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A NEWSLETTER FOR MONTANA HEALTH CARE PROVIDERS
Second Quarter 2011

Medical Policy

Medical policies are published throughout the year, and all revised or new policies are available under New Policies. Any medical policy published with stricter criteria for coverage is available on the website for 90 days prior to implementation.

All medical policies are copyrighted by Blue Cross and Blue Shield fo Montana and may not be reproduced in any manner that is inconsistent with Federal Law

There were no substantial policy revisions or new policies developed in the second quarter.

Rationale for Benefit Administration

Medical policy is developed through consideration of peer-reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity.  BCBSMT reserves the right to make exceptions to medical policy that benefits the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions.  Providers are expected to make treatment decisions based on their medical judgment.  Blue Cross and Blue Shield of Montana recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply, or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.

Federal Mandate

Federal mandate prohibits denial of any drug, device, or biological product fully approved by the Federal Drug Administration as investigational for the Federal Employee Program.  In these instances, coverage of these FDA-approved technologies is reviewed on the basis of medical necessity alone. 

Advanced Member Notice

Participating providers can have a member complete and sign an Advanced Member Notification form stating that BCBSMT will not cover this service, supply, device, or drug.  Refer to the Advanced Member Notification medical policy for more information.

Coordination of Benefits Updates and Changes

Dual BCBS Coverage (Blue on Blue) and FEP Claims

When a patient has two BCBSMT health plan ID numbers, it is only necessary to submit one claim under one ID number. The claim will be processed under both ID numbers when the information is entered into the BCBSMT claims processing system.  To avoid duplicate claims, do not submit another claim under the secondary ID number.  
 
However, Federal Employee Program (FEP) health plan ID numbers are excluded from this rule because FEP claims are processed on a different system.  You must submit another electronic or paper claim using the secondary health plan ID number and include a copy of the explanation of benefits.  Send paper claims to:

Claims Department
Blue Cross and Blue Shield of Montana
P.O. Box 5004
Great Falls, MT 59403

You can check claims status under both ID numbers when you register with us at www.bcbsmt.com.  If the claim is not listed under either ID, you can inquire about the claim online or call Customer Service. 
 
Primary Insurance Coverage Changes Effective September 1, 2011
 
BCBSMT has updated its procedures to determine the primary insurance coverage when a member is covered on two or more policies.  These changes are effective September 1, 2011.

Members are usually primary on their insurance coverage before any other coverage unless they are the policy holder on two insurance plans. 

When one policy is a retiree plan, the retiree plan is generally secondary with some exceptions such as the Federal Employee Program.

When one policy is Medicare, the Tax Equity and Fiscal Responsibility Act (TEFRA), student plans, employer group size, and other circumstances are considered when determining primacy. 

When one policy is COBRA, primacy is determined the same as any other group policy. 

Questions concerning primacy should be directed to the BCBSMT Customer Service Department.  BCBSMT has established a COB unit to assist Customer Service in determining primacy.

BCBSMT will coordinate benefits up to the BCBSMT allowance for each service whether it is paying as primary or secondary.  A participating provider is required to accept BCBSMT’s allowable fee as payment in full even if BCBSMT is the secondary payer.  To determine whether a patient may be balance billed, the primary amount and the BCBSMT payment should be added.  If this total equals the BCBSMT allowance of the secondary policy, the patient’s responsibility is zero. 

If one policy is BCBSMT and the other policy is with a different carrier, file claims with both BCBSMT and the other carrier because claims will not automatically crossover.  File with the primary carrier first, and then include a copy of the explanation of benefits when filing with the secondary carrier. 

BCBSMT participating providers will be limited to the BCBSMT allowable fee of the secondary policy as payment in full when coordinating benefits.

Other Party Liability Customer Service Changes
 
BCBSMT has established the OPL Team to work with participating providers to assist with the proper filing of claims with such entities as Workers’ Compensation, third-party liability insurers, and automobile medical payers. 

When a claim has been paid by Workers' Compensation or another party, the provider should include additional information, when possible, such as date of injury, name of other insurance carrier, claim number, and a copy of the Explanation of Benefits or check from the other payer. 

For more information about Workers' Compensation, automobile medical, third-party liability insurers, and subrogation for the Federal Employee Program, call 1-800-438-7555 and select the corresponding option listed below:

Member Last Name

Option

B, C, H, I, J, L, S, T, U, V, W, X

4

A, D, E, F, G, K, M, N, O, P, Q, R, Y, Z

3





For more information about Workers’ Compensation claims, call 1-800-447-7828 and use the appropriate option listed below:

Member Last Name

Option

A, D, E, F, G, N, Y, Z

3

B, C, H, J, S, T, V, W

4

I, K, L, M, O, P, Q, R, U, X

2

Electronic Remittance (835) Provider Email Group Created

The BCBSMT Health Care Services Department is creating an email group to send information relevant to 835 electronic remit notices.  You will be able to ask questions directly of BCBSMT staff and learn about any changes to your 835 remit notice such as:

  • Claim adjustment reason code (CARC) mapping changes
  • Remit adjustment reason code (RARC) mapping changes
  • Electronic Fund Transfer testing and updates
  • HIPAA 5010 information

If you would like to be added to this list, send an email to mturney@bcbsmt.com.  Include in the subject line all of the following information:

  • 835 Communication
  • Your full name
  • Name of your office or facility
  • Telephone number

Medicare Blue PPO Clinical Practice and Disease Management Guidelines

In May 2006, the Regional Quality Improvement Committee approved the implementation of the Institute for Clinical Systems Improvement Clinical Practice Guidelines for the Medicare Blue PPO plan administered by the BCBS Northern Plains Alliance.  The guidelines were developed using an evidence-based approach, which emphasizes the critical evaluation of scientific evidence rather than expert opinion or consensus.

Currently published guidelines include Adult Breast and Cervical Cancer Preventive Guidelines and Chronic Obstructive Pulmonary Disease (GOLD) Guideline.  In addition, Medicare Blue PPO offers a heart failure disease management program based on the American College of Cardiology and American Heart Association’s 2005 guideline for the Diagnosis and Management of Chronic Heart Failure in the Adult.

For complete information, read the guidelines and disease management program in their entirety.  The guidelines and disease management program are published in their entirety online at http://www.yourmedicaresolutions.com/for_provider.  If you have questions, you may call Kris Thompson at 406-437-6462.

Social Security Numbers Being Removed from Military ID Cards

Beginning June 1, 2011, to protect the privacy and security of TRICARE's® 9.6 million beneficiaries, the Department of Defense (DoD) will no longer issue military ID cards with an individual's Social Security Number (SSN) as an identifier.

As individuals enlist or as a card expires, the DoD will issue new cards without SSNs.

The SSNs will be replaced by two new numbers:

  • DoD Identification Number (DoD EDI-PI or DoD ID): This unique 10-digit number is assigned to every person who has a record in the DoD’s Defense Enrollment Eligibility Reporting System (DEERS).  This number already exists and is commonly known as the Electronic Data Interchange Person Identifier (EDI-PI).
  • DoD Benefits Number (DBN): This 11-digit number will be used to determine benefits eligibility. The first nine digits are common to the sponsor, and the last two digits identify the specific person, much like with a commercial benefit plan.  This number can be found above the bar code on the back of the ID card.

Verifying Eligibility
The SSN is still a valid identifier and will not be removed from the government systems.  Providers can still use their existing processes and forms to collect information from the beneficiaries including the sponsor's SSN.

However, with this change described above, providers will have additional options to check a TRICARE beneficiary's eligibility.

  • TriWest's secure website will allow verification with either the SSN or the first nine digits of the DBN.
  • EDI 270/271 can verify eligibility using all three options: SSN, DoD ID, or DBN.
  • TriWest's Interactive Voice Response (IVR) system can currently verify with the sponsor's SSN and will be changed to accept both the DoD ID and DBN.  Be sure to monitor the provider eNews for updates.

In case a beneficiary cannot recall their or their sponsor's SSN, providers who are secure website users may query the eligibility by using the following three data elements, which must be entered in the same query:

  • First nine digits of the DBN (enter this data in the SSN data field)
  • Individual's first name
  • Individual's Date of Birth

TriWest will submit the information electronically to DEERS for validation.  The provider will then receive the patient's/sponsor's SSN data from DEERS via TriWest's IT systems.

Referral/Authorization Submission
Providers submitting referrals/authorizations online may use the SSN, DoD ID, or the first nine digits of the DBN to submit their claims.  Those who submit using the fax process may also use any of the three ID numbers.  Registered providers can use the sponsor’s SSN or patient name and date of birth to view referral/authorization status.

Claims Submission and Claims Status
Providers submitting claims online at www.triwest.com may use either the SSN or DBN to submit their claims. Those who submit via EDI or by paper may use any three of the ID numbers.  Registered providers may use the SSN or DBN to view claims status.  Those submitting via EDI may use all three numbers to view claims status.  Those using the IVR system may check claims status with the SSN. The IVR system will be enhanced to additionally accept the DoD ID and DBN.

If you have questions concerning the SSN reduction plan or the new ID cards, email CACsupport@osd.pentagon.mil or visit www.tricare.mil.

“TRICARE” is a registered trademark of the TRICARE Management Activity. All rights reserved.

Website Demonstrations Available

TriWest Healthcare Alliance Corp. (TriWest) has created a set of website demonstrations to help you understand the many benefits of the secure provider portal at www.triwest.com/provider.

The website offers demonstrations on the following topics:

  • Account Administration – Learn to manage your online account
  • Eligibility – Learn how to check beneficiary eligibility
  • West Region Benefit Lookup Tool – Learn to research covered benefits and check referrals, authorizations, and medical review requirements for specific codes
  • Online Referral/Authorization Submission – Choose between two demonstrations for medical/surgical and behavioral health
  • Online Referral/Authorization Status – Learn how to check the status of a referral or authorization online
  • Online Claims Submission – Learn about electronic claims submission for the UB-04 and CMS-1500
  • Online Claims Status – Learn how to check the status of your claims online
  • Online Claims Correspondence/Webmail – Learn how to correspond with TriWest online regarding claims and your secure account
  • Provider Connection – Take a tour of the Provider Connection webpage
  • Behavioral Health Portal – take a tour of the Behavioral Health webpage

If you are not registered for the secure provider portal, please sign up today at www.triwest.com/provider/registration.aspx and take advantage of these features: 

  • Verify patient eligibility
  • Research covered benefits and check referral/authorization and medical review requirements for specific codes
  • Submit referrals/authorizations online and check their status regardless of how the request was submitted
  • Submit claims online and check claim status regardless of how the claim was submitted
  • Download remittance advices
  • Download claims status reports
  • Submit corrected claims
  • Claims correspondence/Webmail

 For more information, refer to www.triwest.com/provider.

Fraud: Providing Pain Relief While Preventing Abuse

Opioids and narcotics play an important role in the treatment of pain.  Unfortunately, patients can also experience problems with these substances – including addiction, physical dependence, and tolerance.  Other patients have capitalized on the dependence often created by these substances and seek them with the intention of illegally selling them on the street.

Opium and its derivatives have been used for thousands of years, dating as far back as 3400 B.C. when opium poppies were cultivated in lower Mesopotamia.  In 1552 B.C., the Therapeutic Papyrus of Thebes mentions opium as a component of 700 remedies and in 400 B.C. Hippocrates recommended medicinal use of poppy juice (sparingly and controlled).  Opioid is a broad term used to refer to all compounds related to opium.  Narcotic is a term typically used today in a legal context to refer to a variety of substances, not restricted to opioids, with abuse or addiction potential.

BCBSMT is concerned about the abuse of narcotics for several reasons.  First and foremost is the appropriate treatment of the patient and their safety.  Secondly, the abuse of narcotics is a major driver in utilization and related premium prices – not just in the cost of the drugs themselves, but also in the related costs associated with office visits, testing, and or emergency room charges.  A major insurer performed a study of these costs several years ago and found that more than $40 was paid for office visits and related procedures for every dollar spent on narcotics.

What can you do?  Watch for the following; then take the recommended steps.

Typical Behaviors Often Seen in Drug Diverters/Abusers

  • Strange stories justifying why they need medication
  • Unusually high or low understanding about medications
  • Specific drug requests
  • Reluctance to cooperate with a treatment program
  • Use of multiple physicians or pharmacies
  • Repeated episodes of lost or stolen prescriptions
  • Exaggerating symptoms
  • Demanding immediate appointments or calling after hours
  • Unwilling to divulge information about medical history 

How To Protect Prescription

  • Keep prescription pads locked and secure
  • Write quantities and strengths in both numbers and letters
  • Use tamper-proof prescription pads or electronic submissions
  • Never sign an incomplete prescription

What to Do

  • Remember, a person abusing or addicted to narcotics is in need of treatment
  • Refer the patient for addiction treatment if appropriate
  • Consult the patient’s primary care provider before prescribing a narcotic
  • Contact authorities if you are threatened in any way

The ultimate goal is to identify patients with drug abuse problems and direct them to appropriate care.  Careful evaluation and recommendations will not only benefit the patient, but should result in a long-term reduction in utilization. 

If you have questions or concerns about fraud or questionable practices, call our fraud hotline at
1-800-621-0992, or you may e-mail us at fraud@bcbsmt.com.  More information is also available on our website at www.stopfraud.bcbsmt.com

  Participating Providers

 
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