Capsule NewsSM
A Newsletter for Montana Health Care Providers

Fourth Quarter 2014

Postponed: BCBSMT Interactive Voice Response (IVR) Phone System

In the Third Quarter 2014 edition of Capsule News, Blue Cross and Blue Shield of Montana (BCBSMT) communicated the December 2014 IVR phone system implementation. In an effort to insure the IVR transition is seamless, the implementation will be postponed until 2015. Our goal is to be transparent to our provider community and ensure you are ready for the transition. More information will be communicated as we approach the new go-live date for the IVR implementation in the second quarter of 2015. Thank you for your understanding.

Visit the Provider Announcements page on the BCBSMT website for future communications.

Billing with National Drug Codes (NDCs)

NDC data on claims will play a significant role in 2015. A previous Capsule News article reviewed when to include NDC information when drugs are billed on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims.

Currently, BCBSMT requests inclusion of NDCs and related NDC data (i.e., qualifier, unit of measure, number of units and price per unit), along with the appropriate Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code(s) on claim submissions for unlisted or Not Otherwise Classified (NOC) professional provider administered/supplied drugs. NDCs provide a better identification of certain unlisted drugs and allow for proper adjudication of your claim.

NDC pricing will be implemented for professional/ancillary claims within calendar year 2015. At time of implementation, professional/ancillary claims for drugs administered in professional provider offices will require NDCs and NDC data in order to be accepted for processing by BCBSMT.

To help your office make the transition, be on the lookout for additional NDC related materials in the months to come. Please continue to watch the Capsule News, as well as the Announcements section of our Provider website.

CPT copyright 2012 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Pharmacy Program Introduces Electronic Prior Authorization Process

As mentioned in last quarter's Capsule News, BCBSMT has enhanced the process for submitting Prior Authorization (PA) requests for drugs that are part of our PA program.

We're pleased to announce there are two opportunities to use new Electronic Prior Authorization tools on our website at

A link can be found on the Provider Pharmacy page in the Prior Authorization and Step Therapy section. This link takes you to the login page for CoverMyMeds®, an online tool with a list of BCBSMT forms that can be completed and submitted electronically.

Additionally, you can also submit medical pharmacy PA requests online using iExchange, our web-based tool that accepts benefit prior authorization requests, 24 hours a day, seven days a week.* In addition to PA requests for medical/surgical and behavioral health services, iExchange supports outpatient PA requests for the following specialty drugs, which may be considered eligible for benefits under the member's medical benefit: Avastin, Mybloc, Reclast, Botox, and Remicade.

Using online options for prescription drug Prior Authorization requests replaces the need to fax paper forms to BCBSMT. Additionally, there are many advantages, including:

  • Immediate confirmation upon receipt
  • No need to resubmit or call to check status
  • Connects the pharmacy with the physician


From the CoverMyMeds login page, new users can select Create an Account to sign up and create a password. CoverMyMeds will confirm that you are a BCBSMT contracted provider prior to granting access. If there are any questions, a live chat feature is available. There is no cost to use CoverMyMeds.

When a request is initiated, CoverMyMeds will first check eligibility to verify that the patient is a BCBSMT member who has Prime Therapeutics as their pharmacy benefit manager. After you submit your request, you'll receive an immediate confirmation with details on when the determination will occur. Upon approval, you'll receive an electronic notification from CoverMyMeds. Likewise, the member's pharmacy is contacted with the decision and pending claims can then be processed accordingly.


To get started using iExchange, new users can register by completing the online enrollment form found on the iExchange page of our Provider website. Upon completion, users will receive login information to access iExchange via the Provider login page.

For reference, a Submitting an Outpatient Pharmacy Preauthorization Tip Sheet is available on the iExchange page of our Provider website. This tip sheet offers step-by-step instructions for submitting a medical pharmacy PA request using the iExchange tool.

Additional training for iExchange is available upon request by contacting the iExchange training team at

Additional enhancements will be announced in the coming months. Watch for more details in future issues of Capsule News and on the Provider Announcements page of our website.

*With the exception of the third Sunday of every month when the system will be unavailable from 11 a.m. to 2 p.m. Third party brand names are the property of their respective owners.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. BCBSMT makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the products or services they offer, you should contact the vendor(s) directly.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSMT contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSMT, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

New Provider Contracting & Credentialing Process

As a reminder, BCBSMT is transitioning its credentialing processes to utilize the Council for Affordable Quality Healthcare (CAQH) Universal Provider Data source (UPD), a nonprofit alliance of health plans and trade associations to electronically collect provider credentialing data. CAQH collaborates on initiatives that simplify healthcare administration for health plans and providers.

Providers may utilize the UPD at no cost.

In addition, BCBSMT will be implementing new in-house technology to handle its contracting and credentialing processes.

Initial Credentialing Process

Effective 9/11/14, when a new professional provider applies for network participation, existing providers adding additional providers to their practice contract must submit the Agreement "Add Sheet"/ Amendment B with the new provider's information. New providers not affiliated with an existing contracted practice must request a BCBSMT Provider Record ID by submitting a form, which will be provided on our website at A new Fax number is being established for submittal of these forms, or they may be submitted via e-mail to

After receiving either form, BCBSMT will create a provider record and assign a provider i.d. in its system. BCBSMT will then add the provider to its roster with CAQH and for new providers not affiliated with an existing contracted practice, a contract will be sent and will need to be signed and returned. CAQH will send a registration letter including an assigned ID and instructions on how to register using the UPD. The provider is then able to access the UPD database via the Internet and enter the credentialing application. Only organization(s) the provider authorizes will have access to their data. The provider must authorize BCBSMT to view their credentials.

Providers that are already utilize CAQH and are registered must simply authorize BCBSMT to view their credentials.

As you may recall, BCBSMT became a division of Health Care Service Corporation (HCSC) in August of 2013. BCBSMT is working in collaboration with our HCSC partners in the Texas Plan on the credentialing process. Staff in the Texas office will collect additional information required and will verify the information supplied in the credentialing application.

BCBSMT's local Credentialing Committee, consisting of practicing healthcare providers in the state of Montana, will continue to review and approve the applications.

Once the credentialing process is complete, the credentialing approval letter is sent. The contract will be executed and a welcome letter will be sent along with a copy of the executed agreement and effective date of the contract.

As a reminder, the effective date of the contract is the credentialing approval date. Effective dates are not backdated. Please be sure to start the process prior to the provider's start of practice to avoid non-participating status.

Once the provider's credentialing information is entered into CAQH, the provider will receive an automatic reminder to review, update and attest to data accuracy once every four months.

Recredentialing Process

BCBSMT will access the UPD database for a provider's data during their scheduled recredentialing cycle every third year. CAQH will automatically transmit information to BCBSMT if information is complete & current. The provider will only receive a recredentialing notice if his/her information in the UPD is not current.

Effective September 1, 2014, CAQH began collecting the data required for the BCBSMT recredentialing for providers whose recredentialing is due in December 2014 and going forward. Providers will begin receiving recredentialing notices 6 months in advance of their recredentialing due date, if the provider has not recently updated the CAQH.


Working with CAQH will make the credentialing process more uniform and ease your administrative processes, saving both time and money. It will eliminate the need to complete multiple credentialing applications for multiple health plans. Your information can be kept current at all times. You will only receive recredentialing notices if your information in the UPD is not current. The UPD online credentialing application process supports BCBSMT's administrative simplification and paper reduction efforts.

What Next?

If you are already registered with CAQH through your participation with another health plan, you will need to log in to the UPD database at and add BCBSMT as one of the health plans authorized to access your information or select "global authorization." This will allow BCBSMT to obtain your current credentialing information from the UPD database. You may do so at this time.

If you are not already registered with CAQH, 6 months in advance of your recredentialing due date, you will be rostered by BCBSMT and will receive notice that you are due for recredentialing and the letter will include your CAQH assigned ID and instructions on how to register using the UPD. You may then access the UPD database via the Internet and enter your credentialing application. If you do not have Internet access, you may call the CAQH Help Desk at 888-599-1771 and complete the application by telephone. Supporting documentation for the credentialing process may be faxed to a specific toll-free fax number 866-293-0414.

If you have a new provider that will be joining your practice, or are a new provider not affiliated with an existing contracted practice, follow the Initial Credentialing process defined above to obtain a BCBSMT provider record. Please account for time to complete the entire process prior to the provider's start date. The process takes an average of 45 days to complete.


Please watch the BCBSMT Provider page at for more information in the future. The Provider page will be updated to provide resources to guide providers through the process.

For more information on the CAQH application process visit its web site at . The CAQH Help Desk may be reached by phone at 888-599-1771 or e-mail at

Pharmacy Program Benefit Changes, Effective Jan. 1, 2015

As a reminder, BCBSMT will be implementing pharmacy benefit changes as of Jan. 1, 2015, for some members with prescription drug benefits administered through Prime Therapeutics.*

Based on claims data, letters will be sent from BCBSMT to alert members who may be taking, or who may have been prescribed, a medication that may be affected by the 2015 pharmacy benefit changes. A summary of the changes, as outlined in the member letters, is included below for your reference.

Day Supply Limit Change — Benefits for covered medications are changing from a 34-day supply to a 30-day supply for prescriptions filled at retail pharmacies.

Medication Coverage Exclusions — Non-sedating antihistamines and compound medications will no longer be covered under the prescription drug benefit.

Prescription Drug Coverage Change — Glucose meters & control systems and insulin pump supplies will be covered under the member's medical benefit and will no longer be covered under the prescription drug benefit.

If your patients have questions about their prescription drug benefits, please advise them to contact the number on their member ID card. Members also may log in to Blue Access for MembersSM for a variety of online resources.

*Changes may be applied for some members, if applicable, based on their employer's 2015 group plan renewal, or new plan effective date.

Prime Therapeutics LLC is a pharmacy benefit management company. Blue Cross and Blue Shield of Montana (BCBSMT) contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSMT, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member's certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.

One-on-One Relationship with Providers Make the Difference

Thank you to all providers who are partnering with BCBSMT through the Total Health Management program!

The Wellness Team from BCBSMT extends a huge thank you to all providers who work with their patients to complete the Total Health Management (THM) assessment!

While wellness programs are not novel to the health care field, THM presents the next innovative step. We know that you, the provider, play a powerful role in the outcomes your patients experience. Through THM, patients are encouraged to form a relationship with you, starting with regular wellness screens.

While knowledge of tobacco use status, blood pressure, cholesterol, weight, and cancer screening status are indices of disease risk, they are also effective baselines from which to set goals. By taking the time to go over these results with your patients, you engage them and work together toward early detection, intervention, and prevention of diseases and ailments. This time you spend is invaluable as you equip them with the tools they need to set and achieve their goals toward a healthier, more fulfilling life.

Early detection leads to healthier outcomes, and you are an integral part in your patients' success. Thank you for your time and dedication.

If you have questions or would like to know more about the THM program, please visit , or email us at

In the Know: Medicare Marketing Guidelines for Providers

The 2015 Centers for Medicare & Medicaid Services (CMS) Annual Election Period for beneficiaries is fast approaching. For those providers who are independently contracted with BCBSMT to provide services to our Blue Cross Medicare Advantage PPO‚Ą† members, it's important to keep in mind the rules established by CMS when marketing to potential enrollees.

You may not be planning specific marketing activities, but what if a patient asks for information or advice? Remaining neutral when assisting with enrollment decisions is essential. Below, you'll find a partial listing of additional "Dos" and "Don'ts" for providers, as specified within the CMS Medicare Marketing Guidelines (MMG) for contract year 2015 (section 70.11.1 on Provider-Based Activities).


  • Provide the names of Plans/Part D Sponsors with which [you] contract and/or participate (see MMG section 70.11.2 for additional information on provider affiliation)
  • Provide information and assistance in applying for the LIS*
  • Make available and/or distribute plan marketing materials
  • Refer their patients to other sources of information, such as SHIPs** plan marketing representatives, their State Medicaid Office, local Social Security Office, CMS' website at or 800-MEDICARE
  • Share information with patients from CMS' website, including the "Medicare and You" Handbook or "Medicare Options Compare" (from ), or other documents that were written by or previously approved by CMS


  • Accept Medicare enrollment applications
  • Make phone calls or direct, urge or attempt to persuade beneficiaries to enroll in a specific plan based on financial or any other interests of the provider
  • Mail marketing materials on behalf of Plans/Part D Sponsors.
  • Offer inducements (e.g., Free Health Screenings, Cash, etc.) to persuade beneficiaries to enroll in a particular plan or organization
  • Distribute materials/applications within an exam room setting

The above lists provide just a sampling of important points for your convenience. For a more in-depth review of the guidelines that are applicable to providers, please refer to the Provider Medicare Marketing Guidelines PDF Document located in the Important Links section on the Provider home page of our website.

If you have questions about these guidelines or are planning marketing activities, please refer to the Managed Care Marketing page located under Health Plans, in the Medicare section of the CMS website, at .

*LIS refers to low income subsidy

**SHIPs are Senior Health Insurance Assistance Programs Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Open Enrollment: Helping Your Patients Shop with Confidence

For more than 75 years, BCBSMT has demonstrated a firm commitment to providing excellent customer service as well as expanding access to cost-effective, quality health care for our members. As a recognized leader in the health insurance industry, our portfolio of product offerings continues to grow and change in response to market innovations and customer demands.

While the majority of our membership comes from employer groups, our retail and government program member population is growing as well. The number of new BCBSMT members increased significantly after the first open enrollment period under the Affordable Care Act (ACA) last year, but there still are millions of uninsured people to reach.

Open enrollment on the Health Insurance Marketplace begins Nov. 15, 2014, and BCBSMT is ready. In addition to first-time shoppers, many of our current members will be renewing for the first time. Where applicable, some members may be migrating from their current policies to new ACA-compliant plans. This means that some of your current patients may be shopping for a new plan and will need to know if they can still see you as an in-network provider. Or, you may receive calls from prospective patients who are doing preliminary research before they make a decision.

Educating consumers is critical, particularly during open enrollment.

We would also like to call your attention to a new brochure that may be helpful if your patients come to you with questions. The brochure is titled, Understanding Health Insurance — Your Guide to the Affordable Care Act. It offers quick tips and sample scenarios to help your patients understand the basics, such as:

  • Why health insurance is necessary
  • When and how to purchase a health insurance plan
  • Financial considerations, special programs and exceptions
  • Description of the four plan levels (Bronze, Silver, Gold, Platinum)
  • Guaranteed coverage overview (essential health benefits and preventive services)
  • Definitions of key terms, such as premium, deductible, copayment, out-of-pocket maximum and in-network provider

The brochure also includes a list of questions to help the newly insured prepare for next steps, once they've decided on a health care plan. The information is organized to call the reader's attention to important details, such as how to make premium payments, what's on the member ID card, how to find a primary care physician and the importance of confirming in-network provider status.

To view the Understanding Health Insurance — Your Guide to the Affordable Care Act brochure, visit the Standards and Requirements/Affordable Care Act/Patient Perspective section of our website. If you would like to order printed copies of this brochure and other materials you can share with your patients, please contact your assigned Provider Representative.

For additional information on open enrollment and ACA-related resources, please watch upcoming issues of the Capsule News, as well as the Providers' Announcements section of our Provider website.

This communication is intended for informational purposes only. It is not intended to provide, does not constitute, and cannot be relied upon as legal, tax or compliance advice. The information contained in this communication is subject to change based on future regulation and guidance.

Blue Cross and Blue Shield Top Medical Executive Talks Affordable Care Act

Stephen L. Ondra, M.D., Senior Vice President and Chief Medical Officer of Health Care Service Corporation, was featured in the July 2014 issue of Chicago Medicine magazine. A recognized leader in the health care industry, Dr. Ondra is a neurosurgeon, veteran of the Iraq War, former health advisor to President Obama, and former senior vice president and chief medical officer at Northwestern Memorial Hospital. In the Chicago Medicine article, Dr. Ondra discusses his ideas on what physicians may need to do to prepare for the next round of initiatives under the Affordable Care Act, as well as other changes coming to health care as a result of potential impact on insurers, employers, other payers and the public at large. Here's what he has to say  PDF Document.

Submitting Electronic Replacement and/or Void Claims

For electronic professional and institutional claims (837P and 837I transactions), it is important to use the appropriate Claim Frequency Code in CLM05-3 to indicate the claim is a correction of a previously adjudicated (approved or denied) claim. The valid claim frequency codes are:

1 Indicates the claim is an original claim

7 Indicates the new claim is a replacement or corrected claim – the information present on this bill represents a complete replacement of the previously issued bill.

8 Indicates the claim is a voided/canceled claim

For additional information on replacement, void and duplicate claims — along with important updates on upcoming changes — click here PDF Document.

How providers can impact HEDIS®

Do the services you provide to your patients count? BCBSMT values the care you provide to our members. Properly submitting your annual Healthcare Effectiveness Data and Information Set (HEDIS) records enables the quality, value and performance of the health care you provide to count.

As providers, you are an important part of the HEDIS process because of your role in submitting accurate and timely records. As January approaches, it is time to prepare for the HEDIS data collection period. The information in this article will help you better understand what is expected of you as a provider and how your compliance positively impacts HEDIS scores.

What is HEDIS?

Healthcare Effectiveness Data and Information Set (HEDIS) is a collection of performance measures developed by the team of clinicians and researchers at the National Committee for Quality Assurance (NCQA) to measure the effectiveness of health care received by health plan members. Controlling high blood pressure is an example of a current tracked measure. The HEDIS team reviews medical records of members diagnosed with hypertension to identify the percentage of members whose blood pressures are adequately controlled during the measurement year.

How is data collected?

Health plans start collecting data from the previous measurement year in January (i.e. HEDIS 2015 data will measure 2014 performance). Three different methods can be used:

Administrative Data — obtained from claims
Hybrid Data — obtained from medical record reviews to augment administrative data rates
Survey Data — obtained from member and provider surveys e.g. Consumer Assessment of Healthcare Providers and Systems (CAHPS)

How is HEDIS data used?

The results are used by employers, consultants and consumers along with accreditation information, to help them select the best health plan for their needs by offering a measure-by-measure comparison of quality metrics. Results are also used by health plans to measure performance, identify quality initiatives and provide educational programs for providers and members.

What about HIPAA?

The Health Information Portability and Accountability Act (HIPAA) privacy rule allows the collection and release of HEDIS data with no special patient consent or authorization.

How can you help as a provider?

The quality of care and services offered by our providers and their staff is reflected in the improvement of HEDIS scores. As a provider, you and your staff can help facilitate the HEDIS process by:

  • Documenting accurately in medical records
  • Coding all claims accurately
  • Responding quickly to our request for medical records within five business days

Non-responses by the provider office count as a negative toward HEDIS scores.

If you have any questions regarding requests for medical records, contact BCBSMT Accreditation Coordinator Kristin Thompson at 406-437-6462 or

Medical Record Submission 'Dos and Don'ts'

In certain cases, we may need to request additional information – such as medical records, operative reports or other supporting documentation – to process a claim. In such cases, BCBSMT will only request the minimum Protected Health Information (PHI) necessary per the Health Insurance Portability and Accountability Act (HIPAA).

It is very important that you submit only the information that is requested and only if it is requested. Below are some quick reminders on when and how to submit medical records and other information, if you receive a request from BCBSMT.

  • Use the letter you receive from BCBSMT as your cover sheet when submitting the requested information to us. This letter contains a barcode that will ensure we match the requested information directly to the appropriate file and/or claim.
  • Submit only the information that pertains specifically to what is requested by BCBSMT.
  • Do not submit a Claim Review Form in addition to the letter you receive from BCBSMT, as this could delay the review process.


Do not automatically submit medical records for claims that have been denied due to "not a covered benefit" or similar reasons. If you submit medical records for claims that have already been denied for these reasons, you will receive a letter from BCBSMT alerting you that your request will not be reviewed as the services performed are not eligible for coverage under the patient's benefit plan.

Medicare vs. Commercial Risk Adjustment

Risk adjustment is a tool used to help predict health care costs based on the relative risk of enrollees to protect against potential effects of adverse selection. It is a way to help evenly distribute the weight of illness, demographics and other factors that patients bring to a health care encounter. Medicare risk adjustment has been in place for Medicare Advantage plans for many years and has evolved over time.

There are several important differences between the Health and Human Services Hierarchical Condition Categories (HHS-HCC) commercial risk adjustment model and the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) model used in Medicare Advantage plans.

  • The HHS-HCC risk adjustment model is concurrent, which means that the risk score calculated for each patient is based on diagnoses from the same year as the associated revenue. For commercial risk adjustment, HHS employs the HCC groupings logic used in the Medicare risk adjustment program, but with HCCs refined and selected to reflect the expected risk adjustment population. There are currently 3,518 diagnosis codes that map to 1 of 127 HCCs.
  • The CMS-HCC model uses risk adjustment diagnosis codes and demographic data reported for one year to determine payment for the next year. Calculations for payment are based on patient risk scores. Medicare risk adjustment utilizes HCC groupings logic in its risk adjustment model. Medicare Advantage plans cover an older population with inherently more chronic medical conditions. There are currently 3,034 diagnosis codes that map to 1 of 79 HCCs.

For both HHS and CMS risk adjustment models medical conditions have to be treated/addressed and documented annually or need to specify that the patient no longer has the condition. The conditions need to be documented during face-to-face encounters with an acceptable Provider type. Chronic conditions not documented annually are not captured in risk scores.

Additionally, risk scores for Medicare Advantage plans represent a member's heath status while HHS commercial risk scores represent health status and member benefit plan selection. For example the historical conditions for the CMS HCC model are coded and reported and transfer with the patient. The HHS models does not transfer patient level data between plans and all conditions need to be documented annually when the plan changes. For more information about risk adjustment, visit our provider website and the CMS website .

Medicare Part D Formulary Updates

A summary of recent BCBSMT Medicare Part D formulary changes can be found by clicking here PDF Document.

Provider Account Consultants Contact Information


Jenifer Sampson, 406-437-6121, (West region, including Butte, Missoula, Kalispell and adjacent areas)

Christy McCauley, 406-437-6068, (West region)


Julie Sakaguchi, 406-437-6122, (Central region, including Helena, Great Falls, Lewistown and adjacent areas)


Susan Lasich, 406-437-6223, (East region, including Bozeman, Billings and eastern Montana areas)

Troy Smith, 406-437-5214 (East Region), (East region)