UpdateSM February 2021 Recap - Independence ...
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update SM
February 2021 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 Health and Wellness
● C heck member ID cards and verify ● A new approach to diabetes
eligibility management
● Concierge medical care violates the ● Encouraging care for parents and
terms of your provider agreement with guardians of your Keystone HMO CHIP
Independence patients: Appropriate treatment for
● NaviNet Open and EDI: eBusiness children with upper respiratory infection
hotline will be discontinued on ● Encourage pregnant Independence
March 15, 2021 members to enroll in Baby BluePrints®
● Stay informed! Join our email list
to receive the latest news from Medical
Independence ● R
eminder: eviCore Lab Management
Program expanded to Medicare
Billing & Reimbursement Advantage members
● E nhanced claim edits to support correct
coding principles – new coding validation NaviNet Open
program now in effect ● R
etirement of Clinical Care Reports and
● Enhanced Claim Editor Program: Coding Clinical Alerts from NaviNet Open
Validator review and the reporting of
manual therapy and CMT Quality Management
● TC+ providers for 2021
PEAR portal
In 2021, we are transitioning to the Provider Engagement, Analytics & Reporting
(PEAR) portal! Learn more about the portal and its applications on the dedicated
PEAR portal tab.
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
February 2021 | Partners in Health UpdateSM 2 www.ibx.com/pnc
ADMINISTRATIVE
Check member ID cards and verify eligibility
Published February 1, 2021 (Read online)
Some Independence patients received a new member ID card for coverage effective in 2021.
Please confirm the member’s coverage and eligibility at each visit and before rendering services.
Best practices
1. Make a copy of their ID card. Use the most recent member
information when submitting claims. Medical Policy/PreCertification
For out-of-area Blue Plan members, refer to the Quick guide to for out-of-area Blue Plan
Blue member ID cards. members
The Medical Policy/Precertification Router
2. Verify eligibility and benefits. Use the Eligibility and Benefits allows an Independence network provider
Inquiry transaction on the NaviNet® web portal (NaviNet Open).* access to information about the out-of-area
or out-of-area Blue Plan members, use the BlueExchange® Out
F Blue members Home Plan through NaviNet
of Area transaction. Open.* For more detailed information about
NaviNet Open and for access to our NaviNet
3. Complete the COB, as applicable. For out-of-area Blue Plan
Open transaction user guides, visit the
members, have them complete the Coordination of Benefits
NaviNet Open section.
(COB) Questionnaire for Out-of-Area Members, if applicable.
If a member does not have their new ID card yet or forgot it, ask the member to print a temporary ID card by logging on to
our secure member portal available at ibx.com.
For your convenience, NaviNet Open* and ibx.com are available seven days a week.
*If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics &
Reporting (PEAR) portal, you can use the Eligibility & Benefits and BlueExchange® Out of Area transactions to view this
information. Additional information and self-service training materials are available in the PEAR H
elp Center.
NaviNet® is a registered trademark of NantHealth, an independent company.
February 2021 | Partners in Health UpdateSM 3 www.ibx.com/pncADMINISTRATIVE Concierge medical care violates the terms of your provider agreement with Independence Published February 9, 2021 (Read online) As a reminder, Participating Providers who require members to pay a designated fee (e.g., a surcharge) for Covered Services to remain in their practice are in violation of their Independence Professional Provider Agreement (Agreement) and are subject to termination from the Independence network. This is typically referred to as concierge medical care, or retainer medicine, and is in violation of the terms of your agreement. Participating Providers are required to comply with the terms and conditions of their Agreement, which requires them to accept Independence’s payment as payment in full for all Covered Services. Covered Services include: ● well-patient visits ● emergency telephone consultation available 24 hours a day, seven days a week ● treatment of acute conditions ● coordination of medically necessary care ● referrals to appropriate specialists for treatment Under your Agreement, it’s mandatory that you provide Covered Services during normal business hours, in addition to 24/7 telephone access for consultation on medical concerns and emergencies. If you have any questions, review your contract or contact your Network Coordinator. February 2021 | Partners in Health UpdateSM 4 www.ibx.com/pnc
ADMINISTRATIVE NaviNet Open and EDI: eBusiness hotline will be discontinued on March 15, 2021 Published February 10, 2021 (Read online) Effective March 15, 2021, the eBusiness hotline (215-640-7410) will be discontinued. Providers should use the online Provider eBusiness Inquiry Form for NaviNet® web portal (NaviNet Open) and electronic data interchange (EDI) related issues and questions, or Trading Partner Registration escalations.* Providers must use the Provider eBusiness Inquiry Form beginning March 15, 2021. All NaviNet Open and EDI inquiries will be answered in the order that they are received. *Only providers participating in an Independence network can obtain NaviNet Open access. NaviNet® is a registered trademark of NantHealth, an independent company. February 2021 | Partners in Health UpdateSM 5 www.ibx.com/pnc
ADMINISTRATIVE Stay informed! Join our email list to receive the latest news from Independence Published February 26, 2021 (Read online) Sign up today to receive email communications from Independence with important news and information relevant to the provider community, including: ● COVID-19 (Coronavirus) resources: Information to assist you in providing care to your patients. ● Provider Engagement, Analytics & Reporting (PEAR) portal: Stay informed about our transition ● Partners in Health UpdateSM: Includes changes to claim payment and medical policies, new programs and products, and administrative procedure updates ● Medical Director emails ● Provider Bulletins ● General news Sign up today! Complete the Provider Communications Email Sign-up Form to be added to our email distribution list. Be sure to complete the form in its entirety. You will be added to the list to receive targeted emails from Independence. It’s that simple! February 2021 | Partners in Health UpdateSM 6 www.ibx.com/pnc
BILLING & REIMBURSEMENT
Enhanced claim edits to support correct coding principles –
new coding validation program now in effect
Published February 4, 2021 (Read online)
Independence has a variety of programs in place dedicated to ensuring claims are billed accurately and in accordance
with industry standard coding principles, including:
● Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI),
modifier usage, and global surgery guidelines
● American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
● CMS HCPCS LEVEL II Manual coding guidelines
● ICD-10 Instruction Manual coding guidelines
In order to verify all providers are adhering to Independence’s claim payment policies and the industry standard source
guidelines listed above, as of February 1, 2021, Independence’s Enhanced Claim Editor Program includes coding
validation performed by a team of Registered Nurses and Certified Professional Coders that will review select professional
and outpatient facility claims in conjunction with patient claim history.
Areas of focus
Independence’s coding validation program focuses on the areas listed below:
● NCCI edits with modifier override allowed and an override modifier is on the claim line (excluding Modifier 25)
● AMA unbundling rules
● Multiple providers billing the same procedure, for the same member, on the same day
With the implementation of coding validation, claim lines found to be submitted with inappropriate coding may be denied.
Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility),
which will include a reason code for the claim line denial. This program should have little or no impact to billing practices
for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding
standards.
Identifying claims that went through the coding validator process
If your claim was affected by one of the coding validation reviews, the edit explanation will be displayed on your electronic
remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages
have been created that begin with E819X. Should your claim line contain an E819X code/message, it means it was
affected by the coding validation review. You can also find the E819X codes/messages on the Claim Status Inquiry
Detail screen on the NaviNet® web portal (NaviNet Open).* To view, hover your mouse over the service line and select
View Additional Detail. If you see an E819X code/message, the line went through coding validation. Only E8XXX codes/
messages are part of the enhanced claim editor, which will include coding validation as of February 1, 2021. All other
codes/messages are unrelated to the enhanced claim editor.
Request for coding validator claim review
While you may use NaviNet Open* to view detailed information on a coding validator E819X denial, clinical information is
needed in order to dispute the denial. Please ensure that all applicable medical records, notes, and tests are submitted
along with a cover letter explaining the reason for the dispute.
continued on the next page
February 2021 | Partners in Health UpdateSM 7 www.ibx.com/pncBILLING & REIMBURSEMENT continued from the previous page To facilitate a review, submit the documents listed above via: ● Email: claimcodingvalidation@ibx.com ● Mail: Independence Blue Cross Claim Coding Validation 1901 Market Street Philadelphia, PA 19103 *If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal, you can use the Claim Search transaction to view this information. Additional information and self-service training materials are available in the PEAR Help Center. For more information For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ). Note: The FAQ will be updated as more information becomes available. If you still have questions after reviewing the FAQ, please send an email to claimeditquestions@ibx.com. CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. NaviNet® is a registered trademark of NantHealth, an independent company. sandae mi, sum rehenes doluptat. February 2021 | Partners in Health UpdateSM 8 www.ibx.com/pnc
BILLING & REIMBURSEMENT
Enhanced Claim Editor Program: Coding Validator review and
the reporting of manual therapy and CMT
Published February 22, 2021 (Read online)
Independence has a variety of programs in place dedicated to ensuring claims are billed accurately and in accordance
with industry standard coding principles, including:
● Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI),
modifier usage, and global surgery guidelines
● American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
● CMS HCPCS LEVEL II Manual coding guidelines
● ICD-10 Instruction Manual coding guidelines
In order to verify all providers are adhering to Independence’s claim payment policies and the industry standard source
guidelines listed above, as of February 1, 2021, Independence’s Enhanced Claim Editor Program includes coding
validation performed by a team of Registered Nurses and Certified Professional Coders that will review select professional
and outpatient facility claims in conjunction with patient claim history.
Area of focus: Manual therapy reported with chiropractic manipulative treatment (CMT)
and proper use of modifiers and diagnosis pointers
NCCI claim edits bundle manual therapy (97140) to chiropractic adjustment codes (98940 – 98942) when performed in
the same anatomic region. However, manual therapy reported on the same date of service as CMT for the same member
is eligible for separate reimbursement when reported for separate anatomic body regions. When the two procedures are
performed in separate regions, the claim lines should have the proper diagnosis code pointers representing the condition
treated in each area and be appended with the appropriate modifier to indicate separate regions.
Example: A patient receives a spinal adjustment of the lumbar region and manual therapy on the right
shoulder. The patient’s diagnoses are lumbar degenerative disc disease (M51.36) and “frozen” right
shoulder (adhesive capsulitis) (M75.01). The diagnosis pointers must correctly point the manual therapy
97410 to the adhesive capsulitis diagnosis code M75.01 and the CMT 98940 to the lumbar disc disease
code M51.36. Additionally, the manual therapy should be appended with Modifier XS to signify that the
therapy was performed on a separate structure from the CMT.
With the implementation of coding validation, claim lines found to be submitted with inappropriate coding may be denied.
Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility),
which will include a reason code for the claim line denial. This program should have little or no affect to billing practices
for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding
standards.
Identifying claims that went through the coding validator process
If your claim was affected by one of the Coding Validation reviews, the edit explanation will be displayed on your
electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and
messages have been created that begin with E819X. Should your claim line contain an E819X code/message, it means it
was affected by the Coding Validation review. You can also find the E819X codes/messages on the Claim Status Inquiry
Detail screen on the NaviNet® web portal (NaviNet Open) and on the PEAR portal.* To view, hover your mouse over
the service line and select View Additional Detail. If you see an E819X code/message the further detail in the Rationale
and Description section will state Per Coding Validation review. Only E8XXX codes/messages are part of the enhanced
claim editor, which will include coding validation as of February 1, 2021. All other codes/messages are unrelated to the
enhanced claim editor.
continued on the next page
February 2021 | Partners in Health UpdateSM 9 www.ibx.com/pncBILLING & REIMBURSEMENT continued from the previous page Request for coding validator claim review While you may use NaviNet Open or the PEAR portal* to view detailed information on a Coding Validator E819X denial, clinical information is needed in order to dispute the denial. Please ensure that all applicable medical records, notes, and tests are submitted along with a cover letter explaining the reason for the dispute. To facilitate a review, submit the documents listed above via: ● Email: claimcodingvalidation@ibx.com ● Mail: Independence Blue Cross Claim Coding Validation 1901 Market Street Philadelphia, PA 19103 *If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal, you can use the Claim Search transaction to view this information. Additional information and self-service training materials are available in the PEAR Help Center. For more information For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ). Note: The FAQ will be updated as more information becomes available. If you still have questions after reviewing the FAQ, please send an email to claimeditquestions@ibx.com. CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. NaviNet® is a registered trademark of NantHealth, an independent company. February 2021 | Partners in Health UpdateSM 10 www.ibx.com/pnc
HEALTH & WELLNESS
A new approach to diabetes management
Published February 8, 2021 (Read online)
Independence has partnered with Livongo® to offer a new diabetes management program aimed at reducing the
prevalence and cost of managing diabetes. The Livongo for Diabetes program launched on January 1, 2021 for self-
funded groups who have opted-in to the program.
Diabetes continues to be a major health concern in the United States. More than 34 million Americans are currently living
with diabetes.1 Research shows the traditional approach to managing diabetes is no longer working. People living with
diabetes face several barriers when it comes to managing their condition; from access to care to testing supplies. The
program addresses the gaps in care by providing the economic and personal support needed to help patients live better
and healthier lives.
Livongo for Diabetes
The Livongo for Diabetes program provides tools and support to help patients manage their condition outside of the
hospital setting. These tools provide real time analytics and guidance on blood glucose readings. This helps to reduce
medical costs by reducing emergency room and hospital visits. Eligible patients will receive a free, easy to-use blood
glucose meter, a mobile app to help track, review, and report their health status, unlimited testing supplies, and 24/7
support from Livongo expert coaches. Patients can share their blood glucose records with their Livongo coach and
receive feedback in real time – within minutes if there is an emergency.
Best of all, the program is available at no additional cost to patients whose group has opted-in to the program.
Helps patients get and stay on track
The program can help drive behavioral change in your patients with diabetes. To help them get and say on track, the
program offers the following resources:
● Blood glucose meter: The interactive blood glucose meter has an easy-to-use touchscreen. The meter interprets the
data and provides real-time analytics, insights, and monitoring.
● Expert coaching: Livongo’s coaches are available for 1:1 live coaching and 24/7 remote monitoring. Your patients will
receive proactive outreach from a Livongo coach if their levels are out of control.
● Digital tools: The program offers digital tools across mobile and web platforms. Patients can easily share their health
data with their health care providers and family members.
● Health NudgesTM: Patients receive daily encouragement and referrals on their blood glucose meter, based on their
blood glucose patterns.
● Unlimited strips and lancets: Patients can check their blood sugar as often as needed without worrying about
running out of supplies. The meter will automatically trigger automatic refills when supplies get low.
Next steps
Your eligible patients with diabetes should have received several communications on how to sign-up for the program. Talk
with your patients and encourage them to take advantage of the available tools and support to help them achieve positive
and long-term success.
1
https://www.cdc.gov/diabetes/basics/index.html
February 2021 | Partners in Health UpdateSM 11 www.ibx.com/pncHEALTH & WELLNESS Encouraging care for parents and guardians of your Keystone HMO CHIP patients: Appropriate treatment for children with upper respiratory infection Published February 8, 2021 (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 appropriate treatment for children with upper respiratory infection. Important information on HEDIS measures Measure: The percentage of children 3 months –18 years who were given a diagnosis of upper respiratory infection and were not dispensed an antibiotic prescription. ● Bacterial resistance to antibiotics is a global public health threat. Experts warn we may soon run out of treatment options for serious infections that are becoming antibiotic resistant. ● Prescribing antibiotics inappropriately (e.g., for viral infections) and prescribing broad-spectrum antibiotics when a more targeted therapy is warranted, contributes substantially to the problem of resistance. How you can help Follow these tips to ensure patients get the care they need: ● ensure patients are educated on the proper usage of antibiotics and long-term risks of antibiotic usage ● ensure the correct diagnosis and CPT® codes are used when submitting claims for diagnoses and treatments Stay tuned for more topics regarding care for your Keystone HMO CHIP patients. CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. February 2021 | Partners in Health UpdateSM 12 www.ibx.com/pnc
HEALTH & WELLNESS Encourage pregnant Independence members to enroll in Baby BluePrints® Published February 16, 2021 (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). Among the many benefits to enrolling in this program, are members who are found to have certain health issues or history that may place them at high risk are referred to a Registered Nurse 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. If you have any questions about the program, please call Customer Service at 1-800-ASK-BLUE (1-800-275-2583). February 2021 | Partners in Health UpdateSM 13 www.ibx.com/pnc
MEDICAL Reminder: eviCore Lab Management Program expanded to Medicare Advantage members Published February 1, 2021 (Read online) Independence expanded its utilization management program for genetic/genomic tests, certain molecular analyses, and cytogenetic tests for all Independence Medicare Advantage members as of January 1, 2021. We are working with eviCore healthcare (eviCore), an independent specialty benefit management company, to manage precertification and/or prepayment coverage reviews for these tests. To learn more about the program, please read our announcement article. February 2021 | Partners in Health UpdateSM 14 www.ibx.com/pnc
NAVINET OPEN® Retirement of Clinical Care Reports and Clinical Alerts from NaviNet Open Published February 19, 2021 (Read online) On March 19, 2021, Independence will retire the Clinical Care Reports and Clinical Alerts features found within the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal (NaviNet Open). Reports available on PEAR AR Through the Analytics & Reporting (AR) application within the Provider Engagement, Analytics & Reporting (PEAR) portal, there are several reports available that offer clinical member information. These reports can assist you in proactively scheduling and monitoring care for your patients: ● Admission Analytics report ● Attributed Member Snapshot ● Congestive Heart Failure report ● Diabetes report ● Emergency Room and Urgent Care Visit report ● Gaps in Care report ● Practice-specific Population Health Dashboard ● Prescription Adherence Accessing the reports For organizations with access to PEAR AR, your Population Health Dashboard will display upon login. The Attributed Member Snapshot report is found by selecting Report Center, then Attributed Member Snapshot. All other reports noted above are available by selecting Report Center, then Population Health Reporting. If your organization is not registered for the PEAR portal, you can submit a registration request at www.pearprovider.com. Learn more Review the Quick Start Guide and Companion Guides available in PEAR AR by clicking the information (i) icon at the top right of the page, then selecting Help & Feedback. Frequently asked questions and training resources for PEAR AR are available on our PEAR portal page. If you have questions about using PEAR AR or the reports, please submit a PEAR Portal Inquiry form at www.pearprovider.com/providerinquiry/form. NaviNet® is a registered trademark of NantHealth, an independent company. February 2021 | Partners in Health UpdateSM 15 www.ibx.com/pnc
QUALITY MANAGEMENT TC+ providers for 2021 Published February 15, 2021 (Read online) Congratulations to these physician offices who met the qualifications to be designated as a Total Care+ (TC+) provider for 2021. Identifying TC+ providers Each year, Independence performs an evaluation of its Total Care (TC) providers for the TC+ designation. TC+ recognizes those TC providers who demonstrate higher quality care at a lower cost than the other TC program participants. Independence’s TC+ providers were identified using an established methodology that considered national selection criteria from the Blue Cross Blue Shield Association (BCBSA), an association of independent Blue Cross® and Blue Shield® plans, and a provider’s PPO performance in the Quality Incentive Payment System (QIPS) program during measurement year 2019 (top 50 percent in the Quality Performance Measurement score program and top 50 percent in cost efficiency measures). Learn more You can learn more information about the TC/TC+ program in the current QIPS program manual or on the BCBSA’s Total Care page. For specific provider information, contact Alison Devers. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. February 2021 | Partners in Health UpdateSM 16 www.ibx.com/pnc
IMPORTANT RESOURCES
Contact numbers
Please visit the Contact Information section of the Providers section of our website for a complete list of important
telephone numbers.
Websites
NaviNet® Open Quick Links
The NaviNet web portal (NaviNet Open) is our ● Bulletins
secure, online provider portal that gives you and ● Demographic Maintenance Guide
office staff access to critical administrative and ● Forms
clinical data. To help you navigate the portal ● Frequently Asked Questions
and various transactions, we have created a
● Medical and Claim Payment Policy Portal
central location for a variety of NaviNet Open
resources, including user guides, webinars, and a ● NaviNet Open Login
communications archive. ● Provider Home
● Services that require precertification
NaviNet Open − Commercial
− Medicare Advantage
Utilization Management
Certain utilization review activities are delegated Archives
to different entities. Here you will find detailed ● Partners in Health Update past edition PDFs
information on our utilization management ● Cumulative Index
programs and common resources used among ● ICD-10 Transition
them.
Utilization Management
Email sign up
● Sign up for email from Provider Communications
Opioid Awareness
We have created a repository of tools and
resources to assist you in managing your patients
who are prescribed opioid medications.
Opioid Awareness Resources
Provider Communications
Independence Blue Cross
1901 Market Street
28th Floor
Philadelphia, PA 19103
provider_communications@ibx.com
Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (Independence) created to provide valuable
information to the Independence-participating provider community that provides Covered Services to Independence members. This
publication may include notice of changes or clarifications 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. Refer to the Provider News Center to stay up to date on news and information from Independence.
Models are used for illustrative purposes only. Some illustrations in this publication copyright 2016 www.dreamstime.com. All rights reserved.
This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call
Provider Services for the member’s applicable benefits 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 benefits plans. Members should refer to their
benefits contract for complete details of the terms, limitations, and exclusions of their coverage.
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