October 2021 - Healthy Blue Provider
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October 2021
FACILITIES
Inpatient Prior Authorizations
Facilities Getting prior authorization
is an important step when
Inpatient Prior Authorizations 2 it comes to inpatient
services. When submitting
DME Providers an inpatient prior
authorization request, it
Medicaid Continuous Glucose
Monitoring Systems 2 is important to include
the tax identification
All Providers number (TIN) and national
provider identifier (NPI). By
Availity®: Eligibility and Benefits 3 ensuring this information
is included, it will help
Prior Authorization Updates
for Specialty Pharmacy 4 avoid the need to send
the request back and, in
Clinical Laboratory turn, allows for a quicker
Improvement Amendment 4 turnaround for approvals.
EnrollSafe 5
DME PROVIDERS
HEDIS® Measure: Diabetes Care 6
Sexually Transmitted Infections Testing 7 Medicaid Continuous Glucose
Monitoring Systems
On Nov. 1, 2021, Healthy Blue will implement a change regarding
continuous glucose monitoring systems (CGMs). In 2020, we made it
more convenient for members to obtain CGMs (devices and supplies)
at their preferred in-network retail pharmacy or the IngenioRxSM home
delivery pharmacy.
Beginning Nov. 1, 2021, CGM access (including but not limited to
HCPCS codes A9276, A9277, A9278, K0553 and K0554) will only
be available to a Healthy Blue member through their in-network retail
pharmacy or IngenioRx home delivery pharmacy and no longer a
durable medical equipment (DME) provider. Members receiving CGMs
and their prescribers will be notified of the change.
Please refer prescribers to the Customer Care Center at 866-757-8286
or members to Pharmacy Member Services at 833-207-3118 for
additional information.
IngenioRx Inc. is an
independent company
providing pharmacy
fb.me/HealthyBlueSC benefit management
services on behalf of
@CoachBlueSC BlueChoice HealthPlan
of South Carolina.
@HealthyBlueSC
Note: This change only
applies to CGMs and not
2 www.HealthyBlueSC.com insulin pump delivery systems.
ALL PROVIDERS
Availity: Eligibility and Benefits
Availity is a beneficial tool used for a vast number of things, including verifying member eligibility. For your
convenience, a refresher course was put together to ensure you have a thorough understanding on how to
properly use the tool.
Learn how to check patient eligibility and benefits and review the results in Availity here.
Availity is an independent company providing a secure portal on behalf of BlueChoice®.
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ALL PROVIDERS
Prior Authorization Updates for Specialty Pharmacy
Effective for dates of service on and after Nov. 1, 2021, the following specialty drug codes from current or new clinical
criteria documents will require prior authorization.
Please note, inclusion of national drug code (NDC) on your claim will help expedite claim processing of drugs billed
with a not-otherwise-classified (NOC) code.
Visit the Clinical Criteria website to search for the specific clinical criteria listed below.
Clinical criteria HCPCS or CPT® code(s) Drug Drug classification
ING-CC-0170 J1823 Uplizna® Immunosuppressive agents
ING-CC-0172 J3490, J3590, C9071 Viltepso® Muscular dystrophies
ING-CC-0173 J3490, J3590 Enspryng™ MISC conditions
ING-CC-0174 J3490, J3590, C9399 Kesimpta® Multiple sclerosis
ING-CC-0168 J9999, C9073 Tecartus™ CAR-T
ING-CC-0171 J9223 Zepzelca™ Cancer
ING-CC-0169 J9316 Phesgo™ Cancer
ING-CC-0175 J9015 Proleukin® Cancer
ING-CC-0176 J9032 Beleodaq® Cancer
ING-CC-0178 J9262 Synribo® Cancer
ING-CC-0177 J3304 Zilretta® Osteoarthritis
ING-CC-0002 Q5122 Nyvepria™ Blood cell deficiency
ING-CC-0038 J3110 Forteo® Osteoporosis
ING-CC-0179 J9037 Blenrep Oncology
ING-CC-0180 J9349 Monjuvi® Oncology
ING-CC-0181 J3490 Veklury® COVID-19
Clinical Laboratory Improvement Amendment
The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing (except research) performed on
humans in the U.S. through Clinical Laboratory Improvement Amendments (CLIA). The overall objective of the CLIA
program is to ensure quality laboratory testing for your patients, our members. All clinical laboratories must be certified to
receive Medicare or Medicaid payments.
To make sure we have the appropriate information on file for our providers, CLIA certificate verification has been added
to the initial credentialing application and the recredentialing application, regardless of the network. This update ensures
consistency when it comes to verifying the existence of current CLIA certificates for each location of a provider’s practice
that offers in-office laboratory services.
Note: A CLIA certificate number is needed for each location in your practice that provides laboratory services.
4
ALL PROVIDERS
EnrollSafe
Effective Nov. 1, 2021, EnrollSafe will replace CAQH EnrollHub® as the electronic funds transfer (EFT) enrollment website
for Healthy Blue providers. As of Nov. 1, 2021, CAQH EnrollHub will no longer offer EFT enrollment to
new users. Learn more here.
Provider Bulletin
September 2021
Get your payments faster when you sign up for electronic funds
transfer
Effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub® as the electronic funds transfer (EFT)
enrollment website for Healthy Blue providers. As of November 1, 2021, CAQH Enrollhub will no longer offer
EFT enrollment to new users.
When you sign up for EFT through https://enrollsafe.payeehub.org,* the new enrollment website, you’ll
receive your payments up to seven days sooner than through the paper check method. Not only is receiving your
payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.
EnrollSafe is safe, secure and available 24-hours a day
Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org* to
enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll
provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making
changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use https://enrollsafe.payeehub.org* to update your
account.
Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposit. You’ll
be issued a trace number with your EFT deposit that matches up with your ERA on the Availity Portal. Availity,
LLC is an independent company providing administrative support services on behalf of BlueChoice HealthPlan.
To access the ERA, log onto https://www.availity.com and use the Claims and Payments tab. Select Send
and Receive EDI Files, then select Received Files Folder. When using a clearinghouse or billing service, they
will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance
Advice through the Remittance Inquiry app.
* This link leads to a third-party site. That organization is solely responsible for the contents and privacy policies on its site.
www.HealthyBlueSC.com
BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with
Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections.
To report fraud, call our confidential Fraud Hotline at 877-725-2702. You may also call the South Carolina Department of Health and Human Services
Fraud Hotline at 888-364-3224 or email fraudres@scdhhs.gov.
BSC-NL-0348-21 September 2021
5
ALL PROVIDERS
HEDIS Measure: Diabetes Care
Helpful tips for diabetes testing and screening HEDIS measures:
• Have reminders set in your electronic medical record (EMR) to alert staff when screenings are due.
• Provide reminders to patients for upcoming appointments and screenings. Most adults seem to be
responsive to SMS.
• Draw labs in your office if available or refer patients to a local lab for screenings. Make sure the local labs can
send a copy for your records.
• Refer patients to participating eye professionals for annual retinal eye exams.
• Follow up on lab tests, eye exams and specialist referrals and document in your chart.
• Telephone visits, e-visits and virtual check-ins are acceptable settings for blood pressure readings and should
be recorded in the chart.
• Include Category II reporting codes on claims to reduce the burden of HEDIS medical record review.
Educate patients on topics (for example, home monitoring of blood sugar and blood pressure; taking medications
as prescribed; and other healthy lifestyle topics like diet, exercise and smoking cessation).
Other available resources:
• Clinical Practice Guidelines are available on our provider self-service website.
• Contact Healthy Blue for a copy of Quality Measures Desktop Reference for Medicaid Providers and the
HEDIS Benchmarks and Coding Guidelines for Quality.
• Diabetes programs may be available to our members. Contact your Provider Solutions representative
for more information.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
6
ALL PROVIDERS
Sexually Transmitted Infections Testing
Effective Jan. 1, 2022, Healthy Blue will allow reimbursement of sexually transmitted infection (STI) tests unless
provider, state, federal, or CMS contracts and/or requirements indicate otherwise. We consider certain STI testing
CPT® codes to be part of a laboratory panel grouping. When Healthy Blue receives a claim with two or more single
tests laboratory procedure codes reported, we will bundle those two or more single tests into the comprehensive
laboratory procedure code listed below.
Applicable single STI CPT codes:
• 87491: Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, amplified probe technique
• 87591: Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, amplified probe technique
• 87661: Infectious agent detection by nucleic acid (DNA or RNA); trichomonas vaginalis, amplified probe technique
Applicable comprehensive code:
• 87801: Infectious agent detection by nucleic acid (DNA or RNA),
multiple organisms; amplified probe(s) technique
Healthy Blue will reimburse the more comprehensive, multiple organism
code for infectious agent detection by nucleic acid, amplified probe
technique (CPT code 87801), when two or more single test CPT codes
are billed separately by the same provider on the same date of service.
Reimbursement will be made based on a single unit of CPT code 87801
regardless of the units billed for a single code. No modifiers will override
the edit.
For additional information, please review the Sexually Transmitted Infections
Testing — Professional Reimbursement Policy at www.HealthyBlueSC.com.
7
BlueChoice HealthPlan is an independent licensee of the Blue Cross Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan LLC, an independent company,
for services to support administration of Healthy Connections. Amerigroup Corporation, an independent company, administers utilization management services for BlueChoice HealthPlan.
Some links in this newsletter lead to third-party sites. Those organizations are solely responsible for the content and privacy policies on these sites.
The codes listed are for informational purposes only and are not intended to suggest or guide reimbursement. If applicable, refer to your provider contract or health plan contact for reimbursement information.
To report fraud, call our confidential Fraud Hotline at 877-725-2702. You may also call the South Carolina Department of Health and Human Services Fraud Hotline at 888-364-3224 or email fraudres@scdhhs.gov.
BSC-NL-0365-21 September 2021 214300-9-2021
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