BlueNewsSM. for Providers. Healthy Focus: Dental Care. July When to File Claims With Non-Physician Practitioners as Rendering Providers

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1 July 2015 BlueNewsSM for Providers When to File Claims With Non-Physician Practitioners as Rendering Providers HEDIS Measure Focus Follow-Up After Hospitalization for Mental Illness Healthy Focus: Dental Care This month, BlueCross BlueShield of South Carolina is focusing on dental care and oral hygiene. Good dental hygiene not only protects teeth and gums from decay and dental problems but can also prevent other medical issues. The American Dental Association (ADA), the leading advocate for oral health, recently shared data the Centers for Disease Control and Prevention (CDC) reported that shows the need for increased access to dental care, with a greater emphasis on preventing disease. The ADA and the CDC are independent organizations that offer health information on behalf of BlueCross and BlueChoice HealthPlan of South Carolina. Ninety-one percent of Americans over 20 years of age have had cavities at some point in their lives, and 27 percent of those adults have had untreated caries. There is a notable, disproportionate rate of disease among 42 percent of African-Americans and 36 percent of Hispanics. According to an Expenditure Panel Survey, adults who do not plan to visit a dentist in the next 12 months most frequently state cost and the belief that they do not need dental care as reasons. With all the advances in the capability to prevent, detect and treat dental disease, there needs to be greater outreach to the general population to seek regular dental care. While it is critical to treat disease that has already occurred, a community focus on prevention is vital. Teaching people how to take care of their families teeth and gums and getting the greatest possible number of children and adults into dental practices are the keys to better oral health for all. Give your patients more information on oral health, including prevention, care and treatment of dental disease by encouraging them to visit the ADA s consumer website, Source: American Dental Association (ADA) This link leads to a third party site. That organization is solely responsible for the contents and privacy policies on its site.

2 HEDIS Measure Focus Follow-Up After Hospitalization for Mental Illness Approximately one in four adults in the U.S. suffers from mental illness in a given year. Nearly half of U.S. adults will develop at least one mental illness in their lifetime. People with a mental illness are less likely to use medical care and to follow treatment plans. It s these findings that motivate the National Committee for Quality Assurance (NCQA) to measure how effectively health providers and insurers manage this trend. Members who were hospitalized for treatment of specific mental health disorders, ages 6 years and older, should have a follow-up appointment with a licensed mental health provider within seven days of discharge. Follow-Up After Hospitalization (FUH) for Mental Illness is the Healthcare Effectiveness Data and Information Set (HEDIS) measure that focuses on these members. If mental health providers follow up with their discharged patients within seven days, they can realize several benefits. The successes of prompt outpatient follow-up include improved engagement in outpatient counseling, fewer no-show appointments and reduced readmission rates. Consider the integral role your office plays in ensuring you see members promptly in order to help them take charge of their recovery and continue the healing process. When filing claims, you can help improve our awareness of the services you provide related to FUH for Mental Illness by using the appropriate CPT or HCPCS codes. Visit our websites to read our HEDIS Provider Reference Matrix (adult and pediatric versions) that includes a complete listing of the appropriate codes you should use for this measure. Also available to you on our websites are HEDIS Documentation Charts (adult and pediatric versions) and our specially created HEDIS Compliance Companion forms for medical documentation. Source: National Committee for Quality Assurance (NCQA) Palmetto Provider Webinar Schedule Are you a new provider? Or perhaps an experienced provider who needs a refresher course? Take advantage of our Palmetto Provider University modules. You ll learn about the many tools we offer providers and the best ways to communicate with us. Check out our list of upcoming course offerings and descriptions. To sign up for a webinar, please visit the Provider Training page on our website, Select Provider, then select Education Center and select Provider Training. Please check our Provider Training page regularly for the latest course registrations. Course Name and Description Dates Offered Time and Duration Dental Created especially for our dental providers, this webinar July 14 outlines the credentialing process, instructs you on how to effectively 10 a.m. July 15 use My Insurance Manager SM and My Remit Manager, describes our Approximately 1 hour July 16 dental networks and gives important dental plan updates.

3 When to File Claims With Non-Physician Practitioners as Rendering Providers BlueCross credentials physician assistants (PA) and nurse practitioners (NP) who are not under direct supervision of a doctor. When it comes to submitting medical and laboratory claims, PAs can choose to file for services they provide in the office under their legacy identifiers or rendering National Provider Identifiers (NPIs). Credentialed NPs must submit claims under their NPI numbers or bill claims under the supervising physician s NPI as the rendering provider. This will help ensure that we apply the level of benefits (i.e., primary care physician vs. specialist copay) based on the supervising doctor s credentials. PAs can also bill under the supervising physician s legacy identifier or NPI but not as an assistant to surgery. If a PA is assisting during surgery, the PA must file the claim as the rendering provider using an AS modifier. Our current policies do not cover services a PA performs as an assistant surgeon, and only reimburse for those a licensed medical doctor performs. We consider non-physicians ancillary support for the surgeon and therefore cannot consider them as assistants at surgery. Credentialed PAs or NPs, however, can bill under their rendering NPIs for surgical services a surgical PA provides. The electronic claim format allows you to submit both a rendering and supervising NPI in the 2310B and 2310D loops, respectively. For additional information about our surgical guidelines, please review medical policy CAM 564 at or Latest Medical Policy Updates We regularly review and revise the medical policies we use to make clinical determinations for a member s coverage. Here are the latest medical policies we reviewed or updated. Please visit the Education Center of and frequently to stay abreast of these changes, and read any policy in its entirety. CAM 009 Allergy Immunotherapy. We will increase the number of doses we allow you to file per 12-week period for procedure code from 24 to 30. CAM 094 Women s Preventive Services (new policy). We will always consider evaluation and management codes for preventive services preventive. CAM Artificial Pancreas Device Systems. We have added additional coding A9276, A9277 and E0784.

4 Tobacco Cessation Coverage We now cover tobacco cessation products at zero member cost share, in accordance with Affordable Care Act guidance. This is for members of non-grandfathered (and some grandfathered) plans. We developed our program based on accepted national smoking cessation treatment guidelines. We will use reasonable medical management, in the form of prior authorization, to promote the safe and cost-effective use of the available therapies. These are tobacco cessation drugs we cover at zero member cost share: Prescription-only bupropion 150mg (generic Zyban) Prescription-only Chantix Prescription-only nicotine nasal spray or inhalers (ex: Nicotrol NS, Nicotrol inhaler) Over-the-counter (OTC) nicotine patches/transdermal systems (ex: Habitrol OTC, Nicoderm CQ OTC) OTC nicotine gum (ex: Nicorette gum OTC) OTC nicotine lozenges (ex: Nicorette lozenge OTC, Nicorette mini lozenge OTC) To learn about requirements for coverage, length of treatment and tobacco cessation counseling, please read the full article on our Prescription Drug Information page at Reminder about Preauthorization for Maternity Our participating obstetricians and gynecologists should contact the appropriate Blue Plan when you provide service to a new expectant mother in your office. BlueCross requires pregnancy notification in order for you to receive an automatic authorization number when you request precertification through My Insurance Manager SM. The State Health Plan requires vaginal delivery notification only. Your precertification request through My Insurance Manager will not give an automatic authorization number, but it will be placed in pending status. Our internal staff of precertification nurses and technicians will closely review your request. If we approve it, we will grant your preauthorization within 24 hours of submission. Hospital-based providers should notify BlueCross at the time of admission. We consider this a notification, not a preauthorization. Please review our guide What You Need to Know About Precertifications and Referrals, available on our websites, to get additional information.

5 Questions from the Field Here are questions the provider community has asked us. If you have a question you would like to submit, us at provider.education@bcbssc.com. We will post new questions and answers online and in our monthly newsletters. Topic Question Response Provider Web Tools Does BlueCross have a Web link or listing with updated alpha prefixes for all Blue Plans? We do not have an all-inclusive list of each Home Plan s alpha prefixes. To determine which network you should use for a specific prefix, you can use the National Doctor and Hospital Finder available on the Blue Cross and Blue Shield Association website at Medicare Advantage Compliance Training If you no longer offer Medicare Advantage plans, why are we required to complete compliance training this year? Although we no longer offer the Medicare Advantage preferred provider organization (PPO) plans, we continue to offer the prescription drug plans. CMS mandates that we require annual compliance training of our participating providers. Have a Question for Provider Education? Contact our Provider Education department by phone at , ext , or by at provider.education@bcbssc.com. Our provider advocates are equipped to handle your inquiries. Or, you can request a visit from one of our external advocates. BlueCross BlueShield of South Carolina and BlueChoice HealthPlan are independent licensees of the Blue Cross and Blue Shield Association