Studies show that better-informed

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1 April 2005 For your convenience, we now contract with two Specialty Pharmacy providers Contents Web-based Tools page 1 Caremark and Medco page 1 Count on PBCBS AK page 2 New ID Numbers page 2 Medical Policy Update page 3 Health Risk Management page 4 High-risk Pregnany page 5 New Phone Scam page 5 Oncology Management page 5 Questions and Answers page 6 Web-based Tools Add Knowledge, Improve Decision Making Studies show that better-informed consumers make smarter decisions. Centralized, accurate information is key to members taking a more active role in their health-care decisions. That s why we launched Healthcare Advisor on our Web site at in February. Healthcare Advisor is a decision-support tool administered by Subimo to help members evaluate their health-care options and make informed health-care decisions. This interactive online tool has two main functions: Access to information A powerful personal health-management and information tool allows members to learn more about their condition, common complications, treatment options and recommended procedures. An online medical encyclopedia provides easy-tounderstand language and links to other relevant health-care sites. Hospital comparison This tool helps members select the hospital that best fits their personal needs through the comparison of statistics, in many ways, including: Self-reported hospital data compiled from recognized public sources (e.g., CMS, Leapfrog Group, Health Forum, and state and federal agencies); Providing clinical information that is adjusted based on risk factors such as age or severity of illness. Members can use the Healthcare Advisor to better understand their condition, particularly if they face a significant health-care decision. Contact our Provider Relations team at if you have any questions about Healthcare Advisor. Caremark and Medco Special Care Pharmacy To help you and your patients obtain Specialty Drugs without the hassle of stocking or billing for them, we now contract with two Specialty Pharmacy providers: Caremark and Medco Special Care Pharmacy. These Specialty Pharmacies can assist you in ordering office-injected Specialty drugs for your Premera Blue Cross Blue Shield of Alaska (PBCBS AK) patients. Drugs commonly provided by our Specialty Pharmacies include therapies for Hepatitis C, Multiple Sclerosis, Rheumatoid Arthritis, Growth Hormone Deficiency, IVIG therapy and Hemophilia. Please note that your participation in this program is optional. These Specialty Pharmacy providers coordinate verification of eligibility and benefits, and bill PBCBS AK directly for each medication that is ordered. They can also coordinate the delivery of the medication when you need it, and Continued on page 2 An Independent Licensee of the Blue Cross Blue Shield Association April 2005 Network News 1

2 For Physicians and Providers Caremark and Medco Continued from page 1 provide you and your patient with clinical support for their therapy. Ordering medications is fast and easy. Here s how: Contact Caremark or Medco Special Care Pharmacy directly, or Caremark: Provider Phone: Provider Fax: April 2005 Network News Visit our Web site at select Pharmacy and then the Pharmacies/Home Delivery section. Here you can obtain more information, download a Specialty Pharmacy enrollment form, or view the Specialty Drug List. To get started simply call or fax: Medco Special Care Pharmacy: Provider Phone: Provider Fax: Phone Number Correction We recently sent out a News Brief that listed incorrect phone numbers for placing Specialty Pharmacy orders. The correct phone number for Caremark is The correct fax number for Medco is Please accept our apologies. Count on PBCBS AK PBCBS AK has put many systems and processes in place to ensure efficiency in our collaboration with you. We implemented the Washington Health Forum s Administrative Simplification Workgroup s guidelines and procedures to streamline processes and simplify physician and health plan interactions.* We also offer a variety of numerous, free resources including the following: Visit our secure Provider Portal for quick access to eligibility, benefits and claims status information, including up-to-the-minute medical policies. First-time users can register with OneHealthPort for a free, secure sign-on. Once you have your user ID and password, you can use a single sign-on to access the secured Web pages. Visit to learn more. Count on rapid payment of claims most of the time. PBCBS AK pays 95% of claims in under 30 days even quicker for electronic claims. We operate our own clearinghouse at no charge to providers. Check out EMC Hotline for the latest EDI information. To become an electronic submitter with us, contact EDI at Confirm member eligibility or benefits coverage, request a benefit advisory, or determine medical necessity criteria for a particular service. Visit our Web site at and navigate to Care Facilitation and then to Care Management. Save time connecting with PBCBS AK Customer Service by using our new, automated phone system. It uses speech recognition to validate callers and reduce the time it takes Anthem s New ID Numbers As of Jan. 1, 2005, ID cards for any Anthem Blue Cross Blue Shield (including affiliated Anthem health plans) members that you see will contain a three-letter alpha prefix followed by two alpha characters and seven numbers. The first number in this new arrangement will be a zero. We wanted to bring this new format to your attention due to the fact that the zero (6 th character) can sometimes be mistaken as an O. Here is an example: ANTAN note the zero is shown as upright oval ( O is circular) When billing for Anthem members, please note that the first five characters are alpha, followed by seven numeric characters starting with zero. to get you the information your need. Count on our Case Managers to help members and providers to navigate the health-care system. We help members understand and maximize their benefits, and comply with their physician s care plan. Disease management is also available for members with some types of cancer, heart disease and diabetes. PBCBS AK is also proud to support many organizations in the local community including the American Heart Association, March of Dimes and American Diabetes Association. For more information about these activities, please call our Provider Relations team at , option 4. (*To learn more about simplifying processes in your office, visit

3 For Physicians, Providers and Office Staff Medical Policy Update PBCBS AK medical policies are guides in evaluating the medical necessity of a particular service or treatment. We adopt policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, we reserve the right to review and update our policies as appropriate. When there are differences between the member s contract and medical policy, the member s contract prevails. The existence of a medical policy does not guarantee that the member s contract allows the service. Medical policies are now available on the Web site. Go to the Provider Portal and then to Library. Click on Reference Info and then click on Medical Policies. If you are not able to obtain the policy from that site and you would like a copy of a particular medical policy, your request to [email protected]. If you do not have Internet access, you may call Note: All policy numbers begin with CP.MP. The following policy changes are effective for dates of service of January 11, 2005, and later: BC Cooling Devices Used in the Outpatient Setting. New policy. Active and passive cooling devices are considered not medically necessary. PR Mechanical Stretching Devices for Joint Stiffness and Contracture. Mechanical stretching devices such as Dynasplints, Flexionators and JAS splints may be considered medically necessary when certain criteria are met. BC Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions. Tendonitis of the elbow is now considered investigational. BC Monitoring of Regional Cerebral Blood Flow Using An Implanted Cerebral Thermal Perfusion Probe. New policy. Monitoring of regional cerebral perfusion using an implanted cerebral thermal perfusion probe is considered investigational. BC Breath Test for Heart Transplant Rejection Detection. New Policy. The measurement of volatile organic compounds with the Heartsbreath test to assist in the detection of grade 3 heart transplant rejection is considered investigational. BC Temporary Prostatic Stent. New policy. A temporary prostatic stent is considered investigational. PR Xenon Chloride Excimer Laser Therapy for Phototherapeutic Treatment of Psoriasis. Policy statement changed to medically necessary under certain circumstances. PR Medical Management of Obesity. New policy. Medical treatment of obesity may be considered medically necessary under certain circumstances. BC Non-invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting. New policy. Non-invasive measurement of left ventricular end diastolic pressure (LVEDP) in the outpatient setting is considered investigational. BC Detection of Circulating Tumor Cells in the Management of Patients with Cancer. New policy. Detection and quantification of circulating tumor cells is considered investigational in the management of patients with cancer. PR Surgery for Morbid Obesity. Both open and laparoscopic gastric bypass using a Roux-en-Y anastomosis may now be considered medically necessary. Laparoscopic malabsorptive procedures are considered investigational. BC Digital Imaging Systems for the Screening, Detection and Evaluation of Diabetic Retinopathy. New policy. Digital imaging systems may be considered medically necessary as a screening technique for the detection and interpretation of diabetic retinopathy. The following policy change is effective for dates of service of February 8, 2005 and later: PR Charged particle (Proton or Helium Ion) Radiation Therapy. Policy statement revised to include treatment for prostate cancer as medically necessary. Continued on page 4 April 2005 Network News 3

4 For Physicians, Providers and Office Staff Medical Policy Update Continued from page 3 The following policy changes are effective for dates of service of June 15, 2005 and later: BC Laser Treatment of Acne. New policy. Laser treatment of active acne is considered investigational. BC Non-Pharmacologic Treatment of Rosacea. New policy. Non-pharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking and electrosurgery, is considered investigational. BC Homocysteine Testing in the Screening, Diagnosis and Management of Cardiovascular Disease. Measurement of plasma levels of homocysteine is considered investigational in the screening, evaluation and management of patients for cardiovascular disease. The following policy change is effective for dates of service of July 1, 2005 and later: PR Epidermal Growth Factor Receptor Inhibitors. New policy. EGFR-TK Inhibitors (Erlotinib, Gefitinib) may be considered medically necessary under certain conditions. Bevacizumab may be considered medically necessary under certain conditions. Time Ripe for Health Risk Management As many of us have heard, Consumer Directed Health Plans are increasingly popular health insurance options. As more people subscribe to these plans, they and their employers demand highquality health information to guide them in their health-care decisions. We are committed to keeping you up to date on the new programs we are offering our members to assist them in their health care and lifestyle decisions. You may hear from your patients directly regarding programs such as the Health Risk Management Program. You are well aware that most people do not maintain their bodies as well as they take care of their cars. They are vigilant about changing their car s oil regularly or making sure their tires are properly inflated, but taking care of themselves is a different story. The majority do not exercise at least 30 minutes daily, are overweight, have questionable eating habits, are either stressed or depressed, and do not know their measurements when it comes to their bad (LDL) cholesterol, fasting blood sugar, or body mass index (BMI). 4 April 2005 Network News Here s what some of the evidence shows: In a three-year study of 46,026 employees, the increase in medical expenditures associated with high-risk employees who reported the following risk factors was: Depression 70.2% Stress 46.3% Blood Sugar control 34.8% Overweight 21.4% Smoking 14.5% Blood Pressure 11.7% Sedentary Lifestyle 10.4% Other studies showed: These risk factors were associated with significantly higher absenteeism, disability and worker s compensation costs Health risks can be effectively managed with health risk assessments, individual feedback, personal coaching and incentives. The reported rates of return for businesses that participate in health risk assessment programs can be significant, even when considering only the direct medical and pharmacy costs. PBCBS AK is now partnering with an industry leader with years of experience and a proven track record in the health risk management field to offer Health Risk Management programs to employer groups. We now offer several packages and pricing options to fit the varied demands of our members and employer groups. Currently, these programs are available to employers with at least 200 adult eligible lives. For more information about the content of these programs, call Liz Stewart by phone at (509) or , extension 7052, or by at [email protected]. Fall Workshop Follow-up Did you attend our workshop and had a question that needed a follow-up? You can soon download our Fall 2004 Office Staff Workshop Q&A from our Web site at You can also call our Provider Relations team at , option 4, to request a copy.

5 For Physicians, Providers and Office Staff New Phone Scam Affecting Providers The Blue Cross Blue Shield Association informed us of a new phone scam occurring in California where an individual calls the medical or dental office posing as an insurance representative. The caller asks to confirm information to process a claim, release payment for services, or update information in the doctor s file. The caller acquires the doctor s birth date, Social Security number, tax ID number, and other confidential information. Soon, calls are made to the doctor s creditors. Account and billing information is then changed to another address, and in some cases, new credit cards are acquired. Multiple purchases are made on the credit accounts before the change is detected. If the phone call was not solicited by your office, there is a danger when providing personal information. Please note that if PBCBS AK needs information, we will handle this with your office via mail or fax not by phone. Medicare Primary Coverage EOBs We have identified an issue that is coming up on EOBs for members who have Medicare primary coverage. Due to the fact that our EOBs are coded to reflect our allowable charge and not Medicare s, the patient balance on our EOBs may not reflect Medicare discounts. We are, therefore, referring the members with Medicare coverage primary to look to you to advise them of their patient balance via a new message on their EOB. When a member has Medicare primary coverage the message shown on their EOB will be as follows: Please call your provider for the amount due, if any. Case Management for High-risk Pregnancy Case management for high-risk pregnancy is now available to PBCBS AK Managers for high-risk pregnancy Each call to PBCBS AK RN/Case members. RN/Case Managers are triggers a process to identify the experienced in working with mothers member s questions and concerns, who have a high-risk pregnancy, or a which leads to a support plan. To reach history of prior problems including a PBCBS AK RN/Case Manager and diabetes, and pre-term delivery. Case refer a PBCBS AK member, please call Managers provide additional resources , extension 4394 or to help support the physician s plan of care so mothers and babies can achieve better outcomes. This service is confidential and free to members. Oncology Disease Management Program We are pleased to offer our Oncology Disease Management Program to members with breast or lung cancer. This optional program is designed to help participants gain self-confidence in their ability to control their symptoms, understand how their health problems affect their lives and obtain provider referrals to community and health-care resources. Supporting the physician/patient relationship and treatment plan is central to our Oncology Disease Management Program. Here are highlights to consider for those patients who wish to participate: Overall health: Our goal is to improve the overall health and quality of life by emphasizing the prevention of complications utilizing evidence-based practice guidelines and patient empowerment strategies, and to evaluate clinical and humanistic outcomes on an ongoing basis. Patient satisfaction: Enhance patient satisfaction by assigning each participant to a personal case manager a registered nurse with specialized training in oncology. The nurse assists participants and their families by coordinating care among multiple providers and coaching for self-management skills. Specialized services: Participants receive specialized case management services, and assistance with their health plan benefits as well as identifying community resources. The nurse assists participants to maintain their highest state of wellness and, when appropriate, facilitate a smooth transition to palliative care. Bereavement: Our case managers are also skilled in framing death and dying issues that lead to open communication of difficult discussions about health-care options, including palliative, supportive, or hospice care. Proven success: Our program has already helped hundreds of patients comply with their treatment plan and make the changes that lead to a better quality of life. PBCBS AK believes that by working together we can provide your patients with peace of mind about their heath-care coverage, while providing the structure to assist our members and their health-care team to achieve better health-care outcomes. April 2005 Network News 5

6 Premera Blue Cross Blue Shield of Alaska P.O. Box 327 Seattle, WA PRESORTED STANDARD U.S. POSTAGE PAID SEATTLE, WA PERMIT NO Please post or circulate this newsletter in your office Questions & Answers Does PBCBS AK hold all accidental claims until the total adds up to the $1,000 before payment? No, claims are processed until the total reaches the $1,000 threshold, the claim is submitted with information indicating that the member was involved in a motor vehicle accident, or that worker s compensation is involved. Once the $1,000 threshold is reached, an Accident Investigation form is mailed and subsequent related claims pend until the Accident Investigation form is completed and returned. Failure to return the completed Accident Investigation form results in a denial of the claim and becomes the responsibility of the member. Can Federal Employee Program members use BlueCard? No, the Federal Employee Program is exempt from the BlueCard program. Please follow the billing guidelines for this program when submitting claims. Who has primary coverage for dependents in joint custody arrangements? Does the birthday rule apply? If two parents have joint custody and one has financial responsibility per the divorce decree, that parent would have primary coverage. If both parents have equal financial responsibility, the birthday rule applies. Can I search for News Briefs on your Web site with the topic function? Yes, you can search for a News Brief by topic and by date. The name of the News Brief is listed under the date. Network News Editor: Karen Brandvick-Baker , ext Fax: [email protected] Back issues of Network News are on our Web site at in the Library on the Provider page under Communications. 6 April 2005 Network News ( )