providers: Formulary Search Function We have enhanced our provider web site once again. A Formulary Search function is now available to you. The Formulary Search is an application designed to provide quick access to formulary data, including drug tiers, limitations that a medication may have and any drug therapy and/or prior authorization forms associated with that medication. To access this new feature, starting from our home page, select: I m a Provider, then select Clinical Resources. On the left side of the page under Pharmacy Services, you will find: Drug Therapy Guidelines Formulary Updates Formulary Search If a drug requires prior authorization, you may print a copy of the prior authorization request form by clicking the icon within the formulary search. The Formulary Search tool will assist you in determining: What tier a drug falls under If a drug requires prior authorization If a specialty pharmacy needs to be utilized If a drug is a Step Therapy drug If a generic form of the drug is available Using the search enables you to: Search by drug name or drug category Obtain the following drug tier information: Tier 1: Generic Tier 2: Plan-preferred brand name Tier 3: Non-preferred brand name View or download the following PDF forms and guidelines: Prior Authorization Form Drug Therapy Guidelines Provider Call Center Hours of Operations BlueCross BlueShield of Western New York Provider Service representatives are available to answer your telephone inquiries Monday through Friday, from 8:30 a.m. 12:00 p.m. and 1:00 p.m. 5:00 p.m. For even faster service, remember that you always have access to multiple electronic tools located in the Provider Online Services section of our website at What Content is Available? Provider Online Services gives users access to many of our print communications electronically, as well as: Billing Guidelines Clinical Edit Search Application Code & Comment Application Fee Information Provider Manuals Formulary Search Application Stat Bulletins Provider Newsletters Medical Protocols Clinical Practice Guidelines Local Provider Search Commonly Used Forms (pdf download) WNYHealtheNet In addition to the tools located on our web site, to save phone and administrative time, you may also access the following at Confirm member eligibility, PCP, copay, referral requirements and benefits Submit or look up patient referrals for specialists, PT/OT/Speech Check the status of patient service preauthorizations Check status of processed claims We remain dedicated to providing you with the most up-to-date information you need, as quickly and efficiently as possible. It s important for providers to refer to our web site frequently for the most current Drug Therapy Guidelines. Page 3

5 Why Screen for Chlamydia The National Chlamydia Coalition has created an informative and helpful guide for health care providers on the important issue of Chlamydia screening. It provides rates of infection, sequelae (pelvic inflammatory disease, infertility or ectopic pregnancy) of untreated Chlamydia, screening, diagnostic tests and much more. Providers will find suggestions and examples for sexual history taking, what age to begin, and in what format (by completion of a form or directly by a provider). The direct link to this information is: Member Rights and Responsibilities Our members have certain rights to help protect them and responsibilities that we ask they assume. We encourage all of our participating providers to review these policies. The most current version of our Member's Rights and Responsibilities is available on the provider web site at Paper copies are available upon request by contacting our Provider Service Department. A Message from the Pesticide Poisoning Registry The New York State Department of Health (NYSDOH) Pesticide Poisoning Registry (PPR) strives to increase reporting in the medical community of pesticide-related illnesses and injuries and to develop interventions that reduce the risk of pesticide poisoning. Poisonings may result from residential application of total release foggers, structural applications, lawn applications, in manufacturing and formulation settings, farm settings or any other location where pesticides are used and stored (e.g. kitchen cabinets, home improvement store shelves and stockroom areas). Because of the toxicity and easy availability, accidental or intentional ingestion of pesticides is an ever-present threat. In 1990, pesticide poisonings were added to the list of reportable conditions in New York State as part of an effort to reduce the risk of health effects. Physicians and health facilities are required to report suspected or confirmed cases of pesticide poisoning. A definitive diagnosis is not needed prior to calling. NYSDOH staff will investigate the reported case to collect information from the exposed individual(s) and to determine the health effects of pesticide exposure. Staff may intervene in situations where a continued risk of pesticide poisoning exists. Physicians or other medical personnel with access to the patient's medical record should contact the NYSDOH PPR to report a case. Reports can be made by calling the toll-free number at within 48 hours of treating any patients they suspect of having pesticide poisoning. Medical records and discharge summaries related to the pesticide exposure may be faxed to Page 4

6 Medical Services Protocol Updates The following clinical protocol update includes information on protocols that have had an annual review recently resulting in revision to the guidelines, no change to the guidelines, or deletion of the published guidelines. Three new Protocols have also been added. Please note that some of these protocol updates may not pertain to the members you provide care to, as it may relate to contracts that are not available in your geographic area. Protocol Revision Summary The effective date of these changes is July 1, 2009: Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer Guidelines clarified that the medically necessary criteria apply to the Oncotype DX TM assay test Other assays such as Mammostrat TM or the Molecular Grade Index as well as MammaPrint and the Breast Cancer Gene Expression Ratio are all investigational Autologous Chondrocyte Implantation Includes medically necessary indication for the treatment of disabling full thickness articular cartilage defects of the knee caused by acute or repetitive trauma, in patients who have had inadequate response to a prior surgical procedure when criteria specified in the protocol are met Prior approval required Remains investigational for other joints Continuous Passive Motion (CPM) in the Home Setting Limited medically necessary criteria after specific knee procedures added. Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Added medically necessary criteria for renal cell cancer in limited situations Remains investigational for all other cancers Enhanced External Counterpulsation (EECP) for Chronic Stable Angina or Congestive Heart Failure Investigational for all indications Medicare Advantage will continue to have a separate guideline statement with medical necessity criteria, and require prior approval Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions Another method, radial ESWT, has been added to the description and indicated as investigational in the policy statement. Immunotherapy for Allergic Disorders Change made to the description to include that the physician preparing the extracts is qualified to do so by training, and has been the one to have examined the patient, and determined the treatment plan. (continued on page 6) Page 5

7 (continued from page 5) Magnetoencephalography/Magnetic Source Imaging Added medically necessary criteria including for the purpose to determine laterality of language function as a substitute for the WADA test in patients undergoing diagnostic workup for evaluation of surgery for epilepsy, brain tumors or other indications requiring brain resection Other indications, including localization of seizure focus for patients undergoing evaluation for surgical treatment of intractable seizures are investigational Meniscal Allograft Transplantation Includes medically necessary criteria for patients who have had prior meniscectomy and symptoms related to the affected side persisting after 6 months despite PT and analgesia and meeting the specified criteria indicated in the Protocol Prior approval required Occlusion of Uterine Arteries Using Transcatheter Embolization or Laparoscopic Occlusion to Treat Uterine Fibroids Added a policy guideline section that indicates when fibroids are generally considered being appropriate to require any type of treatment (not specific to only this particular treatment). Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders Added medically appropriate criteria for high frequency chest wall compression for patients with cystic fibrosis or chronic diffuse bronchiectasis when standard chest physiotherapy has failed or is unavailable or not tolerated Criteria for the Flutter or Acapella device added Other devices and uses are investigational Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Medically necessary as a technique to repair large full thickness chondral defects caused by acute or repetitive trauma in patients who have had an inadequate response to prior surgical procedure if they meet the specific criteria indicated in the Protocol Prior approval required Prolotherapy This is indicated as investigational as a treatment of musculoskeletal pain. Spinal Cord Stimulation Treatment for refractory angina pectoris added as investigational The medically appropriate indication of severe & chronic pain of trunk or limbs that is refractory to all other pain therapies is further defined by a policy guideline section Vagus Nerve Stimulation Obesity added to the investigational indications Changed the medically refractory partial onset seizures to medically refractory seizures under the medically appropriate criteria Added separate Medicare Advantage criteria, because Medicare still limits to the partial-onset seizures (continued on page 7) Page 6

8 (continued from page 6) New Protocols The effective date of the following is 7/1/09: Charged-Particle (Proton or Helium Ion) Radiation Therapy Medically appropriate for melanoma of the uveal tract with no evidence of metastasis or extrascleral extension, post operative therapy in patients who have undergone biopsy or partial resection of chordoma or low grade chondrosarcoma of the basisphenoid region, and localized prostate cancer Because this treatment is not proven to be more beneficial than existing appropriate treatments for prostate cancer, it may be rejected as not medically necessary for members with contracts having least costly alternative language as part of their medical necessity definition. The effective date of the following is 4/1/09 (changes related to these new policies were also previously communicated in the First Quarter Provider Newsletter): Intensity Modulated Radiation Therapy (IMRT) of the Breast and Lung Investigational Potential to be medically appropriate for lung cancer for Medicare Advantage Intensity Modulated Radiation Therapy (IMRT) of the Prostate Medically necessary for prostate cancer when higher radiation doses are needed Clinical Protocols Reviewed Without Change Previous effective dates indicated remain accurate: Acupuncture Ambulance Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology) End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema Gastric Electrical Stimulation Implantable Cardioverter Defibrillator In Vitro Chemoresistance and Chemosensitivity Assay Serial Endpoint Testing for the Diagnosis and Treatment of Allergic Disorders Deleted Protocols Effective immediately, the following Protocol is archived: Blood or Marrow Transplantation This Protocol is archived and not replaced due to a national criteria set that is followed with possible reissue of a corporate medical protocol in the future. The above are brief summaries. Please refer to the Protocols, posted on the Provider web site, for the details of the Protocols that effect your practice. If you need assistance obtaining specific protocol updates, please contact Provider Service. (continued on page 8) Page 7

9 (continued from page 7) Other Related Clinical Information The following comment has been added to Code and Comment for the Prior Approval information for CPT procedure codes 29871, 29874, and 29877: Not required, but recommended for diagnosis of osteoarthritis when that is the only diagnosis. Use for osteoarthritis only may not be medically necessary, and supporting documentation must be submitted to Use Management Quality Improvement Program Overview Each year, our Quality Improvement department (QI) compiles outcomes data on the progress our programs and departmental initiatives are making in improving health care for our enrollees. More information about the programs and outcomes can be found on our web site at or upon request. The following is a sample of some of the initiatives included in our QI programs: Customer Service Blue Cross and Blue Shield Association Member Touchpoint Measures (includes claims accuracy and timeliness) Customer Service Representative Coaching and Monitoring Network Services Network Adequacy - Access to Care Credentialing Program Physician Pay for Performance Health Care Quality Improvement National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS ) Consumer Assessment of Healthcare Providers and Systems (CAHPS ) Quality Assurance Reporting Requirements (QARR) Culturally and Linguistically Appropriate Services Patient Safety Continuity and Coordination of Care Medical Record Review for Standards Quality of Care Investigations (as reported by members) Blue Distinction Centers for Cardiac, Rare and Complex Cancer, and Bariatric Care Hospital Quality Incentive Program (continued on page 9) Page 8

10 (continued from page 9) Health Management (Disease Management) Asthma Attention Deficit Hyperactivity Disorder Chronic Obstructive Pulmonary Disease Diabetes Depression Heart Disease Preventive Health Immunizations (childhood, adolescent and adult) Well Visits (childhood, adolescent and adult) Screenings (Lead/Osteoporosis/Chlamydia/Pharyngitis Testing, Breast/Cervical/ Colorectal Cancer Screening) Case Management Support Blue (end of life care/palliative Care) Right Start (prenatal care) Chronic Kidney Disease Transplant Complex co-morbid conditions Health Promotion BlueLife Health Education and Wellness (health education, e.g., nutrition, fitness, stress management) BlueLife Worksite Wellness Lifestyle Benefits (Discounts on fitness memberships and Health and Wellness practitioners) Smoking Cessation Obesity Management Myhealth (interactive web site that promotes member self-management of health) More information about our Quality Improvement department programs, along with collaborative and coalition activities, can be found in the Providers section of our web site at If you would like a paper copy of this report or need additional information, you may contact the Quality Improvement Department at , on our web site via Click and Comment or write to us at: Quality Improvement, PO Box 80, Buffalo, New York Page 9

11 Quest Diagnostics Service Reminds Patients to Schedule Upcoming Tests You care about your patients health. You offer them reminder cards and follow-up calls to schedule important examinations and lab tests. Sometimes patients, especially those with chronic conditions such as diabetes and heart disease, need more prompting. Let the Reminder Service from Quest Diagnostics help. Your patients can sign up for this free service and receive periodic s to remind them about important exams and lab tests. During an easy online registration, patients can select how often to receive alerts. They can select a custom reminder for tests or topics that are most relevant to them and choose to receive reminders in English or Spanish. Each reminder your patient receives will list upcoming tests and remind them to discuss these tests with you. When it is time for a test, your patient can easily schedule an appointment for lab testing at a Quest Diagnostics Patient Service Center from a link in the . Patient Health Reminders from Quest Diagnostics Diabetes Hemoglobin A1c, Microalbumin, Lipid Panel, Blood Pressure, Eye Exam, Foot Exam, and egfr Heart Disease Lipid Panel, Expanded Lipid Profile, Cardio CRP and Homocysteine, Blood Pressure, and BMI Women s Health Clinical Breast Exam, Cholesterol, Chlamydia and other STI s, Blood Pressure, Blood Glucose Test, BMI, Skin Exam, Thyroid Function, Mammogram, Colorectal Screening, and Bone Density Men s Health Colorectal Screening, Blood Pressure, Cholesterol, BMI, Blood Glucose Test, and Skin Exam Custom Reminders Patient selects the topics and tests that best fits their needs Each reminder also includes links to monthly health awareness topics such as skin cancer, food allergies, ovarian cancer, and chronic kidney disease. Let your patients know about this convenient service at their next appointment. They can register at The Reminder Service is offered exclusively by Quest Diagnostics. Page 10

12 Continuity and Coordination of Care Projects Our Healthcare Quality Improvement Department has initiated its annual Continuity and Coordination of Care projects for Previous project outcomes along with member and provider concerns have identified opportunities to improve information exchange between the hospital/urgent care center/behavioral health provider and the primary care practitioner (PCP)/medical home. Based on a random selection of members receiving emergency room, urgent care and behavioral health care services, facilities/providers will be evaluated for compliance with our Information Exchange Policy which is supported by Centers for Medicare and Medicaid Services (CMS), New York State Public Health Law, National Committee for Quality Assurance (NCQA) and New York State Mental Hygiene Law. As a reminder, participating provider agreements with our plan require cooperation with quality improvement initiatives and administrative policies designed to improve the health care of our members. We thank you in advance for your participation with these initiatives. Physical Accessibility of Provider Sites for People with Mobility Impairment In accordance with the Americans with Disabilities Act (ADA), it is our desire to ensure that health care services rendered by participating providers are readily accessible and usable by individuals with disabilities. When a health care provider applies for participation with BlueCross BlueShield, we ask if the office location is wheelchair or handicapped accessible. Physical accessibility is not limited to entry to a provider s office, but also includes access to services within the site, such as exam tables and medical equipment. If the office is not physically accessible, a documented plan should be in place and submitted to BlueCross BlueShield for review, in order to be certain that a reasonable alternative site and/or services are available. It is BlueCross BlueShield s responsibility to provide the most up-to-date, accurate information for members regarding the practice status of our participating providers, including physical accessibility of the office. The Participating Provider Directory includes information for the member regarding wheelchair accessibility of offices, including alternate plans for those locations that are not accessible. If you have not notified us of the handicapped accessibility status of your practice location(s), or if there has been a change thereof, please fax your information to the Provider Enrollment Department at If your office is not wheelchair accessible, we ask that you submit a documented plan expeditiously, detailing how you will accommodate persons with disabilities in an effort to make provider services readily accessible. If you would like to speak to someone directly about accessibility of your practice location, please contact the BlueShield Provider Relations Department at or Page 11

13 Provider Telephone and Web Site Reference Guide Provider Services or (Traditional) or (Managed Care) (Government Programs) Provider Relations Use Management or Web Site Page 12