Clarification on Regence MedAdvantage vision claims submission (02/9/2012)
We have updated information about the recent change to the routine vision benefits on Regence MedAdvantage, including the relevant International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) codes to help you determine whether a claim is routine or not. Learn more.
Health insurance exchange: Let’s “Keep it in Idaho” (1/31/2012)
You may have seen headlines about Idaho’s public discussion of whether to implement a state health insurance exchange, as allowed under the federal reform law, or let the U.S. Department of Health and Human Services run such an exchange.
Regence BlueShield of Idaho has joined the Keep It In Idaho coalition because we believe strongly that the right thing for Idaho is that our Legislature pass a bill to create a State Exchange. This will keep the health insurance market in local hands and out of federal control.
It’s very important that our legislators know there is broad support across Idaho for a State Exchange. Please visit the Keep It In Idaho website for more information about why this is vital to Idaho businesses and residents.
When you visit the site, please take a few moments to use the tools on the site to contact your legislators directly to alert them to your position on a State Exchange. And please share this site with your colleagues so that they can also be engaged in this process.
Provider Center—Your first contact for member eligibility, benefits and claims information (1/23/2012)
Beginning March 1, we will require dentists, physicians, other health care professionals and facilities to access the Provider Center to verify information regarding eligibility, benefits and simple claims status.
Most providers have found it’s faster to obtain this information online rather than waiting on hold for a Customer Service specialist. Using this free, online tool can save you up to five minutes per inquiry, and the information is available for most members Monday through Saturday 24 hours a day and on Sunday (except from 8 a.m. to noon for maintenance).
Customer Service will continue to be available to answer complex inquiries or questions you have about the information you are unable to view online.
Note:
Medical multi-year accumulators now available
Note: We are experiencing technical difficulties with this functionality and are working to install a fix as quickly as possible. Please check the Provider Center for the current status.
The Provider Center now displays medical multi-year accumulators that are applicable to each member’s product. This information is not currently available for Federal Employee Program (FEP) or BlueCard members.
The following information is displayed:
- Benefit maximums
- How much of the benefit the member has remaining
- How much of the benefit the member has used to date
To see this information for your patients, simply navigate to the Medical Benefits, Multi-year Accumulators tab. From the drop-down menu, select the service. Then select ’Submit’. The multi-year accumulator information will be displayed below.
View our Eligibility and Benefit Guide (PDF) for step-by-step instructions on verifying member information on the Provider Center.
Current Procedural Terminology (CPT®) code updates for 2012 (01/09/2012)
Claims pended for new codes
The Centers for Medicare & Medicaid Services (CMS) has added 250 new CPT codes effective January 1, and is in the process of assigning Relative Value Units (RVU) to them. As a result, we have been directed to temporarily pend claims that include these CPT codes until RVU’s are assigned and our systems are updated. We expect to begin processing these claims by mid-January.
Note: Claims with a pended status may not be available in the Provider Center.
2012 genetic testing codes
Effective January 1, the American Medical Association (AMA) added 101 new CPT molecular pathology (genetic testing) codes: CPT 81200-81408. While these codes are more specific than the existing codes, CMS has given these new codes a Status Indicator of “B” (Bundled Code) and has not assigned any pricing.
Instead, CMS will reimburse the existing genetic testing codes, according to their current policies. CMS has advised providers to bill both the existing codes and the new codes on the same claim. This will enable CMS to accumulate information to help establish pricing for these codes in 2013.
Regence has adopted the same approach regarding reimbursement of these new codes. We will deny new genetic testing codes as invalid or bundled and they will not be reimbursed. However, we will continue to reimburse the existing codes (e.g., CPT 83890-83914, 88363-88366, HCPCS G9143, S3800, S3818-S3890) in accordance with our Medical Policy.
We encourage providers to bill using the same process requested by CMS. This applies to all products, including group and Individual, Federal Employee Program, Uniform Medical Plan and Regence MedAdvantage.
View our Invalid Services (#107) reimbursement policy.
New preventive services benefits added for Medicare (01/05/2012)
The Centers for Medicare & Medicaid Services (CMS) has recently issued several national coverage determinations (NCDs) that affect members with Medicare coverage:
The benefits added by these NCDs are available to Regence MedAdvantage members under their preventive care benefits with no copayment, coinsurance or deductible when services are rendered by primary care providers.
Healthcare Management Administrators (HMA) members to begin using our provider networks in January (12/30/2011)
Regence BlueShield of Idaho is pleased to announce that beginning January 1, 2012 additional employer group members will be utilizing our Participating and Preferred networks.
These members are covered by self-funded health plans administered by Healthcare Management Administrators (HMA), a wholly owned subsidiary of Regence BlueShield. HMA provides third-party administrative services to over 100 self-funded employer groups primarily located in Oregon and Washington.
These members may live in or travel to our service area and seek services from you. The HMA Preferred product uses the Regence BlueShield of Idaho Participating and Preferred Provider Organization (PPO) networks as the provider network for their HMA Preferred product. Reimbursement is the same as Regence BlueShield of Idaho Participating and/or Preferred networks.
Learn more about:
- Identifying members
- Submitting claims to HMA
- Receiving vouchers and payment
- Obtaining pre-authorization, eligibility and claims status
Annual Wellness Visit Program updates (12/30/2011)
We are making a few updates to the Annual Wellness Visit Program for 2012.
If you have received a request for medical records for the Annual Wellness Visit Program, please submit them promptly to receive your payment. Payments for this program are sent quarterly. Effective February 1, physicians and other health care professionals who have enrolled in the Annual Wellness Visit Program but have not submitted requested charts will be removed from the program. Impacted providers have been notified via email.
To be eligible for Annual Wellness Visit Program payment:
- Beginning April 1, requested charts must be received within 60 days
- Documentation for wellness visits must substantiate that the provider addressed all required visit components. Providers should identify chronic diseases, injury risks, modifiable risk factors and urgent health needs of the patient as well. Learn more about the eligible codes and visit components.
The Annual Wellness Visit Program encourages Regence MedAdvantage members to schedule an annual wellness visit with their physician or other health care professional. Find out how to participate.
Generic Lipitor® now available (12/21/11)
The Food and Drug Administration (FDA) has approved the first generic version of the cholesterol-lowering drug atorvastatin (Lipitor®).
What is the difference between atorvastatin and the other generic statin medications?
- Atorvastatin is the first generic high-potency statin available. It may be helpful for people who need to lower their LDL-C by more than 40%. Atorvastatin is the most expensive generic option and requires prior authorization.
- There are several well known generic low-potency statins available. They are helpful for people who need to lower their LDL-C by up to 40%. They offer a good value and are available without prior authorization. They include:
- simvastatin (Zocor®)
- pravastatin (Pravachol®)
- lovastatin (Mevacor®)
Do all high-potency statins require prior authorization?
In support of the best value generic statins, RegenceRx will continue to require prior authorization of new prescriptions for high-potency statins, including generic atorvastatin, Crestor®, Vytorin®, and Lipitor®.
How will generic atorvastatin be covered for group and Individual product members?
When prior authorization of generic atorvastatin is approved, it will be covered at the generic copayment.
How will generic atorvastatin be covered for Medicare Part D members?
Members with Medicare Part D coverage will be able to receive generic atorvastatin without prior authorization at the non-preferred generic copayment tier.
What are the specific details for prior authorization of high potency statins?
- Generic atorvastatin and Crestor may be covered when a generic low-potency statin is not effective in obtaining the LDL-C lowering needed or when the member needs LDL-C lowering more than 40%.
- Brand name Lipitor and Vytorin may be covered when treatment with generic atorvastatin or Crestor is not effective.
- Members currently taking brand name Lipitor will be able to switch to generic atorvastatin without prior authorization.
What other resources are available?
To learn more about statin medications, view our ConsumerRx medication summary.
Generic atorvastatin will be included in our Half Tablet Program.
View our statin medication policy.
View our pharmacy prior authorization form.
If you have questions or need additional information, please call Pharmacy Customer Service at 1(800) 643-5918.
Prior authorization to be required for brand name antipsychotic medications beginning in January (12/21/11)
Effective January 1, 2012, prior authorization will be required for coverage of new prescriptions for the following brand-name atypical antipsychotics:
- Abilify®
- Fanapt®
- Geodon®
- Invega®
- Latuda®
- Saphris®
These medications may be covered when generic antipsychotics are ineffective, not tolerated or contraindicated.
Recently, several commonly-prescribed antipsychotics have become available generically, such as olanzapine (Zyprexa) and risperidone (Risperdal). We encourage the use of these generic options, as they remain the best values for most of our members.
What is the coverage policy?
Regence:
View our specific coverage policies for atypical antipsychotics:
How can I obtain prior authorization for my patient?
Complete our prior authorization request form.
What if my patients are already established on therapy?
Prior authorization will be needed only for new prescriptions. Members currently using a brand-name antipsychotic will not need prior authorization.
If you have any questions, please contact Pharmacy Customer Service at (800) 643-5918.
Idaho Power Pre-authorization List now in effect (12/08/11)
Idaho Power, group #100006786, has a specific Idaho Power Pre-authorization List that is in effect now. Use this specific list for all Idaho Power members instead of using the Group and Individual Medical Pre-authorization List.
Note: Beginning March 1, 2012, specific inpatient surgeries identified on the list by CPT codes will require pre-authorization.
Survey for Regence MedAdvantage providers (12/08/11)
Regence MedAdvantage network providers recently received a letter requesting they participate in a short network availability survey.
The letter included a personalized password for your clinic. Please use this password to complete the survey online by December 31.
Once you open the survey and enter your password, you will see a list of physicians or other health care professionals under your tax identification number who currently participate in the Regence MedAdvantage network. For each provider, please indicate if he or she:
- Was accepting new Regence MedAdvantage patients on January 1, 2011
- Will be accepting new Regence MedAdvantage patients on December 31, 2011
If you have difficulty accessing the survey or need your password, please contact your provider consultant.
For past announcements, please view the What's New archive.
|
