SM March 2015 - provcomm.ibx.comprovcomm.ibx.com/ibc/news/PIH/IBC_PIH_March2015.pdfeffective April 1, 2015 Effective April 1, 2015, we will implement a quarterly update to our Professional

updateSM

Billing procedures for credentialed Certified Registered Nurse Practitioners page 12

Updated Provider Manual now available page 3

Professional Injectable and Vaccine Fee Schedule updates effective April 1, 2015 page 4

March 2015

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2015 www.dreamstime.com. All rights reserved.Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.This is not a statement of benefi ts. Benefi ts may vary based on state requirements, Benefi ts Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefi ts information. Members should be instructed to call the Customer Service telephone number on their ID card.The third-party websites mentioned in this publication are maintained by organizations over which Independence exercises no control, and accordingly, Independence disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefi ts plans. Members should refer to their benefi ts contract for complete details of the terms, limitations, and exclusions of their coverage.NaviNet is a registered trademark of NaviNet, Inc., an independent company.FutureScripts and FutureScripts Secure are independent companies that provide pharmacy benefi ts management services.CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of Independence Blue Cross and its affi liates (Independence), created to provide valuable information to the Independence-participating provider community. This publication may include notice of changes or clarifi cations to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with Independence. This publication is the primary method for communicating such general changes. Suggestions are welcome.

Contact information:Provider CommunicationsIndependence Blue Cross1901 Market Street27th FloorPhiladelphia, PA 19103

[email protected]

Keystone Health Plan East, Personal Choice®, Keystone 65 HMO, and Personal Choice 65SM PPO have an accreditation status of Commendable from NCQA.► Articles designated with a blue arrow include notice of

changes or clarifi cations to administrative policies andprocedures.

For articles specifi c to your area of interest, look for the appropriate icon:

Professional Facility Ancillary

Inside this editionAdministrative► Updated Provider Manual now available

ICD-10► Join us for the next What’s Up Wednesday call on

March 18, 2015

Business Transformation● Stay informed during our transition to a new platform

Billing► Professional Injectable and Vaccine Fee Schedule updates

effective April 1, 2015► POA indicator and properly fi lling out claims► Proper screening colonoscopy billing for Medicare Advantage

members► Claim submission requirements when billing with place of

service code 22► Important billing information for modifi ers 25 and 59

NaviNet®

► Changes coming to NaviNet in March

Medical► Clarifi cation: Injectable hyaluronate acid products being

removed from the Direct Ship Injectables Program► Medical and claim payment policy activity posted from

January 24 – February 20, 2015► Non-emergent outpatient radiation therapy to be reviewed for

medical necessity

Credentialing► Billing procedures for credentialed Certifi ed Registered Nurse

Practitioners► New CAQH recredentialing process now in effect

Pharmacy ► Select Drug Program® Formulary updates► Prescription drug updates

Quality Management● Highlighting HEDIS®: Appropriate testing for children

with pharyngitis

March 2015 | Partners in Health UpdateSM 3 www.ibx.com/providers

Updated Provider Manual now availableThe Provider Manual for Participating Professional Providers (Provider Manual) has recently been updated and is now available through the NaviNet® web portal. The Provider Manual is located in the Current Publications section of Independence NaviNet Plan Central.

For a list of changes that were made to the Provider Manual, please refer to the Revision History, which outlines the revision dates, a brief description of the changes, and the sections of the manual that were affected. Updates include changes to our policies, procedures, and programs as previously communicated through Partners in Health Update, Provider Bulletins, and/or direct mailings.

For your convenience, a printer icon appears at the beginning of each section so you can easily print individual sections.

Updates to the manuals are made as needed, so please be sure to check Independence NaviNet Plan Central frequently to ensure you have the most up-to-date information regarding our policies, procedures, and programs.

If you do not yet have access to NaviNet, please visit www.navinet.net to register. Paper copies of the manuals are available by submitting an online request at www.ibx.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

ADMINISTRATIVE

Join us for the next What’s Up Wednesday call on March 18, 2015What’s Up Wednesday is a monthly teleconference hosted by Pennsylvania’s Blue Plans to help prepare health care professionals for the ICD-10 transition on October 1, 2015. What’s Up Wednesday features special guest speakers and ICD-10 experts who will lead discussions to help you get ready for the compliance date. All providers, clearinghouses, information trading partners, and information networks are encouraged to participate.

How to participate ● No registration is required. Prior to the call, visit the What’s Up Wednesday web page at www.ibx.com/providers/claims_and_billing/icd_10/whatsupweds.html to access and download the presentation materials.

● On the day of the call, dial 1-800-882-3610 and enter pass code 5411307 when prompted. Please dial in five minutes prior to the start of the call.

QuestionsIf you have specific ICD-10-related questions during the call, please email them to [email protected].

Call details

Date: Wednesday, March 18, 2015 Time: 2 – 3 p.m. ET Phone number: 1-800-882-3610 Pass code: 5411307

ICD-10

www.ibx.com/providers/claims_and_billing/icd_10/whatsupweds.html

www.ibx.com/providers/claims_and_billing/icd_10/whatsupweds.html


BUSINESS TRANSFORMATION

Stay informed during our transition to a new platformIndependence has nearly completed the process of transitioning its membership to the new operating platform, with the remaining commercial members migrating to the new platform on March 1, 2015. All Medicare Advantage HMO and PPO members were migrated to the new platform on January 1, 2015.

We are committed to working closely with our entire provider network as we complete this Business Transformation. We will continue to provide comprehensive communications and resources to support our members and provider network after the transition to the new platform is complete. Visit our Business Transformation site at www.ibx.com/pnc/businesstransformation, where you will find several resources, including a communication archive and frequently asked questions. If you still have questions after reviewing these resources, email us at [email protected].

BILLING

Professional Injectable and Vaccine Fee Schedule updates effective April 1, 2015 Effective April 1, 2015, we will implement a quarterly update to our Professional Injectable and Vaccine Fee Schedule for all contracted providers. These updates reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables.

If you have any questions about the updates or where to view them, please contact your Network Coordinator.


BILLING

Proper screening colonoscopy billing for Medicare Advantage members When billing a screening colonoscopy for Medicare Advantage HMO or PPO members, it is important to report code G0105 (for high-risk patients) or code G0121 (for patients who are not high-risk) to ensure patients receive the highest level of available benefits. If code G0105 or G0121 is not reported for screening colonoscopies, it could create significant and unnecessary member out-of-pocket costs and patient dissatisfaction.

Note: If during the course of the screening colonoscopy, a lesion or growth is detected and results in a biopsy or removal of the growth, the appropriate diagnostic CPT® code classified as a colonoscopy with biopsy or removal should be reported rather than code G0105 or G0121. Please note that if a screening colonoscopy turns into a diagnostic colonoscopy, the member is responsible for applicable cost-sharing.

POA indicator and properly filling out claims As part of industry standards for claims processing, Independence enforces present on admission (POA) indicator billing requirements and claims processing policies for acute-care hospitals on our new operating platform. Claims processed on the new platform with dates of service on or after November 1, 2013, without a valid POA indicator (as applicable) will be rejected. All hospitals are required to follow instructions from the Centers for Medicare & Medicaid Services regarding identification of the POA for all diagnosis codes for inpatient claims submitted on the UB-04 and ASC X12N 837 Institutional (837I) forms.

However, it is important to note that number “1” is no longer valid on electronic claim submissions under the version 5010 format. The POA field should instead be left blank for codes exempt from POA reporting.

If you have any questions about the POA indicator, please contact your Network Coordinator.


Required fi eldsFor claims submitted electronically:

● Loop 2310C NM1(Service Facility Location Name)

— N3 (Service Facility Location Address) — N4 (Service Facility Location City, State, ZIP Code)

— REF (Service Facility Location Secondary Identifi cation)

For claims submitted on paper: ● Box 32 (see image, right)

Completing all required fi elds ensures the accurate application of your contractual business arrangement with Independence.

For complete information on submitting claims electronically, refer to the Independence Blue Cross HIPPA Transaction Standard Companion Guide available at www.highmark.com/edi-ibc. For complete information on submitting paper claims, please read the Claims Submission Toolkit for Proper Electronic and Paper Claims Submission available at www.ibx.com/providers/claims_and_billing/claims_resources_guides.html.

BILLING

Claim submission requirements when billing with place of service code 22When billing with place of service code 22, outpatient hospital, it is important to remember that you must complete all required fi elds in their entirety, including the proper ZIP code, to receive payment.

Attention! An update has been made to the content of this article.

https://www.highmark.com/edi-ibc/resources/index.shtml

https://www.highmark.com/edi-ibc/resources/index.shtml

www.ibx.com/providers/claims_and_billing/claims_resources_guides.html

www.ibx.com/providers/claims_and_billing/claims_resources_guides.html


BILLING

Important billing information for modifiers 25 and 59 This is a reminder that as of January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) edits are applicable to claims submitted on the CMS-1500 claim form or through the 837P transaction. Please refer to our Commercial and Medicare Advantage policies on NCCI edits which are available at www.ibx.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you’d like to view:

● Commercial: #00.01.56a: National Correct Coding Initiative (NCCI) Code Pair Edits;

● Medicare Advantage: #MA00.041: National Correct Coding Initiative (NCCI) Code Pair Edits.

The CMS NCCI tables (Column 1/Column 2) are composed of code pair edits. These code pair edits identify services that are a component of a more comprehensive code or two codes that should not be reported together. Procedure code pairs designated by CMS with an NCCI modifier indicator of 0 (zero) are not eligible to be reimbursed separately when reported on the same date of service for the same member when performed by the same provider. The NCCI edit identified in the CMS NCCI file for these procedure code pairs will be applied by Independence regardless of the presence of a modifier.

Modifiers 25 and 59Procedure code pairs designated by CMS with an NCCI modifier indicator of 1, when clinically appropriate, are eligible to be reported with an appropriate modifier for separate reimbursement. The most frequently used modifiers are 25 and 59.

● Modifier 25. Modifier 25 is required when a significant, separately identifiable Evaluation and Management (E&M) service is performed by the same physician on the same day of a procedure or other service. For example, if an E&M service was also performed on the same day as an administration of an immunization, the E&M service should be billed with the modifier 25.

● Modifier 59. Modifier 59 is required to indicate that a procedure or service is separate, distinct, or independent from other non-E&M services performed on the same day by the same individual.

For more informationFor more detailed information regarding the appropriate use of these modifiers, please visit our Medical Policy Portal at www.ibx.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you’d like to view:

● Modifier 25: — Commercial: #03.00.06l: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service;

— Medicare Advantage: #MA03.003a: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service.

● Modifier 59: — Commercial: #03.00.08c: Modifier 59: Distinct Procedural Service;

— Medicare Advantage: #MA03.005: Modifier 59: Distinct Procedural Service.

Please refer to the CMS NCCI file for procedure code pair edits and the associated modifier indicators: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html.

www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html


NAVINET®

Changes coming to NaviNet in MarchAs previously communicated, significant changes are scheduled to be made in March to the NaviNet web portal. Please review this information to understand how these changes may affect how you do business with Independence.

NaviNet office conversionWe are converting all NaviNet offices to the new platform on March 20, 2015. Most providers will see a difference in their provider group drop-down menus within many individual transactions on NaviNet.

Some of the more significant changes that providers will see on the new platform include: ● new presentation of provider data within drop-down menus; ● expanded drop-down lists for all office locations associated with a group record; ● elimination of PPO/HMO lines of business designators; ● elimination of customized provider group name descriptions.

As there may be significant impacts to your NaviNet office, we strongly encourage you to review the NaviNet Office Conversion Guide and webinar that will be available soon in the NaviNet Transaction Changes section of our Business Transformation site at www.ibx.com/pnc/businesstransformation.

Allowance Inquiry transactionA new Allowance Inquiry transaction will be added as an option in the list of transactions, replacing the retired Fee Schedule Inquiry transaction. This new transaction will return fees for professional providers only and will indicate where primary care physician (PCP) capitation is generally applicable. The fees returned via Allowance Inquiry will not include results for Traditional or Comprehensive Major Medical members. A detailed user guide will be posted to the NaviNet Transaction Changes section of our Business Transformation site.

Referral Submission enhancementsBeginning March 20, 2015, Procedure Code will be a required field when creating a new referral. In addition, the selection of values under Service Type will be consolidated to include:

● Medical Care (Consult and Treat) ● Consultation ● Dialysis ● Therapy (PT/OT/Hand)

Tiering information enhancementsIn order to better serve our Keystone HMO Proactive members and self-funded customers in tiered network programs, we are introducing enhancements on March 20, 2015, that will:

● assist providers in identifying appropriate member cost-sharing (e.g., copayment); ● help providers with the referral and preapproval submission processes.

The following NaviNet transactions will be enhanced with tiering information: ● Eligibility and Benefits Inquiry. A Billing Provider drop-down menu will be added to the search screen. When searching for member eligibility and benefits information, you will need to select the appropriate provider group or facility before entering the member search criteria. The combination of provider and member information entered will assist in identifying the appropriate member cost-sharing. The Eligibility and Benefits Details screen offers several links to benefit provisions. When selecting a benefit link, the member’s tier benefit cost-sharing will be highlighted based on the provider group or facility you selected.

Note: Selecting an incorrect provider group or facility on the Eligibility and Benefits Search screen may result in incorrect member cost-sharing information being highlighted.

continued on the next page


● Authorization Submission. Where applicable, you will see an additional column in the search results screen when looking for a physician or facility while submitting an Emergency Room Admission Notification or an authorization request for one of the following:

— medical/surgical procedures — chemotherapy/infusion services — home health — home infusion — durable medical equipment

This new column will identify the benefit tier placement associated with that physician or facility. Members with tiered benefit programs pay the lowest level of cost-sharing when they use providers on the most cost-effective tier.

● Referral Submission. Where applicable, PCPs will see an additional column in the search results screen when looking for a physician or facility while submitting a referral. This new column will identify the benefit tier placement associated with that physician or facility.

Reminder: As of January 1, 2015, some Independence small group and individual commercial members have the new Preventive Plus benefit for colon cancer preventive screening colonoscopies. When performed at a freestanding ambulatory surgery center (ASC), the Preventive Plus benefit fully covers a colon cancer preventive screening colonoscopy with no member cost-sharing (i.e., $0 copayment, deductible, or coinsurance). When the services are performed at a hospital outpatient facility or hospital-based ASC, the member will incur cost-sharing of up to $750.

● Network Facility Inquiry and Network Provider Inquiry. When searching for a physician or facility through these transactions, the Network drop-down menu will include options for Keystone HMO Proactive and other self-funded customer tiered network programs. Once you have selected one of these options and entered the appropriate search criteria, your results will include a new column that displays the applicable tier information.

Look for a user guide to be posted to the NaviNet Transaction Changes section of our Business Transformation site for additional details on the upcoming tiering enhancements.

Direct Ship medical injectable drugsEffective March 20, 2015, the Drug Pre-Authorization transaction will be retired. Therefore, providers will no longer be able to submit Direct Ship requests through NaviNet for medical injectable drugs eligible for coverage under the medical benefit.

Moving forward, providers must download the appropriate drug request form, located at www.ibx.com/directship, to request direct shipment of a medical injectable drug. Once complete, the form must be faxed, along with a valid prescription, to Independence at the number listed on the form. These forms also serve as the preapproval/precertification request. If there is not a specific form for the requested drug, providers should use the general Direct Ship Injectables Request Form.

Note: Drugs covered under the pharmacy benefit, including oral, self-injectable, and self-administered drugs, should be submitted through FutureScripts®, an independent company, not through Independence’s Direct Ship program.

For more information We strongly encourage you to review the NaviNet Transaction Changes section of our Business Transformation site at www.ibx.com/pnc/businesstransformation for more information about upcoming changes to NaviNet. We will notify providers through NaviNet Plan Central and the Provider News Center when new user guides and webinars are available. If you have any questions about these changes, please call the eBusiness Hotline at 215-640-7410.

continued from the previous page

NAVINET®


Clarification: Injectable hyaluronate acid products being removed from the Direct Ship Injectables Program Effective April 1, 2015, injectable hyaluronate acid products to treat osteoarthritis of the knee will no longer be available through the Independence Direct Ship Injectables Program. The drugs that are included with this change are EuflexxaTM, Gel-One®, Hyalgan®, Monovisc®, Orthovisc®, Supartz®, Synvisc®, and Synvisc-OneTM.

These eight drugs will continue to be covered under the medical benefit for members who meet the medical necessity criteria listed in the applicable medical policy:

● Commercial: #11.14.07l: Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis; ● Medicare Advantage: #MA11.023: Hyaluronan Acid Therapies for Osteoarthritis of the Knee.

How this change affects providersProviders who prescribe hyaluronate acid products will need to purchase these drugs from the manufacturer or a specialty pharmacy vendor and stock them in their office. In order to receive reimbursement for the cost of the pharmaceutical, the provider will need to submit a claim to Independence.

Depending on the terms of the member’s 2015 benefit contract, members may be subject to additional cost-sharing amounts for these drugs. Therefore, providers should discuss this change with their patients prior to April 1, 2015.

In January, letters were sent to physicians who prescribe and administer hyaluronate acid products to notify them of this change and to provide more information about the process for purchasing these drugs.

Clarification: As of January 1, 2015, precertification requirements were removed for Orthovisc®, Synvisc®, and Synvisc-OneTM, our three preferred products. The other five drugs in this class (EuflexxaTM, Gel-One®, Hyalgan®, Monovisc®, and Supartz®) still require precertification from Independence. Providers who administer nonpreferred hyaluronate acid products without precertification approval will not be reimbursed. Providers who are currently ordering any hyaluronate acid product through the Direct Ship Injectables Program must continue to obtain authorization from Independence, regardless of whether the drug requires precertification. As a reminder, March 31, 2015, is the last day that hyaluronate acid products can be ordered through the Independence Direct Ship Injectables Program.

MEDICAL

Medical and claim payment policy activity posted from January 24 – February 20, 2015 Each month, new policy activity is posted to our Medical Policy Portal. Policy activity may include new, updated, reissued, or archived policies and coding updates.

Included with this edition of Partners in Health Update is a supplementary listing of policy activity that occurred for our commercial and Medicare Advantage portfolios from January 24 – February 20, 2015.

For the most up-to-date information about medical and claim payment policy activity, go to www.ibx.com/medpolicy and select Accept and Go to Medical Policy Online. Then select either the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you’d like to view. You can also get to our Medical Policy Portal through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.


MEDICAL

Non-emergent outpatient radiation therapy to be reviewed for medical necessity As previously communicated, providers are required to obtain precertification through CareCore National, LLC (CareCore), an independent company, for non-emergent outpatient radiation therapy services for all commercial and Medicare Advantage HMO, POS, and PPO members. For members under age 19, services requested will be automatically approved. However, precertification through CareCore is still required to ensure accurate and timely claims payment.

Beginning May 1, 2015, Independence will transition to the use of CareCore Radiation Therapy Criteria related to outpatient radiation therapy services. In addition, Independence will delegate precertification for proton beam radiation therapy, radium Ra 223 dichloride (Xofigo®), and immunotherapy using Zevalin® to CareCore. Note: Proton beam radiation therapy and radium Ra 223 dichloride (Xofigo®) currently require precertification by Independence. Providers must continue to request precertification for these services using the Authorizations transaction on the NaviNet® web portal until April 30, 2015.

Note: Precertification is not required when radiation therapy is rendered in the inpatient hospital setting. Also, these precertification requirements do not apply to Federal Employee Program, Comprehensive Major Medical, Traditional/Indemnity, or Medigap Security members.

Precertification guidelinesThe criteria that will be used as the basis for reviewing precertification requests as of May 1, 2015, are available on CareCore’s website at: https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx.

In addition, the following medical policies include a link to the criteria that CareCore will use to determine medical necessity for radiation therapy services as well as a complete list of procedure codes that require precertification.

● Commercial: #09.00.56: Radiation Therapy Services; ● Medicare Advantage: #MA09.020: Radiation Therapy Services.

To view these policies, visit our Medical Policy portal all www.ibx.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you’d like to view. Then type the policy name or number in the Search field.

Requesting precertificationYou can initiate precertification for non-emergent outpatient radiation therapy in one of the following ways:

● NaviNet. Select CareCore from the Authorizations transaction.

● CareCore provider portal. Access the CareCore provider portal directly at www.carecorenational.com. A login and password are required. This login information will be needed every time you request precertification through CareCore. If you already have access to the CareCore provider portal, please use your current login information.

● Telephone. Call CareCore directly at 1-866-686-2649.

Precertification for high-technology diagnostic imaging services Precertification requests for all high-technology diagnostic imaging services (e.g., CT, MRI, PET) will continue to be handled by AIM Specialty Health® (AIM), an independent company, through the current process.

https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx


Billing procedures for credentialed Certified Registered Nurse PractitionersLast year, Independence began to accept credentialing applications for Certified Registered Nurse Practitioners (CRNP) employed by participating primary care physician (PCP) practices. As of January 1, 2015, Independence requires Individual Agreements or Amendments to Professional Group Provider Agreements for these CRNPs to be participating providers.

Once contracted, CRNPs may bill directly for their services as the performing provider using the following elements:

● PCP group tax identification number; ● PCP group NPI number; ● CRNP’s individual NPI number; ● CRNP’s detailed taxonomy code.

To review our policy on the reimbursement for CRNP services, visit www.ibx.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version you’d like to view. Then type the policy name or number in the Search field:

● Commercial: #00.10.40: Reimbursement for Certified Registered Nurse Practitioners (CRNP);

● Medicare Advantage: #MA00.045: Reimbursement for Certified Registered Nurse Practitioners (CRNP).

You can also view policy activity through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

Obtaining credentialingIf your PCP practice is interested in credentialing a CRNP as a PCP to participate in our network, please complete the Council for Affordable Quality Healthcare (CAQH) credentialing form found at https://proview.caqh.org/pr. Once the form is completed, providers should notify our Provider Networks and Value-Based Solutions Administration Department at [email protected]. Please include the following information in your email:

● CRNP’s name; ● CRNP’s mailing address – should be same as PCP Group’s mailing address;

● CRNP’s office address – should be same as PCP Group’s office address;

● CRNP’s CAQH ID number; ● CRNP’s NPI; ● CRNP’s Group NPI – should be same as PCP Group’s Group NPI;

● taxonomy code; ● contact person’s name, telephone number, and email address.

If you have any questions regarding this process, please contact Customer Service at 1-800-ASK-BLUE.

CREDENTIALING

https://proview.caqh.org/pr


mailto: [email protected]

mailto: [email protected]


New CAQH recredentialing process now in effect*Independence offers our participating providers the Council for Affordable Quality Healthcare® (CAQH) Universal Provider DataSource® (UPD) for completing the recredentialing process. The CAQH UPD is a single, national process that eliminates the need for completing multiple recredentialing applications.

As previously communicated, CAQH made significant improvements to simplify the recredentialing process even further. Along with these improvements came a new name: CAQH ProViewTM. The launch of CAQH ProView is scheduled for March 2, 2015.

Benefits of using CAQH ProView The following new features make it easier for health care providers to make updates — reducing the time and resources necessary to submit accurate, timely data to Independence. CAQH Proview gives providers the ability to:

● complete and attest to multiple state credentialing applications in one intelligent workflow design; ● upload supporting documents directly into CAQH ProView to eliminate the need for manual submission and to improve the timeliness of completed applications;

● review and approve Practice Manager information before data is imported; ● protect against delays in data processing with more focused prompts and real-time validation; ● self-register with the system before a health plan initiates the application process.

New submission processWhen CAQH ProView launches, all providers must apply online. Paper applications are no longer accepted. CAQH ProView is a completely electronic solution, allowing providers to easily submit information through a more intuitive, profile-based design. The CAQH electronic credentialing application is free to providers and available on the CAQH website at https://proview.caqh.org/pr. Independence may still request paper documentation, such as billing forms and contracts; however, the initial credentialing and recredentialing process with CAQH will be paperless.

If you have questions about CAQH ProView, please email them to [email protected].

*This does not apply to Magellan Behavioral Health contracted providers.

Magellan Behavioral Health, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members.

CREDENTIALING



PHARMACY

Select Drug Program® Formulary updates The Select Drug Program Formulary, which is available for commercial members, is a list of medications approved by the U.S. Food and Drug Administration that were chosen for formulary coverage based on their medical effectiveness, safety, and value. The list changes periodically as the Pharmacy and Therapeutics Committee reviews the formulary to ensure its continued effectiveness. The most recent changes are listed below.

Generic additionsThese generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the appropriate generic formulary level of cost-sharing:

Generic drug Brand drug Formulary chapter Effective date

amlodipine-valsartan Exforge® 4. Heart, Blood Pressure, & Cholesterol October 6, 2014

amoxicillin ER Moxatag® 1. Antibiotics & Other Drugs Used for Infection August 18, 2014

entecavir Baraclude® 1. Antibiotics & Other Drugs Used for Infection September 8, 2014

fluorouracil Carac® 5. Skin Medications October 20, 2014

olopatadine Patanase® 6. Ear, Nose, Throat Medications October 27, 2014

testosterone* Fortesta® 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones September 8, 2014

*Generic requires prior authorization.

Brand additionThis brand drug was added to the formulary as of the date indicated below and is covered at the appropriate brand formulary level of cost-sharing:

Brand drug Formulary chapter Effective datePlegridyTM 3. Pain, Nervous System, & Psych February 1, 2015

Brand deletionsEffective April 1, 2015, this brand drug will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Generic drug Formulary chapter

Prometrium® progesterone 10. Female, Hormone Replacement, & Birth Control

The generic drug for the above brand drug is available at the generic formulary level of cost-sharing.

Effective April 1, 2015, this brand drug will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternative Formulary chapter

Viagra® Cialis® 13. Urinary & Prostate Meds

There is no generic equivalent for the above brand drug, however, there is a formulary therapeutic alternative drug. This therapeutic alternative drug is available at the appropriate formulary level of cost-sharing.


PHARMACY

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Prescription drug updatesFor commercial members enrolled in an Independence prescription drug program, prior authorization and quantity limit requirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medically necessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medication based upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for a particular drug. The most recent updates are reflected below.

Drugs requiring prior authorizationThe prior authorization requirement for the following non-formulary drugs was effective at the time the drugs became available in the marketplace:

Brand drug Generic drug Formulary chapter Effective date

ActiclateTM Not available 1. Antibiotics & Other Drugs Used for Infection August 11, 2014

BunavailTM Not available 3. Pain, Nervous System, & Psych August 4, 2014

CerdelgaTM Not available 15. Diagnostics & Miscellaneous Agents September 1, 2014

Contrave ER® Not available 3. Pain, Nervous System, & Psych September 22, 2014

Esbriet® Not available 12. Allergy, Cough & Cold, Lung Meds October 27, 2014

HarvoniTM Not available 1. Antibiotics & Other Drugs Used for Infection October 20, 2014

InvokametTM Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones August 18, 2014

Jardiance® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones August 11, 2014

Ofev® Not available 12. Allergy, Cough & Cold, Lung Meds October 27, 2014

TrulicityTM Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones October 6, 2014

Zydelig® Not available 2. Cancer & Organ Transplant Drugs August 4, 2014

Effective April 1, 2015, the following non-formulary drugs have been added to the list of drugs requiring prior authorization:


Ativan® lorazepam 3. Pain, Nervous System, & Psych

Ciclodan® 8% solution, 0.77% cream Not available 5. Skin Medications

EvzioTM Not available 3. Pain, Nervous System, & Psych

Jublia® Not available 5. Skin Medications

KerydinTM Not available 5. Skin Medications

Lipitor® atorvastatin 4. Heart, Blood Pressure, & Cholesterol

Migranal® dihydroergotamine 3. Pain, Nervous System, & Psych

NortheraTM Not available 4. Heart, Blood Pressure, & Cholesterol

OnmelTM Not available 1. Antibiotics & Other Drugs Used for Infection

Penlac® ciclopirox 5. Skin Medications


PHARMACYcontinued from the previous page


Percocet® oxycodone/acetaminophen 3. Pain, Nervous System, & Psych

Valium® diazepam 3. Pain, Nervous System, & Psych

Xanax® alprazolam 3. Pain, Nervous System, & Psych

Drugs requiring prior authorization with new criteriaEffective April 1, 2015, current members taking these medications will require a new prior authorization:


Levitra® Not available 13. Urinary & Prostate Meds

Staxyn® Not available 13. Urinary & Prostate Meds

StendraTM Not available 13. Urinary & Prostate Meds

Viagra® Not available 13. Urinary & Prostate Meds

Drugs with quantity limitsEffective April 1, 2015, quantity limits will be added or updated for the following drugs:

Brand drug Generic drug Quantity limit

BunavailTM 2.1-0.3 mg Not available 120 tabs per 30 days

BunavailTM 4.2-0.7 mg Not available 90 tabs per 30 days

BunavailTM 6.3-1 mg Not available 30 tabs per 30 days

PlegridyTM Not available 1 box per 28 days

Suboxone® 8-2 mg buprenorphine/naloxone 8-2 mg 90 tabs per 30 days

Suboxone® 12-3 mg buprenorphine/naloxone 12-3 mg 60 tabs per 30 days

Zubsolve® 5.7-1.4 mg Not available 90 tabs per 30 days

Drug no longer requiring prior authorizationEffective February 1, 2015, prior authorization has been removed for the following drug:

Brand drug Generic drug Formulary chapterPlegridyTM Not available 3. Pain, Nervous System, & Psych

For additional information on pharmacy policies and programs, please visit www.ibx.com/rx.


Highlighting HEDIS®: Appropriate testing for children with pharyngitis

This article series is a monthly tool to help physicians maximize patient health outcomes in accordance with NCQA’s* HEDIS®† measurements for high quality care on important dimensions of services. Go to www.ibx.com/providers/resources/hedis.html to view previously published Highlighting HEDIS® topics. If you have feedback or would like to request a topic, email us at [email protected].

QUALITY MANAGEMENT

HEDIS® definitionAppropriate testing for children with pharyngitis: The percentage of children ages 2 – 18 who were diagnosed with pharyngitis, dispensed an antibiotic, and received group “A” streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing).

Why this measure is importantPharyngitis is the only condition among upper respiratory infections (URI) where diagnosis is validated easily and objectively through administrative and laboratory data, and it can serve as an important indicator of appropriate antibiotic use among all respiratory tract infections. Overuse of antibiotics has been directly linked to the prevalence of antibiotic resistance. Promoting judicious use of antibiotics is important to reducing the prevalence of antibiotic resistance. Pediatric clinical practice guidelines recommend that only children diagnosed with group “A” streptococcus (strep) pharyngitis, based on appropriate lab tests, be treated with antibiotics. Appropriate testing for group “A” strep pharyngitis includes a rapid strep assay and/or throat culture. — NCQA, HEDIS 2015 V1

Plan performanceThe chart below shows a five-year trend where improvements in antibiotic prescribing have occurred; however, a substantial number of patients are still receiving inappropriate antibiotic treatment. — 2014 State of Health Care Quality (NCQA)

Quick tips for improvement 9 Only about 30 percent of all cases of pharyngitis in children are caused by bacteria. Be sure to follow the pediatric guidelines for appropriate treatment. — 2014 State of Health Care Quality (NCQA)

9 Educate caregivers and patients on the risks of antibiotic resistance. 9 The Poster Board Pledge: Recent studies have shown that displaying poster-sized commitment letters in exam rooms to avoid inappropriate antibiotic prescribing was a simple, low-cost, and effective method for improvement. — JAMA Internal Medicine

* The National Committee for Quality Assurance (NCQA) is the most widely recognized accreditation program in the U.S.

† The Healthcare Effectiveness Data and Information Set (HEDIS) is an NCQA tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care.

‡ QIPS is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care.

QIPS‡ alertAppropriate testing for children with pharyngitis is a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers.

Visit our Provider News Center: www.ibx.com/pnc

*Outside 215 area code†The Provider Automated System is available only for those members who have not yet been migrated to the new operating platform. For more information, go to www.ibx.com/pnc/businesstransformation.

Important Resources

Anti-Fraud and Corporate Compliance

Hotline 1-866-282-2707 or www.ibx.com/antifraud

Care Management and Coordination

Baby BluePrints® 215-241-2198 / 1-800-598-BABY (2229)*

Case Management 1-800-313-8628

Condition Management Program 1-800-313-8628

Credentialing

Credentialing Violation Hotline 215-988-1413 or www.ibx.com/credentials

Customer Service/Provider Services

Provider Automated System† (eligibility/claims status/precertification) 1-800-ASK-BLUE (1-800-275-2583)

Provider Services user guide www.ibx.com/providerautomatedsystem

Electronic Data Interchange (EDI)

Highmark EDI Operations 1-800-992-0246

FutureScripts® (commercial pharmacy benefits)

Prescription drug prior authorization 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.ibx.com/rx

FutureScripts® Secure (Medicare Part D pharmacy benefits)

FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.ibxmedicare.com

NaviNet® web portal

Independence eBusiness Hotline 215-640-7410

Registration www.navinet.net

Other frequently used phone numbers and websites

Independence Direct Ship Injectables Program (medical benefits) www.ibx.com/directship

Medical Policy www.ibx.com/medpolicy

Provider Supply Line 1-800-858-4728 or www.ibx.com/providersupplyline

1January 24 – February 20, 2015

The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from January 24 – February 20, 2015.

For the most up-to-date information about medical and claim payment policy activity for commercial business, go to www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, and then select the Commercial tab. You can also view policy activity using the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

New policyThe following commercial policy has been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with Independence.

Policy # Title Notification date Effective date00.01.61 Reimbursement for Components of Comprehensive Laboratory Panels February 4, 2015 March 6, 2015

Updated policies The following commercial policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other procedures for doing business with Independence.

Policy # Title Type of policy change Notification date Effective date

01.00.09c Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump

General Description, Guidelines, or Informational Update N/A January 28, 2015

05.00.05hEquipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes

Medical Necessity Criteria January 5, 2015 February 9, 2015

05.00.24l

Interstitial Continuous Glucose Monitoring Systems (CGMSs) and Artificial Pancreas Device Systems (APDS)

Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

N/A February 11, 2015

05.00.32g Speech and Non-Speech Generating Devices

Medical Coding; Medical Necessity Criteria N/A February 11, 2015

06.02.01f Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment

Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

January 26, 2015 February 25, 2015

07.03.05r Sleep Disorder Testing and Positive Airway Pressure Therapy

Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

January 15, 2015February 15, 2015 Published February 13, 2015

07.03.10e Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)


07.13.05h Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®) Medical Coding N/A February 11, 2015

08.00.25h

Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents Intended for Home Use

General Description, Guidelines, or Informational Update N/A February 11, 2015

Medical and claim payment policy activity Commercial business



08.00.26s Botulinum Toxin Agents General Description, Guidelines, or Informational Update February 9, 2015 March 11, 2015

08.00.51h Enzyme Replacement for the Treatment of Gaucher's Disease

Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update


08.00.69a Agalsidase beta (Fabrazyme®) General Description, Guidelines, or Informational Update N/A February 11, 2015

08.00.70b

Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase™, Vimizim™, Naglazyme®, etc.)

Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update


08.00.72f Alglucosidase alfa (e.g., Myozyme®, Lumizyme®)

Medical Necessity Criteria; General Description, Guidelines, or Informational Update


08.00.82d Ustekinumab (Stelara®) for Subcutaneous Injection


08.00.92l Coagulation Factors for Hemophilia Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

N/A January 28, 2015

08.00.96c Cabazitaxel (Jevtana®) General Description, Guidelines, or Informational Update N/A January 28, 2015

08.01.14b Radium Ra 223 dichloride (Xofigo®) Injection

Medical Necessity Criteria; Medical Coding N/A February 11, 2015

09.00.49g Proton Beam Radiation Therapy Coverage and/or Reimbursement Position; Medical Necessity Criteria

December 31, 2014 Revised February 12, 2015

April 1, 2015 (Tentative)

10.00.02b Day Rehabilitation General Description, Guidelines, or Informational Update N/A February 11, 2015

11.01.06bBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids

Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

February 5, 2015 May 6, 2015

11.03.15g Gastric Electrical Stimulation (Enterra™), Gastric Pacing Medical Coding N/A January 28, 2015

11.06.04i Uterine Artery Embolization


January 28, 2015 Removed from Notification on February 12, 2015

11.07.02g Sentinel Lymph Node Biopsy General Description, Guidelines, or Informational Update N/A January 28, 2015

11.14.06g

Autologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage Lesions


11.14.11f Arthroscopic Electrothermal Joint Repair



Reissued policiesThe following commercial policies have been reviewed, and no substantive changes were made.

Policy # Title Reissue effective date

Reissue published date

00.10.35g Remote Patient Management: Telemedicine and Telehealth February 4, 2015 February 4, 2015

05.00.37e Compression Garments February 4, 2015 February 4, 2015

05.00.70a Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures February 4, 2015 February 4, 2015




07.03.09j Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG) February 18, 2015 February 19, 2015

07.03.15c Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS) February 4, 2015 February 4, 2015

07.03.18i Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies February 18, 2015 February 19, 2015

07.03.21g Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter February 18, 2015 February 19, 2015

07.05.02l Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon February 18, 2015 February 19, 2015

07.08.03b Medical and Surgical Treatment of Temporomandibular Joint Disorder February 18, 2015 February 19, 2015

09.00.53 Magnetic Resonance Imaging (MRI) for Monitoring the Integrity of Silicone-Gel-Filled Breast Implants in Asymptomatic Individuals February 18, 2015 February 19, 2015

11.00.09d Solid Organ Transplants February 4, 2015 February 5, 2015

11.02.16o Ventricular Assist Devices (VADs) February 4, 2015 February 4, 2015

11.14.24 Manipulation Under Anesthesia February 18, 2015 February 19, 2015

Coding updatesThe following commercial policies have been reviewed and updated to add new and revised medical codes (e.g., ICD-9 and ICD-10 diagnosis codes; CPT® and HCPCS codes; revenue codes) and/or remove terminated medical codes.

Policy # Title Effective date Published date00.01.14l Reporting and Documentation Requirements for Anesthesia Services January 1, 2015 February 9, 2015

00.01.25yPPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

January 1, 2015 January 26, 2015

00.01.41b STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products January 1, 2015 February 9, 2015

00.03.02s Diagnostic Radiology Services Included in Capitation January 1, 2015 February 6, 2015

00.03.07jLaboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products


00.10.36l Radiologic Guidance of a Procedure January 1, 2015 February 9, 2015

00.10.39e Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus January 1, 2015 February 6, 2015

03.00.07p Modifier 51: Multiple Procedures January 1, 2015 February 13, 2015

03.00.16l Modifier 57: Decision for Surgery January 1, 2015 February 9, 2015

11.00.11h Use of an Operating Microscope During a Surgical Procedure January 1, 2015 February 9, 2015

Archived policyIndependence has determined that it is is no longer necessary for the following commercial policy to remain active.

Policy # Title Notification date Archive effective date

11.17.07f Radiofrequency Micro-remodeling (by transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence February 11, 2015 March 13, 2015

Continue to the next page for information about Medicare Advantage policy activity.


The following pages list the policy activity for Medicare Advantage business that we have posted to our Medical Policy Portal from January 24 – February 20, 2015.

For the most up-to-date information about medical and claim payment policy activity for Medicare Advantage business, go to www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, and then select the Medicare Advantage tab. You can also view policy activity using the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

New policyThe following Medicare Advantage policy has been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with Independence.

Policy # Title Notification date Effective dateMA01.006 Reimbursement for Components of Comprehensive Laboratory Panels February 4, 2015 March 6, 2015

Updated policies The following Medicare Advantage policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other procedures for doing business with Independence.


MA00.002aContinuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)



MA01.004a

Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump


MA05.003a Speech and Non-Speech Generating Devices

Medical Necessity Criteria; Medical Coding N/A February 11, 2015

MA06.006aLyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment

Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update


MA07.003a Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®) Medical Coding N/A February 11, 2015

MA07.039a Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)


MA07.058a Sleep Disorder Testing and Positive Airway Pressure Therapy


January 15, 2015February 15, 2015 Published February 13, 2015

MA08.004a Coagulation Factors for Hemophilia Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

N/A January 28, 2015

MA08.016a

Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents Intended for Home Use


Medical and claim payment policy activity Medicare Advantage business



MA08.017a Botulinum Toxin Agents General Description, Guidelines, or Informational Update February 9, 2015 March 11, 2015

MA08.023a Enzyme Replacement for the Treatment of Gaucher's Disease



MA08.033a Agalsidase beta (Fabrazyme®) General Description, Guidelines, or Informational Update N/A February 11, 2015

MA08.034a

Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase™, Vimizim™, Naglazyme®, etc.)

Medical Coding; Medical Necessity Criteria; General Description, Guidelines, or Informational Update


MA08.036a Alglucosidase alfa (e.g., Myozyme®, Lumizyme®)

General Description, Guidelines, or Informational Update; Medical Necessity Criteria


MA08.042a Ustekinumab (StelaraTM) for Subcutaneous Injection


MA08.054a Cabazitaxel (Jevtana®) General Description, Guidelines, or Informational Update N/A January 28, 2015

MA08.069a Radium Ra 223 Dichloride (Xofigo®) Injection

Medical Coding; Medical Necessity Criteria N/A February 11, 2015

MA09.007a Proton Beam Therapy Coverage and/or Reimbursement Position; Medical Necessity Criteria February 12, 2015 April 1, 2015

(Tentative)

MA10.005a Day Rehabilitation General Description, Guidelines, or Informational Update N/A February 11, 2015

MA11.045a Uterine Artery Embolization


January 28, 2015 Removed from Notification on February 12, 2015

MA11.049aBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids


February 5, 2015 May 6, 2015

MA11.064a

Implantable Miniature TelescopeTM (IMT) for the Treatment of End-Stage Age-Related Macular Degeneration (AMD)

Medical Necessity Criteria January 15, 2015 April 15, 2015

MA11.068a Sentinel Lymph Node Biopsy General Description, Guidelines, or Informational Update N/A January 28, 2015

MA11.082a

Autologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage Lesions


MA11.085a Arthroscopic Electrothermal Joint Repair



Reissued policiesThe following Medicare Advantage policies have been reviewed, and no substantive changes were made.



MA00.036 Remote Patient Management: Telemedicine and Telehealth February 4, 2015 February 5, 2015

MA05.043 Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures February 4, 2015 February 5, 2015

MA05.045 Compression Garments February 4, 2015 February 5, 2015

MA07.005 Ambulatory Blood Pressure Monitoring (ABPM) February 4, 2015 February 5, 2015




MA07.015 Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS) February 4, 2015 February 5, 2015

MA07.018 Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters

February 18, 2015 February 20, 2015

MA07.022 Wireless Capsule Endoscopy February 18, 2015 February 20, 2015

MA07.024 Medical and Surgical Treatment of Temporomandibular Joint Disorder February 18, 2015 February 20, 2015

MA07.033 Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies February 18, 2015 February 20, 2015

MA07.050 Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG) February 18, 2015 February 20, 2015

MA09.019 Magnetic Resonance Imaging (MRI) for Monitoring the Integrity of Silicone-Gel-Filled Breast Implants in Asymptomatic Individuals February 18, 2015 February 20, 2015

MA11.011 Artificial Hearts and Ventricular Assist Devices (VADs) February 4, 2015 February 5, 2015

MA11.033 Solid Organ Transplants February 4, 2015 February 5, 2015

MA11.091 Manipulation Under Anesthesia February 18, 2015 February 20, 2015

Coding updatesThe following Medicare Advantage policies have been reviewed and updated to add new and revised medical codes (e.g., ICD-9 and ICD-10 diagnosis codes; CPT® and HCPCS codes; revenue codes) and/or remove terminated medical codes.

Policy # Title Effective date Published dateMA00.009a Reporting and Documentation Requirements for Anesthesia Services January 2, 2015 February 9, 2015

MA00.010aPPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


MA00.019a Radiologic Guidance of a Procedure January 2, 2015 February 9, 2015

MA00.021aSTAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products


MA00.027a Diagnostic Radiology Services Included in Capitation January 2, 2015 February 6, 2015

MA00.030aLaboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products


MA00.037a Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus January 2, 2015 February 6, 2015

MA03.004a Modifier 51: Multiple Procedures January 2, 2015 February 13, 2015

MA03.010a Modifier 57: Decision for Surgery January 2, 2015 February 9, 2015

MA03.013a Modifier 51 Exempt January 2, 2015 January 26, 2015

MA11.037a Use of an Operating Microscope During a Surgical Procedure January 2, 2015 February 9, 2015

Archived policyIndependence has determined that the following Medicare Advantage policy is no longer necessary to remain active.

Policy # Title Notification date Archiveeffective date

MA11.038 Radiofrequency Micro-remodeling (by transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence February 11, 2015 March 13, 2015

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SM March 2015 - provcomm.ibx.comprovcomm.ibx.com/ibc/news/PIH/IBC_PIH_March2015.pdfeffective April 1, 2015 Effective April 1, 2015, we will implement a quarterly update to our Professional

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