A green Blue Link. Inside: News from Blue Cross and Blue Shield of North Carolina. Why we need to conserve our forests

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1 News from Blue Cross and Blue Shield of North Carolina Fall 2007 Volume No. 12 Issue No. 2 Inside: A green Blue Link How to improve claim inquiries... 2 Conservation means different things to different people. In your home or office, it may mean energy efficient light bulbs, reusable canvas shopping bags, biking more, driving less, buying locally grown fruits and vegetables, or diligently recycling. At BCBSNC, we support all of these efforts and want to do our part too, which is why the Blue Link is going green. By green we mean that we re practicing conservation by transitioning Blue Link away from a paper-based communication to a Web-based provider newsletter, available on our Web site for providers at b c b s n c. c o m / p rov i d e rs /. High-tech Diagnostic Imaging Program... 3 Preventive care guidelines... 7 P F A Rx Free provider toolkits help jump-start preventive health conversations... 8 Coming soon: More improvements to our phone system For articles specific to your area of interest, look for the appropriate icon. P Physicians/Specialists F Facilities/Hospitals A Ancillary Rx Pharmacy Why we need to conserve our forests Forests play crucial roles in North Carolina s ecology and our way of life, providing us with clean water and clean air. Our forests convert carbon dioxide and water into oxygen, replenishing the air we breathe. Forests absorb pollutants and purify rainwater. Our forests are the starting point for 60 percent of the water that we use1 and more than five million North Carolinians drink from surface impoundments, which are supplied with water that flows from North Carolina s forests2. But did you know that North Carolina could be losing nearly 100,000 acres of forests annually3? When this happens the quality of our remaining forests declines, threatening the state s future forests, as the highest quality trees are harvested while leaving behind trees with lesser ecological value. More than one million acres of forest disappeared in North Carolina from 1990 to This onemillion-acre loss is larger than the land areas of the Research Triangle counties of Durham, Orange and Wake combined. Since the 1960s, cumulative forest loss in North Carolina has risen to 2.1 million acres, a loss greater than any other state in the nation3. The Southern Forest Resource Assessment, compiled in 2002 by the U.S. Forest Service, projected an additional four million acre decline in North Carolina forests over the next four decades, which would be a 30 percent decline statewide4. (continued on page 2) 1 U4577 BlueLink r001.indd 1 11/7/07 3:23:43 PM

2 A green Blue Link (continued from page 1) P F A Rx There are many reasons to support conservation but at BCBSNC a leading cause is one you ve probably already heard about from us our commitment to improving the health of North Carolinians. BCBSNC does this in many ways; like our Member Health Partnerships SM1 health management program that encourages members to meet their personal health goals, Blue Points SM rewards for wellness activities and our online health survey, which provides to members a personalized health report that outlines their potential health risk factors and steps for staying healthy. These are just a few of the ways that we express our commitment to a healthy North Carolina. We also believe that an essential part of keeping North Carolina healthy is our performance as a neighbor, using natural resources wisely and helping to improve our states environmental performance. Conservation for a healthy state goes hand-in-hand with our commitment to improving the health of all North Carolinians. So please remember that your next edition of Blue Link will be available to you on the "providers" page of our Web site at bcbsnc.com/providers/. Just visit us at bcbsnc.com either on or after December 27, 2007, and your next copy of Blue Link will be waiting there for you. All you ll need to do is click and save a copy to your desktop computer, or if you prefer, you can still have a paper copy by simply sending to your office printer. Also, once you have saved a copy to your desktop, the Blue Link will be in a PDF format that you can quickly and easily share with others in your office by . How to improve claim inquiries and/or disputes responses P F A Rx We receive a high number of requests for claim and medical record reviews from providers. To help us respond more quickly to these requests, we want to provide you with a list of the main reasons that providers request a re-review, and to let you know that when we don t have enough information, our response can be delayed. Please review this information and ensure that your claims and any requests for review are complete and accurate before submitting them to BCBSNC. This will help you to decrease the inconvenience of having to call to inquire of the status of your request. The main reasons that requests for re-review of claims/ medical records may not be reviewed timely include: t Invalid or missing NPI and/or BCBSNC individual or group provider number t Invalid, incomplete or missing member ID (please include the complete member ID including applicable prefixes and suffixes as they appear on the member s current ID card) t Invalid place-of-service code (filing one-digit code instead of a two-digit code) t Missing or incorrect number of units t Missing patient s date of birth t Missing onset date of symptoms t Missing or incomplete specific diagnosis t Missing primary payor s EOB if BCBSNC is secondary t Missing admission and discharge dates for inpatient claims Medical records For initial medical records submission, please do not send medical records unless requested by BCBSNC. We will send you a medical record request form with the required information; this must be returned with the records requested. This medical request form is critical to getting your medical records routed to the correct area to review. Not submitting your medical records with the medical record request form contributes to the delay or possible loss of the medical record. Filing with unlisted codes Per CPT/HCPCS coding guidelines, all unlisted codes require the submission of pertinent records, such as the operative report, detailed description of the service in question, etc., to support the use of the unlisted code. This supporting information is required in order for us to make coverage and pricing determinations. By submitting it with the claim, you ll prevent any payment delay that will result if we have to request medical records. For unlisted drugs, such as codes J3490, J3590, J9999, we require the NDC number, the name and dosage of the drug provided. If there is a valid CPT or HCPCS code, then do not submit the unlisted code. 2

3 High-tech Diagnostic Imaging Management Program American Imaging Management, Inc. (AIM) administers the diagnostic imaging management program for BCBSNC. For dates of service on or after February 15, 2007, prior plan approval has been required for the nonemergency, outpatient diagnostic imaging services when they are performed in a physician s office, the outpatient department of a hospital, or a freestanding imaging center. Services include: t CT/CTA scans t MRI/MRA scans t Nuclear cardiology studies t PET scans Ordering physicians must contact AIM via Web, phone, or fax to obtain an authorization prior to scheduling an imaging exam for outpatient diagnostic non-emergency services. Servicing providers (hospitals and freestanding imaging centers) should confirm that an authorization was issued prior to scheduling the exam. Issuance of an authorization is not a guarantee of payment; claims will be processed in accordance with the terms of a subscriber s health benefit plan. Only ordering physicians can obtain authorizations. Hospitals and freestanding imaging centers that perform the imaging services cannot obtain the authorization. Ordering physicians can obtain and/or confirm authorizations by contacting AIM in one of three ways: 1. By logging on to Provider Portal through Blue e SM : seven days a week, 4 a.m. to 1 a.m., Eastern Time 2. By calling AIM: (toll free), Monday through Friday, 8 a.m. to 5 p.m. Eastern Time, or 3. By faxing AIM: (toll free), using the fax form found on the Providers page of our Web site at imaging.faces or by calling AIM at the number above. Imaging service providers can also contact AIM either through the provider portal or by phone, to ensure that an authorization has been issued or to confirm that the authorization information is correct. Imaging service providers can also call AIM to either change the date of service on the authorization or request add-on procedures. Neither AIM nor BCBSNC will issue retro-authorizations. However, if the requested scan is of an urgent nature, the ordering physician can request the authorization within 48 hours of the procedure. If you are not currently registered to use Blue e you will need to register online at bcbsnc.com/providers/edi/bluee.cfm. BCBSNC provides Blue e to providers free-of-charge. Once your registration is completed, please allow two weeks for processing. Please note that each individual user will need an individual username and password. You can contact your Electronic Solutions representative to add users. Most BCBSNC employer groups are participating in the Diagnostic Imaging Management Program. However, not all groups are participating, so BCBSNC has a Webbased group number search available on the Web at faces and on Blue e. The employer group number search allows providers to quickly determine whether an authorization is needed. BCBSNC updates this system as new groups enter the program, so it is important that you confirm participation regularly. BCBSNC conducted several provider office staff training sessions throughout North Carolina in December 06 and January 07. The training materials from those sessions are available at imaging.faces. If you would like more information about the Diagnostic Imaging Management Program, please contact your local Network Management field office or visit providers.bcbsnc.com/providers/imaging.faces. P F 3

4 National provider identifier P F A Rx In April, the Centers for Medicare & Medicaid Services (CMS) announced, a contingency plan for covered entities that did not meet the May 23, 2007 compliance date for obtaining a national provider identifier (NPI). The announcement indicates that covered entities will be protected from enforcement actions if they continue to act in good faith moving towards compliance. Blue Cross and Blue Shield of North Carolina (BCBSNC) is evaluating the Enforcement Guideline and is completing a contingency plan. We ve made the following decisions: t BCBSNC will continue to aggressively collect NPI(s) from providers. t BCBSNC will continue to accept HIPAA defined transactions submitted with the BCBSNC five character proprietary provider number only (without NPI) after May 23, t The date that BCBSNC will no longer accept proprietary provider numbers on HIPAA defined transactions has not yet been determined, however is not expected to extend past May 22, t BCBSNC will continue to accept HIPAA defined transactions submitted with a combination of BCBSNC five character proprietary provider numbers and NPI(s) after May 23, 2007 please register your NPI with BCBSNC quickly. t BCBSNC will continue to accept HIPAA defined transactions submitted with NPI(s) only, however, only if the NPI(s) have already been registered with BCBSNC. t BCBSNC will continue to work with providers and trading partners to promote the transition from use of proprietary provider numbers to using NPI(s) on HIPAA defined transactions. Please note that the contingency period is intended to allow testing of crosswalks and not for continued processing under proprietary numbers. For more information about NPI, including application procedures and the CMS contingency plan, visit the National Plan and Provider Enumeration System (NPPES) at If you have not applied for your NPI(s) already, please start the process. Once you have obtained your NPI(s) you must register it/them with BCBSNC. The registration of your NPI(s) at BCBSNC is critical to continued receipt of accurate payments from BCBSNC. We are collecting NPI(s) through Blue e (if you are currently an authorized Blue e user), or through the mail if you have not yet signed up for Blue e access. When we receive your NPI registration, BCBSNC will link your NPI(s) and your BCBSNC provider number(s). The NPI(s) will be accepted on claims and mapped to the appropriate BCBSNC provider numbers (based on your registration information). Your claims will then process through our claims systems with the BCBSNC provider number(s) and will be returned to you with your NPI(s). As part of our NPI collection methods, providers will have the option to register both the group and its associated individual providers NPI(s). As a reminder, there are two types of NPI that are assigned via the CMS enumeration system, NPPES: t Type 1: Assigned to an individual who renders health care services, including physicians, nurses, physical therapists and dentists. An individual provider can receive only one NPI. t Type 2: Assigned to a health care organization and its subparts that may include hospitals, skilled nursing facilities, home health agencies, pharmacies and suppliers of medical equipment (durable medical equipment, orthotics, prosthetics, etc). An organization may apply and receive multiple NPIs to support their business structure. It is important to evaluate your business or organization and associated relationships (vendors, clearinghouses, health plans, etc.,) prior to applying for your NPI(s). The NPI(s) will replace all carrier provider identifiers, including those used for Medicare, Medicaid, BCBSNC and other health care payors. It will not, however, replace current BCBSNC policies and procedures for credentialing and provider participation. Therefore, depending on your type of business, it is your responsibility, to determine how many NPIs are needed in order to continue your current business functions. The following Web sites are available for further information about NPI, the enumeration system, and industry recommendations: t NPI overview and application process: t Enumeration system: t Industry recommendations and white papers: If you use a billing service or software vendor to file your claims or other electronic transactions, you must ensure that these entities are ready to transmit and receive NPI(s). BCBSNC can accept and process electronic claims with both the NPI and the BCBSNC provider number or with the NPI only. 14 (continued on page 5)

5 National provider identifier (continued from page 4) Your next steps: t Review your organization structure to determine how you will enumerate. t Apply for NPI(s) through NPPES. t Receive your assigned NPI(s). t Register your NPI(s) with BCBSNC through Blue e or by returning the paper forms in the mail. If you cannot locate the mailed forms, you can still register your NPI(s) by sending to us on your health care business letterhead, your NPI information along with the corresponding BCBSNC assigned numbers. Registering by mail: BCBSNC NPI Collection, Network Management P. O. Box 2291 Durham, NC P F A Rx Once your NPI(s) is/are registered with BCBSNC, you may file your NPI(s) along with your BCBSNC provider number on your electronic claims. However, you must wait 24 hours after registering your NPI(s) with BCBSNC before submitting your NPI(s) on your electronic claims in order to allow the BCBSNC systems to be completely updated. Please note that effective May 21, 2007, BCBSNC discontinued returning the BCBSNC provider number on paper explanations of payments EOP if the NPI has been registered with BCBSNC. Only the NPI will be listed on the returning EOP. Electronic remittances (835) will continue to return both the NPI(s) and BCBSNC provider number(s). NPI questions and answers What requirements does BCBSNC have for sharing NPIs prior to production use? We have requested that all providers register NPIs directly with BCBSNC. BCBSNC will share registered NPIs with Partners National Health Plans of North Carolina Inc., and the Blue Cross and Blue Shield Association. When both legacy and NPI are present in the same transaction, which ID is used for processing? If the NPI is registered with BCBSNC, BCBSNC will use the NPI to confirm the BCBSNC crosswalk mapping. If the NPI and BCBSNC provider ID submitted on the transaction agree with the NPI and BCBSNC provider ID in the BCBSNC crosswalk, BCBSNC will process using the NPI. If the NPI and BCBSNC provider ID submitted on the transaction do not agree with the NPI and BCBSNC provider ID in the BCBSNC crosswalk, BCBSNC will reject the transaction with a business edit. If the NPI is not registered with BCBSNC, BCBSNC will use the BCBSNC provider ID to process the transaction. How does BCBSNC recommend providers test transactions with NPI? BCBSNC strongly recommends that the provider submit transactions with both the NPI and the BCBSNC provider ID. This will allow both the provider and BCBSNC to verify the mapping of NPI to internal BCBSNC provider ID(s). What are the timelines and transition requirements for paper claims? NPIs should not be used on paper claim forms that are being phased out. NPIs may be sent on the new UB04 and the new CMS1500. BCBSNC Provider IDs may be sent on the new forms. BCBSNC will also accept both the NPI and the BCBSNC provider ID on the new forms. t If you have not registered your NPI(s) with BCBSNC, please call us at (continued on page 6) 5

6 National provider identifier (continued from page 5) BCBSNC NPI contingency plan: P F A BCBSNC has officially adopted an NPI contingency plan, in accordance with CMS NPI contingency guidance and applicable regulations. BCBSNC will accept/submit as applicable, the following identifiers in HIPAA electronic transactions: Lists of transactions timetable applies to r837p r837i r837d r835 r270/271 r276/277 r278 r834 Rx Identifier Primary providers Secondary providers (Billing/pay to, rendering) (Referring, ordering, operating, other) Legacy ID only Legacy IDs only will continue to be Legacy IDs only will continue to be submitted/ submitted/accepted through accepted through May 22, 2008 May 22, 2008 NPI+Legacy NPI + Legacy submitted/accepted NPI + Legacy submitted/accepted October 1, 2006 October 1, 2006 NPI + Legacy will continue to be NPI + Legacy will continue to be submitted/accepted submitted/accepted through through May 22, 2008 May 22, 2008 NPI Only NPI only submitted/accepted NPI only submitted/ accepted October 1, 2006 October 1, 2006 NPI only will be required to be NPI only will be required to sent/received starting May 23, 2008 be sent/received starting May 23, 2008 Legacy IDs will not be permitted Legacy IDs will not be permitted after May 22, 2008 after May 22, 2008 If one table does not apply to all transactions that your organization performs, please provide additional table(s) as appropriate and mark with an r. Note: for definition of primary and secondary providers see CMS FAQ 6926 uhttp://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=_2owaqai BCBSNC needs your correct information it s critical to our members and to doing business with you! BCBSNC routinely updates the online provider directory with addresses, phone numbers and current lists of all providers at a participating facility or practice, so that our members can quickly locate health care providers and schedule appointments. Our ability to successfully direct members to you for their medical care depends on the accuracy of the information we have on file for your facility or practice. You are encouraged to visit the Find a Doctor page located on the BCBSNC Web site bcbsnc.com to validate your health care businesses information. P F A Rx If you find that your information is in need of updating, please let us know by contacting your local BCBSNC Network Management field office or complete and return a provider demographic form that can be found on the providers page on our Web site at Please note that our having accurate mailing information on file for your practice also ensures you receive claims payments and other important correspondence in a timely manner from BCBSNC. 6

7 How are medical necessity decisions made? We want to ensure that all physicians are aware of the criteria and guidelines that we use to make medical necessity decisions at BCBSNC. In these decisions we are guided by the Milliman Care Guidelines and BCBSNC corporate medical policy. In July of 2007, the new 11 th edition of the Milliman Care Guidelines were implemented. This edition contains many enhancements to the inpatient management section, an expanded common complications and conditions section, problem-oriented guidelines, as well as having the 2007 NCQA HEDIS and JCAHO Quality of Care measures throughout. Our licensed nurses use Milliman Care Guidelines to authorize coverage for inpatient services, home care, and rehabilitation services. Practitioners can obtain a copy of a specific Milliman Care Guideline or a BCBSNC medical policy by calling our Member Health Partnership P F A Operations department at , ext Our medical policies are also available through our Web site at bcbsnc.com via the Provider portal. If a nurse cannot approve a service, a BCBSNC medical director (who is licensed in North Carolina) will review the case and may approve or deny coverage based on Milliman Care Guidelines or BCBSNC medical policy, along with clinical judgment. Only a medical director can deny coverage for a service based on medical necessity. We encourage you to take part in a peer-to-peer consultation regarding a case before or after a determination, because a discussion between physicians can help clarify a situation and affect the determination. A BCBSNC medical director is always available during regular business hours and can be reached by calling , ext Preventive care guidelines at your fingertips Want nationally recognized, current and accurate screening guidelines, all in one place? Look to BCBSNC to provide them! To help promote preventive health services and encourage appropriate health assessment, BCBSNC updates preventive health guidelines annually based on the most current evidence-based information available. The guidelines include immunization schedules and age-specific health assessment recommendations for general and high-risk populations. Both member and provider versions were developed to present an appropriate level of clinical content for the different audiences. Conveniently located on the Provider page of our Web site bcbsnc.com, these comprehensive guidelines are adapted from nationally recognized organizations, such as: t U.S. Preventive Services Task Force t Centers for Disease Control and Prevention t American Academy of Pediatrics t American Academy of Family Physicians t American Cancer Society All guidelines receive rigorous review on an annual basis from BCBSNC medical directors and the BCBSNC s Physician Advisory Group (an external group of physicians who provide guidance and oversight for BCBSNC s Quality Improvement activities). To view our Preventive Care Guidelines, go to bcbsnc.com, click on Provider, and then click on Clinical Practice and Preventative Health Guidelines. If your patients would like to view their version of the guidelines, send them to bcbsnc.com, have them click on Member, then click on Preventive Health. P A Rx 7

8 Free provider toolkits help jump-start preventive health conversations P F Rx At BCBSNC, we recognize the importance of your role in encouraging your patients to live healthy lives by taking care of themselves and taking advantage of preventive screenings. A physician s recommendation for lifestyle changes or preventive screenings is one of the most important predictors of health behaviors. To make these conversations easier, BCBSNC offers free toolkits on a variety of preventive health topics. The toolkits contain materials for both providers and patients. Provider resources include practice guidelines, tip cards and other assessment tools, such as BMI wheels. Patient materials include helpful worksheets, educational brochures, and handouts to assist your patients in achieving a healthier lifestyle. Toolkits are available on the following topics: t Adult obesity t Adult tobacco cessation (English and Spanish toolkits available) t Chlamydia screening t Colorectal cancer screening t Depression screening t Healthy weight for kids t Mammography t Stress management To order your free toolkits, please call BCBSNC Member Health Partnerships at

9 Inter-Plan Programs: Updates and reminders Quick claims filing tips for providers with multiple Blue Plans Health care providers, particularly those serving border counties of North Carolina, may serve patients covered by Blue Plans other than BCBSNC. If you provide care to BlueCard members from other Blue Plans, please follow these claim filing guidelines: t If you contract with both BCBSNC and a bordering Blue Cross plan for the same product type (i.e. PPO or CMM), you may file a border state s Blue Plan member s claim with either Plan. For example, if it s a PPO member and you have a PPO contract with both BCBSNC and Blue Cross and Blue Shield of South Carolina, you can file the claim with either health plan, but only if the Blues covered member is from a Blue health plan other than BCBSNC or BCBSSC. l If you contract with both BCBSNC and a bordering Blue Cross and/or Blue Shield Plan and the member is a BCBSNC member, file the claim to BCBSNC. If the member is a BCBSSC member, file the claim to BCBSSC. t If you have a PPO agreement with one Blue Plan, but a CMM contract with another Blue Plan, file the out-of-area Blue member s claim by product type. For example, if it s a PPO member, file the claim with the Blue Plan that has your PPO contract. t If you contract with one Plan but not the other, file all out-of-area (BlueCard) claims with your contracted Plan. For assistance with additional out-of-area (BlueCard) claims filing questions, please contact BlueCard customer service at or contact your local network management field office. Medicare crossover claims and BlueCard: Important information that all providers need to know There are some basic rules when it comes to Medicare primary coverage and BlueCard, which begin with always file to the Medicare contractor first. We ask that you never file to both the Medicare contractor and BCBSNC at the same time. Instead, wait until the claim has been processed and Medicare has provided you with an explanation of benefits EOB or a payment advice. The reasoning behind these rules are simple; the member s benefits cannot be determined by the member s Plan without knowing what Medicare has allowed. If you P F A submit a claim to us before Medicare has provided their payment information, your claim will result in a claim denial. As such, there are steps you can take to avoid denials, duplicate claims and administrative rework. Let s start with the basics you have filed a claim to the Medicare contractor, now what? Very often there s not much that needs to be done. You followed the basic rules and filed to the Medicare contractor first and then stopped. If all goes smoothly you will next receive the Medicare EOB or remittance advice containing a message that the claim has automatically crossed over to the member s Plan, or an EOB listing the remark code MA18, which means that the claim has been automatically forwarded for processing. The claim should then be processed by the member s Plan, and, if you accept assignment, the secondary payment should be in hand soon. Something that you can do to help ensure this occurs is to always include the member s complete BCBS identification number, including the alpha prefix and the Blue Plan name as it appears on the member s ID card, when you are submitting the initial claim to the Medicare contractor. But what if the rules were followed, the claim was sent to the Medicare contractor first and they have paid the claim but the returned EOB or remittance advice does not list remark code MA18 or a message indicating that the claim has been forwarded to the member s Plan? This is when you should file a second claim. If the claim was not crossed over, you should submit the secondary claim to BCBSNC with the Medicare remittance advice or Medicare remittance information (if the secondary claim is being submitted electronically). After we receive the claim, we ll take care of getting it to the out-of-state member s Plan for benefits determination. If you have any questions after sending the claim to us, contact us, either by using Blue e claim status to view your answer or call our customer service line at If you have a question about a claim you have sent to us, please contact BCBSNC and not the member s Plan. Did you know that Blue e can also be used for the out of state member s information when the Medicare crossover claim was not sent through BCBSNC? Here s how: t You request claim status using Blue e by entering your correct NPI (that you have already registered with BCBSNC) and/or your BCBSNC assigned number. (continued on page 10) 9

10 Inter-Plan Programs: Updates and reminders (continued from page 9) t Verify that the correct date of service and member information has been entered into Blue e. t Blue e then routes a Medicare crossover claim status inquiry to the Blue Cross and Blue Shield Association (BCBSA) through BlueExchange SM using a 276 transaction containing the NPI (if available), the tax ID and the PPN: l PPN is the acronym for proprietary provider number, which is the same as your BCBSNC assigned number. t BCBSA sends the request to the member s Plan. t The member s Plan searches for the claim by associated tax ID or NPI. t The member s plan then sends back to BCBSNC the response (277 transaction) through BlueExchange. t The response is mapped into the Blue e claim status display screen for you to view. Please remember that a second claim should not be filed to BCBSNC when the initial claim has crossed over to the member s Plan directly, as part of the Medicare crossover process. Medical record requests via fax to Provider Link At BCBSNC the Inter-Plan department uses a Web based application called Provider Link to request and submit medical records electronically. Providers can access Provider Link by use of a fax machine. The Provider Link fax connection allows you to send medical records to us, faxing as many as 50 pages per medical record, which is much faster and more cost effective than conventional mail. All you need is a fax machine to take advantage of this level of service. If you interested or would like more information about sending medical records to our Provider Link connection, please call our Customer Service number at and they will be happy to set you up as a fax user. For providers that are currently using fax services to forward medical records, please keep in mind the following tips: t Please do not send in medical records unless you have received a request form from BCBSNC. t Please remember to use the fax back cover sheet when faxing medical records to BCBSNC. The cover sheet contains a bar code that allows us to quickly identify the records and match them to the patient s claim. Provider-initiated refunds for out-of-area members When we receive non-requested refunds for out-of-area Blue Plan members, both BCBSNC and the member s Plan are involved in the transaction. Because of this P F A coordination with other Blue Plans, it is critical that we receive accurate information whenever you send us a refund for out-of-area members. BCBSNC s goal is to minimize the occurrence of returned payments. However, if you do return a payment to us, the Inter-Plan Programs team will work with both you and the member s Plan to process the returned payment and it s associated claim, in an accurate and timely manner. So that we can effectively represent you when contacting the member s Plan about a refund, we need sufficient documentation to link a particular refund to a specific claim. When sending provide initiated refunds to BCBSNC, please use the following checklist to help ensure that all necessary information is provided: t All explanation of benefits pertaining to the claim t Patients name and ID number including the alpha prefix t Provider name, ID number and mailing address t The specific reason why the refund is being returned such as; duplicate payment, workers compensation, Medicare payment is primary, other carrier paid primary, corrected claim, billing error, etc. Unfortunately, if we cannot accurately associate your returned payment amount to the appropriate claim, BCBSNC must return the payment to you. Submitting the above information will help ensure that you re returned payment is processed appropriately. Verifying Blue Member eligibility now easier and better At BCBSNC, provider satisfaction is our top priority. We understand you need the right tools and resources to provide the best care to Blue members. To help you obtain member eligibility more quickly, we have enhanced our Blue e electronic services. In addition to the detailed eligibility information for BCBSNC members, you can obtain comparable information for out-of-area Blue members, including: You can now request eligibility information for a specific service type and receive the eligibility information for that specific service type, such as benefit limitations and benefits for the place of service. For example: t The number of times a member can visit for chiropractic care or physical therapy, or the maximum age for well-baby care. t Any benefit differentials according to where the service is performed for example, $10 copayment for surgery in dermatologist office or $50 copay for surgery in a hospital outpatient setting. t You can also receive explicit patient responsibility information if the member has tiered benefits. 10 (continued on page 11)

11 Inter-Plan Programs: Updates and reminders (continued from page 10) To submit Blue e electronic eligibility requests for Blue members, follow these three easy steps: 1. Sign on to Blue e 2. Select verify member eligibility 3. Submit your request In addition to receiving eligibility verifications electronically, you can always call the BlueCard eligibility line at BLUE (2583). Providers with Blue e can verify eligibility, benefits and claim status immediately and from the convenience of their desktop computer. To find out more about signing up for Blue e, visit BCBSNC Electronic Solutions on the Web at Medical record initiatives In an ongoing effort to continue increasing provider satisfaction, BCBSNC has launched initiatives to improve convenience and efficiency for providers responding to medical records requests. In the past, this has been a source of provider dissatisfaction, mostly due to concerns about claim processing delays, additional follow-up and possible adjustments, all of which result in higher administrative costs and delays in payment. The following is an overview of some our medical record initiatives currently in process to benefit both our members and providers: t A new Inter-Plan Program (IPP) business processes that allows us to direct misrouted information (e.g., claims, medical information) to all other Blue Plans t Streamlining customer service methods to map received medical information quickly and efficiently to a suspended claim t Improving clarity and quality of medical information requests sent to providers t Improving the information provided on the notification of payment NOP when a claim is denied because we need more information in order to process t Participating in a pilot program along with BCBSA and other Blue plans to identify how we may be able to reduce medical information requests from providers t Introducing the touch-less medical request processes for our Inter-Plan Programs (IPP) department t IPP is continuing to identify ways to optimize the use of the Provider Link and fax between BCBSNC host and providers, as well as, BCBSNC host and the member s Plan. You have a key role in providing information P F A By only sending medical information after receiving a formal request from BCBSNC for the needed documentation not after receiving a NOP or EOB. l When medical records are needed to process a BlueCard member s claim, the provider from whom records are needed will receive a medical records request letter. Medical records should not be sent for processing a BlueCard member s claim due to a remark code listed on an NOP or EOB. Please remember to always attach the medical records request letter from BCBSNC as the cover sheet, placing it on top of the medical records before you submit them to BCBSNC. This will allow us to efficiently match the information to the claim and speed up claim processing. Please remember that you play a key role by providing all information necessary to help us validate membership, benefits, and make correct payments for rendered services. Some of these medical record initiatives are IPP specific, where others will enable BCBSNC to make overall improvements to how we handle medical records. In future Blue Links we will continue to provide you with updates as these initiatives are implemented. Our intent is to keep you informed, so also watch for updates via Blue e and through meetings with your servicing teams. BCBSNC Commercial formulary information The most up-to-date formulary information for BCBSNC commercial plans can be found on the Prescription Drug Search located on our Web site at bcbsnc.com. Just type in the name of the drug you are looking for, and you will find information on that drug s tier value, generic availability, average ingredient cost and other important information. To compare tier and average cost information between drugs in the same or similar therapeutic class, click on Review Options. The prescription drug formulary for commercial BCBSNC health plans will soon be available as a printable document at bcbsnc.com. This document will be updated quarterly. 11

12 Blue e updates Health eligibility In the Spring 2007 edition of Blue Link, we provided preliminary information regarding the redesign of Health Eligibility on Blue e. BCBSNC is pleased that the enhancements were implemented in April Blue e now features a redesigned Eligibility transaction offering exciting new features and more comprehensive benefits information. A detailed Job Aid describing these new features is available for review by clicking Help from the Blue e home page. NPI entry In March 2007, BCBSNC made necessary changes to allow for the entry of the National Provider Identifier (NPI) for the Admission Notification transaction on Blue e. Admission Notification can accept the fivecharacter BCBSNC provider number or the ten-digit NPI. Two screens require the entry of a provider identifier within the Admission Notification transaction: Admission/ Treatment Input screen for the billing provider ID and the Admission/Treatment Add screen, which has a section where the attending physician s identifier can be added. Hospitals can access the Job Aid for these changes by clicking Help from the Blue e home page. 837 Denial Listing As a reminder, the HIPAA Claim (837) Denial Listing transaction is used to search for 837 institutional and professional claims that have failed processing because of business edits or HIPAA Implementation Guide edits. Claims that appear on the 837 Denial Listing have not been accepted into BCBSNC s processing systems. These claims should be resubmitted as original claims unless there is already a claim on the BCBSNC claims processing systems and the submission is a corrected or replacement claim. NPI for physician assistants and nurse practitioners If your office employs physician assistants or registered nurse practitioners, you may have applied and received National Provider Identifiers for them. However, please do not use the physician assistant or nurse practitioner s NPI when reporting services in claim submissions to BCBSNC. Instead, please continue to report services provided by them under the NPI or BCBSNC assigned provider number of the supervising physician providing the oversight. UB-04 and CMS-1500 UB-04 and CMS-1500 claim entry users can obtain information and instruction for entering UB04 and CMS-1500 claims on Blue e by referring to the UB-04 and CMS-1500 job aids, available at Help on the Blue e home page. Blue e account management You now have the ability to request additional user IDs and provider identifier additions online. Previously, the only option was to fax a request using the PDF forms available at Remember, if you have an existing Blue e account, you are not required to complete a new Interactive Network Agreement. The online request for user IDs and provider number additions to existing Blue e accounts is available within Blue e at: We will process your online requests within five business days of receipt. Please note: Providers that handle their own Blue e security should contact their Entity Administrator for any user ID additions or deletions. There is also now a secure online utility available on the Blue e logon page if you forget your user ID. HIPAA transaction updates P F A The Introduction and Eligibility sections of the BCBSNC HIPAA Companion Guide have been revised to reflect the increased member benefit information and real time inquiry processing changes that were effective in April To review these revisions, please visit our Web site at If you utilize the services of a vendor or clearinghouse, please discuss these changes with them and their plans for implementation for your facility or practice. P F A Please note that BCBSNC does not directly reimburse physician assistants or registered nurse practitioners for services provided in a physician s office and that filing claims using physician assistants or registered nurses NPI can delay claims processing, which can also delay payment to your practice. 12

13 State Health Plan: Updates and reminders for State Health Plan CMM (indemnity) and NC Health Choice Vaccine administration codes and The State Health CMM (indemnity) Plan and NC Health Choice will now allow benefits for the following two vaccine administration codes when a member receives a vaccine in a provider s office that has been purchased by the provider: Immunization administration (one vaccine) Immunization administration (each additional vaccine) The allowance for codes and will be $13.71 each. If a provider submits a claim for codes and 90472, the reimbursement will be $ The maximum reimbursement allowed per day will be $27.42 regardless of the number of units billed. If a member receives a state supplied vaccine, the provider should file the claim with the specific procedure code, and append a modifier 52. This modifier indicates that the provider is only requesting payment for administering the vaccine. The allowance will be $13.71 for one vaccine, and a maximum of $27.42 will be allowed for two or more vaccines. If a provider administers state supplied vaccines and purchased vaccines on the same day, the vaccines that were purchased by the provider must be listed on the claim first, or codes and will be denied. Anesthesia claims The State Health CMM (indemnity) Plan is no longer mailing anesthesia claims back to providers if the start and stop time(s) is not indicated. The number of minutes must be indicated in the units field of the claim form. All anesthesia claims (with the except of claims filed with codes 01960, and 01967) must be submitted with the nationally recognized code sets for anesthesia services and affixed with one of the following modifiers: AA, AD, QK, QS, QX, QY, QZ. If any of the above information is missing, the claim will be mailed back to the provider. Positron Emission Tomography PET Scans The State Health CMM (indemnity) Plan does not participate in the BCBSNC Diagnostic Imaging Management Program; therefore, prior approval is not required for a State CMM (indemnity) member before receiving a PET scan. However, most hospitals ask us to do a courtesy review so they will know if the PET scan will be eligible by the State CMM (indemnity) Plan. For clinical criteria, see the Positron Emission Tomography medical policy on the State Health Plan Web site at Clinical documentation, including diagnosis and other recent imaging studies should be faxed to For all cases, include the anticipated place of service, a contact name, and a phone and fax number. If the physician is requesting a PET scan for a patient who does not meet the clinical criteria, as outlined in the medical policy, we must have a statement from the ordering physician stating the reason for ordering a PET scan at this time, as well as how the results will impact the treatment plan. NC HealthSmart P F A Rx The North Carolina State Health CMM (indemnity) Plan offers NC HealthSmart, an initiative designed to help eligible members* stay healthy and to support physicians as they care for members with chronic medical conditions. One of NC HealthSmart s goals is to link members more closely with their physicians, supporting the Medical Home concept. NC HealthSmart provides broad health and wellness support for members, particularly those who have diabetes, asthma, coronary heart disease, heart failure and chronic obstructive pulmonary disease. All members with these diseases receive mailed educational information and are encouraged to call Health Coaches 24/7 for health care information or support. In addition to working with members, the NC HealthSmart initiative supports physician practices. A practice support tool, the SMART Registry, offered twice a year, is designed to assist physicians in providing high quality, evidence based care to NC HealthSmart eligible patients with chronic illnesses. The SMART Registry offers practical, relevant information about the physician s patients in an easy to use format. This tool enables physicians to identify State Health Plan members who have targeted chronic illnesses and helps physicians more easily monitor the member s care plan. The NC HealthSmart initiative also supports physician practices with access to Provider Service Specialists, clinicians who are knowledgeable about NC HealthSmart. Provider Service Specialists are available to meet with physicians and their office staff to provide additional program information and practical patient education and management tools. Physicians can request information, refer a member for health coaching, or provide program feedback by calling the NC HealthSmart Provider Support Line at (continued on page 14) 13

14 Updates and Reminders for State Health Plan CMM (indemnity) and NC Health Choice (Continued from page 13) P F A Rx Visit NC HealthSmart and learn more at State Health Plan Benefits Update The North Carolina State Health Plan has updated benefits for the Plan years! These benefit changes affect State employees and retirees actively enrolled in the State Health Plan Indemnity plan or one of the NC SmartChoice SM Blue Options SM PPO plans. Visit the State Health Plan s Web site at for more information. *Members eligible for NC HealthSmart services are members whose primary health insurance is through the NC State Health Plan, and who are not on COBRA. Blue Cross and Blue Shield of North Carolina and the State Health Plan reward North Carolina physicians for raising the quality of care 114 BCBSNC has recognized and rewarded more than 135 physicians statewide, representing 29 practices, for meeting stringent national quality health care standards under the national Bridges to Excellence 1 coalition. The Bridges to Excellence coalition is a not-for-profit organization created to encourage significant leaps in the quality of care by recognizing and rewarding health care providers who demonstrate that they deliver safe, timely, effective, efficient and patient-centered care. Bridges to Excellence participants include large employers, health plans, the National Committee for Quality Assurance, Medstat, and WebMD Health, among others. The organizations are united in their shared goal of improving health care quality through measurement, reporting, rewards and education. BCBSNC is the first health insurer in North Carolina to implement Bridges to Excellence, which has programs in seven other states. The North Carolina State Health Plan is collaborating in the three-year pilot program and contributed funds to the physician incentive reward pool. Bridges to Excellence rewards physicians and physician practices for delivering safer, more effective and more efficient care through incentives and recognition, said Bob Greczyn, president and CEO of BCBSNC. This, in turn, will enhance the quality of care received by BCBSNC and State Health Plan members. We think the program will also address affordability by encouraging more costeffective care delivery. Some examples of changes implemented in these North Carolina practices include improving follow up and tracking of patients, applying electronic prescribing, changing follow-up triage systems and improving overall office efficiencies by using information systematically to improve the quality of patient care. Physicians achieved recognition in three distinct programs to be eligible for rewards and recognition. All three areas are based on standards established by the National Committee on Quality Assurance (NCQA): t Diabetes care t Heart and stroke care t Physician office management, including clinical information systems, patient education and support, and care management BCBSNC launched the Bridges to Excellence program in 2006 as a three-year pilot program to evaluate the program s effectiveness in improving care and reducing costs. Physicians may apply for additional recognition twice yearly and are eligible for an annual payment for each recognition. To learn more about Bridges to Excellence or to ask about participation in North Carolina, please visit the Bridges to Excellence Web site at

15 Claims submission and status management made easy with RealMed Are you tired of losing track of your insurance claims after they leave your office? Do you spend hours of your precious time making calls or visiting Web sites in a time consuming attempt to check claim status? How much easier would your job be if you could submit and track your claims more efficiently? Streamlining your claims submission and status management processes by submitting claims electronically will save your staff from making phone calls and filling out paperwork, as they chase unpaid claims. Additionally, filing claims electronically allows you to spot errors that could lead to claims denials early in the submission process, which will lead to quicker payments and increased cash flow. RealMed, an all-in-one revenue cycle management solution, can help your practice reap the benefits of electronic claims submission. Here are just two of the ways RealMed can help take the pain out of your practice s claims submission and status management processes: FEP Healthy Endeavors program The Federal Employees Health Benefits Program is pleased to announce the addition of Healthy Endeavors a disease management program available to our Service Benefit Plan members. In addition to our diabetes program we are now offering a cardiac program as of September By enrolling in these free programs, members will receive valuable educational materials and have the opportunity to work with a health coach to develop personal health objectives. In addition to these two in-house programs, we have also contracted with Accordant and Magellan to offer even more services to our members. Accordant manages our members with the following rare, chronic diseases: seizure disorders, RA, MS, Parkinson s Disease, SLE, Myasthenia Gravis, Sickle Cell Anemia, CF, Hemophilia, Scleroderma, Polymyositis, CIDP, ALS, Dermatomyositis, and Gaucher Disease. Magellan Health Services offers Condition Care Management Med/Psych a program designed to assist members who have co-existing medical and behavioral conditions as well as severe medical conditions that can be addressed utilizing behavioral health support techniques. All of our programs are absolutely free to FEP Service Benefit Plan members and are voluntary. If you would like to learn more about our programs, please call Healthy Endeavors at t Claims submission RealMed allows your practice to instantly submit single claims or unlimited-size batch files to payors through a Web-based, HIPAA-compliant system. Because of RealMed s direct connections to major payors, claims are processed in real-time. As a result, you receive a significantly faster return of remittance and payment. t Status management P F A RealMed updates claim status each day on most pending claims, and allow you to sort them by status category, payor, date range, age, claim number and provider, so that you can see problem claims or categories of claims. This shifts the use of your staff s time from seeking status information to actually using it and taking action accordingly. For additional information on how RealMed can boost your cash flow and improve your administrative efficiency, contact Jeff Dolan at or visit RealMed online at 15

16 How can you access health-coaching staff? P F A Health coaches work with physicians to facilitate the most medically appropriate, cost effective quality care for our members. Health coaches are available to discuss the health care management process and the authorization of services for your patients. You can contact a health coach by the following methods: t You can obtain certification, request discharge services, and get information regarding a request by calling Monday through Friday, 8 a.m. 5 p.m. Eastern Time. When calling after hours: o For discharge services, leave a detailed message at extension for response on the next business day. o For all other requests, leave a detailed message at the identified prompt for response on the next business day. If you are contacting health coaching to request prior plan approval, you may request by fax or use our online request form, both available on the BCBSNC Web site at When faxing a request please use one of the following numbers, 24 hours a day, 7 days a week: t State PPO t Region 1 - Asheville/Charlotte t Region 2 - Raleigh/Chapel Hill/Greenville (includes out of state requests) t Region 3 - Durham/Greensboro/Winston Salem/ Wilmington t Pharmacy t Discharge Services Health care management functions can be accessed via the Provider Blue Line at , and information may also be obtained via Blue e, our free Web-based tool available to participating providers. Claims filing reminder for HDME providers: Submitting miscellaneous codes P F A BCBSNC considers home durable medical equipment (HDME) as any equipment that that can withstand repeated use in the patient s home and provides therapeutic benefits to the patient due to certain medical conditions and/or illness. HDME consists of items that are primarily and customarily used to serve a medical purpose, are not useful to a person in the absence of illness or injury and are ordered or prescribed by a physician. Certain HDME services and equipment require prior plan approval (PPA). The complete list of HDME that requires PPA is located on the BCBSNC Web site at Claims for HDME should be reported on a CMS-1500 claim form (version 08/05), with the HDME clearly identified by the appropriate HCPCS code. In the absence of a suitable HCPCS code, BCBSNC will accept code E1399 or other miscellaneous codes, however, only if a designated HCPCS code is nonexistent (E1399 for HDME that has a purchase price of $ and above requires prior plan approval). When billing "miscellaneous" codes to BCBSNC, always submit the following required documentation with the claim: Submitting information in the following manner will delay payment: t Submission of invoices with white out covering information on the invoices t Submission of manufacturers suggested retail pricing and not actual invoices t Submission of work orders t Submission of invoices showing wholesale prices but not the actual cost of the equipment If you are a HDME provider and have questions about how to submit claims to BCBSNC, please contact your local Network Management field office for assistance. t Complete description of the item t Factory invoice for the item t Certificate of medical necessity form with physician s signature 1 16

17 Coming soon: More improvements to our phone system P F A Rx Based on feedback from providers like you, we are making more changes to our automated phone system (also known as the VRU) that will be introduced this fall. Here s what you have to look forward to: t Menu options moved up front One of the biggest changes you ll see is that we ll capture your reason for calling right up front, so no matter if your question is about authorizations, prior approvals or Blue e, you ll be routed immediately, instead of being prompted for patient information. If you have a question about benefits and eligibility or claims, you ll still be asked for patient information, but you ll no longer need to decide up front how many patients you want to enter information. Instead, you can choose to enter additional patient information as you go. t Prompting for National Provider Identifier (NPI) You ll also be asked to enter your National Provider Identifier (NPI) number, which providers are requested to register with BCBSNC. Entering your NPI instead of your BCBSNC assigned provider number allows us to more quickly identify you. And since the NPI is all numeric, you can easily enter this number using your telephone keypad or by just speaking. But don t worry you ll still be able to use your Tax ID or BCBSNC provider number if you don t yet have an NPI, through the final migration date for full NPI usage. t Automated benefits and eligibility summaries All callers requesting benefits and eligibility information will automatically receive an eligibility summary, so you ll know right away whether or not the patient s policy is active and if a pre-existing waiting period is in effect (and if there is one in effect, you ll find out what day it will end). If you like, you can also request an automated benefits summary, which will tell you what the patient s copayment, coinsurance and deductible amounts are and how much of the deductible and/or coinsurance maximums have been met. You ll be able to inquire about as many patients as you like within the VRU, but will still be able to reach a representative if you have additional questions. As an added bonus, this self-service capability will be available to you nearly 24 hours a day, seven days a week! Help us to help you It will make your call go faster if you have your NPI number and relevant patient records available when you call. Here s the information you may be asked for, depending on the reason for your call: t Your NPI number t Each patient s subscriber number (including alpha prefix) t Each patient s date of birth t The relevant claim date(s) of service And remember, these are some things you can do to help make the call go faster: Use a regular handset (rather than a speakerphone, headset or cell phone) Speak in your normal voice (speaking louder or more slowly than normal will actually make it more difficult for our system to understand you) Try to place your calls in a quiet area where there is not a lot of background noise When the system asks you for the letters at the beginning of the patient s subscriber number, please provide all the letters, including the W, if there is one. Also, remember that many of your customer service needs, including eligibility and claim status inquiries, claims filings, admission and treatment notifications and remittance information, can be handled using Blue e, our online provider system. Contact your Electronic Solutions field consultant or visit bcbsnc.com/providers to find out more about Blue e. Protecting your patients health care needs P F A Rx Did you know that there are standards in place that protect health care consumers? The National Committee for Quality Assurance (NCQA), a not-for-profit organization that accredits BCBSNC, has developed standards that do just that. NCQA and BCBSNC want you to know that: Any decisions made about coverage for care or service are based on your patient s benefit plan, BCBSNC medical policy and information from the doctor about the patient s medical condition. The BCBSNC doctors and nurses who review your or your patient s requests for service or coverage are not rewarded for denying or limiting coverage. At BCBSNC, we are committed to making appropriate coverage decisions about our members health care that meet the terms of their health benefit plan while meeting their medical needs. 17

18 New generics are available Generic equivalents for the following drug products have recently become available. These generic products are available at the lowest copayment level, Tier 1, on the BCBSNC commercial and Medicare Part D formularies. Remember to tell your patients that the FDA requires generic drugs to have the same quality, strength, purity and stability as their brand-name counterparts. Please P F Rx save money for your patients and prescribe generic drug products when appropriate. Please note: Omeprazole (generic Prilosec) is now covered on the BCBSNC commercial and Medicare Part D formularies. New Generics Tier 1 (Lowest copayment amount) Brand-name Generic Therapeutic Class Prilosec 20 mg Omeprazole 20 mg Proton Pump Inhibitors Ambien Zolpidem tablet 5, 10 mg Hypnotic Agents Inderal LA Propranolol long-acting Beta Blockers Mavik Trandolapril ACE Inhibitors Univasc Moexipril ACE Inhibitors Uniretic Moexipril / hydrochlorothiazide Combination Antihypertensives Norvasc Amlodipine Calcium Channel Blockers Duragesic 12 mcg/hr patch Fentanyl 12 mcg/hr patch Narcotic Analgesics Cipro XR Ciprofloxacin extended-release tablet Fluoroquinolones Commercial Drug Formulary Update BCBSNC and its Pharmacy & Therapeutics (P&T) Committee have reviewed the following new drugs and determined their formulary tier (copayment) placement on the BCBSNC commercial formulary. Tier 3 Brands (highest copayment amount) Brand-name Generic Therapeutic Class Angeliq Drospirenone / estradiol Estrogen Combinations Invega Paliperidone Miscellaneous Antipsychotics MoviPrep PEG 3350, electrolytes, sodium Bowel Evacuants ascorbate and ascorbic acid for oral solution Femcon Fe Norethindrone / ethinyl estradiol Oral Contraceptives Januvia Sitagliptin Non-Insulin Hypoglycemic Agents Verdeso Desonide 0.05% foam Topical Corticosteroids, Low Potency Desonate Desonide 0.05% gel Topical Corticosteroids, Low Potency Ziana Clindamycin phosphate 1.2% / Therapy for Acne tretinoin 0.025% gel 1 18 (continued on page 19)

19 New generics are available (Continued from page 18) P F Rx Tier 4* Specialty Drugs (coinsurance amount) Brand-name Generic Therapeutic Class Fentora Fentanyl buccal tablet Narcotic Analgesics *For those members with the 4-tier formulary Zostavax vaccine Zostavax (the zoster vaccine) is indicated for the prevention of herpes zoster (shingles) in adults 60 years of age and older. Zostavax works to prevent the incidence of shingles, but even vaccinated individuals who later develop shingles have a lower risk of developing postherpetic neuralgia and certain other complications. Zostavax is administered subcutaneously as a single dose. This vaccine is stored frozen and should be reconstituted immediately upon removal from the freezer. The vaccine should be administered directly after reconstitution and any unused amounts should be discarded after 30 minutes and may not be refrozen. Zostavax is not recommended for patients that: t Are allergic to any of its ingredients, including allergies to gelatin or neomycin t Have a disease or condition that causes immunodeficiency, or are taking immunosuppressives, including high dose corticosteroids t Have active TB (tuberculosis) that is not being treated t Are pregnant or may be pregnant Commercial (non-medicare Part D) members: The Zostavax vaccine, like other vaccines, is considered a medical benefit option vs. a prescription drug benefit for non-medicare members. Eligible members are to obtain the vaccine from their health care provider who should bill BCBSNC. The vaccine is not covered under the commercial pharmacy benefit. Medicare Part D members: Eligible members having Medicare Part D benefits can receive Zostavax vaccine as a pharmacy benefit. In neither case, should a member be sent to a pharmacy to obtain the vaccine, as it must remain in the frozen state until immediately before administration. We are currently asking that members with Medicare Part D (not BCBSNC commercial members) pay at the provider s office for the vaccine and then file a member s claim form directly to BCBSNC for their charge. BCBSNC is currently working with Medco, our pharmacy benefits manager, to develop an easier way for office-administered vaccines to be adjudicated under Medicare Part D and we will share those details once we have a finalized plan. P 19

20 Editor: Howard Barwell PO Box 2291 Durham, NC PRSRT STD U.S. POSTAGE PAID BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA Address Service Requested Visit us online at bcbsnc.com/providers Blue Link going green reminder You re important to us and we don t want to lose you as a reader. Please don t forget to visit us on the Web at bcbsnc.com/providers/ on or after December 27, 2007 to receive your next edition of Blue Link. Find out the latest news from BCBSNC affecting providers, read our medical policies, see the most current prior review listing, review the most current Blue Book provider manual, or catch up on past issues of Blue Link. It s all available on the Web for providers at bcbsnc.com/providers/. Please visit us often! Footnotes 1 Forests and the North Carolina Economy, N.C. State University, Cooperative Extension (2002). 2 United States Environmental Protection Agency, Factoids: Drinking Water and Ground Water Statistics for 2004, EPA 816-K , (2005): Forest Statistics for North Carolina, 2002, Resource Bulletin SRS-88, (2004). 4 The Southern Forest Resource Assessment, General Technical Report SRS-54, (2004). Data available at An independent licensee of the Blue Cross and Blue Shield Association., SM Marks of the Blue Cross and Blue Shield Association. SM 1 Mark of Blue Cross and Blue Shield of North Carolina. 1 Mark of Bridges to Excellence, Inc. U4577, 10/07