Consult Newsletter. Enter the rendering provider NPI # in the unshaded area of the field. Only one provider can be billed per claim form (optional).

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1 Notice If a website link within this document does not direct you to the appropriate information or website location, please contact Provider Services by telephone. The Provider Services directory is located on the last page of this document.

2 1 of 6 First Quarter 2007 Volume 5 Consult Newsletter Inside This Issue CMS Professional Tip Sheet Updated Guidelines for Submission of Consultation Codes Is Your Patient Considering Hip or Knee Replacement Surgery? Accordant Management of Chronic Illnesses to End Medical Management Protocol Updates Continuous Passive Motion in the Home Setting Preventing Childhood Obesity Providing Lead Testing in Your Practice - Clarification Provider Telephone and Web Site Reference Guide CMS Professional Tip Sheet HealthNow New York Inc. accepts both electronic and paper claims. If you are still processing on paper, please contact to discuss options for submitting electronically. Electronic Claim Submission is an easy way to minimize the amount of time it takes your claim to reach and be processed by the health plan. Submitting claims electronically will also save you money by reducing what you spend on orders for paper claims and high postage fees. CMS-1500 CMS announced the replacement of the current HCFA-1500 (12/90) claim form with the CMS-1500 (08/05) form, effective October 1, A transition period, during which both HCFA-1500 (12/90) and CMS-1500 (08/05) forms will be accepted, will run through March 31, Effective April 1, 2007, only the new CMS-1500 (08/05) forms will be accepted. We urge all providers to review the new CMS-1500 form for any changes that might affect your practice management vendors, software, printers, etc. For more detailed information, please visit the National Uniform Claim Committee web site at and the Centers for Medicare and Medicaid Services web site at Contact your vendor to order the new CMS-1500 claim form. If you don t have a vendor, HealthNow uses Standard Register. For pricing information please contact them at Please use the following guidelines to bill your NPI on paper claims: Field 24J Rendering Provider ID # Field 32 Service Facility Location Field 32A Service Facility Location Enter the rendering provider NPI # in the unshaded area of the field. Only one provider can be billed per claim form (optional). Enter the name, address, city, state and zip code where the services were rendered. Enter the name and address information in the following format: 1st line - Name 2nd line - Service Address 3rd line - City, State, Zip Code Enter the NPI # of the rendering provider, if different from the Billing Provider Information.

3 2 of 6 Field 32B Service Facility Location Field 33 Billing Provider Info Field 33A Billing Provider Info Field 33B Other ID # Enter the two digit qualifier identifying the non-npi # followed by the ID #. Do not enter a space, hyphen, or other separator between the qualifier and number. Enter the billing provider or group name, address, city, state and zip code. The phone number is to be entered in the area to the right of the field title. Enter the name and address information in the following format: 1st line - Name 2nd line - Service Address 3rd line - City, State, Zip Code Item 33 identifies the provider/group that is requesting payment for the services rendered and should always be completed. Enter the NPI # of the billing provider. Enter the two digit qualifier identifying the non-npi # followed by the ID #. Do not enter a space, hyphen, or other separator between the qualifier and number. Electronic Billing Information Service location for 837P claims should be billed in Loop 2310D, only if different from billing Loop 2010AA. The Service location for 837I claims should be billed in Loop 2310E, only if different from billing Loop 2010AA. We are following the Medicare guidelines of dual usage of provider numbers. Claims will be rejected prior to the mandate date if legacy provider number is not submitted. NPI HIPAA standards require that all healthcare providers use their NPI number on all claim submissions beginning May 23, HealthNow will require your NPI on both electronic and paper claims. To obtain your NPI number, apply online at or call to request an NPI application form at If you have obtained your NPI number, please fax a copy of your NPI from NPPES to our Provider File Department at Updated Guidelines for Submission of Consultation Codes Effective April 1, 2007, HealthNow has revised its guidelines for the submission of consultation codes. Primary Care Physicians may now utilize consultation codes for performing preoperative clearance services when requested by the surgeon. Please note that the appropriate level consultation code must be selected based on the complexity of the service, as well as the level of complexity involved in the proposed surgical procedure. All of the requirements for a consultation must be met, as stated in the Current Procedural Terminology Manual published by the American Medical Association. Is Your Patient Considering Hip or Knee Replacement Surgery? Please share the following words of support with our members who are preparing for hip or knee replacement surgery. Dear Patient:

4 3 of 6 Hip or knee replacement surgery can mean a new lease on life for people whose lives have been limited by the pain and disability of severe arthritis. Adequate planning on your part can improve the chances that this surgery will be successful. Working in partnership with your physician, HealthNow would like to assist you through this planning process. Planning Far Ahead If you and your doctor are beginning to talk about the need for a hip or knee replacement, you should also begin to talk about how to have the best recovery from this surgery. Being overweight can increase the strain on your joints. If you are overweight, talk to your primary care physician about a physician supervised weight reduction program. Even loosing 10 pounds will ease the stress on your joints. Pain often leads people to reduce their activities leading to more disability. Talk to your physician about starting an appropriate exercise program that will improve your strength and endurance. People with arthritis who start to exercise find that they feel better and function better than before. Pain may also be improved. A free booklet is available at the following web site from the National Institute of Arthritis and Musculoskeletal and Skin Diseases: Take your medication as directed. You are likely to have better control of your pain if you take scheduled medication than if you only take medication "when it hurts." Ask your doctor about generic medication to decrease your costs. They are effective. Work on bone strength through treatment of osteoporosis. If You Have Decided to Have Total Joint Surgery If you and your doctor have decided it is time to plan that surgery, it is even more important that you focus on the four items above. Research supports that an appropriate exercise program started six weeks before surgery can reduce post operative pain and your need for rehabilitation. In addition, being able to move better after surgery will reduce your risk of post surgical complications. We can help! Ask your doctor to schedule a home visit with a visiting nurse service. A nurse or physical therapist will come to your home and provide the following services: Show you how to make your home safer to reduce your risk of falling. Start you on a preoperative exercise program. Assist you with the equipment you will need at home after your surgery. That service will also come back to see you after your surgery and do your rehabilitation in the home until you are better able to move around and get out. There are other things you can do. If you smoke, it is a great time to quit smoking. Identify persons who will be available if you need assistance after the surgery. Be sure you review preoperative scheduling, tests and clearances with your doctor so you are prepared. Understand the risks and benefits of your surgery.

5 4 of 6 Understand the postoperative precautions you need to take to protect the new joint. Inpatient Rehabilitation or Home? If you are an otherwise healthy person and particularly if you have followed the steps above, there is no clinical reason to need inpatient rehabilitation after total joint surgery. Going home has the benefit of being in your own home with your own comforts. You will also reduce your risk of hospital-related infections and post operative complications. The same service that visited you before hospitalization will come back and provide home rehabilitation. Research supports the benefits of rehabilitation in the home. If you are particularly frail or have other medical illnesses, you may benefit from rehabilitation in a skilled nursing facility with plans to go home and complete your recovery at home. Remember A total joint replacement surgery is a big step. It is important to become an active partner in preparing for this surgery and managing the recovery so you will obtain the greatest benefit at the end. We have worked with plan physicians to create special insurance benefits to help you achieve these outcomes. Best of luck! Accordant Management of Chronic Illnesses to End For several years, we have contracted with Accordant Health Services to manage care for our members with chronic conditions such as multiple sclerosis, cystic fibrosis and Parkinson s. Effective March 31, 2007, we will end our contract with Accordant and transfer members into our internal programs, where their care will be managed by our highly-trained nurse case managers. We are confident that we can provide a high level of service to our members and ensure that they receive the education and support services they need. We have notified affected members of this change and have advised them to contact their physicians to talk about any issues they may have been discussing with their Accordant Care nurse. Members have also been advised to call HealthNow if they need assistance in managing their healthcare needs, and we will put the member in contact with one of our nurse Case Managers or Disease Managers, as needed. Members may also continue to access the Accordant website at for educational information and resources and can find general and condition-specific health information on our website at in the Get Health section. Medical Management Protocol Updates As previously notified, HealthNow clinical protocols are available on our web site at in the Provider section under "Clinical Protocols." The following clinical protocol update includes information on protocol summaries for new or revised protocols effective April 1, 2007, a listing of protocols that have been reviewed without change, and a list of deleted protocols. Please note that some of the protocol summaries or parts of the summaries may not pertain to the members you provide care to, as they relate to contracts that are not available in your geographic area. Clinical Protocols Reviewed Without Change The following clinical protocols have recently been reviewed and do not require revisions at this time. Previous effective dates indicated remain accurate. Orthoptic/Vision Therapy effective 04/01/2005 Sclerotherapy as a Primary Treatment of Varicose Veins effective 04/01/2006 In previous communications, HealthNow notified you that hard copies of our clinical protocol updates will no longer be mailed. If you need assistance obtaining specific clinical protocol updates, please contact Provider Service.

6 5 of 6 Continuous Passive Motion in the Home Setting Effective April 1, 2007, HCPCS Code E0935 (continuous passive motion exercise device for use on knee only) will not be reimbursed for any line of business other than Medicare Advantage. HealthNow has determined that this device is not medically necessary for use in the home setting. HCPCS Code E0936 (continuous passive motion exercise device for use on other than knee) remains investigational for all lines of business including Medicare Advantage. If you have any questions regarding this information, please contact your Network Management representative. Preventing Childhood Obesity An important step in improving the health of children and adolescents is screening to identify those who are overweight or obese. This practice is recommended by the American Academy of Pediatrics, the American Academy of Family Physicians, the CDC, and the Institute of Medicine and should begin at age two years. Obesity screening using BMI-for-age percentiles is also now one of the New York State s Managed Care Quality Assurance Reporting Requirements (QARR). The BMI Toolkit available from New York State includes recommendations for preventing childhood overweight and obesity, as well as guidelines for obesity prevention counseling for children and their parents or guardians. Pediatricians, family physicians and nurse practitioners may order BMI Toolkits by visiting: A pediatric/adolescent BMI calculator and sex-specific growth charts (modified from those developed by the CDC) are included to facilitate classification of a child s weight status based on his/her BMI-for-age percentile. For children and adolescents who are not in the healthy weight range, further assessment and evaluation is recommended to identify underlying causes and to guide management plans. Extra BMI wheels and/or additional growth charts may also be ordered. Search or select "BMI Toolkit" for the publication number, download the order form, and return the completed form to: NYS Health Department Box 2000 Albany, NY Or fax the form to: to: B0019W@health.state.ny.us We encourage pediatric/adolescent healthcare providers to implement obesity screening and preventive counseling as part of their routine practice. Providing Lead Testing in Your Practice - Clarification As a healthcare company, we understand the importance of regular preventive health care. Lead poisoning is one of the most prevalent and preventable childhood health problems in New York State. Lead levels as low as 10 micrograms/dl can produce harmful effects. Studies consistently show that even low lead levels contribute to: Behavior problems Learning disabilities Reduced intelligence New York State Public Health Law Mandates the following lead prevention practices: Annual risk assessments of lead exposure for children six months to six years. Regardless of exposure risk, universal blood testing of all children at age one and again at age two years.

7 6 of 6 Lead testing consists of either: Venous blood testing or Capillary lead screening Physicians who are drawing a capillary specimen in your office and sending the sample out for lead screening, will be eligible for reimbursement for the capillary draw (36416) under the following circumstances: A licensed qualified medical professional performs the capillary draw. The test is provided to members between the ages of 12 to 24 months. There is no reimbursement for analysis of the blood sample in the office. All specimens must be sent to an approved lab for analysis. We support your efforts by educating our members about the importance of regular well child visits in our Parenting Guide, as well as with our one and two year-old milestone cards that include lead screening education along with immunizations and child wellness interventions. Provider Telephone and Web Site Reference Guide