UpdateSM December 2020 Recap - Provider News Center
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update SM
December 2020 Recap
This publication contains articles previously published on our Provider News Center.
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.
Inside this edition
Administrative Medical
● O pioid treatment programs available to ● U pdated Lab Management Clinical
eligible Medicare Advantage members Guidelines
● Medicare Outpatient Observation Notice ● Kidney care measures for the
submission guidelines nephrology pay for value (NeP4V)
● Refer members to in-network labs for program
services ● Archival of several medical policies
● Blue HPN Host Membership in our ● Reminder: The annual Synagis®
Service Area (palivizumab) distribution program
● Medical policy changes for polyarticular
Billing & Reimbursement juvenile idiopathic arthritis drugs for
● P rofessional Injectable and Vaccine Fee commercial members
Schedule updates effective ● Introducing a new kidney care
January 1, 2021 management program: Strive Health
● Billing guidelines for leuprolide acetate Kidney Care
(Fensolvi®) ● Independence Administrators to delegate
● BCBSA high-dollar prepayment claims some precertification to eviCore
review policy update ● Preferred products for long- and short-
● Submitting Blue High Performance acting colony-stimulating factors
NetworkSM claims ● Updated list of specialty drugs that
require precertification now in effect
BlueCard®
● F
ind BlueCard® program information on PEAR portal
our dedicated BlueCard page ● We are moving to the PEAR portal!
Health & Wellness Pharmacy
● Improving lead testing and ● F utureScripts® Premium Formulary drug
developmental screening among program updates
Keystone HMO CHIP members
● Independence drug program formulary
● Encourage pregnant Independence updates
members to enroll in Baby BluePrints®
● Updates to free meters as part of the
● Registered Nurse Health Coaches: Blood Glucose Meter Program for
Supporting Independence providers and commercial members
their patients
● Encouraging care for parents and
guardians of your Keystone HMO CHIP
patients: Asthma assessment and
treatment
● Encourage your patients to make New
Year’s resolutions that stick
December 2020 | Partners in Health UpdateSM 2 www.ibx.com/pnc
Inside this edition
Products Quality Management
● N ew! 2021 Medicare Advantage plans ● T ime is running out! Only two weeks
will not include tiering of medical benefits left to opt in to the QIPS program –
● Benefit language changes and measurement year 2021
clarifications for commercial members ● Annual notification regarding utilization
● BCBS launches national high- review decisions
performance network
COVID-19
For up-to-date information on our response to
COVID-19, please visit our Provider News Center.
For articles specific to your area of interest, look for the appropriate icon:
Professional Facility Ancillary
December 2020 | Partners in Health UpdateSM 3 www.ibx.com/pnc
ADMINISTRATIVE Opioid treatment programs available to eligible Medicare Advantage members Published December 3, 2020 (Read online) Opioid treatment programs (OTPs) are covered under Part B of Original Medicare. Independence Medicare Advantage members can receive coverage for these services through their plan. Covered services include: ● U.S. Food and Drug Administration-approved opioid agonist and antagonist treatment medications and the dispensing and administration of such medications, if applicable ● substance use counseling ● individual and group therapy ● toxicology testing A list of in-network providers offering opioid treatment services is available on our website and on the NaviNet® web portal in the Quick Links section of Independence’s Plan Central page. NaviNet® is a registered trademark of NantHealth, an independent company. December 2020 | Partners in Health UpdateSM 4 www.ibx.com/pnc
ADMINISTRATIVE Medicare Outpatient Observation Notice submission guidelines Published December 4, 2020 (Read online) he Centers for Medicare & Medicaid Services (CMS) require that all hospitals and critical access hospitals (CAH) provide T the Medicare Outpatient Observation Notice (MOON) to beneficiaries in Original Medicare (fee-for-service) and Medicare Advantage enrollees who receive observation services as an outpatient for more than 24 hours. This notice informs beneficiaries that they are outpatients receiving observation services and are not inpatients of a hospital or CAH. The hospital or CAH must issue the MOON no later than 36 hours after observation services as an outpatient begin. This also applies to beneficiaries in the following circumstances: ● beneficiaries who are subsequently admitted as an inpatient prior to the required delivery of the MOON; ● beneficiaries for whom Medicare is either the primary or secondary payer. Learn more To access the MOON and completion instructions, please visit the CMS website. December 2020 | Partners in Health UpdateSM 5 www.ibx.com/pnc
ADMINISTRATIVE Medical policy changes for polyarticular juvenile idiopathic arthritis drugs for commercial members Published December 8, 2020 (Read online) Independence is changing how we manage the biologics that are approved by the U.S. Food and Drug Administration (FDA) for the treatment of polyarticular juvenile idiopathic arthritis (pJIA) for members enrolled in our commercial (non-Medicare Advantage) products. There are various biologics on the market, and there is no reliable evidence that demonstrates the superiority of one biologic over the others. However, there are notable differences in cost. Coverage criteria Effective March 8, 2021, the coverage criteria for the indication of pJIA will be updated for Independence’s medical policies on Orencia® (IV) and Actemra® (IV) to reflect that Simponi Aria® is the preferred biologic for pJIA. Simponi Aria was selected based on its demonstrated cost-effectiveness and treatment of pJIA. The criteria apply only to commercial (non-Medicare Advantage) members who have never received a biologic agent as therapy to treat pJIA. Orencia (IV) and Actemra (IV) will only be eligible for coverage and reimbursement in the treatment of pJIA when both of the following criteria are met: ● the member meets the medical necessity criteria in the medical policy for that specific drug; ● the member has a documented failure, contraindication, or intolerance to Simponi Aria, or there is a clinical reason that a trial of Simponi Aria would be otherwise inappropriate for the member. For members who are currently receiving Orencia (IV) or Actemra (IV) for pJIA, these drugs will continue to be eligible for coverage when they are prescribed in accordance with the regimen that has been precertified by Independence. Updated policies For more information, please review the following Independence commercial policies, which were posted as Notifications on December 8, 2020, and will go into effect on March 8, 2021: ● #08.00.62l: Abatacept (Orencia®) for Injection for Intravenous Use ● #08.00.85k: Tocilizumab (Actemra®) for Intravenous Infusion To view these policy Notifications, visit our Medical and Claim Payment Policy Portal and select Commercial from the Active Notifications section. December 2020 | Partners in Health UpdateSM 6 www.ibx.com/pnc
ADMINISTRATIVE
Refer members to in-network labs for services
Published December 14, 2020 (Read online)
In accordance with your Independence Provider Agreement, except in an emergency, a participating provider should
refer members only to participating providers for covered services. (This includes, but is not limited to, ancillary services
such as laboratory and radiology, unless the provider has obtained preapproval from Independence for the use of a non-
participating laboratory.)
Providers are required to direct members and/or their lab specimens to a participating outpatient laboratory provider,
except:
● in an emergency;
● as otherwise described in the applicable Benefit Program requirements;
● as otherwise required by law.
Benefit Program requirements differ by type of plan:
● HMO/POS. All routine laboratory services for HMO/POS members must be referred to their primary care physician’s
(PCP) capitated laboratory site. In the unusual circumstance that you require a specific test that you believe the PCP’s
capitated laboratory site cannot perform, call Customer Service at 1-800-ASK-BLUE (1-800-275-2583). Preapproval
is required to issue a referral to a laboratory other than the member’s capitated laboratory. To confirm a member’s
capitated laboratory site, refer to the Lab indicator on the front of the member’s ID card or use the Eligibility and
Benefits Inquiry transaction on the NaviNet® web portal (NaviNet Open).
● PPO. PPO members should use a participating laboratory, such as Laboratory Corporation of America® Holdings
(LabCorp), to maximize their benefits and save on out-of-pocket costs. PPO members may use a non-participating
laboratory, but they will pay the out-of-network level of cost-sharing (i.e., copayment, coinsurance, deductible) and
may be subject to provider balance billing. In the unusual circumstance that specific services are not available through
a participating laboratory, providers must call Customer Service at 1-800-ASK-BLUE (1-800-275-2583) to obtain
preapproval.
Non-compliance may result in financial and other implications for your practice
When applicable under the terms of your Independence Provider Agreement, if a provider continues to direct members
and/or their lab specimens to a non-participating laboratory and does not obtain preapproval from Independence, the
ordering provider is required to hold the member harmless.
The ordering provider will be responsible for all costs to the member and shall reimburse the member for such costs or
be subject to claims offset by Independence for such costs. In addition, further non-compliance may result in immediate
termination of your Independence Provider Agreement.
Exception to the use of non-participating providers permitted under the terms of your
agreement
If a provider (1) refers a member to a non-participating laboratory for non-emergent services without obtaining preapproval
from Independence to do so; (2) sends a member’s lab specimen to a non-participating laboratory without preapproval; or
(3) provides or orders non-covered services for a member, the provider must inform the member verbally and in writing in
advance of the services:
● which services will be provided;
● that Independence will not pay for or be liable for the listed non-covered services;
● that the member will be financially responsible for such services.
continued on the next page
December 2020 | Partners in Health UpdateSM 7 www.ibx.com/pnc
ADMINISTRATIVE continued from the previous page You can access the Independence Member Consent for Financial Responsibility for Unreferred/Non-covered Services Form on our website. By signing this form, the member agrees to pay for non-covered services specified on the form. The form must be completed and signed before services are provided. Providers should also be aware of the coverage status of the tests they order and should notify the member in advance if a service is considered experimental/investigational or is otherwise non-covered by Independence. The member will be financially responsible for the entire cost of any service that is non-covered (e.g., experimental/investigational). If a provider does not comply with the requirements as outlined above, the ordering provider is required to hold the member harmless. The ordering provider will be responsible for any and all costs to the member and shall reimburse the member for such costs or be subject to claims offset by Independence for such costs. Using eviCore To review eviCore’s lab management and policies, please read Updated Lab Management Clinical Guidelines. Learn more If you have questions related to the referral process for laboratory services, please email our Provider Network Services team at pnsproviderrequests@ibx.com. December 2020 | Partners in Health UpdateSM 8 www.ibx.com/pnc
ADMINISTRATIVE Blue HPN Host Membership in our Service Area Published December 22, 2020 (Read online) he BlueCross® Blue Shield® (BCBS) System will launch the Blue High Performance NetworkSM (Blue HPNSM) on T January 1, 2021. Anthem® Blue Cross Blue Shield is offering Blue HPN to its employees who reside in the Independence service area, as of January 1, 2021. While the final number of enrollees (subscribers and members) is not yet known, we wanted to make you aware of their possible presence. Identifying Anthem Blue HPN patients You can recognize patients with Blue HPN by the Blue High Performance name and the “HPN in a suitcase” logo on the Anthem member ID card. When in a non-Blue HPN market, patients are limited to urgent and/or emergent care at non-Blue HPN health care providers. Plan design Anthem’s Blue HPN EPO benefit design will be supported by Independence’s Blue HPN tiered network. Out-of-network coverage is limited to urgent/emergent care only. ● PCP visits are covered at 100% (along with preventive care) ● Specialist office visits are covered with a $55 copay ● Inpatient care (at tier one facilities) is covered with a $500 copay per admit ● Outpatient care (at tier one facilities) is covered with a $300 copay ● Urgent care is covered with a $25 copay ● Emergency care is covered with a $400 copay You may use the NaviNet® web portal (NaviNet Open) to determine your in-network benefit tier. As a reminder, all members are subject to eligibility verification and the applicable precertification requirements of their Home Plan. Learn more If you would like to learn more about Blue HPN, please our Provider Network Services team via email at pnsproviderrequests@ibx.com. NaviNet® is a registered trademark of NantHealth, an independent company. December 2020 | Partners in Health UpdateSM 9 www.ibx.com/pnc
BILLING & REIMBURSEMENT Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2021 Published December 1, 2020 (Read online) ffective January 1, 2021, updates will be made to our Professional Injectable and Vaccine Fee Schedule for all E contracted providers. These updates are made quarterly and reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables as well as any modifications to the percentage premium. Allowance Inquiry transaction Providers may find the rate for a specific code using the Allowance Inquiry transaction on the NaviNet® web portal (NaviNet Open). To do so, go to Independence NaviNet Open Plan Central, select Claim Inquiry and Maintenance from the Independence Workflows menu, and then select Allowance Inquiry. For step-by-step instructions on how to use this transaction, refer to the Allowance Inquiry Guide, which is available under User guides and webinars in the NaviNet Open section. The Allowance Inquiry transaction only returns current rates for professional providers. The reimbursement rates that go into effect January 1, 2021, will be available through this transaction on or after this effective date. Provider payment allowances are for informational purposes only and are not a guarantee of payment. NaviNet® is a registered trademark of NantHealth, an independent company. December 2020 | Partners in Health UpdateSM 10 www.ibx.com/pnc
BILLING & REIMBURSEMENT Billing guidelines for leuprolide acetate (Fensolvi®) Published December 8, 2020 (Read online) Effective March 8, 2021, changes will apply to providers who bill for leuprolide acetate (Fensolvi®). Fensolvi was approved by the U.S. Food and Drug Administration (FDA) on May 1, 2020 for the treatment of children with central precocious puberty, and is represented by HCPCS J1950 (Injection, leuprolide acetate [for depot suspension], per 3.75 mg). Fensolvi will only be covered for non-oncologic diagnoses based on the medical necessity criteria outlined in our medical policies. Billing guidelines In alignment with other leuprolide acetate products, the following coding guidelines will still apply: ● Leuprolide acetate, 7.5 mg (HCPCS J9217) represents Eligard® and Lupron Depot® and will be covered for both oncologic and non-oncologic diagnoses based on the medical necessity criteria outlined in our medical policies. ● Leuprolide acetate, 3.75 mg (HCPCS J1950) represents Fensolvi and Lupron Depot and will only be covered for non- oncologic diagnoses based on the medical necessity criteria outlined in our medical policies. Medical necessity criteria According to Independence’s definition of medical necessity, a service cannot be more costly than an alternative service that is at least as likely to produce equivalent therapeutic or diagnostic results for the treatment of an individual’s illness. Fensolvi has been FDA approved for the treatment of children with central precocious puberty and will only be covered for that indication. The billing guidelines are also in alignment with Medicare’s (Novitas Solutions, Inc.) local coverage determination on Luteinizing Hormone-Releasing (LHRH) Analogs. Learn more The original article discussing Eligard and Lupron Depot was communicated on January 6, 2017. Notifications were posted on December 8, 2020, for the following updated medical policies that go into effect March 8, 2021: ● Commercial: #08.01.33c: Gonadotropin-Releasing Hormone Agonist (Eligard®, Fensolvi®, Lupron Depot®) ● Medicare Advantage: #MA08.083c: Gonadotropin-Releasing Hormone (Eligard®, Fensolvi®, Lupron Depot®) To view the Notifications for these policies, visit our Medical and Claim Payment Policy Portal and select either Commercial or Medicare Advantage under Active Notifications. December 2020 | Partners in Health UpdateSM 11 www.ibx.com/pnc
BILLING & REIMBURSEMENT BCBSA high-dollar prepayment claims review policy update Published December 17, 2020 (Read online) s previously communicated in a Partners in Health UpdateSM article, as of January 1, 2019, the Blue Cross and Blue A Shield Association (BCBSA), an association of independent Blue Cross® and Blue Shield® plans, requires all Blue plans to obtain an itemized hospital bill up front, in order to process certain BlueCard® claims for out-of-area members. Providers need to submit an itemized bill when they receive a code on an electronic remittance report (835) and/or paper Provider Remittance as identified below. Mandate update Effective January 1, 2021, the claims threshold will now be $100,000 or greater as detailed below. In order to comply with the BCBSA mandate, when hospitals participating in Independence’s network treat out-of-area members of another Blue plan, Independence requires the submission of an itemized bill from the participating hospital in order to process claims when each of the following criteria is met: ● The claim is for inpatient institutional (acute care) services; and ● The claim has an estimated allowed amount of $100,000 or greater; and ● The claim is priced using a global payment methodology that does not incorporate individual services or charges, such as: − Per-diem − Flat-fee case rate − DRG rate Claims for members in a Medicare Supplement/Medigap plan or traditional Medicaid are excluded from this prepayment review. If an itemized bill is not received for claims requiring special treatment in connection with this BCBSA mandate, then the claim may be denied. Providers need to submit an itemized bill when they receive a code on an electronic remittance report (835) and/or paper Provider Remittance as identified below. Identifying a claim affected by this mandate If you have a claim affected by this BCBSA mandate, you will see the following codes displayed on your electronic remittance report (835) and/or paper Provider Remittance with the following messages: ● CARC 252 – An attachment/other documentation is required to adjudicate this claim/service. ● RARC N26 – Missing itemized bill/statement Invoice submission instructions If your claim has been denied, you will need to submit an itemized bill. Please submit itemized bills via email at OOAHighDollarReview@ibx.com. Use this e-mail address for itemized bill submissions only. Learn more If you have additional questions regarding a claim denied as a result of the BCBSA mandate, please email our Provider Network Services team at pnsproviderrequests@ibx.com. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. December 2020 | Partners in Health UpdateSM 12 www.ibx.com/pnc
BILLING & REIMBURSEMENT Submitting Blue High Performance NetworkSM claims Published December 22, 2020 (Read online) Independence members now have access to a national high-performance network, Blue High Performance Network (Blue HPNSM ). The claims filing requirements are different for Blue HPN when compared to BlueCard® PPO. All professional and facility provider claims for Blue HPN members must be submitted to Independence. As a reminder, all members are subject to eligibility verification and the applicable precertification requirements of their Home Plan. For information and requirements about BlueCard PPO claims filing requirements, please read Submit your BlueCard® PPO Host claims to Independence to maximize incentive payments. Ancillary providers For information and requirements about billing guidelines for lab, DME, and specialty pharmacy providers, please read Clarification to billing guidelines for BlueCard® claims for lab, DME, and specialty pharmacy providers. Learn more If you have any questions about submitting Blue HPN claims, contact our Provider Network Services team via email at pnsproviderrequests@ibx.com. Please include “Blue HPN claims” in the subject line of the email. December 2020 | Partners in Health UpdateSM 13 www.ibx.com/pnc
BLUECARD® Find BlueCard® program information on our dedicated BlueCard page Published December 22, 2020 (Read online) The BlueCard program links participating health care providers with the various Blue Cross® and Blue Shield® Plans across the U.S. and in approximately 170 countries and territories worldwide through a single electronic network for claims processing and reimbursement. We regularly publish information about the BlueCard program in Partners in Health UpdateSM. To reference BlueCard rules and requirements, please visit our dedicated BlueCard page. Learn more If you have questions about the BlueCard program, email us at provcommrequests@ibx.com. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. December 2020 | Partners in Health UpdateSM 14 www.ibx.com/pnc
HEALTH & WELLNESS
Improving lead testing and developmental screening among
Keystone HMO CHIP members
Published December 1, 2020 (Read online)
he Pennsylvania Department of Human Services (DHS) states that all children enrolled in Pennsylvania’s Keystone
T
Health Plan East HMO Children’s Health Insurance Program (Keystone HMO CHIP) plan should receive testing for
elevated blood lead levels (EBLLs) and developmental screenings as recommended below.
Lead testing and developmental screening recommendations
Practitioners are encouraged to follow the DHS Medicaid and Bright FuturesTM guidelines for lead testing and
developmental screening. A lead blood test should be completed at ages 9 to 12 months and again by age 24 months.
Formal screening for developmental delays using a standardized tool, such as the Ages and Stages questionnaire
(CPT® 96110), should be completed for children who are 9 months, 18 months, and 30 months of age, or when
surveillance yields concern. The screening should be documented in the patient’s chart and included in a claim.
Screening and documentation are especially important for children enrolled in Keystone HMO CHIP because of the higher
incidence of developmental delay among certain pediatric populations enrolled in government-sponsored programs when
compared to children enrolled in privately insured plans.
Keystone HMO CHIP members should meet the DHS guidelines for lead testing and developmental screening regardless
of risk level. We know many provider practices have already performed these tests, and we thank you and your staff for
the care you provide to our pediatric and Keystone HMO CHIP members.
Additional well visits
Children who turn 15 months old during the measurement year should receive six or more well-child visits. Children ages
3 to 6 should have one or more well-child visit with their health care provider each year.
What your practice can do
To help ensure your patients receive the required testing, your practice can do the following:
● Screen children for EBLLs by performing a risk assessment at 6 months, 9 months, 18 months, and then annually from
ages 3 – 6, with testing as appropriate.
● Perform developmental surveillance at each well-child visit and document the use of a standardized developmental
screening tool for children at 9 months, 18 months, and 30 months of age. Please be sure to document in the
member’s chart and when submitting the claim or when surveillance yields concern. Examples of validated screening
tools for developmental delays can be found on the Bright Futures website:
− infancy
− early childhood
● Discuss recommendations for lead testing and developmental screening with the parents/guardians of your Keystone
HMO CHIP patients.
continued on the next page
December 2020 | Partners in Health UpdateSM 15 www.ibx.com/pncHEALTH & WELLNESS continued from the previous page Identifying Keystone HMO CHIP members To help your practice easily identify Keystone HMO CHIP members, we include the identifying words “PA Kids” on the front of Independence ID cards, as shown in the sample ID card below. Reminder: PROMISeTM ID required to render services to Keystone HMO CHIP members The state of Pennsylvania requires a Provider Reimbursement and Operations Management Information System (PROMISe) ID for all providers who render, order, prescribe, or bill for items or services to Keystone HMO CHIP members. There are a few important things about PROMISe IDs to keep in mind: ● DHS implemented the Affordable Care Act provision that requires all providers who render, order, prescribe, or bill for items or services to Keystone HMO CHIP members be registered with DHS as a Keystone HMO CHIP provider at each provider location. ● Upon acceptance, DHS will issue providers a PROMISe identification number for each location. ● Remember, obtaining a PROMISe ID does not mean providers must accept Medical Assistance beneficiaries. ● As of July 1, 2019, a PROMISe ID is required for providers to receive payment from Independence for services or items rendered, ordered, prescribed, or billed for Keystone HMO CHIP members. ● As of July 1, 2019, claims submitted to Keystone Health Plan East by a provider who does not have a PROMISe ID at the location where services or items were rendered, ordered, prescribed, or billed for Keystone HMO CHIP members will not receive payment. ● Visit the DHS website to access the application, requirements, and step-by-step instructions related to the enrollment process. Resources The following resources provide additional information regarding lead testing and developmental screening recommendations: ● Centers for Disease Control and Prevention (CDC): Childhood Lead Poisoning Prevention Program ● Philadelphia Department of Public Health: 215-685-2788 (Philadelphia residents) ● National Lead Information Center: 1-800-424-LEAD (1-800-424-5323) (non-Philadelphia residents) ● American Academy of Pediatrics: “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening.” Pediatrics. 2006; 405-420. Available from: pediatrics.aappublications.org/content/118/1/405 ● CDC’s Child Developmental Screening ● Independence website CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. December 2020 | Partners in Health UpdateSM 16 www.ibx.com/pnc
HEALTH & WELLNESS
Encourage pregnant Independence members to enroll in Baby
BluePrints®
Published December 9, 2020 (Read online)
The Baby BluePrints program supports expectant mothers and promotes a healthy pregnancy throughout each trimester.
We ask that you inform pregnant Independence members about the Baby BluePrints program at their first prenatal visit
and encourage them to self-enroll by calling our toll-free number, 1-800-598-BABY (1-800-598-2229) (TTY: 711). Upon
calling, a Registered Nurse Health Coach (Health Coach) will explain the program to the member and ask her a series of
questions to complete the enrollment process.
Once enrolled in the program, members will receive a welcome letter that includes information on how to access
educational materials on our secure member website and how to use 1-800-598-BABY (1-800-598-2229) (TTY: 711) for
questions and support during pregnancy. Eligible members enrolled in Baby BluePrints can receive monthly emails or
IBX Wire® communications specific to each stage of pregnancy.* In addition, members who are found to have certain
health issues or history that may place them at high risk are referred to a Health Coach who is specially trained in
maternity care for additional assessment and follow-up. If the assessment identifies the member as high-risk, they may be
followed in our High-Risk Pregnancy Condition Management Program.
Resources available
Upon request, a flyer is available to place in the member’s chart and distribute at the first prenatal visit to encourage her
to enroll in Baby BluePrints. To order flyers, please submit a request using our online form.
Postpartum office visits
As a reminder, postpartum visits should be scheduled 21 to 56 days after delivery. Adhering to this time
frame provides the best opportunity to assess the physical healing for new mothers and to answer questions
around family planning, if necessary. These visits should be scheduled before members are discharged
from the hospital.
If you have any questions about the program, please call Customer Service at 1-800-ASK-BLUE (1-800-275-2583).
*Standard message and data rates may apply. Text STOP to stop and HELP for help. Terms and Conditions available at myhelpsite.net/ibx.
Notification messages within IBX Wire are sent via automated SMS. Enrollment in IBX Wire is not a requirement to purchase goods and services from
Independence Blue Cross. Wire is a trademark of Relay Network, LLC., an independent company.
December 2020 | Partners in Health UpdateSM 17 www.ibx.com/pncHEALTH & WELLNESS
Registered Nurse Health Coaches: Supporting Independence
providers and their patients
Published December 15, 2020 (Read online)
Independence recognizes that the physician-patient relationship is at the heart of patient care. Our Registered Nurse
Health Coaches (Health Coaches) can assist your practice and help provide coordination of care for your patients enrolled
in an Independence benefit plan (members).* We provide information for Independence members, their families, and
physicians, as well as share community resources
Coordination of care
Our highly skilled Health Coaches and licensed Social Workers are available to support your practice in a
variety of ways, including:
● coordinating community resources not covered by insurance, such as medication assistance,
transportation services, food resources, and home modification programs;
● educating your patients on the importance of medication and plan-of-care adherence;
● assisting your patients in making appointments;
● reporting medication discrepancies and your patients’ needs that are otherwise unreported, such as the
need for potential home care;
● assisting with closing gaps in care;
● educating your patients about shared decision-making, which leads to improved adherence to treatment
plans;
● supporting your patients post-discharge;
● providing your patients with education about managing a new or chronic condition;
● encouraging your patients to discuss concerns and questions with their health care provider(s);
● assisting with your patients’ transition to alternative care, if necessary, when benefits cease.
If you would like to refer an Independence member to a Health Coach, please complete the online Case and Condition
Management Physician Referral Form or call 1-800-313-8628 and select prompt 2.
*Independence members who are covered through fully insured employer groups are automatically considered eligible for health coaching. Members
covered through certain self-insured employer groups may not be eligible for all components of health coaching including condition management.
Members can call Customer Service at 1-800-ASK-BLUE (1-800-275-2583) to verify their eligibility.
December 2020 | Partners in Health UpdateSM 18 www.ibx.com/pncHEALTH & WELLNESS Encouraging care for parents and guardians of your Keystone HMO CHIP patients: Asthma assessment and treatment Published December 16, 2020 (Read online) Independence is continuing its series of messages for the parents and/or guardians of our Keystone HMO Children’s Health Insurance Program (Keystone HMO CHIP) members to help families manage their child’s health care. The topics chosen are based on Healthcare Effectiveness Data and Information Set (HEDIS®) measures. We are sharing these topics with you to help support compliance with these measures and to encourage families to obtain these important services. This month’s message is about the importance of assessment and treatment for asthma. Important information on HEDIS measures Children ages 2 through 19 Measure: Assess the percentage of children and adolescents, in this age group, with an asthma diagnosis who have ≥ one emergency room/department (ED) visit in a year. Members ages 5 through 64 Measure: The percentage of members, in this age group, who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: ● The percentage of members who remained on an asthma controller medication for at least 50 percent of their treatment period. ● The percentage of members who remained on an asthma controller medication for at least 75 percent of their treatment period. How you can help Each Keystone HMO CHIP patient should be reminded of the importance of taking his or her medication as prescribed, which can help to lower ED visits related to asthma. In addition, we suggest you explain the following to parents and patients: ● why asthma medication is needed ● how to administer the medication and any potential side effects ● how to handle an asthma attack ● what to do if a dose is missed We appreciate your ongoing support in educating the parents and guardians of your Keystone HMO CHIP patients. Stay tuned for more topics in 2021. December 2020 | Partners in Health UpdateSM 19 www.ibx.com/pnc
HEALTH & WELLNESS Encourage your patients to make New Year’s resolutions that stick Published December 23, 2020 (Read online) “ It really doesn’t matter what exercise you use. The trick is to stick with it. I usually see a large crowd at the health club during January because of New Year’s resolutions, but the crowd starts to thin by February. You can find me there regardless of the month, January through December,” says Robert, a longtime SilverSneakers® member. We all want to feel better, stronger and more confident. That’s why health-related resolutions top many lists every new year. Only a small percentage follow through like Robert, but simple strategies and a strong support network can help your patients stay motivated and committed to fitness resolutions this year … all year! Help your patients set smart goals and create a roadmap Many resolutions fail because they’re too vague. Rather than “train for a marathon,” guide your patients to “exercise for 2.5 hours every week.” Remind them to create “SMART” goals that are simple, measurable, and include an endpoint and a roadmap to help your patients reach their goals. Make it fun Encourage your Independence Medicare Advantage patients to find activities they enjoy. Put that way, exercise sounds like something patients want to do rather than something they must do. Tell your patients to read “Not Motivated to Exercise? Do This…” on the SilverSneakers blog for simple strategies to help them keep their fitness resolutions on track. SilverSneakers online and in person Goals are easier to achieve when friends are involved. SilverSneakers is a community of like-minded people ready to help your patients along their journey. As Medicare Advantage members, your patients have access to SilverSneakers at no additional cost. SilverSneakers members can take classes* at any of the thousands of participating locations† nationwide. Also, hiking and walking groups and a variety of unique classes are held at community parks, recreation centers and other neighborhood locations. If the gym isn’t an option for your patients, no problem. SilverSneakers LIVE full-length classes and workshops are offered via Zoom1 multiple times every day, including weekends. Your patients can pick the classes they want to attend and log on at class time to join other students in these classes led by SilverSneakers instructors. In addition, SilverSneakers On-DemandTM offers a video library with hundreds of online videos your patients can access. Low- and high-impact workouts, fall prevention classes, and stress management workshops are all accessible to them anytime, anyplace. Encourage your Independence Medicare Advantage patients to create and stick to their healthy New Year’s resolutions with the help of SilverSneakers. They can check their eligibility and learn more at SilverSneakers.com. *Membership includes SilverSneakers instructor-led group fitness classes. Some locations offer members additional classes. Classes vary by location. † Participating locations (“PL”) are not owned or operated by Tivity Health, Inc. or its affiliates. Use of PL facilities and amenities is limited to terms and conditions of PL basic membership. Facilities and amenities vary by PL. 1 Zoom is a third-party provider and is not owned or operated by Tivity Health or its affiliates. SilverSneakers members who access SilverSneakers Live classes are subject to Zoom’s terms and conditions. SilverSneakers member must have Internet service to access SilverSneakers Live classes. Internet service charges are responsibility of SilverSneakers member. SilverSneakers, the SilverSneakers shoe logotype, and SilverSneakers On-Demand are registered trademarks of Tivity Health, Inc. © 2020 Tivity Health, Inc. All rights reserved. December 2020 | Partners in Health UpdateSM 20 www.ibx.com/pnc
MEDICAL
Updated Lab Management Clinical Guidelines
Published December 1, 2020 (Read online)
ffective January 1, 2021, updated Independence Lab Management Clinical Guidelines will be used by eviCore
E
healthcare (eviCore), an independent company.
Independence requires precertification and/or prepayment coverage reviews through eviCore for genetic/genomic
tests, certain molecular analyses, and cytogenetic tests for all commercial Independence members. eviCore will use
the updated Lab Management Clinical Guidelines to determine the medical necessity for these tests. For the current
guidelines, go to eviCore’s Independence Resources web page.
Lab management policy and guidelines
New policy for the eviCore Lab
You can now review Medical Policy #06.02.52s: eviCore Lab
Management, which was posted as a Notification on December
Management Program for Medicare
1, 2020, and goes into effect January 1, 2021. The policy Advantage members
includes a summary of the guideline changes and a link to the As a reminder, effective January 1, 2021,
Lab Management Program Clinical Guidelines that eviCore uses Independence is expanding its utilization
during the precertification and prepayment review processes, as management program for genetic/genomic tests,
well as a listing of procedure codes that require precertification certain molecular analyses, and cytogenetic
and/or prepayment review. tests for all Independence Medicare Advantage
members. We are working with eviCore
This policy does not apply to self-funded groups for whom healthcare (eviCore), an independent specialty
eviCore’s Lab management Program is not applicable; individual benefit management company, to manage
benefits must be verified. precertification and/or prepayment coverage
To view the Notification for this policy, visit our Medical and reviews for these tests.
Claim Payment Policy Portal. For more information on the program, please
refer to the following Medicare Advantage policy
Requesting precertification #MA06.034: eviCore Lab Management Program,
You can initiate precertification for genetic/genomic tests in one which was posted as a Notification on
of the following ways: December 1, 2020, and will go into effect on
● NaviNet® web portal. Select eviCore from the Authorizations January 1, 2021.
option in the Independence Workflows menu. To view the Notification for this policy, visit our
● Telephone. Call eviCore directly at 1-866-686-2649. Medical and Claim Payment Policy Portal.
Summary of Lab Management Clinical Guidelines changes effective
January 1, 2021
There are five new guidelines. Thirty-four existing guidelines have been revised (including 21 with substantive
criteria changes). Fifteen guidelines were retired.
Below is a summary of the guideline changes:
continued on the next page
December 2020 | Partners in Health UpdateSM 21 www.ibx.com/pncMEDICAL
continued from the previous page
New Guidelines:
1. Microsatellite Instability and Immunohistochemistry Testing in Cancer
2. Chromosomal Microarray for Solid Tumors
3. Medically Necessary Laboratory Testing
4. Lyme Disease Testing
5. In-vitro testing for HIV
Retired Guidelines:
1. Lynch Syndrome Tumor Screening - First-Tier
2. CYP2C19 Variant Analysis for Clopidogrel Response
3. CYP2C9, VKORC1, and CYP4F2 Testing for Warfarin Response
4. CYP2D6 Variant Analysis for Drug Response
5. DPYD Variant Analysis for 5-FU Toxicity
6. HLA.B*1502 Variant Analysis for Carbamazepine and Oxcarbazepine Response
7. HLA.B*5701 Genotyping for Abacavir Hypersensitivity
8. TPMT Testing for Thiopurine Drug Response
9. UGT1A1 Mutation Analysis for Irinotecan Response
10. SensiGene
11. KRAS Testing for Anti-EGFR Response in Metastatic Colorectal Cancer
12. BRAF Testing for Colorectal Cancer
13. BRAF Testing for Melanoma Kinase Inhibitor Response
14. EGFR Testing for Non-Small Cell Lung Cancer TKI Response
15. FoundationOne CDx
Criteria Updates (Substantive):
1. BRCA Analysis
2. BRCA Ashkenazi Jewish Founder Mutation Testing
3. HLA Typing for Celiac Disease
4. Decipher Prostate Cancer Classifier
5. Genetic Testing for Autism
6. Genetic Testing to Diagnose Non-Cancer Conditions
7. Genitourinary Conditions Molecular Testing
8. Hereditary Cancer Syndrome Multigene Panels
9. Investigational and Experimental Molecular/Genomic
10. Li-Fraumeni Syndrome Testing
11. Liquid Biopsy Testing – Solid Tumors
12. Long QT Syndrome Testing
13. Mammaprint 70.Gene Breast Cancer Recurrence Assay
14. Multiple Endocrine Neoplasia Type 2 (MEN2)
15. Pharmacogenomic Testing for Drug Toxicity and Response
16. Somatic Mutation Testing-Solid Tumors
17. Tay-Sachs Disease Testing
18. myChoice CDx
continued on the next page
December 2020 | Partners in Health UpdateSM 22 www.ibx.com/pncMEDICAL
continued from the previous page
19. Laboratory Claim Reimbursement
20. Exome Sequencing
21. Somatic Mutation Testing - Hematological Malignancies
Criteria Updates (Non-Substantive):
1. Chromosomal Microarray Testing for Developmental Disorders
2. Early Onset Familial Alzheimer Disease (EOFAD) Genetic Testing
3. Genetic Testing for Arrhythmogenic Right Ventricular Cardiomyopathy
4. Genetic Testing for Dilated Cardiomyopathy
5. Genetic Testing for Epilepsy
6. Genetic Testing for Known Familial Mutations
7. Genetic Testing for Non-Medical Purposes
8. Genetic Testing to Predict Disease Risk
9. Hypertrophic Cardiomyopathy Testing
10. OncotypeDX for Breast Cancer Prognosis
11. Hereditary Ataxia Multigene Panel Testing
12. Molecular Respiratory Infection Pathogen Panel (RIPP) Testing
13. Flow Cytometry
NaviNet is a registered trademark of NantHealth, an independent company.
December 2020 | Partners in Health UpdateSM 23 www.ibx.com/pncMEDICAL Kidney care measures for the nephrology pay for value (NeP4V) program Published December 2, 2020 (Read online) As previously communicated in a Partners in Health UpdateSM article, effective January 1, 2021, Independence will launch a new nephrology pay for value (NeP4V) program focused on chronic kidney disease (CKD) and end-stage renal disease (ESRD) members. The NeP4V program is the first incentive-based model offered to nephrology practices in the Independence network. Program incentives The NeP4V program will give nephrology practices an opportunity to earn incentives for continually improving the quality of medical care and service they provide Independence Commercial and Medicare Advantage members with advanced CKD (stages 4 and 5) and ESRD. Practices must meet certain prerequisites to be eligible for participation and payment in the NeP4V program. Payment incentives will be based on the kidney care measures outlined below. Kidney care measures The kidney care measures are based on services provided during the reporting period (January through December of the measurement year, unless otherwise noted). Accurate encounter and claims submissions are important to document these services. The kidney care measures for measurement year 2021 are: ● at-home dialysis therapy for ESRD members ● emergency room/department and inpatient utilization for CKD 4, CKD 5, and ESRD members ● optimal ESRD starts ● transplants per year when member remains dialysis free at 12 months post-transplant NeP4V program prerequisites A complete list of the program prerequisites is outlined in the NeP4V program manual. One requirement is that nephrology practices must be enabled to use PEAR Analytics & Reporting (formerly IndexProTM), our practice reporting tool accessed through the Provider Engagement, Analytics & Reporting (PEAR) portal, to view all NeP4V program-related reports in addition to other valuable value-based data. Learn more on how to enroll for access to the PEAR portal here. Learn more Review the NeP4V program manual, available on our value-based program page, to learn more about the program. If you have questions, please email us at NeP4V@ibx.com. December 2020 | Partners in Health UpdateSM 24 www.ibx.com/pnc
MEDICAL
Archival of several medical policies
Published December 2, 2020 (Read online)
Effective January 1, 2021, the following policies will be archived because the precertification requirement for the
applicable drugs will be removed:
● Commercial: #08.01.19f: Siltuximab (Sylvant®)
● Medicare Advantage: MA08.006f: Siltuximab (Sylvant®)
− The code J2860 Injection, siltuximab, 10 mg is eligible for coverage.
● Commercial: #08.00.98e: Eribulin Mesylate (Halaven®)
● Medicare Advantage: MA08.056c: Eribulin Mesylate (Halaven®)
− The code J9179 Injection, eribulin mesylate, 0.1 mg is eligible for coverage.
● Commercial: #08.00.96e: Cabazitaxel (Jevtana®)
● Medicare Advantage: MA08.054c: Cabazitaxel (Jevtana®)
− The code J9043 Injection, Cabazitaxel, 1 mg is eligible for coverage.
Changes to the precertification requirement list that become effective January 1, 2021, are posted on our website.
Effective January 1, 2021, the following policies will be archived because the information in these policies is now
addressed in our Cosmetic Procedures policies #12.01.03a for Commercial products and #MA12.009a for Medicare
Advantage products:
• Commercial: #08.01.24a: Deoxycholic Acid (KybellaTM)
• Medicare Advantage: MA08.074a: Deoxycholic Acid (KybellaTM)
− The code J0591 Injection, deoxycholic acid, 1 mg will remain a cosmetic service.
Effective January 4, 2021, the following policies will be archived:
• Commercial: #08.00.88f: Ofatumumab (Arzerra®)
• Medicare Advantage: MA08.048d: Ofatumumab (Arzerra®)
− The code J9302 Injection, Ofatumumab acid, 10 mg is eligible for coverage.
Precertification information on the above policies was previously communicated in a Partners in Health UpdateSM
article.
December 2020 | Partners in Health UpdateSM 25 www.ibx.com/pncMEDICAL
Reminder: The annual Synagis® (palivizumab) distribution
program
Published December 7, 2020 (Read online)
he upcoming respiratory syncytial virus (RSV) season runs from November 1, 2020, through March 31, 2021. RSV is
T
the most common cause of bronchiolitis and pneumonia among children younger than one year. PerformSpecialty®, an
independent company, will be facilitating delivery of the RSV drug Synagis (palivizumab) through the Independence Direct
Ship Drug Program.
Synagis is a humanized monoclonal antibody that provides passive immunity against RSV. It is intended to decrease
the morbidity and mortality associated with RSV lower respiratory tract disease in high-risk infants and children. It is not
effective in the treatment of RSV disease, and it is not approved for this indication.
It is mandatory for all participating providers to order Synagis for Independence members through our Direct Ship Drug
Program. The 2020-2021 Synagis order forms are now available on our Direct Ship Drug Program webpage. Please use
these versions, as forms from previous Synagis seasons will not be accepted.
How to order Synagis for office use
The following guidelines apply when ordering Synagis:
● Providers should go to the Independence Direct Ship Drug Program website to access the order forms. The order
forms are under the Specific Drug Request form section. There are two Synagis order form options:
1. Print form: Office staff are required to write the patient and provider information on the form.
2. Fillable form: Office staff can type information directly onto the form.
Important: There is no online submission option for these forms; they must be printed and faxed to the number on the
form.
● T he form must include sufficient clinical information to meet our Synagis coverage criteria, which are based on current
American Academy of Pediatrics (AAP) recommendations.
● Fax the completed form (print or fillable) to 1-855-851-4056. Be sure to include any necessary documentation to
support the request. Incomplete forms may result in ordering delays.
● Since Independence pays PerformSpecialty directly for the drug, providers neither pay for doses ordered through
PerformSpecialty nor receive reimbursement for the actual pharmaceutical. Providers can still receive payment for the
administration of the drug.
● Synagis will generally be approved for office administration only, unless a patient is receiving home nursing services for
a separate indication.
● Upon approval of the request, Synagis will be shipped to the provider’s office monthly during the RSV season.
Shipping for the 2020-2021 RSV season begins on Monday, November 2, 2020, and continues through
Wednesday, March 31, 2021. Up to five doses (one dose every 30 days) will be shipped per member.
Learn more
Independence provides coverage under the medical benefit for the administration of Synagis for infants and children
during the RSV season, in accordance with the current recommendations from the AAP. These recommendations are
subject to change.
The complete list of coverage criteria for Synagis can be found in the Independence Medical Policy #08.00.22n: Immune
Prophylaxis for Respiratory Syncytial Virus (RSV). To view this policy, visit our Medical and Claim Payment Policy Portal.
If you have questions about Synagis, please call Customer Service at 1-800-ASK-BLUE (1-800-275-2583).
December 2020 | Partners in Health UpdateSM 26 www.ibx.com/pncMEDICAL Medical policy changes for polyarticular juvenile idiopathic arthritis drugs for commercial members Published December 8, 2020 (Read online) Independence is changing how we manage the biologics that are approved by the U.S. Food and Drug Administration (FDA) for the treatment of polyarticular juvenile idiopathic arthritis (pJIA) for members enrolled in our commercial (non-Medicare Advantage) products. There are various biologics on the market, and there is no reliable evidence that demonstrates the superiority of one biologic over the others. However, there are notable differences in cost. Coverage criteria Effective March 8, 2021, the coverage criteria for the indication of pJIA will be updated for Independence’s medical policies on Orencia® (IV) and Actemra® (IV) to reflect that Simponi Aria® is the preferred biologic for pJIA. Simponi Aria was selected based on its demonstrated cost-effectiveness and treatment of pJIA. The criteria apply only to commercial (non-Medicare Advantage) members who have never received a biologic agent as therapy to treat pJIA. Orencia (IV) and Actemra (IV) will only be eligible for coverage and reimbursement in the treatment of pJIA when both of the following criteria are met: ● the member meets the medical necessity criteria in the medical policy for that specific drug; ● the member has a documented failure, contraindication, or intolerance to Simponi Aria, or there is a clinical reason that a trial of Simponi Aria would be otherwise inappropriate for the member. For members who are currently receiving Orencia (IV) or Actemra (IV) for pJIA, these drugs will continue to be eligible for coverage when they are prescribed in accordance with the regimen that has been precertified by Independence. Updated policies For more information, please review the following Independence commercial policies, which were posted as Notifications on December 8, 2020, and will go into effect on March 8, 2021: ● #08.00.62l: Abatacept (Orencia®) for Injection for Intravenous Use ● #08.00.85k: Tocilizumab (Actemra®) for Intravenous Infusion To view these policy Notifications, visit our Medical and Claim Payment Policy Portal and select Commercial from the Active Notifications section. December 2020 | Partners in Health UpdateSM 27 www.ibx.com/pnc
MEDICAL Introducing a new kidney care management program: Strive Health Kidney Care Published December 10, 2020 (Read online) ffective January 1, 2021, Independence will enter into a partnership with Strive Health, an independent company, E to offer a new program: Strive Health Kidney Care. This program is designed to support Independence patients diagnosed with chronic kidney disease (CKD) stages 4 and 5, as well as end-stage renal disease (ESRD). Strive has an interdisciplinary team of Nurse Practitioners, Registered Nurse (RN) Care Managers, and Care Coordinators who will work alongside our primary care physicians and nephrologists to provide additional support for kidney care, management of comorbid conditions, education, and specialized care coordination to eligible Independence Medicare Advantage members. Working with Strive Health Strive Health’s high-touch model offers disease and care management services to: ● delay disease progression ● reduce unnecessary emergency room and inpatient utilization ● improve patient mortality and morbidity outcomes ● explore treatment options You can expect that the Strive Health team will keep you up to date on what is happening. They will work with you to determine the best mode of communication and are committed to providing you regular updates on your patients and alerting you to major changes to their care plan, such as tracking inpatient admissions. This collaboration is designed to support nephrology practices in achieving better patient outcomes. In the near future, Strive Health will contact providers to discuss the program in more detail and learn how they can best support your patient care. Learn more If you have questions, please email Joanne Seader, RN, BSN, CDN, Director, Kidney Care Program, Joanne.Seader@ibx.com. December 2020 | Partners in Health UpdateSM 28 www.ibx.com/pnc
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