Reminder: ProviderAccess users no longer receiving paper remittances starting September 1, 2009

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1 AUGUST 7, 2009 NEVADA Exclusive DME Contract with Bennett Medical Services As a reminder, Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada, have an exclusive agreement with Bennett Medical Services to provide all durable medical equipment (DME) services for our members (including FEP and BlueCard members). Medically necessary DME ordered by a physician includes the provision of and instructions for the use of the equipment, as well as routine maintenance and follow-up services. DME includes, but is not limited to: oxygen and respiratory equipment, apnea monitors, nebulizers, CPAP and BIPAP machines, hospital beds, commodes, wheelchairs, walkers, canes, and crutches. Bennett Medical Services can be reached at in Northern Nevada or in Southern Nevada. Members receiving DME services from any DME provider other than Bennett Medical Services will be charged out-of-network fees. They will also be subject to balance billing, so we are counting on you as a contracted provider to direct our members to Bennett Medical Services to help keep their out-of-pocket costs lower. Medical/disposable supplies such as those used for diabetic, ostomy and wound care can be provided via home delivery by calling Edgepark Surgical Supplies at or Sterling Medical Services at Exclusive agreement for Reference Laboratory with LabCorp As a reminder, Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada, have an exclusive agreement with Laboratory Corporation of America (LabCorp ) to provide all laboratory and diagnostic testing for our members (including FEP and BlueCard ). Outpatient laboratory testing must be performed at LabCorp to receive the In Network level of benefit. Provider may draw blood work and Anthem will pay a drawing fee to physicians forwarding specimens to LabCorp for processing. Hospital/Providers may continue to process lab work in their office/facility. Reminder: ProviderAccess users no longer receiving paper remittances starting September 1, 2009 As a reminder from our July issue of Network Update, Anthem is now posting your remittances on ProviderAccess. All ProviderAccess users who have the rights to view claims data online automatically have remittance viewing access. At your convenience, you are now able to view, print, and save your remittances in a protective PDF format. Note: Remittances will be available for Local and BlueCard members (Federal Employee Program members will not be available you will continue to receive these remittances via paper). Through August 31, 2009, you will continue to receive mailed paper remittances and will also be able to view online remittances. Beginning September 1, 2009, ProviderAccess users will no longer receive mailed paper remittances. Now you will have the capability and control of viewing, saving, and printing your online remittances anytime.

2 Additional information: Please find additional information about our online provider remittances at anthem.com > Providers > Nevada. Click on the Anthem is Going Green - Access Provider Remittances Online 24/7! link to view helpful screenshots of our new tool and read answers to frequently asked questions. Register for ProviderAccess today no cost to use! If you re not already registered for ProviderAccess, just visit anthem.com > Providers > Nevada. Click the Register Now link in the Anthem Online Provider Services box to sign up today. New specialty pharmacy benefit for Anthem NV group members Anthem Blue Cross and Blue Shield is working to help members with complex, chronic conditions through our specialty pharmacy program. Beginning October 1, 2009 (on the group renewal date), all Nevada group members will need to obtain medications on our specialty drug list from the in-network specialty pharmacy - PrecisionRx Specialty Solutions - to access the highest benefit coverage level (lowest copay/coinsurance amount). If they use an out-of-network pharmacy, members will pay the full cash price for the medication and must submit for reimbursement at the out-of network rate on a claim form. To minimize abrasion, impacted members will be notified 30 days prior to group implementation date to transfer their prescriptions to PrecisionRx Specialty Solutions. This specialty pharmacy benefit only applies to medications which are billed through the member s pharmacy benefit. It does not apply to medications which are provided by a physician and administered in the office. You can view the NV Self-Administered Specialty Drug List after September 1, 2009 online at anthem.com > Nevada > Provider > Plans & Benefits > Prescription > Specialty Drugs. Specialty drugs will be limited to a 30-day supply with applicable copay/coinsurance. Inclusion of a drug on the specialty drug list is not a guarantee of coverage and certain drugs may require prior authorization (members should refer to their certificate of coverage and benefit material for details of their pharmacy coverage). To learn more about PrecisionRx Specialty Solutions, log on to precisionrxspecialtysolutions.com. Medicare Advantage: fraud, waste and abuse training for delegated and downstream providers The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage plan sponsors to have policies and procedures to identify and address fraud, waste and abuse (FWA) in the delivery of health care services through the Medicare Advantage benefit. This regulation can be found within the Federal Code of Regulations, title 42 parts and CMS also requires Medicare Advantage plan providers to have a procedure in place to facilitate pharmacy fraud, waste and abuse training and education for vendors and providers. In accordance with these CMS stipulations, Anthem Blue Cross and Blue Shield and its subsidiaries requires vendors and providers to train employees in FWA. Many physicians and provider groups may be using a training program developed internally, by corporate headquarters or by their state s medical association. If your practice does not have a training program, the National Health Care Antifraud Association (NHCAA), in conjunction with the Blue Cross and Blue Shield Association (BCBSA), has launched an online Fraud, Waste and Abuse General Compliance Training Course. This course was developed in collaboration with LearnSomething, Inc., a leading producer of customized, multimedia training and learning management solutions. This online training program was specifically developed to help Medicare Advantage first tier and downstream contractors meet CMS compliance requirements. You can access the online training via the course portal at This course is reasonably priced, with volume discounts available and can be purchased through this link.

3 Every provider and vendor that administers services to Medicare Advantage beneficiaries must complete a fraud, waste and abuse training session by December 31, 2009 and annually there after. You are only required to take training once a year to satisfy the CMS requirement for all insurers. In an effort to collect physician and provider group data regarding the FWA training, we are diligently working to implement an attestation statement program for all providers and groups who have an internal FWA training program. Once this program is initiated, we will post additional instructions via our website. Additional information is available via our website or by contacting customer service. Please be sure to check our website for updates to this CMS required fraud, waste and abuse training. Coexisting Depression and Anxiety Program: helping members with chronic medical conditions Anthem Blue Cross and Blue Shield and its health and wellness solution, 360 Health, continues its depression and anxiety screening program for members with chronic medical conditions. The primary goal of the Coexisting Depression and Anxiety Program (CoDA) is to screen, provide education and resources, discuss treatment options and link members with the needed behavioral health services. Integrating services with medical ComplexCare and ConditionCare programs recognizes the mind and body connection to support members with medical and behavioral issues in one comprehensive program. According to the American Academy of Family Physicians, studies show a link between multiple long-term medical conditions and depression. For instance, patients with chronic pain have been shown to have an increased rate of psychiatric diagnoses compared with the general population. In addition, non-depressed patients with a long-term medical condition were twice as likely to develop major depression within one year compared with persons who didn t have long-term medical conditions. The key, then, is to raise members awareness that their emotional health impacts their physical health. Licensed clinicians provide monitoring and coordination of care for six months to members who screen positive and enroll in the program. Also, with member consent, we send a letter to their physician, encouraging a discussion about the member s emotional health needs and any follow-up that s appropriate. It costs nothing for members to participate in this voluntary program, and participating in the screening and decisions regarding follow-up care won t affect their health insurance coverage or eligibility. In 2008, over 3600 referrals were made to the CoDA program. Of the 82% who screened positive and were enrolled, 31% modified their existing treatment or entered into new treatment, and 32% remained compliant with their existing treatment for depression and/or anxiety. That s a total of 63% that took action toward better overall health. If you d like more information, call Mindy Legere at ext Practice Guidelines and Medical Policies available on the web Anthem considers clinical practice guidelines to be an important part of our medical care delivery system and requires contracted providers to adopt the Anthem practice guidelines. All of the current nationally published Clinical Practice Guidelines adopted by Anthem are now available on the Anthem website including guidelines for Oncology, HF Condition Care, and Vascular at Risk Programs. To access the clinical practice or preventive guidelines from our website, go to anthem.com > Provider > Nevada > Health Information > Practice Guidelines. Upon request, we provide copies of the guidelines to Anthem contracted providers. To obtain a hard copy, please call or Current Medical Policies adopted by Anthem are also available on anthem.com under the Answers@Anthem tab.

4 We believe in continuous improvement Commitment to our members health and their satisfaction with the care and services they receive is the basis for the Anthem Blue Cross and Blue Shield Quality Improvement Program. We strive to support the patient-physician relationship, which ultimately drives all quality improvement. To receive information about our quality improvement program go to anthem.com > Provider > Nevada > Health Information > Quality. To obtain a copy by mail, please call or toll-free Medicare Advantage: New Prior Authorization fax number for Medicare Part D Our prescription Prior Authorization (PA) department now has one fax number for all of your for Medicare Part D requests. Please begin using this number immediately: PA Medicare Part D Fax number: The new number is noted on the updated Prior Authorization of Benefit (PAB) forms. To download new forms go to wellpointnextrx.com > Provider > Physician PAB Forms and follow the login instructions. The fax numbers for your non-medicare Part D requests remain the same. For the best response times, please remember to use the Medicare Part D fax line and Medicare Part D PA forms for all Medicare Part D requests. We hope this information will help simplify and expedite the prior authorization process for you and your Medicare Part D patients. If you still have questions, please feel free to contact us at , Monday through Friday, 8 a.m. to 6 p.m. Medicare Advantage: Alere oncology program The Alere oncology program is one of the most comprehensive cancer management programs in the industry. With Alere s team of experienced medical, radiologic and surgical oncologists, and a patient-centric primary nurse model, they are focused on reducing unnecessary hospitalizations, readmissions and ER visits. Nurses provide education, monitoring and support to participants through scheduled phone contact. Anthem Blue Cross and Blue Shield offers this program in conjunction with Alere and is branded as an Anthem Blue Cross and Blue Shield product to the members. Through an integrated and personalized approach, the program facilitates oncology care by: Managing physical and psychosocial aspects of the disease and its treatment Coordinating care among providers and settings in an effective and efficient way Alere care management nurses have an average of 13 years experience in oncology or related care settings. They utilize system-embedded industry guidelines derived from ASCO, NCI, and NCCN. The guidelines assist in reinforcing physician treatment plans for over 200 sites and stages of cancer. For patients meeting certain risk criteria, an in-person visit by an Alere nurse is available to assess the care environment for safety and support, and to consult with the patient and caregivers to optimize symptom management. Members referred to the Oncology program must be: Enrolled in a Anthem Blue Cross and Blue Shield Medicare Advantage Product Be at least 18 years old Diagnosed with cancer, undergoing active treatment, or planning to undergo treatment Please call the Anthem Blue Cross and Blue Shield Condition Care Program at when making a referral.

5 Skilled nursing facilities and home health agencies: file claims electronically save time and resources Many providers already file claims electronically to Anthem and are enjoying the benefits of improved cash flow. Electronic filing helps save time, increases office efficiency and reduces administrative and postage expenses. If you are a skilled nursing facility or home health agency filing paper claims, you should consider the benefits of filing transactions electronically. Though Anthem does NOT charge a fee for connectivity or electronic submission, clearinghouses and electronic vendors may add a fee and costs vary depending on the vendor and the services provided. However, it s still cost effective to file electronically. We work closely with clearinghouses and software vendors to ensure electronically transmitted information complies with the Health Insurance Portability and Accountability Act (HIPAA) guidelines. Take the important first step. Contact your clearinghouse, vendor or Anthem to learn more about electronic claims submissions. Supporting Documentation Is the need for supporting documentation preventing you from submitting claims electronically or from fully utilizing your electronic claims submission capabilities? With the implementation of additional HIPAA requirements, more information can be submitted electronically, reducing the need for supporting documentation. When Anthem pre-authorizes a service, supporting documentation is NOT needed since we have all the necessary information to process your claim. The following table identifies common reasons when supporting documentation is provided along with an explanation of what documentation, if any, is needed. Provider Type Common Supporting Documentation Reasons Supporting Documentation Paper Submission Supporting Documentation Electronic Submission Comments Skilled Nursing / Home Health Skilled Nursing / Home Health Pre-authorization (Health Services Review) Coordination of Benefits (COB) No No Paper/Electronic: When an authorization has been obtained, there is no need to attach a plan of care and plan of treatment. Yes No Electronic: All of the information found on the explanation of benefits (EOB) can be entered directly into the electronic claim file. Paper: Copy of the EOB and/or Explanation of Medicare Benefits (EOMB) is required. Skilled Nursing Level of Care No No Paper/Electronic: Report Level of care I through IV on UB-04 claim form, locator field 80. To learn more about filing electronically to Anthem, visit our web site at or contact an EDI Solutions specialist at