1 Working together to improve the health of our members. ISSUE 4, 2007 Network Update C e n t r a l R e g i o n In This Issue Page Account updates New groups... 1 Administrative Customer viewpoint program survey launched... 2 Anthem hosts 3rd annual Provider Expo in Wisconsin... 2 Zagat survey tool to launch in Ohio for Cincinnati and Dayton Providers... 4 Claims filing Filing claims after a newborn has a name... 5 Change in reimbursement for after hours services... 5 Reimbursement policy for attended modalities and therapeutic procedures... 5 EDI Electronic submitters: Have you filed all 2007 claims?... 6 Get connected with Electronic Funds Transfer... 6 Electronic Remittance Advice: Enroll today and get connected!... 6 Tips to help you reduce electronic claim rejects... 7 Medicare Part A and B crossover process changes... 8 Working with electronic reports from Anthem Blue Cross and Blue Shield... 8 Health care management HEDIS 2008 reporting: Medical office participation is essential... 9 Immunizations for older adults Practice guidelines for treating depression Medical Policy Update Upgrades to Medical Policy websites Prescription Formulary/drug list updates Products and Programs FEP members in Wisconsin and Missouri transition to new system FEP implements new claim refund process Introducing a new hospital surgical product from Anthem Blue Cross and Blue Shield Account updates New groups Chief Industries Effective July 1, 2007, the employees of Chief Industries were covered by BCBSNE under a Preferred Provider Organization (PPO) benefit plan. Currently, the approximately 125 Chief Industry employees reside in the Rensselear, Indiana area and have been covered under a PPO plan administered by Mutual of Omaha. If you have patients who are Chief Industry employees, please update your records with the information provided on their BCBS ID cards. The members new ID number (including the alpha prefix) will be different from what currently appears on your billing records. Bodine Aluminum, Inc. Effective January 1, 2008, Bodine Aluminum, Inc. will be administered on NASCO as part of the currently enrolled TEMA account. They will have the PPO benefits with the same prefix letters TOA. The new group number is Bodine team members are located in St. Louis, MO, Troy, MO and Jackson, TN. (continued on page 2) PCENW1070A (2/08)
2 New groups (continued) Cedar Fair Effective July 1, 2007, the employees of Cedar Fair were covered under a Preferred Provider Organization (PPO) benefit plan for their members who reside in Indiana, Kentucky, Missouri, Ohio and Wisconsin. Administrative Customer viewpoint program survey launched We want to achieve operational excellence for our members and the health care community. We look for ways to bring value, not only through our products and benefits, but also through hassle-free, cost-effective service. With that in mind, we re pleased to have launched our Customer Viewpoint Program survey, designed to listen to the needs of our health care partners, their expectations and experiences. This research program is a valuable tool for us to understand the perceptions of health care professionals, like you, and to guide the way we work to improve services for you and our members. Last year s feedback led to the development of several quality improvement initiatives and task teams throughout Anthem. Customer Viewpoint Program measures Your feedback is important to us We ve worked with Convergys, a strategic research partner, to administer this program and thank you for participating in the survey which helps us ensure we re focusing on what matters most to our health care partners. We look forward to receiving your feedback. Anthem hosts 3rd annual Provider Expo in Wisconsin Question: Where could you go on a workday (with your employer s approval) that generates comments like these? Liked the dancers, music, games and food. Great time. Great information. I think this is such a wonderful outreach! In my opinion, it puts BCBS (Anthem) ahead of the rest! I love the flags & color group idea. I never had to think about where I needed to be next, just find the orange flag. Answer: Anthem s 2007 Provider Expo Fiesta at the Olympia Resort in Oconomowoc, WI More than 200 medical and behavioral health administrators, practice managers and clinicians from across Wisconsin gathered for Anthem s 2007 Provider Expo Fiesta held at the Olympia Resort & Conference Center in Oconomowoc, WI. Anthem is more committed than ever to improving the health of our members and improving the quality and affordability of health care in Wisconsin through collaboration with hospitals, physicians and other health care professionals, said John Foley, vice president of health services for Anthem Blue Cross and Blue Shield in Wisconsin. Our Provider Expo has proven to be an excellent way for us to reinforce our commitment to partnering with providers in Wisconsin and educating them on Anthem s programs and services. Did our attendees agree? Again, here is what they thought: Thank you for reaching out to help the providers. You are one of a kind. Keep on doing this. Thank you Anthem really works hard at making sure the relationship between the provider and Anthem is a good one and at making sure patients/insured s needs and services are met. The program measures the satisfaction and experiences of: Medical physicians and office managers Dentists and dental office managers Behavioral health professionals
3 The event kicked off with opening remarks from John Jesser, Health Care Management Executive for Anthem s Central Zone states. To get warmed up for a full day of educational sessions, dance instructors from Fred Astaire Dance Studios, an exhibitor at the event, taught the group a rousing Latin dance resulting in a sea of smiling faces. Breakout sessions were led by Anthem s staff and outside speakers throughout the day. The sessions focused on clinical, service and business solutions to improve efficiency and working relationship with providers. Topics of the sessions included Anthem s new care management model, behavioral health initiatives and programs, PrecisionRx, E/M and mental health coding, e-review, and the Blue Cross Blue Shield Association s initiatives to enhance provider satisfaction. A complete listing of the subjects covered and downloadable versions of all Expo presentations are available on the Provider Education pages of our websites (anthem.com and bcbswi.com). Here is the URL for the provider education page on anthem.com: wps/portal/ahpprovider?content_ path=provider/wi/f5/s6/t0/pw_ ad htm&rootlevel=4&state=wi& label=provider%20education. Lunch featured a buffet in keeping with the Fiesta theme and entertainment by a live Mariachi band. Spontaneous dancing was spotted in the crowd. We want to thank our sponsors and exhibitors for their support. The Expo would not be possible without their assistance. We have listed our sponsors below. Additional exhibitors are listed in the Expo program posted on the Provider Education page on our websites. Promotions Sponsor and Exhibitor Overture Premiums and Promotions, LLC (www.overturepromo.com) Product/Service: Promotional products, gifts and incentives 595 North Lakeview Parkway, Vernon Hills, IL Phone: ; Fax: Company Representatives: Laura Isaacs and Ashley Baber Overture is woman-owned and has experience in web design, graphics, marketing, printing and fulfillment. From concept to implementation, Overture Premiums & Promotions is your single source for promotional products and gifts offering full in-house services and dedicated team members. Lunch Sponsor and Exhibitor American Imaging Management, Inc. (www.americanimaging.net) Product/Service: Outpatient radiology management services 540 Lake Cook Road, Suite 300, Deerfield, IL Phone: ; Fax: Company Representatives: Branis Pesich and Renee Keats American Imaging Management, Inc. (AIM) partners with leading health plans and health care providers to promote the most appropriate, highest quality and effective use of diagnostic imaging. AIM adds value to their partners through strategic market-based solutions that include client-centered products and services, innovative web-based applications and development of preferred imaging networks. Gold Sponsor and Exhibitor Atlantic Health Partners (www.atlantichealthpartners.com) Product/Service: Vaccine purchasing program 171 Dwight Road, Suite 310, Longmeadow, MA Phone: ; Fax: Company Representatives: Jeff Winokur and Andy Zaback Atlantic Health Partners provides physician practices with the tools and support to better manage vaccine expenses. Their program offers advantageous pricing and favorable purchasing terms directly with leading vaccine manufacturers. Bronze Sponsors MedPlus Inc., A Quest Diagnostics Company (www.care360.com) Product/Service: Care360, a MedPlus Solution 4690 Parkway Drive, Mason, OH Phone: ; Fax: Company Representatives: Cindy Jansen, Matt Graham, Teri Wallenberger Quest Diagnostics, the nation s leading provider of diagnostics testing, information and services, is also the leader in clinical orders and results management with the Care360 Physician Portal developed by MedPlus, the health care technology subsidiary of Quest Diagnostics. The Care360 Physician Portal now offers physicians a robust e-prescribing application. Health plans and physician groups also have access through Care360 to enhance their clinical decision management programs and predictive modeling initiatives. (continued on page 4)
4 Anthem hosts 3rd annual Provider Expo in Wisconsin (continued) Netwerkes, LLC (www.netwerkes.com) Product/Service: Internet-based services to the health care industry N16 W24132 Prairie Court, Suite 170, Waukesha, WI Phone: ; Fax: Company Representatives: Bill Rodakowski and Eric Mueller Netwerkes, LLC, is Wisconsin s leading provider of transaction services for the health care industry. Their service gives providers the tools necessary to manage their entire revenue cycle, reduce A/R days and maximize reimbursements. John Foley, vice president of health services, closed the day with remarks that reinforced Anthem s commitment to education as a key building block for positive working relationships with providers. And, last but certainly not least, attendees had the opportunity to win valuable door prizes. Zagat Survey Tool to Launch in Ohio for Cincinnati and Dayton Providers Anthem Blue Cross and Blue Shield in Ohio is excited to inform you about an innovative online survey tool that will promote peer-to-peer interaction among health care consumers by enabling members to share their experiences with physicians in the greater Cincinnati and Dayton areas. This Zagat Health Survey, which has received considerable media attention, is the result of a collaboration between Anthem and Zagat Survey (a well-known and trusted source for information about where to eat, drink, stay and play). Anthem is committed to providing its members with the data and tools necessary to help them take a more active role in their health care decision making. Consumer experience information such as that enabled by the Zagat Health Survey is an important complement to the clinical quality, cost and other tools Anthem provides to support consumers health care decision making. How Does the Tool Work? Consumers will be able to rate physicians on the following four categories: (1) Trust: Confidence in physician s approach, integrity and recommendations; (2) Communication: Physician s bedside manner, responsiveness and rapport with patients; (3) Availability: Convenient appointments, physician s punctuality and face-to-face time; and (4) Environment: Office condition, staff quality, atmosphere and amenities. Consumers will respond to the questions using Zagat s familiar 30-point scale. Each consumer will also be able to provide a comment about the physicians there are guidelines in place to ensure the comment is appropriate, and the comment and the ratings will be filtered to reduce the risk of inappropriate language. In addition, the tool and rating information are only available to Anthem members, not to the general public. Who Can Use The Tool? Currently, the tool is available to Anthem members who are enrolled in our consumer driven health plans, but it will be extended to all members in these areas during the first quarter of Anthem will continue to progressively introduce this tool across all of Ohio. How Do Providers Access the Information? The ratings will be available to consumers online through their health plan web site, starting with Consumer Driven Health Plan members in early January and then to members enrolled in other products. Beginning in late 2008, Anthem plans to enable providers to view their survey results via the existing Anthem online provider web portals. In the interim, Anthem is planning to share results via mail with those providers for whom sufficient data has been received. Note that physicians who are members covered by our health plans can complete a survey. These providers cannot respond to individual comments nor rate themselves. The survey information is not in any way tied to benefit or physician reimbursement levels. We look forward to sharing additional information about the details of this tool with you in the upcoming months. In the interim, please feel free to contact your local network representative should you have any questions. Thank you for working with us to improve our health care community!
5 Claims filing Filing claims after a newborn has a name We d like to help providers avoid handling newborn claims multiple times. With that in mind, we re asking providers and facilities to bill after they have a newborn s name. The challenges of filing under Baby Boy and Baby Girl Most plans allow for the 31-day baby to be covered, while hospital billing cycles are 15 to 30 days. The result is that claims may be sent with the wrong dates (Anthem needs the first 31 days billed separately in case there is no additional coverage beyond the 31-day time frame). Also, many facilities bill from the first of the month to the end of the month, and if a newborn stays beyond that time due to illness, there may be interim bills. This means days have to be corrected not only on the first claim but the interim claims as well. In addition, when there are twins, the claims could be loaded under the incorrect baby if they are submitted only as Baby A or Baby B. After the baby is named, this creates uncertainty about which infant the patient account number is actually assigned to. This also creates challenges with the interim bills for babies with extended stays. The solution: billing after the baby has a name If facilities and providers wait until after the baby has a name with the first 31 days on the first claim and subsequent charges on the interim bills the claims can be processed up front under the correct baby. This will save providers time and minimize confusion and delayed processing. With your help, we can make filing claims for newborns a smoother process. Change in reimbursement for after hours services Effective May 1, 2008, Anthem in Ohio, Kentucky, Missouri, Indiana and Wisconsin will allow additional reimbursement for only in the place of service office (place of service 11). Codes will be considered part of the primary service and will not be reimbursed separately in any place of service. Anthem recognizes that additional reimbursement is needed when services don t occur during regularly scheduled office hours. However, services that are provided during regular office hours or in 24-hour facilities are considered a normal course of business and are part of the reimbursement for the actual services provided. Below are codes that are used to indicate several miscellaneous services Service(s) provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service Service(s) provided in the office during regularly scheduled evening, weekend or holiday office hours, in addition to basic service Service(s) provided between 10:00 p.m. and 8:00 a.m. at a 24-hour facility, in addition to basic service Service(s) typically provided in the office, provided out of the office at request of the patient in addition to basic service Service(s) provided on an emergency basis in the office which disrupts other scheduled services, in addition to basic service Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service Reimbursement policy for attended modalities and therapeutic procedures Effective May 1, 2008, we will change our policy regarding how to report units for physical therapy procedures and modalities. Please use the following tips to ensure proper payment of your claims. Providers billing for a unit of an attended modality or therapeutic procedure must provide at least 8 minutes of service in order to bill and receive reimbursement for the unit. Services rendered for 7 minutes or less should not be billed as a unit of service and may be retracted upon audit. When partial services are rendered, do not bill these modality and therapeutic procedures using modifier 52. This reimbursement policy is supported by the Centers for Medicare and Medicaid Services (CMS) guidelines for physical medicine and rehabilitation found in the National Correct Coding Policy Manual for Part B Medicare Carriers.
6 Additionally, we ll implement the following protocol for each additional unit: Number of units billed 1 unit 8 minutes - 22 minutes Number of minutes provided in treatment 2 units 23 minutes - 37 minutes 3 units 38 minutes - 52 minutes 4 units 53 minutes - 67 minutes 5 units 68 minutes - 82 minutes 6 units 83 minutes - 97 minutes 7 units 98 minutes minutes 8 units 113 minutes minutes Note: The pattern remains the same for treatment times in excess of two (2) hours. Providers should not bill for services performed for less than eight (8) minutes. EDI Electronic submitters: Have you filed all 2007 claims? 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 year 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, which improves operating efficiency and cash flow for your practice or facility. Additionally, filing electronic claims helps decrease paperwork and reduce administrative expenses. You can also cut down on 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 about the electronic filing process, call our EDI specialists at from 8 a.m. to 5 p.m. ET. Get connected with Electronic Funds Transfer You don t have to wait for your check to arrive in the mail. Anthem can automatically deposit your claims payment through Electronic Funds Transfer (EFT). It s all about convenience, safety and faster payment, and this transaction is available at no cost to electronic claim submitters who are receiving their Remittance Advice electronically. Advantages of Electronic Funds Transfer EFT is a safe, secure and modern alternative to paper checks. Transactions are processed by the bank through the Automated Clearinghouse (ACH) network, the secure transfer system that connects all U.S. financial institutions. You may notice the following benefits with EFT: Offers administrative savings faster access to funds may improve cash flow, reduce paper volume and help staff save valuable time Helps prevent mail delays, lost checks and fraud Eliminates the cumbersome process of manually logging your deposit information Requires less manual intervention Reconciles payments with bank statements more easily Transfers funds electronically to the providers bank usually a full day before paper copies are mailed. Gives providers immediate access to funds The EFT enrollment process is simple Providers interested in taking advantage of EFT will need to complete the enrollment process. To sign up, you may download the Enrollment Form from our website or complete the form attached to the EOB. Follow the instructions provided and fax or mail the completed form along with other banking information required to Damian Sweeney for processing. The fax number is Electronic Remittance Advice: Enroll today and get connected! Quit the paper chase and have Remittance Advices delivered electronically direct to your office. If you currently submit electronic claims to Anthem, you re eligible to receive your claim remittance advice electronically at no cost from Anthem. The Electronic Remittance Advice (ERA) is an added benefit for our electronic claim submitters. If you currently receive paper remits, contact Electronic Data Interchange (EDI) Solutions today and enroll to begin electronic remittances.
7 What is an Electronic Remittance Advice? The ERA explains benefit payment information for Anthem claims. The data contained within the ERA is in the Health Insurance Portability and Accountability Act (HIPAA) compliant format, with nationally recognized HIPAA-compliant remark codes used by Medicare and other payers. Advantages of electronic remittance Offers administrative savings through reduced handling and processing time Eliminates papers and simplifies processes Prevents waiting for mailed copies Gets the file to your electronic mailbox the same day it s issued Provides electronic tracking of data and file storage Offers the option to upload to Practice Management System Automates and simplifies billing to other payers (COB) Helps the environment by reducing paper use Additional ERA options increase efficiency We encourage providers to contact their electronic vendors and/or clearinghouses to learn more about additional options available for ERA such as: Manual and automated posting options Single, easy-to-read, printer-friendly format for multiple payers Easy access to payer Explanation of Benefits (EOBs) Automated coordination of benefit claims filing Capability to quickly locate documents for research and customer service Image retrieval, which eliminates loss of misfiled documents Support and staff training Enrollment Process If you use a vendor or submit to a clearinghouse We recommend that providers using an EDI vendor and/or clearinghouse contact their representative to discuss the electronic remittances. This will ensure that procedures are followed appropriately for ERA enrollment allowing providers to have their questions answered concerning electronic remittance formats, delivery schedules and other support questions. If you submit directly to Anthem EDI Anthem does not charge a fee for submitters to receive the ERA; however, enrollment is required. To sign up with Anthem, you can either download the Enrollment Form from our website or contact your EDI team to request the form. Follow the instructions provided; once completed, fax the form to our EDI specialist for processing. If you have questions regarding the ERA enrollment process, please contact our EDI specialist at from 8 a.m. to 5 p.m. ET. Tips to help you reduce electronic claim rejects For providers submitting electronic claims, Anthem provides online tools to help you obtain claims and eligibility information, and allows you to verify member information prior to claim submission and quickly correct and resubmit claims in error often without missing a remittance cycle. Some of the most common errors are listed below. We ve included details on how you can ensure more accurate claims submissions and cleaner claims resulting in speedy claims payments. Error: Invalid Member Identifiers Submit both paper and electronic claims using the members identification numbers exactly as they appear on Members ID cards including the three-position alpha prefix. Alpha prefixes on Members identification (ID) cards are required for claims filing. Use MyAnthem for Providers to validate member name, sex, relationship and date of birth information prior to claim submission or as part of the electronic error correction. Visit us on the Internet at MyAnthem for Providers. Whenever possible, obtain a copy of the current member Identification card for your files. Error: The Tax ID or SSN must be sent for the Rendering Provider Secondary Identification Qualifier Ensure that you are using the correct combination of Identifiers for the Rendering Provider with the NPI. EDI: (Loop 2310B, REF01=EI or SY) when NPI is submitted (Loop 2310B, NM108=XX). Note: EI = Tax ID and SY = Social Security Number. Make sure you work with your vendor to ensure you are submitting the appropriate data in the correct fields. Complete NPI instructions can be found in our EDI companion guide located on our website at
8 Error: Invalid Code Sets Examples are invalid diagnosis, procedure code, principal diagnosis or procedure and value codes. Enter codes correctly, as codes must be carried to the fourth or fifth digit when required. Anthem adheres to the schedule for code set updates from the Centers for Medicare & Medicaid Services (CMS). Codes may have been updated, deleted or changed such as patient age/sex and code/place of service conflict. Work with your vendor or clearinghouse to ensure code set updates are scheduled and installed in a timely manner. VERY IMPORTANT: NPI ALERT IMMEDIATE ACTION REQUIRED! All providers must register their NPI number(s). Registering your NPI with us helps ensure a seamless conversion to NPI and minimizes any potential payment disruptions. To simplify the process please use the bulk enumeration spreadsheet found at https://npi.wellpoint.com. Getting an NPI is free not having one can be costly. Medicare Part A and B crossover process changes Anthem participates in the Medicare Part A and B crossover process through connectivity to Medicare s national coordination of benefits contractor (COBC). Global Health Inc. (GHI) is the Medicare COBC Contractor. Anthem has the capability to receive crossover claims for all Medicare intermediaries. This helps significantly reduce the need to file supplemental paper claims after Medicare has completed processing. New! Crossover claims delivered to Anthem 14 days after Medicare approval In the past, some Medicare intermediaries and carriers would cross over their claims when claims were approved, and some intermediaries waited until the 14-day Medicare payment floor expired. For consistency, all EDI Primary Medicare claims that indicated a secondary insurance handled via COBC going forward will be crossed over once the 14-day Medicare payment floor has expired. Medicare contractors/cms Fiscal intermediaries will continue to notify providers via an Explanation of Medicare Benefits (EOMB) form, indicating when a claim has been filed through the crossover process. New crossover time frames may cause providers to modify accounts receivable process With the changes implemented by the new COBC contractor GHI, Anthem does not receive Medicare claims until the Medicare payment floor has been satisfied at 14 days after the approval date. Please allow one month before contacting Anthem regarding a particular Medicare crossover claim since most claims are processed well within this time frame. Do not re-file these claims electronically or via paper submissions, as this action creates duplicate claim situations creating processing and payment delays. Going forward, providers should work with their office staff, billing agencies or clearinghouses to ensure they re not converting Medicare claims to a paper format too soon. If you have questions please contact your EDI Helpdesk Solutions team at from 8 a.m. to 5 p.m. ET. Note: if the Medicare primary claim was processed via paper, then the payment floor is 30-days before the claim will be crossed over for secondary process and payment. Working with electronic reports from Anthem Blue Cross and Blue Shield Knowing your electronic reports and how to use them will increase your office efficiency and cash flow and enhance your overall electronic submission experience. The number one advantage of electronic claim submission is that reports provide a detailed audit trail and claim status. Below are tips to understand electronic reports along with valuable information you ll need when working with the clearinghouse or payer. Use reports to: Have an audit trail and summary of submission and claim status. Balance and reconcile electronic claim submissions with the clearinghouse and payer. Quickly recognize submission errors; correct and resubmit electronically often without missing a remit cycle. Receive proof of timely filing for claims accepted by the payer. Providers and their clearinghouse work together Train your office on submission and report functions. Ensure reports are accurate, flexible, clear cut and easy to work. Monitor submissions; balance and reconcile points of submission. Point 1 Provider office to the clearinghouse Point 2 Clearinghouse to the payer Access and review reports, correct errors and resubmit claims electronically. Have contacts and service level agreements available should service issues arise.
9 Reporting tips for providers Anthem reports are delivered within hours after receiving the electronic claims file. Reports are often re-formatted by the clearinghouse as a service to the provider. Work reports daily, or as often as submissions occur, and reconcile claim totals and dollars submitted. As proof of timely filing, providers should have access to the actual electronic report Anthem generated; a re-formatted copy from the clearinghouse can t be accepted. When reports are reformatted by the clearinghouse, providers should contact the vendor directly with questions concerning report content, delivery timeframes, formatting or technical support. When there are errors on claims in Anthem reports, claims can t be routed to our internal processing systems. Those transactions won t be available for viewing on MyAnthem for Providers, our web-based tool. Claims rejected electronically shouldn t be dropped to paper. They need to be corrected and re-submit them electronically. Errors can occur during key entry or at the clearinghouse or payer level. You ll want to know where errors occur and who to contact with questions. If you notice specific errors that re-occur, contact the clearinghouse and ask for a front end edit to be installed to prevent the error from occurring. All Anthem reports provide detail needed for follow-up and/or resolution. Claim detail (i.e., NPI, Member Identifier, Date of Service) Summary of claims received and the status accepted or in error Error code and descriptive error message Contacting Anthem about reports Identify the Anthem report in question. Include the name of the clearinghouse that gives reports to the provider. Provide claim submission date, claim detail and error message(s) returned. Learn more about Anthem reports Anthem provides complete descriptions of all our reports, formatting specifications and error listings. For help resolving Anthem error messages, visit our website or contact our EDI Specialist directly. You may call our EDI Help Desk at between 8 a.m. to 5 p.m. ET, or by visiting and selecting your state. Provider input is vital Input from network physicians is an essential component of HEDIS reporting. While considerable data is obtained from analyzing reported claims, information from patient medical records is invaluable in compiling Anthem s thorough responses to the requirements of the HEDIS dataset. We ll contact you about medical records review Anthem will contact your office in early 2008 to request medical records or to set up a convenient time to conduct an onsite medical records review. This will include a request for specific patient information as needed for completion of HEDIS 2008 reporting. The purpose of the medical chart review is to measure Anthem s aggregate performance, not the performance of individual medical providers. We want you to be confident that all medical information will be confidentially used and maintained in accordance with HIPAA privacy regulations and Anthem corporate policies. Thanks for your help! We appreciate your help as we promote and maintain standards of quality in the services provided to Anthem members. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Health care management HEDIS 2008 reporting: Medical office participation is essential The Healthcare Effectiveness Data and Information Set (HEDIS ) from the National Committee for Quality Assurance (NCQA) is a tool used by more than 90 percent of American health plans to report performance on quality of care and service. Anthem Blue Cross and Blue Shield (Anthem) collects and compiles HEDIS data so our customers can compare Anthem s performance to other managed care organizations, and as a basis for improving the quality of our programs and services.
10 Anthem Blue Cross and Blue Shield HEDIS 2007 report card: central zone commercial plans Measure Description Ohio Kentucky Indiana Membership Number of members Average annual members 248,890 42,884 35,677 Prevention & Disease Management 1. Childhood immunizations Combo 2 Children receiving 4 DPTs, 3 OPVs, 1 MMR, 3 Hibs, 3 HepBs, and 1 VZV by 2 yrs of age 81.9% 83.9% 80.6% Combo 3 (combo 2 + Pneumococcal) 74.9% 78.6% 75.4% 2. Adolescent immunizations 13 year olds who have received a second MMR 90.9% 91.2% 85.9% 3. Appropriate treatment for children with URI 4. Appropriate testing for pharyngitis Combo 2 (2nd MMR + 3 HepBs + VZV) 62.7% 61.2% 53.1% Percentage of children ages 3 mos 18 yrs who were not prescribed antibiotics for URI dx Percentage of children ages 2 18 yrs diagnosed with pharyngitis and had a strep test before antibiotics were prescribed 5. Breast cancer screening Women who received a mammogram during the previous two years 6. Cervical cancer screening Women who received Pap in previous three years 7. Chlamydia screening in women 8. Controlling high blood pressure 9. Persistence of beta blocker treatment after a heart attack 10. Cholesterol management after acute cardiovascular events Women identified as sexually active who had a chlamydia screening test within last year 80.4% 80.2% 79.3% 77.4% 74.0% 59.7% 69.7% 71.5% 73.4% 83.6% 82.7% 84.6% Ages % 26.0% 23.5% Ages % 25.0% 23.6% Patients diagnosed with hypertension whose blood pressure is adequately controlled (BP reading of <140/90) Percentage of members who had a heart attack and remained on beta-blocker medication for 180 days after discharge Members discharged from hospital after AMI, PTCA, or CABG 66.1% 67.4% 60.2% 71.0% 53.3% NA Rate 1--LDL screening within measurement year 87.6% 87.8% 87.5% Rate 2--LDL level <100 mg/dl within measurement yr. No screening counts as higher than the threshold 62.7% 59.3% 59.8% 11. Comprehensive diabetes care Diabetic patients age nine separate measures addressing the clinical management of diabetics 1. HbA1c screening in past yr 86.6% 85.4% 89.2% 2. HbA1c Level indicating poor control (>9.0%) no screening counts as poor control; lower rate is better for rate % 27.1% 25.3% 3. HbA1c good control (<7.0) (new) 40.3% 42.6% 45.1% 4. Eye exam w/in last 2 years 58.9% 59.4% 54.2% 10
12 Prevention & Disease Management 11. Comprehensive 5. LDL screening 85.3% 82.3% 83.6% diabetes care 6. LDL level <100 mg/dl 46.3% 39.7% 43.4% 7. Nephropathy screening w/in last yr 77.1% 74.0% 76.9% 8. Blood pressure controlled <130/80 (new) 29.2% 27.5% 30.2% 9. Blood pressure controlled <140/90 (new) 68.4% 57.4% 59.6% 12. Advising smokers to quit Members advised by physician to quit smoking 71.4% 69.4% 69.1% Maternity care 13. Prenatal care Women receiving prenatal care in 1st trimester 95.6% 91.0% 93.8% 14. Postpartum care Women receiving postpartum care between 85.6% 85.6% 85.1% 3 and 8 weeks after delivery Behavioral Health 15. Follow-up after hospitalization for mental illness 16. Antidepressant medication management 17. Follow-up care for children prescribed attention-deficit/ hyperactivity disorder (ADHD) medication Discharges for members > age 6 hospitalized for mental health and seen outpatient/intermediate treatment with mental health provider Percentage seen within 7 days after discharge 59.24% 44.29% 56.98% Percentage seen within 30 days after discharge 85.76% 77.14% 90.70% Members > age 18 with new depression diagnosis and prescribed antidepressant medication Optimal: At least 3 follow-up visits in 12 week Acute Treatment phase (one with prescribing 16.00% 12.73% 16.81% practitioner) Effective/Acute: Percentage of members remaining on med for entire 12 weeks 61.10% 72.73% 69.75% Continuation: Percentage of members remaining on meds for at least 6 months 43.97% 50.00% 54.62% Children (age 6-12) newly prescribed ADHD med with 3 follow-up visits in 10 month period, one within 30 days of med dispensed Initiation: Percentage of members with 1 visit in 30 days 31.50% 32.32% 34.78% 18. Alcohol and Other Drug Dependence Treatment Continuation/Maintenance: Percentage of members remaining on med and had 2 visits within next 9 mos Initiation: Percentage of members diagnosed with AOD dependence initiating treatment through inpatient admission or outpatient service with additional service in 14 days Engagement: Assess degree to which members engage in treatment with 2 additional services after 30 days initiation NR NR NR 42.80% 46.90% 43.00% 15.00% 11.50% 14.98% 2 Central Blues Weighted Avg is based on OH, KY, IN, BCBSMo and BCBSWi CCB HEDIS 2007 results Quality Compass National Averages are from NCQA and are based on audited HEDIS 2007 data. All data represented above were collected in accordance with the NCQA HEDIS Technical Specifications. The data represent the 2006 measurement year. All rates passed audit inspection and were approved by a NCQA certified HEDIS compliance auditor. Best Central Region rate for each measure is displayed in bold. NA Rate is not reported due to sample size <30. 12
14 Central Region HEDIS 2007 report card: effectiveness of care measures Medicare Clinical Measures Description OH ASA KY ASA Membership Number of members Average annual members 72,896 9,351 Prevention & Disease Management 1. Colorectal cancer screening Percentage of members ages who had appropriate screening for colorectal cancer A A 52.2% 48.2% 2. Breast cancer screening Women who received a mammogram during the previous two years Ages % 49.4% Ages % 60.3% Total 65.8% 59.4% 3. Osteoporosis management in women with fracture Percent of women ages 67+ appropriately tested or treated after a fracture 18.3% 21.1% 4. Controlling high blood pressure Patients diagnosed with hypertension whose blood pressure is adequately controlled (BP reading of <140/90) 61.4% 62.4% 5. Persistence of beta-blocker treatment after a heart attack Percentage of members who had a heart attack and remained on beta-blocker medication for 180 days after discharge 72.9% 61.5% 6. Cholesterol management after acute cardiovascular events Members discharged from hospital after AMI, PTCA, or CABG Rate 1 LDL screening within measurement year 89.1% 90.7% Rate 2 LDL level <100 mg/dl within measurement yr No screening counts as higher than the threshold 7. Comprehensive diabetes care Diabetic patients age nine separate measures addressing the clinical management of diabetics 8. Use of spirometry testing in the assessment & diagnosis of chronic obstructive pulmonary disease (COPD) 64.1% 64.5% 1. HbA1c screening in past yr 89.2% 91.3% 2. HbA1c Level indicating poor control (>9.0%) No screening counts as poor control 17.0% 17.0% 3. HbA1c Level indicating good control (<7.0%) 48.5% 54.9% 3. Eye exam w/in last 2 years 70.4% 63.7% 4. LDL screening w/in last 2 yrs 87.8% 88.1% 6. LDL level <100 mg/dl 52.2% 54.5% 7. Nephropathy screening w/in last year 82.5% 88.3% 8. Blood Pressure Controlled <130/ % 33.4% 9. Blood Pressure Controlled <140/ % 62.6% Percent of members age 40+ with a new diagnosis of COPD who received appropriate spriometry testing to confirm the diagnosis 9. Glaucoma screening in older adults Percent of members 65+ without a prior diagnosis of glaucoma who received a glaucoma eye exam in the last 2 years by eye professional for early identification of persons with glaucomatous conditions. 28.4% 21.8% 55.0% 44.2% 14
15 Clinical Measures Description OH ASA KY ASA 10. Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis Percent of patients diagnosed with rheumatoid arthritis who had at least one ambulatory prescription dispensed for a disease modifying antirheumatic drug 11. Annual monitoring for patients on persistent medications Percent of members 18+ who received at least a 180-days supply of ambulatory medication therapy for the selected therapeutic agent, and at least one therapeutic monitoring event for the therapeutic agent. 76.9% 76.9% ACE inhibitors or ARBs 82.4% 84.6% Digoxin 82.2% 83.3% Diuretics 82.0% 83.4% Anticonvulsants 50.5% 70.6% Total 81.5% 83.7% 12. Drugs to be Avoided in the Elderly At least one prescription for any drug to be avoided in the elderly 17.4% 17.8% At least two prescriptions of different drugs to be avoided in the elderly 4.9% 5.8% All data represented above were collected in accordance with the NCQA HEDIS Technical Specifications. The data represents the 2006 measurement year. An audit of Anthem s HEDIS data and reporting process was performed by an NCQA Certified HEDIS Compliance Auditor. All rates listed above passed audit inspection and were approved for reporting. A Designates use of administrative data collection method only where a hybrid method could have been employed. Immunizations for older adults With the flu season around the corner, it s the perfect time for you and your staff to review immunization practices for older adults. As you know, the elderly and people with certain medical conditions are at greater risk of developing complications. According to the Department of Health and Human Services Centers for Disease Control and Prevention (CDC), an average of 200,000 adults are hospitalized each year due to the flu, and as many as 36,000 die of complications from the flu. As many as 15,000 people die because of pneumococcal pneumonia and invasive pneumococcal infections. Several recommended protocols have been listed below to help those of us concerned with health care prepare for the upcoming flu season. Collect and document history Adults with certain allergies should not be vaccinated. This is why it s important to collect a detailed immunization history. The history and known allergy sections of the medical record should include any previous anaphylactic reaction to a specific vaccine, vaccine component(s) or to eggs. It s also a good idea to document any history of neurological or hypersensitivity reactions to immunizations. Update the history annually. Educate Educate your patients on the importance of vaccinations, including the difference between the flu and pneumococcal vaccines. Document all patient education in the medical record. Free educational material is available through the CDC. Website: Vaccines: VPD-VAC/Adult VPD Immunize The CDC immunization guidelines for older adults include, but are not limited to: Influenza vaccine yearly Pneumococcal vaccine once after the age of 65, with possible revaccination after 5 years, based on history Tetanus-diphtheria toxoid (Td) a booster shot every ten years If immunizations are not available in your office, encourage your patients to check for sites in their local communities (i.e., supermarkets, drugstores, senior centers, etc.). Consider implementing adult immunization standing orders for offices, clinics and hospitals where you practice. 15
16 Document immunizations Document any and all immunizations in a consistent location in the medical record. Be sure to include immunizations that your patient received from a different provider, such as flu vaccine from the supermarket, pneumococcal vaccine during a hospitalization or Td from an emergency room. Practice guidelines for treating depression In a given year, an estimated 18.8 million American adults suffer from a depressive disorder or depression. Without treatment, symptoms associated with these disorders can last for years and lead to death by suicide or other causes. Fortunately, many people can improve through treatment with appropriate medications or talk therapy. Members who have moderate to severe depression are generally good candidates for treatment with antidepressant medication (National Committee for Quality Assurance (NCQA); 2005). Guidelines for treating members with depression The American Psychiatric Association Practice Guidelines for the treatment of members with depression identify distinct phases of treatment: acute, continuation and maintenance. Acute phase (first 12 weeks of treatment) allows the clinician to monitor drug response and assure a full remission of symptoms. Remission phase (about six months of treatment) may be followed by a relapse unless a continuation phase is instituted Maintenance phase (more than six months of treatment) for a select group of patients with depression, must be adopted to prevent future recurrences of symptoms and distress HEDIS measures examine barriers to treatment Many people with a depression do not seek treatment or have difficulty staying on medication for the necessary periods of time. Anthem Blue Cross and Blue Shield collects the Health Plan Employer Data and Information Set (HEDIS) Antidepressant Medication measures to examine barriers that may prevent members from receiving treatment for depression for the necessary duration. Anthem examines HEDIS measures for the following rates: Members who had at least three follow-up visits with a health care provider within 12 weeks of diagnosis (optimal phase). Members who remained on antidepressant medication for 12 weeks following diagnosis (acute phase). Members who remained on antidepressant medication for six months following diagnosis (continuation treatment phase). Medical policy update Upgrades to Medical Policy websites The Office of Medical Policy & Technology Assessment (OMPTA) has upgraded the websites that house Anthem medical policies and clinical Utilization Management (UM) guidelines. In September 2007, different platforms that housed our external websites were consolidated to a single platform. The new, single platform should increase efficiency during the posting of medical policies and clinical UM guidelines. Site navigation remained the same, as did the Search engine. The format of the medical policies and clinical UM guidelines have changed slightly to accommodate new platform requirements; however, it s not expected to affect visitor experience. If you haven t accessed medical policies and clinical UM guidelines online yet, visit our provider page at: anthem.com, select the plan state (e.g., Ohio) and then choose Enter. Scroll down and choose Anthem Medical Policies and Clinical UM Guidelines. Those who do not have access to the Internet may request a paper copy of specific medical policies or clinical UM guidelines by contacting the appropriate provider inquiry department. It s important to Anthem to make sure our members keep appropriate follow-up visits to improve the effective use of anti-depressant medications. 16
17 These policies and guidelines are an informational resource regarding our view of certain procedures, treatments, devices, technologies and drugs. They are not an authorization or an explanation of benefits or a contract to provide benefits. While something may be identified as medically necessary under a medical policy or clinical UM guideline, it may not be covered due to an exclusion within a member s benefit plan. Please check with the appropriate provider inquiry department to determine coverage under a member s benefit plan. As medical technology is constantly changing, the company reserves the right to review and update medical policy and clinical UM guidelines as necessary. Prescription Formulary/drug list updates The following tables illustrate recent status/tier changes made to Anthem s drug lists/formularies that may affect your Anthem patients participating in drug list/formulary-managed plans. You may also access recent changes to the drug lists/formularies by visiting us online at anthem.com and selecting Prescription Information. Or call the drug list/formulary line at Anthem National Formulary/Tiers Additions/Tier changes from Tier 3 to Tier 2 (effective 10/01/07) Therapeutic category Deletions/Tier changes from Tier 2 to Tier 3 (effective 03/26/08) Therapeutic category Formulary/Tier 1 or 2 alternative(s) Janumet Oral Diabetic Products Fortamet Oral Diabetic Products ActoPlus Met, Actos, Avandamet, Avandaryl, Avandia, Prandin Januvia Oral Diabetic Products Glumetza Oral Diabetic Products ActoPlus Met, Actos, Avandamet, Avandaryl, Avandia, Prandin Health Solutions Formulary/Tiers Additions/Tier changes from Tier 3 to Tier 2 (effective 10/01/07) Therapeutic category Deletions/Tier changes from Tier 2 to Tier 3 (effective 03/29/08) Therapeutic category Formulary/Tier 1 or 2 alternative(s) Janumet Oral Diabetic Products None Januvia Oral Diabetic Products None 17
18 Products and programs FEP members in Wisconsin and Missouri transition to new system Anthem has transitioned its Federal Employee Program (FEP) business in two states to a new front-end claim processing system called Streamline. The change became effective October 22, 2007 for Wisconsin members and November 11, 2007 for Missouri members. Blue Cross Blue Shield Service Benefit Plan (known as FEP) members can be identified by the R prefix of their identification number. New system means faster, more accurate FEP claim processing and customer service Streamline interfaces more efficiently between Anthem s systems and the Blue Cross Blue Shield national FEP system, resulting in faster, more accurate claims processing. Streamline also brings more functionality to Wisconsin and Missouri providers by allowing access to our Interactive Voice Response (IVR) system. Improvements for Wisconsin and Missouri providers Your new IVR allows you to retrieve FEP claim status, benefits and access to our eligibility from the convenience of a telephone 24 hours a day, 7 days a week. To use our IVR, call from Wisconsin or from Missouri. You will be asked to enter either the appropriate Tax ID or your new National Provider Identifier (NPI) number, after registering with us by completing as much information as possible on our online NPI Submission Form at https://npi.wellpoint.com/npi/online/onlinesubmit.jsp. Providers now see more extensive benefit information along with eligibility via our secure provider portal, MyAnthem TM at anthem.com. At a later date, you ll also see expanded capabilities such as claims status and Secure Messaging. FEP no longer pays providers based on assignment. Providers are paid based on their contract status. Claims from non-participating providers will be paid to the member. Claims and adjustments received on or after the effective dates are processed on Streamline and appear on the Streamline remittance advice. If you need assistance with the new remittance, please call us. Reminders Please continue to use these addresses and telephone numbers for FEP claims, medical records, correspondence and inquiries: For Wisconsin: Anthem Blue Cross and Blue Shield Federal Employee Program P.O. Box Louisville, KY For Missouri: Anthem Blue Cross and Blue Shield Federal Employee Program P.O. Box St. Louis, MO For both states, checks and returned payments related to FEP should continue to be sent to: Anthem Blue Cross and Blue Shield Central Region CCOA Lockbox PO Box Cleveland, OH Federal Employee Program (FEP) implements new claim refund process The way that Anthem Blue Cross and Blue Shield recovers claim overpayments for members of the Blue Cross and Blue Shield Service Benefit Plan (also known as FEP) is changing. 18
19 Please note the effective dates for the following states: Indiana, Kentucky and Ohio the change became effective January 1, Wisconsin the change becomes effective February 1, 2008 FEP members can be identified by member identification numbers that begin with R. When Anthem identifies that a refund is due from a professional or institutional provider for an FEP claim, the refund amount will be automatically deducted (taken back) from the providers remittance to the extent permitted by the provider contract. Previously, we asked providers to send us a refund check. When the new process is implemented January 1, 2008 in Indiana, Kentucky and Ohio and on February 1, 2008 in Wisconsin, the explanation reason for the overpayment deduction will appear on the providers remittance vouchers. If the provider identifies an overpayment from Anthem, the provider can elect to send us a refund, or call FEP Customer Service at the numbers below to request an automatic deduction from future payments: Indiana Kentucky Ohio Wisconsin If you choose to send a refund check, please mail the refund check and explanation of the overpayment to: Central Region-CCOA Lockbox PO Box Cleveland, OH This change applies to all professional and institutional providers. The federal laws that govern FEP business require the recovery of claim overpayments owed to the Program for up to five years from the end of the contract year in which Anthem paid the claim. Please note that the Federal Employee Program Service Benefit Plan is excluded from the overpayment recovery provisions contained in the Managed Care Settlement and that federal laws replace state laws. Introducing a new hospital surgical product from Anthem Blue Cross and Blue Shield Employers in the Midwest will have another choice for health coverage for their employees. Blue Hospital Surgical products offer affordable coverage for some of the most costly types of care, including emergency room visits, inpatient hospital procedures and surgical care. Beyond that, it even offers protection for some conventional health care such as no limit to office visits for most services, outpatient diagnostic services, generic drugs and state mandated benefits. Blue Access SM Hospital Surgical PPO will be available effective December 1, 2007 in Indiana, Missouri, and Ohio, and effective January 1, 2008 in Kentucky. Blue Preferred Plus Hospital Surgical POS will be available effective December 1, 2007 in Wisconsin. Missouri will also offer a Blue Access Choice Hospital Surgical PPO plan. Blue Hospital Surgical products are robust products designed to help address the issue of the uninsured. Employers who previously couldn t afford coverage for their employees can now offer a low cost hospital/surgery benefit that will help protect their employees against catastrophic events. The products provide coverage employees need at lower premiums, and still deliver the quality, integrity, and value of the Blue products: credentialed network, medical management, ConditionCare, other web tools and access to the BlueCard network. Members who enroll in the Blue Hospital Surgical products will have: Unlimited office visits with a copayment and coinsurance for most covered services (ex. $20/50 percent) Emergency room services subject to $150 copayment and 20 percent cost share Pharmacy benefits ($10 for generic and $20 for mail order) Coverage for state mandated preventive care and most hospital admissions and surgeries Outpatient diagnostic benefit of $300 per member per year Access to medical management programs and tools such as ConditionCare, and to help them lead healthier lives and make more informed health care decisions. The Blue Access and Blue Preferred Plus Hospital Surgical products will use the Blue Access and the Blue Preferred networks of providers, physicians and professionals. For complete benefit information, member eligibility and claims status, please contact your local Anthem Provider Call Center, or verify benefits online by accessing MyAnthem at anthem.com. 19
20 Network Update is produced quarterly by Anthem Blue Cross and Blue Shield s Marketing Division Editor: JoAnn Boyd 4361 Irwin Simpson Road Mason, OH Anthem Blue Cross and Blue Shield 1351 William Howard Taft Road Cincinnati OH The information in this newsletter is for informational purposes only and should not be construed as treatment protocols or required practice guidelines. Diagnosis, treatment recommendations, and the provision of medical care services for Anthem members and enrollees is the responsibility of physicians and providers. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In most of Missouri: Anthem Blue Cross and Blue Shield is the trade name for RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. Life and disability products are underwritten by Anthem Life Insurance Company (ALIC). RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross and Blue Shield of Wisconsin ( BCBSWi ) underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ( Compcare ) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Life and disability products are underwritten by Anthem Life Insurance Company (ALIC). Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. Network Update ISSUE 4, 2007 We urge you to submit your claims electronically. Important phone numbers and addresses Indiana Provider Inquiry: Precert/Referral: See back of member s ID card. Claims Filing: P.O. Box Louisville, KY Kentucky Provider Inquiry: Precert/Referral: See back of member s ID card. Claims Filing: P.O. Box Louisville, KY Missouri Provider Inquiry: Precert: HMO PPO Lumenos Claims Filing: P.O. Box St. Louis, MO Ohio Provider Inquiry: Precert/Referral: Claims Filing: P.O. Box Louisville, KY Wisconsin Provider Inquiry: See back of member s ID card Precert/Referral: PPO Claims Filing: P.O. Box Louisville, KY
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