PROVIDER SEMINAR

1. PROVIDER SEMINAR BlueCross of Northeastern Pennsylvania October 5, 2011

2. WELCOME Jeanne Wisnewski Director, Provider Relations

3. HEALTH PLAN UPDATES Odette Ashby Provider Relations Consultant

4. Updates BlueCross of Northeastern Pennsylvania

5. BCNEPA Updates Radiology Management Program • Effective with date of service November 1, 2011, prior authorization through NIA is required for select non-emergent, advanced outpatient radiology services • All professional offices or free-standing radiology providers who perform these select studies must be privileged by NIA for BCNEPA • Excludes services performed in emergency room, observation, inpatient and qualified contracted urgent care centers

6. BCNEPA Updates Radiology Management Program • Applies to FPLIC and FPH Group Products and CHIP • Does NOT apply to self-funded groups or individual products • In Luzerne County, the existing capitated radiology program still applies for FPH members

7. BCNEPA Updates Radiology Management Program • Ordering physician is responsible for OBTAINING authorization • Luzerne County members whose PCP is part of the Cap Rad program must still be directed to the capitated provider for CT, CTA, CCTA • Rendering providers should VERIFY that authorization has been obtained

8. BCNEPA Updates Radiology Management Program • Applies to the following studies: • Nuclear Cardiology • Stress Echo Cardiology Procedures • CT/CTA/CCTA* • MRI/MRA* • PET Scans* * Continue to call BCNEPA to request authorization for select services for individual members and self-funded accounts

9. BCNEPA Updates Radiology Management Program-Privileging • Establishes consistent standards for all diagnostic imaging services • Establishes minimum participation guidelines • Facility accreditation • Equipment capabilities • Physician and technologist education, training and certification • Procedures for handling emergencies • Radiation safety guidelines

10. BCNEPA Updates Radiology Management Program Training will be offered via webinar on the following dates: • October 18, 2011 • October 19, 2011 • October 20, 2011 • October 25, 2011 • October 27, 2011 There will be 2 hour-long webinars each day – 8:00 am and 12:00 pm To register, contact NIA at 1-800-327-0641 at least one week prior to the session you wish to attend

11. BCNEPA Updates Radiology Management Program • Complete information is available at the BCNEPA Provider Center • Select “Resources and Tools” • Select “BCNEPA NIA Radiology Management Program” • Quick Reference Guide for Facilities • Quick Reference Guide for Ordering Physicians • FAQ’s

12. BCNEPA Updates New Products • Offered August 1, 2011 • AffordaBlue • BlueCare QHD EPO • Developed to: • Provide new products with reduced premiums • Significantly reduce out of network utilization to keep healthcare $$ and services in our service area • Position our portfolio for healthcare reform

13. BCNEPA Updates AffordaBlue • Alpha Prefix - QFZ • 3 Levels (Tiers) of Benefits • Custom PPO Network (FPLIC PPO network plus Lehigh Valley, Berwick, Bloomsburg providers and Bon Secours Hospital • Hospitals that charge a facility fee for an outpatient visit with a hospital based physician and whose costs exceed specific thresholds • BlueCard PPO Network

14. BCNEPA Updates AffordaBlue • Member Cost Sharing • $ Tier 1 Provider = lowest cost • $$ Tier 2 Provider = median out-of-pocket cost • $$$ Tier 3 Provider = highest out-of-pocket cost • Separate deductible and co-insurance applies to each tier • Services rendered by non-network providers are covered for emergency services only

15. BCNEPA Updates AffordaBlue Key Benefit Features • No PCP selection is required • No Referrals • Deductible/co-insurance plan design – no co-pays • Prescription coverage is offered as a rider • Multi-tiered • Generic-based

16. BCNEPA Updates AffordaBlue Key Benefit Features • Benefits are applied based on the provider’s network participation • Preventive services are covered without cost-sharing at the Tier 1 and Tier 2 providers • Member will be liable for costs associated with services provided by Tier 2, Tier 3, and non-participating providers even if the service is not available from a Tier 1 provider. • No coverage is provided for non-emergency services rendered by a non-network provider

17. BCNEPA Updates BlueCare QHDEPO • Alpha Prefix – QFI • Two Tiers of Benefits • Current FPLIC EPO Network (FPLIC PPO Network plus Lehigh Valley, Berwick, Bloomsburg providers and Bon Secours Hospital) • BlueCard PPO Network

18. BCNEPA Updates BlueCare QHDEPO • Member Cost Sharing • $ Tier 1 Provider = lowest cost • $$ Tier 2 Provider = highest out-of-pocket cost • Separate deductible and co-insurance applies to each tier • Deductible and out-of-pocket maximums must differ in each tier • Services rendered by non-network providers are covered for emergency services only

19. BCNEPA Updates BlueCare QHDEPO • No PCP selection is required • No Referrals • Deductible/co-insurance plan design – (no co-pays except for prescriptions) • Integrated Prescription Drug Benefit

20. BCNEPA Updates BlueCare QHDEPO • Benefits are applied based on the provider’s network participation • Preventive services are covered without cost-sharing at Tier 1 providers • Member will be liable for costs associated with services provided by Tier 2 and non-participating providers even if the service is not available from a Tier 1 provider. • No coverage is provided for non-emergency services rendered by a non-network provider

21. BCNEPA Updates Security 65 Processing After Medicare Exhausts • Claim must be submitted on an original red and white UB-04 claim form • Report the applicable occurrence codes and dates in locator #31 • A3 Benefits Exhausted, Payer A • B3 Benefits Exhausted, Payer B • 24 Date Insurance Denied See October, 2011 Provider Bulletin

22. BCNEPA Updates • Medicare Part B claim must be billed to Medicare prior to submitting the Medicare exhaust claim to BCNEPA • Include the Medicare EOMB with the paper claim • Written documentation of the Medicare allowed amounts must be attached to the form (i.e. a screen print from the Medicare system showing the amount they would allow) • Submit claims to: BCNEPA Claims P.O. Box 890179 Camp Hill, PA 17089-0179

23. BCNEPA Updates Home Health Precertification Requests • The Home Health Initial Precertification Worksheet has been updated and now requires an explanation of member’s homebound status. The worksheet is located on our Provider Center • Precert must be requested prior to assessing the patient or rendering services • Retro requests must be submitted within 5 days of the start of services

24. BCNEPA Updates Utilization Management Department • Complete ALL fields on request forms • Check the monthly Provider Bulletin for updates to processes throughout 2011 • Precertification requests may now be e-mailed directly to our Utilization Management Department through a secure, confidential e-mail address: umreviews@bcnepa.com • Current Focus PAC listings for FPLIC, EPO and BC (Non-FPLIC) lines of business are available on our Provider Center

25. BCNEPA Updates Provider Claim Issues For providers without NaviNet access, ALL claim inquiries, reconsiderations and research requests must be initiated through the appropriate Blue Cross of Northeastern Pennsylvania (BCNEPA) address or by contacting the appropriate customer service department * Claim issues directed to any other area may result in a delay in responding to your request

26. BCNEPA Updates • All written Blue Cross/FPLIC claim issue requests must be sent to: Claims PO Box 890179 Camp Hill, PA 17089-0179 • Continue to use the Claims Research Request Form and send FPH claim issue requests to: BlueCare HMO 19 N. Main St. Wilkes-Barre, PA 18711

27. BCNEPA Updates Provider Bulletins • Be sure to review/print the monthly provider bulletin from the BCNEPA Provider Center; this can be accessed via NaviNet or www.bcnepa.com • For those providers with NaviNet access, there is a monthly Blue Alert message indicating the current bulletin is now available

28. BCNEPA Updates Provider Center Our Re-designed BCNEPA Provider Center is your resource for important information and updates. Please check the Provider Center site via NaviNet or www.bcnepa.com prior to contacting us for bulletins, forms, policies, manuals, etc.

29. BCNEPA Updates

30. BCNEPA Updates

31. BCNEPA Updates

32. BCNEPA Updates

33. BCNEPA Updates

34. BCNEPA Updates

35. Highmark Blue Shield Updates

36. Highmark Blue Shield Updates Authorization Requirement Update • 15 new codes added to authorization list effective October 3, 2011 • Applies to Direct Blue (group only) and Freedom Blue PPO • Highmark-sponsored NaviNet should be used to request authorization for services See Special Bulletin dated June 23, 2011 for a complete list of codes

37. Highmark Blue Shield Updates Reimbursement Changes Approved • Increases to specific services effective 7/1/11 • Minimal number of codes decreased effective 9/26/11 • Payment differential updated for E&M services performed in a facility vs. non-facility effective 9/26/11.

38. Highmark Blue Shield Updates Reimbursement Changes • Fee information is available via Highmark’s NaviNet • From the Plan Central Menu, select Allowance, then select Allowance Inquiry to view pricing for specific procedure codes by plan or product type OR • Use “Provider Center/Medical and Claims Payment Guidelines/ Fee Modification” to view the complete list of adjustments

39. Highmark Blue Shield Updates Technical Component Multiple Procedure Payment Reductions • Two or more services on contiguous body parts, same patient, same day • Effective 9/26/11, the highest priced procedure is paid in full • Payment reduction of 50% will be applied to the technical component allowance of each additional procedure • See PRN dated June, 2011 for list of affected procedure codes

40. Highmark Blue Shield Updates Elimination of Paper Initiative • Phase I: Effective 10/01/10, all new assignment accounts and new practitioners are automatically enrolled in Highmark’s NaviNet, paperless EOB’s, and EFT • Phase II: By 6/30/11, all current NaviNet-enabled practitioners will be required to enroll in paperless EOB’s and EFT • Phase III: By 12/31/11, all practitioners doing business with Highmark will be required to enroll in NaviNet, paperless EOB’s and EFT IMPORTANT NOTE: Change in banking information or authorized person requires completion of a new form.

41. Highmark Blue Shield Updates Reminder: Paper versions of the Policy Review and News (PRN) and Behind the Shield publications have been eliminated. Each issue of the newsletters is posted online in the Provider Resource Center • PRN contains medical policies • Behind the Shield is bimonthly newsletter • Special Bulletins are a companion to the above regularly scheduled periodicals and will still be issued • Consider enrolling in E-subscribe

42. Highmark Blue Shield Updates Credentialing & Recredentialing • Effective October 17, 2011, CAQH will be the sole credentialing/recredentialing system for Highmark • Paper will be accepted until 10/16/11 • If no internet access, contact CAQH Help Desk at 1-888-599-1771 for other options

43. Highmark Blue Shield Updates Prescription Drug Formulary • Updated quarterly via Special eBulletin • eBulletins are available on-line at: • Highmark’s Provider Resource Center • NaviNet Plan Central • Walgreen’s Specialty Pharmacy (formerly MedMark) exclusive provider for self-administered injectables or oral biotechnology drugs

44. Highmark Blue Shield Updates

45. Medicare Advantage Updates • Global Surgery Period • Highmark adopted CMS global surgery values of 0 (zero) and 90 (ninety) days in 1999 • 10-day post-op was not recognized due to system limitations and 0 (zero) was used • Effective 7/22/11, Highmark recognizes a 10-day post-op period for Freedom Blue Members only

46. Medicare Advantage Updates Medicare Advantage PPO Network Sharing • A reminder that all “Blue” Medicare Advantage PPO Plans are participating in reciprocal network sharing • The “MA” in the suitcase on the member’s card will help you identify these members • Providers should always check the out-of-area member’s benefits via the Blue Exchange transaction on NaviNet, or by calling the BlueCard eligibility line – 1-800-676-BLUE

47. Medicare Advantage Updates Medicare Advantage PPO Claim Submission • Submit allMedicare Advantage claims to Highmark. • Electronic claims are to be submitted directly to Highmark via trading partner agreement (TPA) with 378 plan code / NAIC # 54771C • To establish a TPA, visit Highmark’s Provider Resource Center, Electronic Data Interchange (EDI) Services and complete the request on-line • Paper Claims: FreedomBlue PPO Claims PO Box 890062 Camp Hill, PA 17089-0062

48. Medicare Advantage Updates National Correct Coding Initiative (NCCI) • Developed by CMS to prevent improper payment when incorrect code combinations are reported • NCCI edits will be applied to all Freedom Blue claims received on or after 10/15/11

49. Medicare Advantage Updates • CMS rates Medicare Advantage plans annually • Results are posted using a “star” score similar to hotels, cars, and other services • Allows Medicare beneficiaries to compare plan options when choosing a Medicare Advantage plan • Highmark Freedom Blue received a four star rating!

50. Medicare Advantage Updates Annual Wellness Visit Covered • Extends the Initial Preventive Personal Examination (IPPE), also known as the “Welcome to Medicare Visit” • AWV is NOT covered during the first 12 months of beneficiary’s initial enrollment in Medicare • Medicare has provided a physician quick reference for the AWV