November 2018

CMO Perspective

Maternal Health Inequity and Rising Mortality Rates: Finding Solutions to Help Reduce the Impact

Our Vice President and Chief Medical Officer, Dr. Derek J. Robinson, M.D., MBA, FACEP, CHCQM, begins this month’s article as follows: While pregnancy should be a condition of joy, not dread, statistics are showing that there may indeed be a cause for alarm. Maternal mortality and morbidity rates in the U.S. are on the rise – in fact, maternal death rates in this country are higher than those in any other developed nation.   

Wellness and Member Education

Talk to Your Patients About Getting a Flu Vaccine

Are your patients protected? With more than 900,000 people hospitalized and more than 80,000 deaths from the flu last season in the U.S., the Centers for Disease Control and Prevention (CDC) emphasizes the seriousness and severity of the flu and strongly encourages a flu vaccine for everyone 6 months of age and older, who do not have contraindications.

Antibiotic Awareness Week is Nov. 12-18, 2018

Studies show that, in U.S. doctors’ offices and emergency departments, at least 47 million antibiotic prescriptions each year are unnecessary, which makes improving antibiotic prescribing and use a national priority. The goal of Antibiotic Awareness Week is to call attention to the problem of antibiotic resistance and the importance of appropriate antibiotic prescribing and use.

Electronic Options

The Blue Review is your newsletter. Tell us what you think!

With the Blue Review, Blue Cross and Blue Shield of Illinois (BCBSIL) strives to provide important information each month to our growing readership of independently contracted providers. We need your feedback to assess the effectiveness of this newsletter in delivering timely content that’s relevant to you and your staff. Please take a few minutes to complete our brief survey. Click here to take the survey now.

Check Eligibility and Benefits: Don’t skip this important first step!

Is your patient’s membership with BCBSIL still active? Are you or your practice/medical group in- or out-of-network for a specific patient? Is benefit preauthorization required for a particular member/service? Don’t take chances. Check eligibility and benefits for each patient, prior to every scheduled appointment.

Government Programs: Interpreting the ‘PLB’ Segment on the 835 Electronic Remittance Advice (ERA)

Reversals and corrections may occur when claim adjudication results have been modified from a previous claim report. The method for revision is to reverse the entire claim and resend with modified data. Provider level adjustments are reported in the Provider Level Balance (PLB) segment within the 835 ERA from BCBSIL.

Focus on Behavioral Health

Behavioral Health Providers: Electronic Options, Training and Related Resources

We’re pleased to offer and support electronic options to help you streamline administrative functions in your office. Were you able to join us for our recent Electronic Options Training for Behavioral Health Providers webinar? Participants gained an overview of tools on the Availity^® Provider Portal and other time-saving paperless options.

Provider Education

Provider Learning Opportunities

BCBSIL provides complimentary educational workshops and webinars with an emphasis on electronic transactions, provider tools and helpful online resources. A list of upcoming training sessions is included in this month’s issue.

‘Annual Visit’ Campaign Continues, Proper Coding is Crucial

In August 2018, we launched a preventive care awareness campaign to remind our members of the importance of scheduling annual visits for routine physical exams. This campaign is still in progress and, this month, we are focused on encouraging members with asthma to see their health care providers.

Reminder: Respond to Medical Record Retrieval Requests from Inovalon

Inovalon was selected to retrieve medical records for out-of-area Blue members starting Jan. 1, 2018, to support Healthcare Effectiveness Data and Information Set (HEDIS^®), risk adjustment and government required programs related to the Affordable Care Act (ACA).  

Quality Improvement and Reporting

Ideas to Increase Primary Care Physician (PCP) and Hospitalist Communication for HMO Members

A hospitalist is a patient’s doctor during an inpatient hospital admission and therefore, communication between hospitalists and PCPs is key to help your patients and our members receive quality medical care. Hospitalists need to know a patient’s detailed medical history and PCPs need to have detailed hospitalization documentation regarding patient medical care.

Improving Coordination of Care for Our Members with Diabetes

Based on results from an August 2017 HMO PCP survey, which was sent to 77 participating Medical Groups/Independent Physician Associations (IPAs), it has come to our attention that some members’ eye exam results from specialists are not being reported back to the referring providers.

HEDIS Measure for Hospital Readmissions

As part of a quality initiative to help assess effectiveness of care and services to our members, BCBSIL uses specifications published by the National Committee for Quality Assurance (NCQA) for HEDIS. Reducing readmission rates is critical to promoting improved outcomes.

Claims and Coding

BlueCard^® Alert: Itemized Bill May Be Required for Some Inpatient Claims, Effective Jan. 1, 2019

Beginning Jan. 1, 2019, BCBSIL will request an itemized bill for any institutional inpatient BlueCard (out-of-area) member claim billed at $250,000 or more. 

Documentation Guidelines for Urine Drug Testing

BCBSIL processes and reimburses claims for urine drug testing in accordance with BCBSIL Medical Policy MED207.154, Drug Testing in Pain Management and Substance Use Disorder Monitoring. BCBSIL only reimburses claims for urine drug testing that are medically necessary under that medical policy.

Pharmacy Program

Specialty Pharmacy Infusion Site of Care: Benefit Preauthorization Requirements

Effective Jan. 1, 2019, benefit preauthorization will be required for select infusion drugs for the BCBSIL members in the networks listed in this article. These select infusion drugs are administered by health care professionals and typically covered under the member’s medical benefit.

Changes to Home-based Sleep Study Benefit Prior Approval Requirements for Some FEP Members

In January 2017, benefit prior approval requirements for sleep studies performed outside the home were implemented for some Federal Employee Program^® (FEP) members. Claims and appeals revealed that when outpatient facilities submitted claims for the equipment used for home-based sleep studies, our claims system presumed the services took place outside the home.

Notification and Disclosure

New Fax Number on Fee Schedule Request Forms

Effective immediately, the fax number on the Fee Schedule Request - Blue Choice PPO^SM and Fee Schedule Request - PPO forms has been changed to 312-729-2457.

Information about BCBSIL’s Quality Improvement Program

The Quality Improvement (QI) Program at BCBSIL addresses both care and services provided to members. A QI Program summary is available upon request if you would like more information about BCBSIL’s QI Program.

Procedure Code and Fee Schedule Updates

As part of our commitment to informing our independently contracted providers of certain developments, BCBSIL has designated a specific section in the Blue Review to notify you of any significant changes to the physician fee schedules.

ClaimsXten^TM Quarterly Updates

New and revised Current Procedural Terminology (CPT^®) and Healthcare Common Procedure Coding System (HCPCS) codes are periodically added to, or deleted from, the ClaimsXten code auditing tool software by the software vendor.

Medical Policy Updates

Approved, new, or revised BCBSIL Medical Policies and their effective dates are usually posted on our Provider website the first day of each month. These policies may impact your reimbursement and your patients’ benefits.

bcbsil.com

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association

300 E. Randolph Street, Chicago, IL 60601

© Copyright 2018. Health Care Service Corporation. All Rights Reserved.

Legal and Privacy  |  Unsubscribe