Capsule NewsSM

First Quarter 2015

Your input is important

Blue Cross and Blue Shield of Montana (BCBSMT) continues to encourage providers to comment on Draft Medical Policies and review Pending Medical Policies. BCBSMT values input from providers and your comments are taken into consideration whenever policies are up for development, review, and revision. All policies are reviewed annually.

Access the BCBSMT Medical Policies.

Draft Medical Policies are posted to the website on the first and fifteenth day of each month — 90 days in advance of implementation. To provide a comment, click on the Draft Policies icon and then click on Comment. Fill in the applicable information and then click on Submit. Comments are accepted for two weeks and are reviewed weekly by the Medical Policy Development team.

Pending Medical Policies are policies that have already been approved and are scheduled for implementation. To navigate the website for Pending Medical Policies, sort the policies by release date. A policy summary is available at the end of each policy. Previous policies are available in the "Archived Document(s)" section, which is also at the end of each policy.

CRSP List to be removed from Provider Portal

Because information on the list of Codes Requiring Special Processing (CRSP List) is incorporated into Medical Policies, BCBSMT will remove the list from the Provider Portal effective March 9, 2015.

As a reminder, services described in medical policy may be reviewed for medical necessity. A predetermination request can be submitted prior to the service for review if a provider is uncertain about coverage or if BCBSMT might not consider the service medically necessary.

Predetermination is a process BCBSMT uses to make coverage decisions in accordance with medical policy or group and member contracts for a service, supply, drug, or device used to diagnose or treat an illness or condition. BCBSMT recommends predetermination for services if a provider is uncertain about coverage or if BCBSMT might not consider the service medical necessary.

Total Health Management — A Program Built To Effectively Prevent Chronic Disease

With a successful 2014 in the books, and a promising new year underway, the BCBSMT Wellness Team would like to thank you and your support staff in our communities for your continued commitment to excellence in patient care. With your help, we saw record numbers of participants in our Total Health Management (THM) Program in 2014, the program's third year. For those who participate in THM, participation means prevention.

At BCBSMT, health and wellbeing are ever-moving targets. We know one thing that helps us stay on target is prevention, and that the future of health care lies in the ability to not only treat disease, but prevent it. The THM program focuses on prevention of chronic disease through measurements of widely recognized metrics identified by the United States Preventive Services Taskforce.

THM encourages providers to measure simple indices of health status such as blood pressure, LDL cholesterol, height, weight, and tobacco status, as well as determine whether your patients are current on their recommended cancer screenings. Receiving preventive cancer screenings at the proper intervals results in early detection, early treatment, and ultimately could mean more lives spared from cancer. In 2014, 78.65%, 93.01% and 92.03% of THM participants received their colon, cervical, and breast cancer screenings within the recommended time frames, respectively. That is a stark contrast between THM participants and nonparticipants, who have screening rates of 19.44%, 39.12%, and 53.75%, respectively. Furthermore, those participating in THM are not only meeting the cancer screening recommendations, but have even met or exceeded the US Benchmark and the Healthy People 2020 Guidelines. Based on these results, we can deduce that participants in the THM program are more likely to get their cancer screenings done than those who do not participate in THM.

We know the role you play in promoting preventive screenings is extremely powerful. We value your partnership, which allows us to stand with our members through sickness and health – let's continue to advocate for health through prevention.

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

Credentialing News for Providers and Practice Managers

CAQH, the online tool for collection of BCBSMT provider credentialing information, is launching the next generation of the Universal Provider Datasource (UPD), now called CAQH ProView.

What You Can Do Now to Prepare

To prepare and ease the transition, there are two action items you will need to complete prior to the scheduled UPD downtime. First, ensure your UPD application is complete. All completed UPD applications will automatically migrate into CAQH ProView. An application is complete when information is entered into required fields and the provider attests to the data. A complete application will migrate into the CAQH ProView even if the attested information is expired. If your application is currently incomplete (e.g. required fields are not complete, the application is started but not attested to) log into the UPD and complete the required information and your attestation. Second, CAQH ProView requires an email address for all users. If CAQH does not have an email address for your practice on file, please enter one now in your current CAQH account to ensure you receive all updates and information about the transition to CAQH ProView.

To enter an email address:

  1. Log in to your CAQH UPD account
  2. Click on "Edit Account"
  3. Enter a valid email address for you or your practice manager
  4. Change your "Contact Method" from FAX to Email

What is Changing?

A range of new features will make it easier to make updates, reducing the time and resources necessary to submit information. Providers and Practice Managers will be able to easily submit information through a more intuitive profile-based design. CAQH ProView's new features allow users to:

  • Complete and attest to multiple states' credentialing applications in one intelligent workflow design
  • Upload scanned copies of supporting documents directly into CAQH ProView to eliminate the need to fax or email the documents and will improve the timeliness of completed applications. CAQH will review all supporting documents for accuracy within approximately 48 hours of submission  
  • Review and approve Practice Manager information before data is imported
  • Use more focused prompts and real-time validation to protect against delays in data processing
  • Self-register with the system before a health plan initiates the application process
  • If you forget your password in the future, you will not need to call the help desk to reset your password.
  • Simplification of data entry and upload process for Practice Managers. The Practice Manager Module will feature a new "bulk upload" to enter and maintain information for multiple providers at one time through a single process.
  • Practice Managers will have the ability to export additional provider profile data.
  • Practice Managers will have access to detailed activity log and export history, as well as the corresponding provider activity.
  • Practicie Managers will have the ability to establish one main Practice Manager Module account with multiple uses.

What to Expect

Just like the UPD, CAQH ProView is available to providers free of charge.

If you have not entered an e-mail address prior to the transition to CAQH ProView, you will be prompted to add one when you login for the first time.

After the transition, the first time you log into CAQH ProView you will be prompted to update your username and reset your password.

Training and Assistance

Training Resources will include a quick reference guide, getting started video, and user manual. CAQH will notify providers when training materials are available. Webinars will also be provided on the new features. Dates and times will be scheduled after the transition is complete.

CAQH has established a CAQH ProView Provider Transition Support Center to help providers and practice managers with the transition. If you need assistance completing your application or have any questions, please email or call 844-259-5347.

Bookmark this link and check back periodically to stay informed about CAQH ProView over the coming months: .

Diagnosis and Medical Management of Sleep Related Breathing Disorders – Revised Medical Policy Reminder

Recently, we announced a change to the BCBSMT Medical Policy for Diagnosis and Medical Management of Sleep Related Breathing Disorders (MED205.001) that will take effect for services rendered on or after May 1, 2015. This policy has been revised to establish new criteria and guidance for testing in the diagnosis of Obstructive Sleep Apnea (OSA). The revised policy is intended to align BCBSMT's Medical Policy with nationally recognized clinical criteria and current industry standards.

The revised policy establishes the criteria for when utilization of unsupervised home sleep apnea tests and supervised polysomnography (PSG) in the diagnosis of OSA will be considered medically necessary under the terms of the member's benefit plan. For adult patients with symptoms suggestive of OSA and without significant comorbidities, unsupervised home sleep apnea tests may be considered medically necessary. PSG administered in a facility or lab will not be considered medically necessary for these patients unless one or more of the following criteria are met:

  • A previous home study was found to be technically inadequate.
  • A previous home study failed to establish the diagnosis of OSA in a patient with a high pretest probability of OSA.
  • A home study is contraindicated due to co-morbid health conditions that may decrease the accuracy of the study, including but not limited to, moderate to severe pulmonary disease, neuromuscular disease, congestive heart failure or hypo-ventilation syndrome.

PSG and facility-based sleep study tests related to OSA and this medical policy will be subject to medical necessity review under the revised BCBSMT Medical Policy criteria for services rendered on or after May 1, 2015. You are encouraged to obtain a medical necessity determination prior to services being rendered by submitting a benefit Predetermination Request Form. This form is available in the Provider Forms section of our website.

To view the revised BCBSMT Medical Policy for Diagnosis and Medical Management of Sleep Related Breathing Disorders, visit the Medical Policy section of our Provider website and look for the Pending Policies link. Pending policies are listed alphabetically — select the title of the policy you wish to view to open the document.

The BCBSMT Medical Policies are for informational purposes only and are not a replacement for the independent medical judgment of physicians. Physicians are to exercise their own clinical judgment based on each individual patient's health care needs. Some benefit plans administered by BCBSMT, such as some self-funded employer plans or government plans, may not utilize BCBSMT Medical Policy. Members should contact their local customer service representative for specific coverage information.

Revised Methodology for Drug Compensation

Effective May 1, 2015, BCBSMT will revise the methodology utilized for determining allowables for HCPCS/CPT drug codes and will require National Drug Codes (NDCs) and related NDC data for compensation. BCBSMT will reimburse all claims submitted with NDCs in accordance with the NDC Reimbursement Schedule, which will be posted on the BCBSMT secure portal.

BCBSMT currently requests the use of NDCs and related NDC data (i.e., qualifier, unit of measure, number of units and price per unit), along with the appropriate Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) code(s), on claim submissions for unlisted or Not Otherwise Classified (NOC) professional provider administered/supplied drugs. These codes are requested when drugs are billed under the medical benefit on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims.

Using NDCs provides better identification of drugs and allows for more accurate reimbursement. Other advantages of NDC pricing include:

  • NDCs/NDC units submitted by providers are verified systematically
  • Reimbursement will be updated monthly, so providers will receive reimbursement reflective of market price
  • Providers will be reimbursed for what was actually administered and billed to ensure accuracy and consistency
  • Automated submission of certain unlisted or NOC drugs

If you are not familiar with NDCs, please see previously published articles in Capsule News for a quick overview that offers basic guidelines on what the NDC is, where to find it and what NDC-related data needs to be included on your claim.

Please continue to watch the Capsule News, as well as the Announcements section of our website for additional information, updates and related resources to assist you and your office when billing with NDCs.

CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

BCBSMT Access and Availability Standards

Participating providers treat BCBSMT members as they would any other patient and have agreed to cooperate in monitoring accessibility of care for members, including scheduling of appointments and waiting times. Participating providers must meet the following appointment standards:

  1. Emergency services must be made available and accessible at all times.
  2. Urgent care appointments must be available within 24 hours.
  3. Appointments for non-urgent care with symptoms must be made available within 10 calendar days.
  4. Appointments for immunizations must be available within 21 calendar days.
  5. Appointments for routine or preventive care must be available within 45 calendar days.
  6. Emergency Services and Emergency Medical Condition

Participating providers are required to have 24-hour availability of emergency services and qualified on-call coverage available to BCBSMT members.

Emergency Services means health care items and services furnished or required to evaluate and treat an emergency medical condition.

Emergency Medical Condition is a condition manifesting itself with symptoms of sufficient severity, including severe pain, in which the absence of immediate medical attention could reasonably be expected to result in any of the following:

  1. The covered person's health would be in serious jeopardy.
  2. The covered person's bodily functions would be seriously impaired.
  3. A body organ or part would be seriously damaged.

Urgent Care

Participating providers must see BCBSMT members within 24 hours of their request for an appointment.

Urgent Care is health care that is not an emergency service but is necessary to treat a condition or illness that could reasonably be expected to present a serious risk of harm if not treated within 24 hours.

Non-Urgent Care with Symptoms

Participating providers must see BCBSMT members within 10 calendar days of their request for an appointment.

Non-Urgent Care is health care required for an illness, injury, or condition with symptoms that do not require care within 24 hours to prevent a serious risk of harm but do require care that is neither routine nor preventive in nature.

Routine Care

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment.

Routine Care is health care for a condition that is not likely to substantially worsen in the absence of immediate medical intervention and is not an urgent condition or an emergency. Routine care can be provided through regularly scheduled appointments without risk of permanent damage to the person's health status.

Preventive Care and Immunizations

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment for preventive care and within 21 calendar days of their request for an appointment for immunizations.

Preventive Care and Immunizations are health care services designed for the prevention and early detection of illness in asymptomatic people.

More information is available in the BCBSMT Provider Manual. If you have suggestions for improvement or content, email your Provider Account Consultant at or call 800-447-7828, Extension 6100.

Anthem® Blue Cross and Blue Shield Introduces Cancer Care Quality Program

Effective Jan. 1, 2015, Anthem® Blue Cross and Blue Shield implemented a Cancer Care Quality Program administered through AIM Specialty HealthSM (AIM). While this program is not applicable to other Blue Plan members, we are sharing information about this program since it is offered to both national and local Anthem members.

This innovative quality initiative is an evidence-based cancer treatment program designed to support provider decision making as it relates to selecting cancer treatment regimens that are consistent with current evidence and consensus guidelines. These Cancer Treatment Pathways (Pathway) have been developed based on medical evidence and best practices from leading cancer experts to support oncologists to identify therapies that are highly effective and affordable.

Claim information collected may help identify members for Anthem's Case Management programs which may result in maximizing the impact to the patients' overall health. Additional information about this program can be found on AIM's website .

Anthem® is a registered trademark of Anthem Insurance Companies, Inc.

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. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions.

ClaimsXten™ Updates — 1st Quarter 2015

BCBSMT reviews new and revised Current Procedural Terminology (CPT®) and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson and are not considered changes to the software version. BCBSMT will normally load this additional data to the BCBSMT claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSMT Provider website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will continue to be posted on the BCBSMT Provider website.

Beginning on or after April 20, 2015, BCBSMT will enhance the ClaimsXten code auditing tool by adding the first quarter 2015 codes and bundling logic into our claim processing system.

BCBSMT will continue with the modifier 59 exempt program through ClaimsXten. This program is based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI).

NCCI guidelines state, "Each NCCI edit has an assigned modifier indicator. A modifier indicator of '0' indicates that NCCI associated modifiers cannot be used to bypass the edit." BCBSTX will continue to use ClaimsXten as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimsXten database will NOT be added.

For details and additional announcements regarding ClaimsXten, refer to the Provider Claims section of our website. Information also may be published in upcoming issues of the Capsule News.

Reminder: ClaimsXten to Add Correct Coding Initiative Rule

The following reminder includes information from an announcement that was posted in the Providers' Announcements on our website in December 2014.

Beginning on or after March 23, 2015, BCBSMT will enhance the ClaimsXten code auditing tool by adding the CMS Correct Coding Initiative Rule into our claim processing system. The purpose of this new rule is to identify claims containing code pairs found to be unbundled according to the CMS NCCI. The CMS NCCI coding policies are based on coding conventions defined in the American Medical Association (AMA) CPT manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice and/or current coding practice.

ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.

CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Fighting Hidden Food Allergens

For BCBSMT providers who offer treatment for food allergies, it is important to mention to patients that not all food labels are reliable when listing allergens. Allergens that are not listed on the label are referred to as "undeclared" and are the leading cause of food recalls by the U.S. Food and Drug Administration (FDA). About one-third of foods reported to the FDA as serious health risks involved undeclared allergens.1

Some known causes of food recalls as a result of undeclared allergens are:

  • Using the wrong label entirely and errors in labels that are printed directly on packaging.
  • False positive results produced by the enzyme-linked immunosorbent assay (ELISA) test that is usually used to detect food allergens.1

Measures that have been taken to reduce instances of undeclared allergens in food include:

  • Increasing allergen awareness in the packaging industry and developing training and outreach programs that support preventive controls of products.
  • Development of new testing methods to analyze allergens more effectively.1

When discussing food allergies with your patients, encourage them to report any food-allergic reactions to the FDA consumer complaint coordinator in their district.1 For more information on food allergies, recent food recalls and other related health topics, visit .


1 U.S. Food and Drug Administration. Finding Food Allergens Where They Shouldn't Be. October 23, 2014. 

The information mentioned above is for educational purposed only and is not the substitute for the independent medical judgment of a doctor or other health care provider. The final determination about services or treatment is between the patient and the doctor.

Legislative Update: Expedited Formulary Exception Process for Exigent Circumstances

On May 27, 2014, the Department of Health and Human Services issued a final regulation entitled, Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond.

Beginning with coverage years on or after Jan. 1, 2015, issuers providing essential health benefits must provide consumers with an expedited formulary exception process for exigent circumstances that exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug.

After receiving a request from an enrollee or the prescribing physician, a health plan issuer must make its coverage determination on these expedited reviews and notify the enrollee or the prescribing physician of its coverage determination no later than 24 hours after it receives the request. A health plan that grants an exception based on exigent circumstances must provide coverage of the non-formulary drug for the duration of the exigency.

For additional information, we encourage you to refer to the Final Rule .

BCBSMT is committed to achieving full compliance by reviewing and responding to formulary exception requests within the timeframes according to the law.

The information provided above is only intended to be a brief summary of legislation that has been proposed or laws that have been enacted and is not an exhaustive description of the law or a legal opinion of such law. This material is for informational purposes only and is not legal advice. If you have any questions regarding this legislation, you should consult with your legal advisor.

HEDIS® Annual Data Collection Reminder

In the Fourth Quarter 2014 Capsule News, we provided an overview of the Healthcare Effectiveness Data and Information Set (HEDIS) and the annual data collection process.

As a reminder, BCBSMT will begin contacting physician offices and facilities over the next few months in preparation for the collection of annual HEDIS data.

In an effort to decrease interruption of the day-to-day functions of your office, BCBSMT offers alternative methods of medical record collection in place of on-site visits, such as the option to fax requested medical records to BCBSMT or to send electronic medical records to us via secure email. The annual HEDIS data collection process includes the following:

  • A nurse from BCBSMT will be contacting your office to obtain key contact information and confirm your preferred data collection method (fax, secure email or on-site visit).
  • Appointments for on-site visits also may be scheduled with your staff.
  • You will receive a letter or fax from BCBSMT outlining the information that is being requested, including a list with members' names and the identified measures that will be reviewed. Please send medical records only upon request and only for the members listed in the letter from BCBSMT. A timely response – within 5 business days – is requested.

All data collected from medical records are protected by the Health Information Portability and Accountability Act (HIPAA) of 1996. The HIPAA Privacy Rule (CFR 160, 164) allows the collection and release of HEDIS data without patient consent or authorization.

If you have questions regarding on-site nurse visits, alternative means of data collection or requests for medical records, please contact our HEDIS Chart Review Coordinator at 800-447-7828.

Aggregated 2015 HEDIS results will be reported in an upcoming issue of Capsule News. To view the 2014 HEDIS results, visit the HEDIS Reports page.

HEDIS is a registered trademark of NCQA.

Insulin Formulary Changes and New Prior Authorization Program in 2015

Starting Jan. 1, 2015, BCBSMT changed its formulary to make Novo Nordisk®' insulin products the preferred brands for members with prescription drug benefits administered through Prime Therapeutics. Additionally, a new Insulin Agents prior authorization (PA) program was implemented.*

All insulin manufactured by Novo Nordisk (Novolin and Novolog) will be the preferred brands and process at the member's preferred brand copay. Additionally, Lantus and Levemir are also preferred brands. Insulin manufactured by Eli Lilly and Company®' (Humulin and Humalog) will be non-preferred brands, and in most cases, will require a PA request to be submitted and approved for coverage consideration. If the PA request is approved, the member's out-of-pocket expense is often higher for a non-preferred brand drug than for a preferred drug. Depending on the member's benefit plan, select diabetic test strips will also move to a non-preferred brand status and require the member to go through step therapy for coverage considerations.**

To submit a PA request, consider using the electronic prior authorization tool CoverMyMeds®, which is available to BCBSMT independently contracted providers for the online submission of pharmacy PA requests for prescription drugs that are part of the BCBSMT PA program. Visit our Provider Pharmacy section for more information regarding Prior Authorization and Step Therapy.

Affected members have been notified of this change. They have been instructed to contact their physician to discuss their insulin drug choices and determine if a preferred brand is right for them.

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 to be implemented based on the member's 2015 plan renewal, or new plan effective date. These changes do not apply to members with Medicare Part D or Medicaid coverage.

** The insulin products Apidra and Apidra Solostar will also require a PA request but are not listed on the BCBSMT Formulary.

Drug 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.

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.

What's New on iExchange®: Enhancements and Webinars

BCBSMT continues to enhance iExchange, our online tool that allows providers to conduct benefit preauthorization requests for inpatient admissions/extensions, and more recently, select behavioral health, pharmacy, and medical/surgical services. This time-saving interactive tool offers real-time responses, online communication and tracking/reporting capabilities, among other advantages.

With iExchange, you can submit benefit preauthorization requests for approval prior to services being rendered, once eligibility, benefits and preauthorization requirements have been confirmed through your current process. Additional iExchange capabilities that are now offered include the capability to add on services to an open request. iExchange is available 24 hours a day, seven days a week to independently contracted BCBSIL physicians, professional providers and facilities.*

Learn More – Attend a Webinar

Webinars have been scheduled through March to provide an overview of the most important and commonly used features in iExchange. Topics covered in these webinars include, but are not limited to:

  • Gaining access through a single sign-on process
  • User account administration
  • Adding submitting providers
  • Submitting outpatient select behavioral health, pharmacy and medical/surgical requests
  • Submitting inpatient requests
  • Conducting a treatment search, and more!

To register now, select a webinar date and time from the list below.

March 11–1 to 2 p.m., MT

March 25–1 to 2 p.m., MT

Not enrolled for iExchange?

Get started today! Additional information on iExchange, including our online enrollment form, is available in the iExchange section of our website. In addition to answers to frequently asked questions, you'll also find a library of helpful tips sheets in this section of our website. We also welcome you to contact our for assistance.

* The system will be unavailable every third Sunday between 10 a.m. and 2 p.m., MT.

Please note that the fact that a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered.

Medicare Part D Formulary changes 2014 to 2015

Learn more PDF Document

Pharmacy Program Updates: Pharmacy Program Changes Effective Jan. 1, 2015

Learn more PDF Document

Updated Alpha-prefix guide

Learn more PDF Document