Behavioral health services transitioning from HBI effective January 1, 2008

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1 I Working together to improve the health of our members in Nevada December 5, 2007 Behavioral health services transitioning from HBI effective January 1, 2008 anthem.com On January 1, 2008, Anthem Behavioral Health will begin managing behavioral health services for Anthem Blue Cross and Blue Shield in Nevada and for our subsidiary, HMO Nevada, Inc. (Anthem). This business is currently being managed by Human Behavior Institute (HBI). This change affects all lines of business, with the exception of state-sponsored programs, BlueCard and national account members. For those members, please refer to the behavioral health/substance abuse phone number on the back of the member s health plan ID card. We are excited about this new network and want you to have the necessary information to provide your patients and our members with the care they need. To refer our members to a behavioral health specialist, please contact Anthem Behavioral Health at one of the following numbers: All local members with alpha prefixes that begin with YF: Federal Employee Health Benefit Program (FEP) members: You can also go to anthem.com to look at our Provider Policy and Procedure Manual, which includes an updated mental health section with information about this change. These changes will be available online effective January 1. As with any change, our goal is to make a smooth transition for our members and their covered dependents. Authorization requirement changes regarding DEXA scans (CPT 77080) and Oncotype DX assay (S3854) We ve listened to what you ve told us. As of January 1, 2008, routine central DEXA scans (CPT 77080) will no longer require pre authorization. Please remember, however, that repeat scanning is not considered medically necessary at less than 24 month intervals. Anthem Clinical Guideline CG-RAD-18, available at discusses indications for both screening and repeat DEXA. Also as a reminder, peripheral bone density measurement such as peripheral DEXA (CPT 77081) is usually considered to be investigational/not medically necessary, as well as peripheral ultrasound bone density measurement (CPT 76977) and DEXA screening for vertebral fractures (CPT 77082) are also considered investigational/not medically necessary and are not covered as benefits. These tests are discussed in Anthem Medical Policy RAD available at Also, based on newly available evidence, Anthem has recently revised Anthem Medical Policy GENE Effective September 21, 2007, Anthem considers the Oncotype DX assay (S3854) to be medically necessary in a highly selected group of patients with breast cancer. Before ordering this test, please review the criteria in that policy which is available at Because of the rapidly evolving clinical evidence, highly technical indications and the substantial cost of this test, Anthem will require that this test be preauthorized, effective January 1, Oncotype DX assays which are not preauthorized and do not satisfy medical necessity criteria in GENE will be considered not medically necessary and will not be covered.

2 We have also clarified how infused drugs are listed on the Pre-Certification Quick Reference Guide (QRG). We specifically added the infused drugs that require pre-certification by drug name rather than including them under Home Health Care umbrella. Please now reference infused drugs by specific drug name on the QRG. A revised Pre-Certification Quick Reference Guide is available at with the above referenced changes. Go to Providers, Nevada, and select Communications, then Publications, and Pre-Certification Quick Reference Guide. This revised list will be effective and available online January 1, Anthem updates contingency plan for the National Provider Identifier Anthem strives to be an industry leader in meeting the requirements of the Health Insurance Portability and Accountability Act (HIPAA), including the National Provider Identifier (NPI). Thanks to extensive efforts over the last three years, Anthem has been able to accept and process the 10-digit NPI numbers for institutional, medical and dental claims, as well as NPI related claim and member status inquiries since the federally mandated deadline of May 23, Earlier in the year, Anthem announced plans to begin accepting only NPIs on electronic transactions filed to us, beginning January 26, We have revised this contingency period to help ensure a smooth NPI transition with ample time for you to adjust to the NPI requirements. Anthem will continue to accept NPI numbers, current provider identification numbers (legacy identifiers) or both in electronic and paper transactions through May 23, By extending the date to May 23, 2008, you can continue to pursue enumeration, NPI registration and system preparations, if needed. Plus, this will help avoid processing and service disruptions in the industry, and it will help us maintain current service levels with timely payments. Our date extension also provides consistency with requirements offered by the Centers for Medicare & Medicaid Services (CMS), so you re not meeting different compliance dates. After May 23, 2008, we ll no longer accept legacy identifiers on electronic transactions. We ll send a reminder notification 60 days in advance of that date. Anthem is committed to making this contingency period as easy as possible. We ll work with providers and their contracted vendors to maintain current business operations and service levels during this transition period, while supporting efforts to comply with the requirements of HIPAA s NPI Rule. To learn more about these efforts, please visit our provider website, which includes an FAQ document and HIPAA companion guides. The following is an excerpt from our guides relating to NPI billing clarity. An Entity Type 1 NPI is assigned to individual physicians or non-physician practitioners An Entity Type 2 NPI is assigned to an organization. If you are contracted with us as an individual, you want to use your Entity Type 1 NPI in the NM109 segment of the 2010AA (Billing Provider Loop) or 2010AB (Pay-to-Provider) loops within the 837 electronic transactions.

3 If you are contracted with us as an organization, you want to use your Entity Type 2 NPI in the NM109 segment of the 2010AA (Billing Provider Loop) or 2010AB (Pay-to-Provider) loops within the 837 electronic transactions. The 2310B Loop is required only when the rendering provider name and address is different from Loops 2010AA or 2010AB; and you are contracted with Anthem as an individual/ Entity type 1 provider. Both of these scenarios must be met before the 2310B Loop is required. Otherwise, only use Loops 2010AA or 2010AB when filing provider information to Anthem. It s essential to quickly move to using the NPI on electronic and paper transactions. Successful implementation of HIPAA standards should reduce costs and administrative burdens for the entire health care industry. You should register your NPI(s) on our NPI Registration website at if you haven t already done so. This website also includes instructions for our bulk submission process for those with multiple NPIs. New Medicare Advantage products available January 1, 2008 Anthem Medicare Preferred L: Anthem will offer a Medicare Advantage Local Preferred Provider Organization (L) health plan to Medicare beneficiaries in Clark and Washoe counties. Anthem Medicare Preferred L provides coverage for all health care services offered by Original Medicare. It also includes extras, such as annual physicals, prescription drugs, and Forever Fit fitness benefit. (An alpha prefix has not yet been assigned. We will update you with that information in the next Network Update.) Provider participation is based on contractual agreement with Anthem. Contact your local provider representative for participation details. Anthem Medicare Preferred L is simple: Members pay a monthly premium of $33, in addition to Part B premium. Annual deductible is $500. Annual out-of-pocket max is $3,000. Members enjoy greatest cost savings when receiving services from network providers. (Exceptions made for emergency and urgent care services.) Members can receive care from non-network providers, with higher out-of-pocket costs. No referrals are required to see physicians or specialists. Claims are filed to Anthem, not Medicare. Pre-certification rules apply for specific services. SmartValue PFFS: Anthem will offer Medicare Advantage Private-Fee-for-Service Plans (PFFS). This family of plans includes SmartValue Classic, SmartValue Plus, SmartValue Enhanced, and SmartValue Enhanced Plus. These innovative plans are available to Medicare beneficiaries in Carson City, Clark, Douglas, Lincoln, Lyon, Mineral, Nye, Pershing, Storey and White Pine counties. They allow providers to participate without network and referral restrictions. Members will be identified by a YFE alpha prefix. SmartValue PFFS is simple. If you re eligible to receive Medicare payments, you can participate in the SmartValue plan and take advantage of the following benefits:

4 No contracting required. You simply agree to the SmartValue plan terms and conditions in the Provider Disclosure, which is available online or by calling customer service. Claims are filed to the SmartValue plan, not Medicare. You re reimbursed directly from the SmartValue plan at the equivalent of the current Medicare Allowable amount for all Medicare covered services minus applicable low Member copayments. Payment from SmartValue is to be considered payment in full. Balance billing is prohibited. SmartValue plans follow Medicare guidelines, so your staff won t need to learn a new set of rules. A dedicated provider call center is there for you. There s a Geriatric Care Management Program with dedicated Case Managers on staff. Pre-notification (which is the member s responsibility) is required for a scheduled inpatient stay or DME over $750. Pre-certification is required for transplants, gastric bypass and carotid endarterectomies. SmartSaver MSA: Anthem will offer a Medicare Advantage Medical Savings Account (MSA) SmartSaver, to Medicare beneficiaries in Carson City, Churchill, Clark, Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye, Pershing, Storey, Washoe and White Pine counties. Members will be identified by a YFQ alpha prefix. SmartSaver provides coverage for all health care services offered by Original Medicare, with no monthly premium. The SmartSaver MSA includes two components: 1) A high deductible health plan, which provides coverage for Medicare covered benefits just like other Medicare Advantage plans, with an annual plan deductible of $4,000. 2) A medical savings account, which is an independent bank account owned by the member to pay for qualified medical expenses. SmartSaver members will receive an annual MSA deposit of $1,175 at the beginning of each calendar year. Like the PFFS plan, there is no provider network. So, if you are eligible to receive Medicare payments, you can participate in SmartSaver plan. Other participation benefits include: No contracting required. You simply agree to the SmartSaver plan terms and conditions in the Provider Disclosure, which is available online or by calling customer service. Claims are filed to the SmartSaver plan, not Medicare. Reimbursement is equivalent to the Medicare Allowable for Medicare covered services. A dedicated provider call center is there for you. Here s how the SmartSaver plan works: Member receives care from a willing, Medicare eligible provider. Provider submits claim to Anthem for processing. If the deductible is met, plan pays provider directly. Plan pays 100% for Medicare covered services after the plan deductible is satisfied. If the deductible isn t met, plan sends EOB to the member and provider detailing the member s responsibility. Member will reimburse the provider using MSA funds via debit card, MSA check book or other means chosen by the member.

5 The allowable amounts for Medicare covered services and any permitted balance billing is applied toward the plan deductible. Additional information about all of our Medicare Advantage products can be found at You may also call our dedicated provider service line at the numbers listed below, Monday through Friday, 5 a.m. to 6.p.m. Anthem Medicare Preferred L [alpha prefix to be determined]: SmartValue [alpha prefix YFE]: SmartSaver [alpha prefix YFQ]: We have updated the Alpha Prefix Reference List with these new products, and attached it for your convenience. Attention electronic submitters: Have you filed all your claims for 2007? As the year draws to a close, Anthem encourages you to file all your claims electronically right away even claims with other coverage information or supporting documentation. By filing electronic claims now, you can greet 2008 feeling confident that your accounts are settled, and the New Year is off to a good start. Filing claims electronically can help you save time, improving operating efficiency and cash flow for your practice or facility. Additionally, electronic claims filing helps decrease paperwork and reduce administrative expenses. You can also reduce the number of re-filed claims, errors and rejected claims by filing electronically. And the electronic process provides easy-to-interpret reports and an audit trail to track claim submissions. If you have questions, please call the EDI Solutions help desk toll free at Anthem closing old P.O. Box, effective January 1, 2008 Our new P.O. Box has been up and running for more than a year, so we re closing our old P.O. Box effective January 1, Please make sure your records are updated with our current mailing address for claims and correspondence: Current Mailing Address: Old P.O. Box closing, effective January 1: Anthem Blue Cross and Blue Shield Anthem Blue Cross and Blue Shield P.O. Box 5747 P.O. Box Denver, CO Denver, CO Any mail sent to the old P.O. Box after January 1, 2008 will be forwarded to the current P.O. Box until April 1. After that date, mail sent to this P.O. Box will be returned to sender.

6 Alpha Prefix Reference List Member Type Alpha Prefix Contract Type Customer Service Phone # Address (Claims, Adjustments, & Appeals) Authorization Phone # Local (New System) YFF , M-F: 7:00 a.m. 5:00 p.m. Anthem Blue Cross and Blue Shield or YFJ Indemnity P.O. Box YFK Denver, CO YFL YFN HMO Note: The preferred method for submitting claims YFP Indemnity is electronically or hard copy. However, fax YFT Indemnity submission is allowed at the following fax YFW numbers: or YFY HMO YFG Medicare Supplement , M-F: 8:00 a.m. 6:00 p.m. No authorization required. YFE Medicare Advantage: SmartValue , M-F: 5:00 a.m. 6:00 p.m YFQ Medicare Advantage: SmartSaver , M-F: 5:00 a.m. 6:00 p.m To be determined Anthem Medicare Preferred L , M-F: 5:00 a.m. 6:00 p.m YFA, YFB, YFC, YFD, YFS, YFX These are all alpha prefixes from our legacy system. Please note that members will be issued new health plan ID cards upon renewal date. Local (Old System, run out only) FEP R + 8 numerics if you have a contract. Indemnity if you have an indemnity contract only. BlueCard BlueCard For Run-out Only (claims received prior to 10/28/06) IntraPlan* Blue Cross of California members All other alpha prefixes not listed above Most common prefixes in NV: AET, AWE, BTW, FRD, HYE, KNK, LSI, NAJ, SAC, UNR, WEP, WFK, XDP if in suitcase logo. Indemnity if empty suitcase logo. Colorado Members XF? if in suitcase logo. Indemnity if empty suitcase logo , M-F: 8:00 a.m. 4:30 p.m. FEP P.O. Box36400 Louisville, KY Claims Customer Service: , M-F: 7:00 a.m. 5:00 p.m. Eligibility: BLUE (2583) (Hours vary by location) Claims Customer Service Run Out only: or M-F: 7:00 a.m. 5:00 p.m. Claims, Eligibility and Benefits Customer Service: , M-F: 7:00 a.m. 7:00 p.m , M-F: 7:00 a.m. 5:00 p.m. Same as Local Anthem Blue Cross and Blue Shield P.O. Box 5747 Denver, CO BLUE (2583) or HMO Nevada Guest Membership / Away From Home Care N/A** HMO , 7 a.m. 3:30 p.m. HMO Nevada Guest Membership*** 700 Broadway, Dept. HU0444 Denver, CO * IntraPlan members are members of the other Blue Plans affiliated with our parent company that are processed on the same claim system. **Guest members do not have an alpha prefix. They are identified by Guest Member on their health plan ID card. *** We cannot accept Guest Membership claims electronically. They must be sent hard copy. Revised: December 5, 2007 Anthem Blue Cross and Blue Shield is the parent company of HMO Colorado, Inc., and HMO Nevada. Independent licensees of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. Registered marks Blue Cross and Blue Shield Association.