11

N e w s f r o m B l u e C r o s s a n d B l u e S h i e l d o f N o r t h C a r o l i n a

Volume No. 12 Issue No. 3Winter 2007 – 2008

Inside:Inter-Plan Programs:Updates and Reminders ...........4

Collecting office visit copayments from members ..................... 10

Blue Options 1-2-3 ............... 13

New Generics ...................... 17

Thomas/Love Settlement ..... 20

For articles specific to your area of interest, look for the appropriate icon.

Physicians/Specialists

Facilities/Hospitals

Ancillary

Pharmacy

Introducing Blue Medicare Blue Cross and Blue Shield of North Carolina (BCBSNC) is the parent company of PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS), a health care company based in Winston-Salem. If you’re not already familiar with PARTNERS, this Medicare Advantage organization provides HMO and PPO plans for approximately 43,000 people within the state.

PARTNERS received a license to identify itself as an affiliate of the Blue Cross and Blue Shield Association. This affiliate designation allows PARTNERS HMO and PPO products to be branded with the Blue Cross and Blue Shield symbols, replacing the Medicare Choice HMO and Medicare Options PPO products with the new Blue Medicare HMOSM and Blue Medicare PPOSM.

Effective January 1, 2008, Blue Medicare HMO and Blue Medicare PPO members have new identification cards featuring a “blue” look. These new cards display the Blue Cross and Blue Shield symbols and are for members who have health care coverage with PARTNERS. This means that when arranging health care and/or submitting claims for services provided to Blue Medicare HMO and Blue Medicare PPO members, PARTNERS in Winston-Salem remains the main contact. We’ve worked to make the member cards distinctive, so you can easily determine whether a claim or question should be directed to PARTNERS or BCBSNC. Please see the sample card image below:

P

F

A

Rx

(continued on page 2)

P F A Rx

Beginning January 1, 2008, both Blue Medicare HMO and Blue Medicare PPO will be available in 37 counties in North Carolina, including areas within the Triangle, Triad and Charlotte regions. Blue Medicare HMO and Blue Medicare PPO are replacement products for PARTNERS Medicare Choice HMO and Medicare Options PPO.

Member Name<John Doe>Member ID<YPWJ12345678-01>

Group No <123456>Effective Date <01/01/2007>Rx BIN <123456>Rx PCN <123456>Rx Group <ABCDEFG>Issuer <123456>

<Office Visit> <$15/30><ER/Urgent Care> <$50/30><IP Hospital> <$350><MHCD Outpatient> <$30><DME> <20%>

Contract # H3449 005

Plan is offered byPARTNERS National Health Plans

of North Carolina, Inc. a BCBSNC Company

Enhanced

Alpha pre� x – pre� xes that are unique to

Blue Medicare members

Pre� xes for Blue Medicare

plans always end in the

letter J

Blue Medicare plan type and PPO or HMO status

Highlighted area lets you know that the Blue Medicare member’s health plan is offered by PARTNERS National Health Plans of North Carolina, Inc.

Blue Medicare ID cards are readily recognizable, but remember that the cards include both BCBSNC and PARTNERS information. It’s important that you review the cards carefully and note the Blue Medicare alpha prefixes and PARTNERS health plan information. Don’t be confused by the Blue Cross and Blue Shield Association symbols and BCBSNC written text. Always remember that Blue Medicare is offered by PARTNERS National Health Plans of North Carolina, Inc., a BCBSNC company. Because of this, the following basic rules apply:

The back of a Blue Medicare member’s identification card provides further information about arranging health care services and claim submission with PARTNERS. The cards also display the PARTNERS claims mailing address and telephone service lines.

*Providers should be aware that neither an individual’s possession of a Blue Medicare member identification card nor information contained in this mailing represents a guarantee of member’s benefits, eligibility or coverage in a Blue Medicare plan. A member’s actual Blue Medicare eligibility and benefits should always be verified in advance of providing services.

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Introducing Blue Medicare (continued from page 1) P F A Rx

With a quick glance at the front of the card, you can see in the upper right hand corner that the member has a Blue Medicare plan and the type of plan the member has chosen is also specified.* Just below that, you’ll see an area shaded in blue that highlights the plan as offered by PARTNERS, which is identified as a BCBSNC company. On the left hand side of the card, you’ll note that the Blue Medicare member’s ID includes an alpha prefix. Blue Medicare alpha prefixes are unique to Blue Medicare members and always end with the letter J.

It’s easy to distinguish between Blue Medicare HMO members and Blue Medicare PPO members. Just look at the alpha prefix at the beginning of the member’s Blue Medicare identification code. The alpha prefix YPWJ lets you know that the member’s coverage type is an HMO plan. If you see YPFJ, you’ll know the coverage type is PPO. Additionally, Reynolds American Inc. retirees have a customized alpha prefix of YPJJ, making them easy to identify as having an individualized HMO plan. Any time that you are presented with one of these alpha prefixes, you’ll know that the claims and health care services are administered by PARTNERS.

YPWJ – Blue Medicare HMOSM YPFJ – Blue Medicare PPOSM YPJJ – Blue Medicare HMOSM for Reynolds American Inc. retirees

The following alpha prefixes identify Blue Medicare plan types:

www.bcbsnc.com/member/medicare

Customer Service: 1-888-310-4110TDD/TTY: 1-888-451-9957Provider Line: 1-888-296-9790Mental Health/SA 1-800-266-6167

Medicare charge limitations may apply North Carolina Hospitals or physicians file claims to:PO BOX 17509 Winston-Salem, NC 27116Hospitals or physicians outside of North Carolina, file your claims to your local BlueCross and/or BlueShield PlanMembers: See 2008 Member Information Booklet for covered services

Members send Correspondence to: Blue Medicare HMOPO BOX 17509Winston-Salem, NC 27116

BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association.

PARTNERS claims mailing

address

PARTNERS provider service line and Blue Medicare contact information

Important information about Blue Medicare: You need to know!

P F A Rx

Member Name<John Doe>Member ID<YPWJ12345678-01>

Group No <123456>Effective Date <01/01/2007>Rx BIN <123456>Rx PCN <123456>Rx Group <ABCDEFG>Issuer <123456>

<Office Visit> <$15/30><ER/Urgent Care> <$50/30><IP Hospital> <$350><MHCD Outpatient> <$30><DME> <20%>

Contract # H3449 005

Plan is offered byPARTNERS National Health Plans

of North Carolina, Inc. a BCBSNC Company

Enhanced

BCBS Association

symbols and BCBSNC text

A Blue Medicare

alpha pre� x:

t YPWJ

t YPFJ

t YPJJ

Blue Medicare

PARTNERS

(continued on page 3)

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Important information about Blue Medicare: You need to know! (continued from page 2) P F A Rx

t Only providers directly contracted with PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS) are considered as in-network for Blue Medicare HMO and Blue Medicare PPO. Participation with BCBSNC does not extend to Blue Medicare HMO and/or Blue Medicare PPO.

t BCBSNC participating providers that are not contracted with PARTNERS can provide services to Blue Medicare PPO members as part of the member’s PPO out-of-network benefits.

t Blue Medicare HMO members have no out-of-network benefits (except for emergency care).

t Blue Medicare plans have unique alpha prefixes:

YPWJ – Blue Medicare HMO (no out-of-network benefits – emergency care only)

YPFJ – Blue Medicare PPO (out-of-network benefits available)

YPJJ – Blue Medicare HMO (most services require referrals from Winston-Salem Health Care)

t Providers participating with both BCBSNC and PARTNERS cannot use Blue e electronic transactions for Blue Medicare HMO and PPO claims and/or member information.

t Claims submitted to BCBSNC for Blue Medicare HMO and PPO members in error will be returned to the submitting provider or electronic clearinghouse. This includes both paper and electronic claims.

t BCBSNC health coaching services, claims processing, post adjudication review and medical policy do not apply to Blue Medicare HMO and Blue Medicare PPO. These services and functions are administered by PARTNERS at its Winston-Salem location.

Interested in seeing Blue Medicare members?

If your health care location participates with BCBSNC but not with PARTNERS, please contact your local network management field office to find out how your health care business can become an in-network provider for Blue Medicare HMO and/or PPO members.

New product logos make Blue Medicare HMO and Blue Medicare PPO plans more recognizable as an affiliate of the Blue Cross and Blue Shield Association. However, the name Blue Medicare also applies to BCBSNC prescription and supplemental plans as shown below.

BCBSNC products

O� ered by PARTNERS National Health Plans of North Carolina, Inc.

O� ered by PARTNERS National Health Plans of North Carolina, Inc.

PARTNERS products

Blue Medicare product logos P F A Rx

(continued on page 4)

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As you can see, the logos for the BCBSNC products and PARTNERS products appear very similar. However, you can easily distinguish between BCBSNC products and PARTNERS products with the following information:

1) Logos for Blue Medicare HMO and Blue Medicare PPO1 both include text in their design that reads: “Offered by PARTNERS National Health Plans of North Carolina, Inc.”

2) Logos for Blue Medicare HMO and Blue Medicare PPO include either an HMO or PPO designation in their design.

Reminder: When filing claims for Blue Medicare, always send claims for Blue Medicare HMO and Blue Medicare PPO services to PARTNERS National Health Plans of North Carolina, Inc. Claims for Blue Medicare RxSM and Blue Medicare SupplementSM should be filed with BCBSNC.2

1 Blue Medicare HMO and Blue Medicare PPO are replacement names for PARTNERS Medicare Choice HMO and Medicare Options PPO health care benefit plans.

2 Blue Medicare Rx is a prescription drug coverage plan for Medicare beneficiaries, which is sponsored by Medicare and provided through BCBSNC. Blue Medicare Supplement plans are supplemental health plans offered by BCBSNC for Medicare beneficiaries enrolled in Medicare Part B. To learn more about Blue Medicare Rx and/or Blue Medicare Supplement, visit www.bcbsnc.com/plans/medicareplans.cfm .

Blue Medicare product logos(continued from page 3) P F A Rx

(continued on page 5)

Medicare Advantage Private Fee for Service (MA PFFS)

Terms and Conditions Finder available online https://www.bcbsnc.com/providers/edi/pffs.cfm

If you are a Medicare participating provider, you might be seeing members from around the country who have health care coverage from a Blue Cross and/or Blue Shield Medicare Advantage Private Fee for Service (MA PFFS) plan. These members should be carrying a Blue Cross and/or Blue Shield ID card with this logo:

Please note the following information about MA PFFS, as this product varies from other Blue products:

t Health care providers can see and treat any Medicare Advantage PFFS member without having a contract with BCBSNC.

t Services must be provided under the Terms and Conditions of that member’s home Blue Plan.

t Please refer to the back of the member’s ID card for information on accessing the Plan’s Terms and Conditions. You may choose to render services to a MA PFFS member on an episode of care (claim-by-claim) basis.

t MA PFFS terms and conditions might vary for each Blue Cross and/or Blue Shield Plan. We advise that you review them before servicing MA PFFS members.

t Submit your MA PFFS claims to BCBSNC.

If you have questions, please contact you local Network Management field office.

Blues move to automatic crossover for all Medicare claims:

All claims will be automatically submitted to the secondary payor

Effective January 1, 2008, all Blue Plans will crossover Medicare claims for services covered under Medigap and Medicare Supplemental products. This will result in automatic claims submission of Medicare claims to the Blue secondary payor, and it will reduce or eliminate the need for the provider’s office or billing service to submit an additional claim to the secondary carrier. Additionally, with all Blue Plans participating in this process, Medicare claims will crossover in the same manner nationwide.

How do I submit Medicare primary / Blue Plan secondary claims?

t For members with Medicare primary coverage and Blue Plan secondary coverage, submit claims to your Medicare intermediary and/or Medicare carrier.

t When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card for additional verification.

t Be certain to include the alpha prefix as part of the member identification number. The member’s ID will include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and coverage, and crucial in facilitating prompt payments.

Inter-Plan Programs: Updates and reminders

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(continued on page 6)

When you receive the remittance advice from the Medicare intermediary, look to see if the claim has been automatically forwarded (crossed over) to the Blue Plan:

t If the remittance indicates that the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. There is no need to resubmit that claim to BCBSNC.

t If the remittance indicates that the claim was not crossed over, submit the claim to BCBSNC with the Medicare remittance information.

t In some cases, the member identification card may contain a COBA ID number. If so, be sure to include that number on your claim. COBA is an acronym for coordination of benefits agreement.

t For claim status inquiries, contact BCBSNC.

When should I expect to receive payment?

The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan only after they have been processed by the Medicare intermediary. This process may take up to 14 business days. This means that the Medicare intermediary will release the claim to the Blue Plan for processing at about the same time you receive the Medicare remittance advice. As a result, it may take an additional 14 to 30 business days for you to receive payment from the Blue Plan.

What should I do in the meantime?

If you submitted the claim to the Medicare intermediary/carrier, and haven’t received a response to your initial claim submission, don’t automatically submit another claim. Rather, you should:

t Review the automated resubmission cycle on your claim system

t Wait 30 days

t Check claims status before resubmitting

Sending another claim, or having your billing agency resubmit claims automatically, actually slows down the claim payment process and can create confusion for the member.

What if I have questions?

If you have a question about a specific claim, please call BCBSNC BlueCard customer service at 1-800-487-5522 or for general questions about BlueCard and the automatic crossover process; please contact your local Network Management field office.

The Blue health care debit card: Easy to recognize and simple to use

You may have already noticed that some Blue Plan members have a Blue health care debit card, which has value-added features to assist you in collecting members’ cost-sharing amounts. The card allows members to pay for out-of-pocket costs using funds from their health reimbursement account (HRA), health savings account (HSA) or flexible spending account (FSA). Some cards are “stand-alone” debit cards designed to cover out-of-pocket costs, while others also serve as member ID cards. Using the new cards can help you simplify your administration process and:t Reduce bad debt

t Reduce billing statements

t Minimize bookkeeping and patient accounts-receivable

The health care debit cards are easy to recognize. Just look for the familiar Blue Cross and/or Blue Shield logos, along with the logo from a major debit card, such as MasterCard or Visa.

Sample stand-alone health care debit card

Inter-Plan Programs: Updates and reminders (continued from page 4)

Sample combined debit card and member ID card

Health care debit cards are easy to use and operate like any other debit card. The member’s copayment, or any other out-of-pocket costs, will be automatically deducted from the member’s designated HRA, HSA or FSA account.

Cards save time and money

Combining a health insurance ID card with a source of payment serves as an added convenience to members and providers. Members can use their cards to pay outstanding balances on billing statements. They can also use their cards by phone to submit payments. In addition, members are more likely to carry their current ID cards because of the payment capabilities. If your office currently accepts credit card payments, no additional equipment is necessary.

Helpful tips when using the debit cards

Ask members for their current member ID card and obtain new photocopies of the front and back of the card regularly. Having a copy of the member’s current health care debit card on file will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delays.

Check eligibility and benefits by calling BlueCard Eligibility®

at 1-800-676-BLUE (2583) and provide the alpha prefix, or use electronic capabilities. If the member presents a health care debit card (standalone or combined), be sure to verify the copayment amounts before processing payment.

Please do not use the card to process full payment upfront. If you have any questions about the member’s benefits, please contact 1-800-676-BLUE (2583). For questions about the debit card processing instructions or payment issues, please contact the toll-free number for the debit card administrator listed on the debit card.

Call BlueCard Eligibility® for easy access to membership and coverage information

Not sure how to verify eligibility and benefits for out-of-area Blue Plan members? First, look for the three character alpha prefix that precedes the identification number on the member’s ID card. Once you have located the alpha prefix, you should call BlueCard Eligibility at 1-800-676-BLUE (2583) to verify the patient’s membership and coverage. Provide the member’s alpha prefix and you will be routed to the member’s Blue Plan. Remember to submit claims to BCBSNC.

How to handle questions from Blue Plan members

BCBSNC is your central point of contact for most out-of-state and international Blue Plan patients receiving care within North Carolina. Contact us for claims processing, payment and claims adjustment questions. However, due to HIPAA privacy regulations, members must contact their Home Plans for all inquiries and claims-related issues. Under the HIPAA privacy regulations, we are required to verify a member’s protected health information (PHI) before we can answer questions over the phone. BCBSNC cannot access out-of-state members’ PHI as this is maintained with the members’ Home Blue Plans. To assist members with their questions, we ask that if you are approached by an out-of-state member with questions about a current claim, or a previously processed claim and

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Inter-Plan Programs: Updates and reminders (continued from page 5)

If you’re interested in facilitating faster payments,

submit an electronic eligibility inquiry by using Blue e.

P F A

(continued on page 7)

information is needed from any of the Blue Plans, please advise the member to contact their home Blue Plan where their PHI can be verified and their questions answered.

Frequently asked questions about Blue Plan Medicare-related claims

If you are a provider who accepts Medicare assignment and renders care to members from other Blue Plans, the following information can make filing your Medicare claims easier.

What are Blue Plan Medicare-related claims?

Blue Plan Medicare-related claims occur when Blue Plan members have Medicare as their primary coverage and a Blue Cross and/or Blue Shield Plan that is secondary/supplemental. Examples include: Medigap (also called Medicare Supplemental, Medicare Complementary and Medicare Extended) and Medicare carve-out.

How are members with Medicare-related policies recognized?

When members arrive at patient check-in and are requested to provide all active identification cards, Blue Plan members with Medicare-related policies will have two cards to present. Members should have both their standard Medicare card and a Blue Plan ID card displaying the Blue Cross and/or Blue Shield logo.

Where should Blue Plan Medicare-related claims be filed?

Medicare primary claims should be sent to the Medicare intermediary and/or Medicare carrier. After receipt of the explanation of payment, or Medicare Remittance Notice (MRN) from Medicare, look to see if the claim has been automatically forwarded (crossed-over) to the secondary payor:

t If the remittance shows that the claim was crossed-over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan. You can make claim status inquiries through BCBSNC.

t If the claim was not crossed-over, submit the claim to BCBSNC with the MRN. For claim status inquiries, contact BCBSNC. Remember to include the member’s alpha prefix in the first three positions when filing to BCBSNC for the member’s secondary/supplemental benefits. The alpha prefix is critical for confirming eligibility and coverage and key to facilitating prompt payments.

t Do not submit Medicare-related claims to BCBSNC before receiving a Medicare Remittance Notice from the Medicare intermediary and/or Medicare carrier. Duplicate claims submissions can delay claim processing.

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Inter-Plan Programs: Updates and reminders (continued from page 6)

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The 2007 N.C. legislative session resulted in the approval of several health-insurance related bills that impact BCBSNC and its members. One that is causing a bit of confusion due to the effective date of the legislation is the chiropractic benefit change. Here’s what you need to know:

t Beginning January 1, 2008, or upon a group's subsequent renewal date, chiropractic services will be subject once again to the specialist copayment.

t The bill took effect October 1, 2007, but BCBSNC made the decision to postpone implementing the change until January 1, 2008. However, for members enrolled in State Health Plan PPO plans, the specialist copayment was applied October 1, 2007.

Please note that the chiropractic benefit change does not affect ASO (administrative services only) products, as groups can customize their chiropractic copayment amounts.

Confused about chiropractic benefit changes? Here’s what you need to know

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P F ATake advantage of the Office-administered Specialty Drug Network

New additions effective January 1, 2008 include:

t Histrelin acetate (Supprelin LA)

t Lanreotide acetate (Somatuline Depot)

t Protein C Concentrate (Ceprotin)

t Temsirolimus (Torisel)

A complete listing of the current pharmaceuticals available to you and your patients under the Office-administered Specialty Drug Network, as well as a listing of all additions or deletions (which will become effective at the beginning of the next quarter) can be viewed on our Web site at: bcbsnc.com/providers/injectable-drugs/available.cfm .

Participating vendors include:

Caremark – • 1-800-571-3922

Medmark Inc. – • 1-888-884-8714

McKesson – • 1-888-456-7274

US Bioservices – • 1-800-816-7758

Hemophilia Resources of America – • 1-336-854-3128

(Please note that Hemophilia Resources of America is the vendor to provide factor drugs only)

(continued on page 9) (continued on page 9)

During 2007, BCBSNC expanded the list of available network drugs to include:

t Alglucosidase Alpha (Myozyme)

t Decitabine (Dacogen)

t Etonogestrel Implant (Implanon)

t Idursulfase (Elaprase)

t Naltrexone (Vivitrol)

t Nelarabine (Arranon)

t Panitumumab (Vectibix)

t Ranibizumab (Lucentis)

t Recombinant Hyaluronidase Human Injection (Hylenex)

t Zoledronic Acid (Reclast)

BCBSNC offers the Office-administered Specialty Drug Network, which can supply you with select provider-administered injectable drugs for the treatment of your BCBSNC patients. By taking advantage of the Office-administered Specialty Drug Network, certain member-specific and dose-specific injectable drugs can be delivered directly to your office and the network vendors will bill BCBSNC directly for the drug.

The Office-administered Specialty Drug Network will:

t Improve access and simplify the process of obtaining select injectable drugs

t Remove financial risk that you may have incurred when supplying injectable drugs in the past

t Reduce paperwork for your office

t The specialty pharmacy provider will verify eligibility with BCBSNC and inform the provider of prior approval requirements, when applicable

t Streamline the submission of injectable drug claims

Before you use the Office-administered Specialty Drug Network, remember:

t Use of the Office-administered Specialty Drug Network is voluntary

t Network vendors will bill BCBSNC directly for the injectable drug

t If you order a member-specific or dose-specific injectable drug from a network vendor, do not file a claim with BCBSNC for the drug. The vendor will bill BCBSNC directly.

You should note that certain self-administered medications have been excluded from BCBSNC’s medical benefits but are covered under the prescription drug benefit. In instances where a patient requires assistance with the administration of these medications, you can continue to file for administration fees; however, BCBSNC will no longer provide reimbursement to physicians for the designated self-administered medications. A list of these medications can be found at bcbsnc.com/services/formulary/injectmed.cfm . Please continue

to obtain injectable drugs for these patients through your current process. Medicare Supplement and Blue Options State Health PPO subscribers are excluded from this program. To find out more about the Office-administered Specialty Drug Network, and to view the complete listing of provider-administered specialty injectable pharmaceuticals available, visit our Office-administered Specialty Drug Network Web page at bcbsnc.com/providers/injectable-drugs/available.cfm .

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(continued on page 10)

Take advantage of the Office-administered Specialty Drug Network (continued from page 8)

Our Network Management staff has replaced the local field office telephone numbers with new regional toll-free numbers that are available for you to call when you need to notify us of changes at your health care business or to find answers to your questions about BCBSNC.

Network Management is available to assist you with a variety of issues, including:

t Questions regarding BCBSNC contracts, policies and procedures

t Changes to your organization including:

• Opening/closing locations

• Change in name or ownership

• Change in Tax ID number, address or phone number

• Merging with another group

• Educational needs

BCBSNC Network Management field offices are located across the state and are assigned territories to support the provider community by specific geographical region. To find the Network Management office that serves your area, please refer to the map.

BCBSNC Network Management:New toll-free numbers

P F A Rx

Charlotte Region P. O. Box 35209 Charlotte, NC 28235 Phone 1-800-754-8185 Fax 1-704-676-0501

Hickory Region P. O. Box 1588 Hickory, NC 28603 Phone 1-877-889-0002 Fax 1-828-431-3155 (fax)

Greensboro Region 2303 West Meadowview RoadSuite 200 Greensboro, NC 27407 Phone 1-888-298-7567Fax 1-336-316-0259 (fax)

Raleigh Region Note new address 1830 Chapel Hill BlvdChapel Hill, NC 27517Phone 1-800-777-1643Fax 1-919-765-7109 (fax)

Wilmington / Greenville Region2005 Eastwood Road Suite 201 Wilmington, NC 28403 Phone Wilmington: 1-877-889-0001Phone Greenville: 1-888-291-1780Fax 1-910-509-3822 (fax)

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BCBSNC Network Management: New toll-free numbers (continued from page 9)

Members with a coverage plan that includes office visit copayments are responsible for the copayment at the time services are received. You should collect the copayment amount listed on the member’s BCBSNC ID card when:

t A charge for an office visit is made using an Evaluation and Management (E/M) code

t Surgery is performed in the office

t A second surgical opinion or consultation service is provided

t The patient is seen by a physician, physician’s assistant, clinical nurse practitioner, nurse midwife, physical therapist, occupational therapist or speech therapist

Often, members can have differing copayment responsibilities, depending on whether care is provided by a primary care physician or a specialist. OB/GYNs should always collect the primary care office visit copayment for Blue Care and Blue Options patients.

Copayments should not be requested when there is not an E/M service code for an office visit being charged (e.g., when a member comes in to get an allergy injection, lab service only, second surgical opinion, consultation and surgery in addition to an office visit). Copayments are not required when members are receiving chemotherapy, radiation therapy or dialysis performed in the office and are not being billed for an E/M service, or when services are provided in a hospital setting.

When collecting copayments, you should collect only one per office visit as shown on the member’s ID card. Always verify the member’s ID card for copayment amounts, as amounts can vary depending on their benefit plan. Also, when to collect can be different between benefit plans. Please use the following tips for when to collect an office visit copayment:

Federal Employee Program: The copayment covers any face-to-face encounter with a physician, physician’s assistant, clinical nurse practitioner or nurse midwife.

Blue Care, Blue Options (copayment product) and Blue Advantage: All covered services rendered during the course of the office visit are subject to one copayment.

Blue Options (deductible and coinsurance only): All services are subject to deductible and coinsurance, as office visit copayments do not apply.

Classic Blue: Covered services rendered to members are always subject to deductible and coinsurance, regardless of the place of service.

Collecting office visit copayments from members

P F A Rx

The following is a listing of our Network Management offices and their respective contact information:

P F A Rx

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State Indemnity (CMM) benefit changes

Benefit changes have been made to the State Indemnity program, effective July 1, 2007. The changes are as follows:

t Deductible increased from $350 to $450

t Family deductible increased from $1,050 to $1,350

t Medical copayment increased from $15 to $25

t Preferred brand drug with no generic equivalent tier copayment increased from $25 to $30

During the 2007 legislative session, provisions were made to discontinue the State Indemnity plan, effective June 30, 2008. Over the course of the next year, the State Health Plan will work to develop a clearer understanding of the three improved PPO options in order to help State Indemnity plan members transition to a PPO plan more easily.

CRNA coverage change reminder:

For State Health Indemnity (CMM) Plan members

Effective September 1, 2007, certified registered nurse anesthetist (CRNA) services will be covered for all State Indemnity (CMM) and NC Health Choice members. In the past, the State Health Plan provided coverage for CRNA services only when Medicare was the primary carrier. The revised policy is available on the SHP Web site at http://statehealthplan.state.nc.us/pdf/SU0025.pdf.

North Carolina State Health Plan Indemnity (CMM) worksite wellness Web site launched

U.S. employees spend an average of 50 hours a week at work, and eat about one-third of their meals there. When polled, about 40 percent of those same workers indicated that they feel “very” or “extremely” stressed at work.

The State Health Plan encourages members to participate in a wellness program at their workplace to help employees adopt better lifestyle habits, including healthy eating, physical activity, tobacco cessation and stress management. Ask your North Carolina State Health Plan Indemnity (CMM) members to check with their human resources department to find out whether such a program is available at their workplace.

The NC HealthSmart* Worksite Wellness Toolkit and other resources, including presentations, brochures and

data, can be found at http://www.shpnc.org/worksite-wellness.html. Your State Health Plan Indemnity (CMM) patients can use this site to organize and sustain a wellness program where they work.

These resources are not only for wellness committees but also for leaders and employees, and include:

t The NC HealthSmart Worksite Wellness Toolkit and training presentations

t Success stories from wellness committees across North Carolina

t Wellness Works bimonthly e-newsletters

t Brochures such as “What is Worksite Wellness?” and “Making the Case for Worksite Wellness”

t Research on the benefits of worksite wellness

t Presentations such as “Why Employers Should Invest in Worksite Wellness?” and “How Does Worksite Wellness Help Me?”

The NC HealthSmart Worksite Wellness Program is a partnership between the State Health Plan and the North Carolina Division of Public Health that assists state agencies, public universities, community colleges and public schools to create health-friendly work environments. The site provides tools and information for employees, human resources professionals, managers, executives and wellness committees.

*To be eligible for NC HealthSmart services, the North Carolina State Health

Indemnity (CMM) Plan must be your primary insurer.

North Carolina State Health Indemnity (CMM) Plan – Over the counter generic nicotine replacement therapy and counseling program

In January 2007, the NC State Health Indemnity (CMM) Plan launched a new benefit for its members who use tobacco and are ready to quit. The Plan offers over-the-counter (OTC) generic nicotine replacement therapy patches for a one-time 10 week course of therapy per year. Each box of patches costs $5.00 and requires a prescription. Typically, an individual trying to quit will need three to four boxes of patches over a 10-week course. The prescription must be filled at a local participating network pharmacy.

State Health Plan Indemnity (CMM) members who receive counseling for smoking cessation can have the $5.00 copayment waived for the generic patches. Members may receive counseling from their health care provider

State Health Indemnity Plan: Updates and reminders for State Health Plan Indemnity (CMM) and NC Health Choice

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Multiple occurrences During the fall of 2007, BCBSNC began using the CPT defined lists of Add-On Codes and Modifier 51 Exempt codes to determine payment for claims submitted with multiple occurrences. The codes are listed in the CPT Code Book annually and the BCBSNC systems will be kept current with the information.

If you have questions, please contact your local Network Management field office.

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State Health Indemnity Plan: Updates and reminders for State Health Plan Indemnity (CMM) and NC Health Choice (continued from page 11)

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or through the NC Quitline. A behavioral health specialist may also provide counseling, but a prescribing provider must request the prescription waiver. Copayment waivers will be active at the pharmacy approximately two business days after a member’s certification form has been faxed by a health care provider or the NC Quitline.

Health care providers can visit the State Health Plan Web site to obtain the fax form to certify that smoking cessation counseling has been provided. The Web address for the Smoking Cessation Counseling Prescriber Confirmation Form is located at http://statehealthplan.state.nc.us/pharmacy.html. Forms can be faxed to Medco at 1-319-896-5904.

Members may also call the NC Quitline at 1-800-QUIT-NOW (1-800-784-8669) for free smoking cessation support. When asked about health insurance, the member needs to indicate their enrollment in the State Health Plan for Indemnity (CMM). Providers may download a patient referral form from www.quitline.com and fax it to the NC Quitline to have a member registered for the free smoking cessation. For those patients who wish to quit but are having a hard time getting started, a call from the Quitline may help them establish a plan of action. Forms should be faxed to 1-800-483-3114.

For questions, members may call Member Services at 1-800-336-5933.

Members with additional health questions (not benefit information), can be referred to a NC HealthSmart Health Coach at 1-800-817-7044 or the NC HealthSmart personal Web portal located at www.shpnc.org.

When should you submit medical records? Information applies to medical records for members enrolled in the State Health Indemnity (CMM) Plan and does not apply to NC SmartChoice PPO Plans.

If you receive a Notification of Payment (NOP) for a claim that has been denied with code 233 (233 = medical information has been requested from the provider to determine liability), the requested information should be sent to the State Health Indemnity (CMM) Plan Medical Review department at:

State Health Indemnity (CMM) Medical Review P.O. Box 30111Durham, NC 27702-3111

When you receive a 233 denial code for a State Health Indemnity (CMM) Plan member’s claim, the claim will remain denied until the medical records are received. When submitting medical records, you should include the patient’s name and ID number, your name, phone number and fax number. The State Health Indemnity (CMM) Plan will not send a request for medical records unless we receive incomplete medical records or additional records are needed.

Removal of PA for AnorexiantsAs of January 1, 2008, BCBSNC is removing the prior authorization (PA) requirement for weight loss drugs Xenical and Meridia. These agents have some long-term safety and efficacy data available and will continue to be covered on Tier 3 of the formulary. During this past summer, a half-strength OTC version of Xenical called Alli was released.

BCBSNC is a national leader in helping its members make good health choices. In 2004, we became the first insurer in the nation to cover obesity as a primary condition. By tackling obesity, our goal is to reduce the incidence of long-term health problems related to obesity and being overweight. BCBSNC believes that taking a preventive approach in regard to the obesity epidemic will help our members stay healthier longer, while lowering the overall cost of health care.

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Blue Options 1-2-3SM

Encouraging primary care and preventive services Beginning January 2008, your patients may be enrolled in one of our newest PPO plans, Blue Options 1-2-3. The plan promotes members’ establishment of a medical home with a primary care physician, and it encourages preventive health screenings and regular physical exams. The plan also utilizes the same Blue OptionsSM network

that our traditional PPO and HSA/HRA plans do today. Blue Options 1-2-3 divides services into three coverage levels. Depending on the type of service and where the service is provided, the member will pay either a copayment or coinsurance amount. Here’s how the three levels are applied:

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(continued on page 14)

LESS ENGAGEMENT & COST SHARING MORE ENGAGEMENT & COST SHARING

Plan Highlights*

Level 1 Level 2 Level 3

Type of service Primary care preventive care

Inpatient care Outpatient care / Professional specialist care

In-network copayment or coinsurance amounts1

Employees pay $15-25 copayments for Level 1 covered services

Employees pay:

$250-500 for each • inpatient stay PLUS

0-30% coinsurance for • Level 2 covered services after deductible

Employees pay a 10-20% higher level of coinsurance than Level 2 for Level 3 covered services after deductible

In-network covered services

Primary care office visits:1

All covered services, including lab tests and X-rays

Preventive care:1,3

Routine exams, immunizations, diagnostic procedures (Pap test, screening mammography and colonoscopy, etc.), well-baby and well-child care, well-woman care, prostate exam

Inpatient hospital services (admitted hospital stay, including maternity care)

Home health care

Hospice care

Skilled-nursing facility care

Inpatient mental health services or substance abuse care

Emergency room service (if admitted)

Outpatient hospital services: Lab tests and X-rays, outpatient surgery, therapeutic services (occupational, physical, speech)

Emergency room service (if not admitted)

Urgent care services

Ambulatory surgery services

Specialist office visits: Office-based services, including lab tests and X-rays, therapeutic services (occupational, physical, speech)

Outpatient mental health services or substance abuse care

Prescription drug coverage

Prescription drugs are covered by our standard four-tier design2

Deductible In-network: $250-5,000 for individual coverage / $500-10,000 for Family coverage

Out-of-network: $500-10,000 for individual coverage / $1,000-20,000 for Family coverage

Coinsurance maximum

In-network: $2,000-10,000 for individual coverage / $4,000-20,000 for Family coverage

Out-of-network: $4,000-20,000 for individual coverage / $8,000-40,000 for Family coverage

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Blue Options 1-2-3 Encouraging primary care and preventive services(Continued from page 13)

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Are you familiar with BCBSNC standards for access to care, facilities, medical records and preventive health? BCBSNC remains committed to excellence in health care quality. We developed standards for access to care, facilities, medical records and preventive health in an effort to ensure that our members have a safe environment in which they can receive the quality health care they need in a timely manner. These standards are based on NCQA requirements and current standards of practice. They are reviewed annually by our Physician Advisory Group. The following BCBSNC standards and guidelines can be found on the provider section of bcbsnc.com under the Blue Book:

t Access to Care for Primary Care Providers

t Access to Care for Specialists

t Facility Standards for Primary Care Providers and Specialists

t Medical Records Standards for Primary Care Providers

t Preventive Health Guidelines

t Facility Standards for Urgent Care

t Medical Record Standards for Urgent Care

BCBSNC conducts on-site reviews for all primary care and OB/GYN providers at a minimum of every three years. BCBSNC Quality Management Consultants conduct these reviews to assess compliance with these standards. To ensure your practice’s success with our quality audits, we encourage you to visit our Web site regularly for the most current standards and guidelines in use.

1 Some services and supplies received by members in an office setting or in connection with an office visit are in fact outpatient hospital-based services provided by hospital-owned or operated practices. These services and supplies may be subject to Level 3 deductible and coinsurance. Please see the BCBSNC provider listing to identify these providers.

2 Please refer to your benefit booklet for details about the Tier 4 Forumlary as well as your BCBSNC member ID card for the levels of pharmacy benefits.

3 Certain preventive care services are limited to in-network benefits.

*Notice: Your actual expenses for covered services may exceed the stated coinsurance percentage or copayment amount because actual provider charges may not be used to determine the health benefit plans and members payment obligations. For out-of-network benefits, you may be required to pay for charges over the allowed amount, in addition to any copayment or oinsurance amount. Pre-existing condition waiting periods may also apply. Pre-existing conditions are those for which medical advice, diagnosis, care or treatment was received or recommended within 12 months of the date that your Blue Options 1-2-3 coverage begins. You may receive credit toward the 12 month waiting period if we receive your completed application within 63 days of the termination of your previous health coverage.

At the right is the ID card used by patients enrolled in Blue Options 1-2-3. BCBSNC has not made any modifications to existing utilization management or prior review and certification processes.

For additional information about Blue Options 1-2-3, contact your local Network Management field office.

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Colorectal cancer screening benefitColon cancer is the third leading cause of cancer deaths among men and women in the United States. The good news is that in recent years the incidence and mortality of colon cancer has decreased, which the CDC attributes to the increase in early detection and polyp removal. We encourage providers to talk with members over the age of 50 and all high-risk members under the age of 50 about colon cancer screening options.

Colorectal cancer screening benefit information

Colorectal cancer screening is a covered benefit for BCBSNC members.1 Out-of-pocket costs for colon cancer screening will depend on the test that is chosen and where the test is done. For example, the cost of having a colonoscopy performed in a doctor’s office is a specialist copayment (usually around $20-$60).2 If a colonoscopy is done in a hospital outpatient department or an ambulatory surgery center, the average cost will be more than $500 and will be applied to the members’ deductible and coinsurance.

For a list of credentialed office-based colonosocopy centers in your area, please visit BCBSNC’s provider

directory and select “colonoscopy-office based” or visithttp://www.bcbsnc.com/services/search/

colonoscopy/.

This benefit information is summarized in a benefit flyer for use in your clinic.

Source: CDC Call to Action colon cancer screening presentation, 2003

1 Specific benefit information can be found in members’ benefit booklets or by calling BCBSNC Customer Service. Out-of-pocket costs will vary depending on members’ specific benefits, the type of screening that is done and where the screening takes place.

2 An office-based colonoscopy may not be appropriate for everyone.

Did you know that only 50 percent of patients with chronic illnesses take their medications as directed by their doctor?1 Increasing medication adherence can provide significant health benefits for members and help to lower their overall health care costs. With these goals in mind, BCBSNC is offering its members our new Medication DedicationSM program, which is designed to help them improve their overall health and reduce out-of-pocket prescription drug expenses.

Focus on four chronic conditions

The first phase of Medication Dedication removes cost barriers that may contribute to a member not taking their medications as prescribed. By waiving the copayment for specific generic drugs used for the treatment of congestive heart failure (CHF), high blood pressure, diabetes and high cholesterol, our members can keep their medical costs down. These conditions were selected based on their prevalence in the population and overall impact to health care costs.

Another cost-saving program component involves moving more expensive brand-name drugs to treat the same chronic conditions listed above into the second lowest copayment tier. For a complete list of the drugs included in this program, visit bcbsnc.com .

Provider involvement is key

BCBSNC will communicate details about Medication Dedication directly with members who currently take any of the specific medications for the four conditions listed above. However, your relationship with BCBSNC patients will be an integral part of this member-education effort. Medication adherence should be viewed as a collaborative process between the patient, physicians and pharmacists, with the mutual goal of optimizing clinical outcomes. Providers can increase patient awareness about the importance of taking prescription drugs as prescribed by looking for evidence of poor adherence, emphasizing the importance of the drug regimen, making the regimen simple and customizing the drug therapy to the patient’s lifestyle, when applicable.

For more information on Medication Dedication, and to view a list of the drugs included in the program’s generic copayment waiver and tier changes, visit bcbsnc.com .

1 World Health Organization Report. “Adherence to long-term therapies: Evidence for action.” <http://www.emro.who.int/ncd/Publications/adherence_report.pdf> <February 2007>

BCBSNC members can improve their health with Medication DedicationSM

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For a list of credentialed office-based colonosocopy

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Focus on quality As part of our commitment to quality, BCBSNC has a continuous quality improvement program. BCBSNC participates in NCQA accreditation and is proud to have full accreditation for the PPO product, the highest level of accreditation.

At BCBSNC, we conduct the CAHPS® member satisfaction surveys to understand whether members are pleased with the care they receive from health care providers and whether they are satisfied with their health plan. Recent CAHPS survey results show that BCBSNC members’ satisfaction with their doctors and their health plan is significantly higher than the national average.

Overall, the Quality Improvement Program indicates clinical improvements in the utilization of select preventive care services, such as adolescent immunizations, chlamydia screening, follow-up after hospitalization for mental health

illness, flu vaccinations, and in most aspects of diabetes management. Opportunities still exist to improve care related to depression medication adherence, cardiac care and HbA1c management of diabetes care.

BCBSNC also spearheads provider-focused initiatives to improve quality of care, including a Bridges to Excellence pilot. There has been a dramatic rise in physicians in North Carolina with NCQA practice recognitions following the implementation of Bridges to Excellence, making North Carolina the 3rd leader in the United States for NCQA physician recognition.

If you would like a copy of BCBSNC’s quality improvement program, please email quality@bcbsnc.com. We welcome your suggestions for improving quality. Please contact your local Quality Management Consultant with comments or suggestions.

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RealMed users enjoy secondary efficienciesHealth eligibility

RealMed can submit your secondary claims electronically for all major payors, including BCBSNC..

Clients who generate HIPAA-compliant 837 batch claim files from their practice management systems are seeing better efficiency and increased receivables. For those who cannot submit the 837 file, RealMed can still assist you by allowing your staff to enter primary payment information directly into your claim via its Edit/Error management screen and then create the electronic secondary on your behalf.

How do providers submit secondary claims before the 837 or RealMed? By printing the CMS-1500, attaching the payor’s Notice of Payment (NOP) and mailing them to the secondary payor. Then, they wait for payment, calling the payor for the status of the claims.

With RealMed, the secondary claim is submitted to RealMed and edited for all primary payor information the payor requires. If any information is missing, the provider’s representative can enter the missing fields immediately on the screen. The claim is then electronically forwarded to the payor. RealMed tracks the status of the claim in the same way that primary claims are tracked for many of their payor partners.

RealMed can help providers decrease printing, mailing costs and increase efficiency. If you would like more information on what RealMed can do for you, contact Jeff Dolan at 1-919-806-4405 or email jeff.dolan@realmed.com. Your BCBSNC Electronic Solutions field consultant is also available to assist you if you have questions.

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New GenericsGeneric equivalents for the following drugs have recently become available. These generic products are available at the lowest copayment level (Tier 1) on BCBSNC commercial and Medicare Part D formularies.

Remember to tell your patients that the FDA requires generic drugs to have the same quality, strength, purity and stability as their brand-name counterparts. Save money for your patients and prescribe generic drug products when appropriate.

Please note: Omeprazole (generic Prilosec) is now covered under the BCBSNC commercial and Medicare Part D formularies.

The following list is active at the time of this publication; however, it is subject to change at any time. Please refer to the BCBSNC online prescription drug search for the most up to date information at bcbsnc.com/apps/drugsearchweb/drugSearch.

(continued on page 18)

New Generics – Tier 1 (Lowest copayment amount)Brand-name Generic Therapeutic Class

Prilosec 20 mg Omeprazole 20 mg Proton Pump Inhibitors

Ambien Zolpidem tablet 5, 10 mg Hypnotic Agents

Toprol XL Metoprolol Succinate, All Strengths Beta Blockers

Coreg Carvedilol 3.125, 6.25, 12.5, 25 mg Tablet Beta Blockers

Inderal LA Propranolol long-acting Beta Blockers

Corzide Nadolol / Bendroflumethiazide Combination Antihypertensives

Mavik Trandolapril ACE Inhibitors

Univasc Moexipril ACE Inhibitors

Uniretic Moexipril / hydrochlorothiazide Combination Antihypertensives

Verelan PM Verapamil SR Capsule Calcium Channel Blockers

Norvasc Amlodipine Calcium Channel Blockers

Lotrel Amlodipine Besylate / Combination Antihypertensives Benazepril 2.5/10, 5/10, 5/20, 10/20 mg Capsule

Colestid Colestipol 1 g Tablet, 5 g Powder Pkt Lipid/Cholesterol-lowering agents

Duragesic Fentanyl 12 mcg/hr patch Narcotic Analgesics12 mcg/hr patch

Focalin Dexmethylphenidate Tablet Miscellaneous Psychotherapeutic Agents

Floxin Otic Ofloxacin 0.3% Drops Miscellaneous Otic Products

Omnicef Cefdinir Cephalosporins, Third Generation

Lamisil tablet* Terbinafine Tablet* Antifungal Agents

Famvir Famciclovir Miscellaneous Antivirals

Nasarel Flunisolide Nasal Spray Intranasal Steroids

Vospire ER Albuterol Sulfate Extended Beta Agonists Oral Release Tablet

*Prior Approval required.

17

New Generics (Continued from page 17)

Commercial Drug Formulary UpdateBCBSNC and its Pharmacy & Therapeutics (P&T) Committee have reviewed the following new drugs and made the following decisions regarding their formulary tier (copayment) placement on the BCBSNC commercial formulary.

Tier 2 – Preferred Brands (middle co-payment amount)Brand-name Generic Therapeutic Class

Pulmicort Flexhaler Budesonide Powder Inhaler Inhaled Corticosteroids

Symbicort Budesonide / Formoterol Inhaler Miscellaneous Pulmonary Agents

Pylera Biskalcitrate Potassium / Other Ulcer Therapy Metronidazole / Tetracycline Capsule

Januvia Sitagliptin Non-Insulin Hypoglycemic Agents

Janumet Sitagliptin / Metformin Non-Insulin Hypoglycemic Agents

Twinject Epinephrine Injection Adrenergics Combination Package

Geodon Ziprasidone Miscellaneous Antipsychotics

Tier 3 – Brands (highest co-payment amount)Brand-name Generic Therapeutic Class

Tekturna Aliskiren Renin Inhibitor

Tykerb Lapatinib Ditosylate Tablet Miscellaneous Antineoplastic Drugs

Invega Paliperidone Miscellaneous Antipsychotics

MoviPrep PEG 3350, Electrolytes, Sodium Bowel Evacuants Ascorbate & Ascorbic Acid for Oral Solution

Lialda Mesalamine Delayed-release Tablet Miscellaneous Gastrointestinal Agents

Femcon Fe Norethindrone / Ethinyl estradiol Oral Contraceptives

Lybrel Levonorgestrel / Ethinyl estradiol Oral Contraceptives

Verdeso Desonide 0.05% Foam Topical Corticosteroids, Low Potency

Desonate Desonide 0.05% Gel Topical Corticosteroids, Low Potency

Ziana Clindamycin phosphate 1.2% / Therapy for Acne Tretinoin 0.025% gel

Altabax Retapamulin Ointment Topical Antibacterials

Elidel Pimecrolimus Cream Miscellaneous Dermatologicals

Actonel Risedronate Tablet Osteoporosis Therapy

Actonel w/ Calcium Risedronate Tablet, Calcium Osteoporosis Therapy Carbonate Tablets

118 (continued on page 19)

New Generics (Continued from page 18)

Tier 3 – Brands (highest co-payment amount)Brand-name Generic Therapeutic Class

Alora Estradiol Patch Estrogens

Angeliq Estradiol / Drospirenone Estrogen Combinations

Elestrin Estradiol Gel 0.06% Estrogens

Estraderm Estradiol Patch Estrogens

Estring Estradiol Vaginal Ring Estrogens

Divigel Estradiol Gel 0.1% Estrogens

Femhrt Ethinyl Estradiol / Norethindrone Estrogen Combinations Acetate Tablet

Femring Estradiol Acetate Vaginal Ring Estrogens

Prefest Estradiol / Norgestimate Tablet Estrogen Combinations

Tyzeka Telbivudine Miscellaneous Antivirals

AzaSite Azithromycin 1% Ophthalmic Solution Ophthalmic Antibiotics

Pataday Olopatadine 0.2% Ophthalmic solution Miscellaneous Ophthalmologics

Astelin Azelastine Nasal spray Antihistamines

Brovana Arformoterol Inhalation Solution Beta Agonists, Inhaled

Veramyst Fluticasone Furoate Nasal Spray Intranasal Steroids

Vyvanse Lisdexamfetamine Miscellaneous Psychotherapeutic Agents

Tier 4* – Specialty Drugs (coinsurance amount)

Brand-name Generic Therapeutic Class

Fentora Fentanyl Buccal Tablet Narcotic Analgesics

*For those members with the 4-tier formulary

BCBSNC Commercial Formulary Information

The most up-to-date commercial formulary information for BCBSNC plans can be found on the Prescription Drug Search at bcbsnc.com . Type in the name of the drug you are looking for and information on that drug’s tier value, generic availability and other important information can be seen. To compare tier information between drugs in the same or similar therapeutic class, click on “Review Options.”

The prescription drug formulary for commercial BCBSNC health plans will soon be available as a printable document at bcbsnc.com . This document will be updated quarterly.

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Thomas/Love SettlementIn April 2007, BCBSNC joined the majority of other Blue Plans and state medical societies across the country in settling a national class-action lawsuit. Love, et al. v. Blue Cross Blue Shield Association, et al, formerly Thomas, et al. v. Blue Cross Blue Shield Association, et al. The settlement resolved a number of past issues between physicians and Blue Plans regarding claims processing. BCBSNC is committed to maintaining a strong relationship with our network physicians, and is continuing to make

enhancements to support greater transparency and operational efficiency.

For more information about the Thomas/Love Settlement Agreement, access BCBSNC online at bcbsnc.com/providers for public information or logon to Blue e (https://providers.bcbsnc.com/providers/login.faces) for secured information.

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BCBSNC emergency disaster preparedness for our members As a participating provider, you may be interested to know that if a disaster is proclaimed by the N.C. governor, BCBSNC will offer flexibility for our members located in the disaster area.* This includes deferral of premium payments for 30 days and deferral of other actions that fall due during the disaster period, including submission of claims, filing of appeals and submission of information requested by BCBSNC. If the N.C. governor or the president declares a major disaster, we will work with local media and others to publicize our member’s options and flexibility. In the event of large-scale disasters such as hurricanes, BCBSNC may waive other requirements for members in the disaster area, depending on the severity of the disaster and its impact.

If the Department of Insurance notifies us of a state of disaster or emergency, BCBSNC will make it easier for members with prescription drug benefits who live in the designated geographic area to obtain refills of a current prescription. At a member’s request, and within 29 days of the notification, BCBSNC will waive time restrictions on early refill of prescriptions. Members may obtain one replacement prescription for a recently filled prescription that was lost or destroyed or one refill, if additional refills remain on the prescription.

*Members are defined as subscribers of individual products and asunderwritten groups with billing addresses in the disaster area.

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Electronic Solutions: Updates and remindersNPI and electronic transactions submission

BCBSNC’s NPI contingency will terminate on May 23, 2008. In our continuing effort to help providers migrate to the NPI, BCBSNC has compiled the following frequently asked questions concerning the use of the NPI when submitting claims and inquiries to BCBSNC.

FAQ about NPI and electronic submissions

Question:Does BCBSNC currently accept the NPI on electronic transactions?

Answer:BCBSNC currently accepts claims that contain just a BCBSNC provider number, both a BCBSNC provider number and NPI or claims that just have a NPI. Providers are encouraged to submit their NPI on all electronic transactions, including claims.

If your clearinghouse will not pass your NPI on to BCBSNC, or will not submit a claim with NPI only, contact BCBSNC Electronic Solutions at 1-888-333-8594 and explain the situation to them. BCBSNC will contact the clearinghouse on your behalf.

Question:I have both a group NPI and an individual NPI. Where should they go on the claim?

Answer: Your group NPI (also known as a Type 2 NPI) should be in the billing segment of the claim. This varies for different claim forms:

t CMS 1500 – The group NPI should be in box 33A.

t UB04 – The group NPI should be in box 56.

t 837 – The group NPI should be in loop, 2010AA or 2010AB, element NM109, with an element NM108 qualifier of XX.

Your individual NPI (also known as a Type 1 NPI) should be in the rendering segment of the claim:

t CMS 1500 – Box 24J

t 837(Professional) Loop 2420A, element NM109 with element NM108 qualifier of XX.

Question:What happens if I submit my individual NPI in the billing segment of the claim?

Answer:Currently, BCBSNC will attempt to determine the correct BCBSNC provider number and process the claims accordingly. If the correct BCBSNC provider number can not be determined, the claim will be rejected.

After May 23, 2008, if a claim is received with an incorrect NPI, it will be rejected.

Question:I have registered my NPI with BCBSNC. When can I start using my NPI on electronic transactions?

Answer:You can begin submitting your NPI on electronic transactions two business days after you have registered your NPI with BCBSNC.

Question:How long can I use my BCBSNC provider number?

Answer:BCBSNC will require an NPI on all electronic transactions, including claims, effective May 22, 2008. At that time, your BCBSNC provider number will not be used for processing.

Question:What happens if I do not register my NPI with BCBSNC?

Answer:After May 22, 2008, you will not be able to submit electronic transactions, including claims to BCBSNC.

Question:Why do I need to register my NPI with BCBSNC?

Answer:There is no automatic notification to BCBSNC when a provider receives their NPI. You must notify BCBSNC and register your NPI so BCBSNC can identify you when we receive electronic transactions with your NPI included in them.

If you have not registered your NPI(s) with BCBSNC, please call us at 1-800-858-5966. You can register with BCBSNC through Blue e by contacting your Network Management field office. When you register your NPI with BCBSNC, the information is shared with our subsidiary, PARTNERS National Health Plans of North Carolina, Inc.

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Electronic Solutions: Updates and reminders (continued from page 21)

Blue e application tips

Blue e health eligibility

Eligibility response is now presented on three tabs at the top of the page:

t Member information tab – high level coverage and demographic information

t Benefit information tab – detailed benefits that include other BCBS plans and FEP members

t Coordination of benefits tab – lists any other insurers on file for the member

A greater level of detail information includes:

t Categories of coverage with specific benefits

t Institutional, professional and specialized services

t Coinsurance, out-of-pocket and out-of-network benefit period maximum amounts

t Lifetime benefit maximum

t Insurance type – underwritten or self insured

Blue e 837 denial listing

The Blue e 837 denial listing will save you time and phone calls.

t You can check the Blue e 837 denial listing each time you transmit claims. The 837 denial listing displays a list of report dates indicating failed claims within the previous 14 calendar days.

t The HIPAA claim 837 denial listing transaction is used to search for 837 institutional and professional claims that have failed processing because of business edits or HIPAA Implementation Guide edits.

By using the 837 claim denial listing, you can identify claim errors, correct them on your management system and resubmit them for adjudication.

How to search for denied 837 claims utilizing Blue e:

1. Click on HIPAA claim 837 denial listing on the Blue e home page. The 837 claim denial listing input page will appear.

2. Enter a provider number in the Provider No. field, then click on either the BCBSNC button for claims submitted to BCBSNC. The appropriate 837 claim denial listing selection page will appear.

3. If you want more records to display on a page than the default number of 40, select an alternative number from the drop-down menu for Number of records to return.

4. If you want a different sort order of claims than the patient account number default, select an alternative option format the Sort Order drop-down menu.

5. Click on the link for the desired report date. The appropriate 837 claim denial listing display page will appear with a listing of all denied claims for the selected date.

6. Click the Home button to return to the Blue e home page or click New Search to initiate a new search.

Remittance inquiry

The Blue e remittance inquiry allows users to view, print or save copies of their paper Notification of Payment (NOP) and Explanation of Payment (EOP) files. The files available for download are electronic copies of the actual paper NOP/EOP remits you receive via US mail. The EOP files for BCBSNC’s Blue products are available for 365 days. The NOP/EOPs are PDF files. Use the binocular icon in the Acrobat Reader window to perform a search for data (i.e. patient account number, patient name or BCBS ID number) in the EOP/NOP.

Claim status inquiry

Blue e claim status has a new look and feel. The transaction features access to a link to view the detailed EOP/NOP for Blue products.

Thomas litigation disclosures on Blue e

BCBSNC joined the majority of other BCBS Plans and state medical societies across the country in reaching a settlement in April 2007 in a national class-action lawsuit known as the Thomas/Love Case. The Thomas Compliance Program is being implemented by BCBSNC as a comprehensive approach to addressing our settlement responsibilities. Blue e provides a link to the Thomas/Love Case Disclosures under the administrative heading.

Manage account

The manage account transaction under the administrative heading is used to add or remove a user ID or provider ID from your Blue e account profile. This transaction enables requests to be handled electronically instead of fax. Click on the link identifying the task you want to perform. Available links include:

t Add users

t Remove users

t Add providers

t Remove providers

Self-administered provider sites should continue to contact their Entity Administrator for user ID additions.

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Blue e training

Are you new to using Blue e? Would refresher training be helpful to you?

The Electronic Solutions field staff will conduct training sessions at each of the BCBSNC field offices continually in 2008. Come learn about all of the transactions and how to best utilize them for your practice or facility. Space is limited and is available on a first come, first served basis. Blue e training in 2008 is scheduled for the following dates:

Region 1st Q '08 2nd Q '08 3rd Q '08 4th Q '08

Charlotte 3/13/08 6/13/08 9/11/08 11/20/08

Greensboro 3/11/08 6/10/08 9/16/08 12/8/08

Greenville 2/13/08 5/14/08 8/13/08 11/12/08

Hickory 2/13/08 5/14/08 8/12/08 11/12/08

Raleigh 01/09/08 05/07/08 07/09/08 09/10/08

Wilmington 02/06/08 04/02/08 06/04/08 08/06/08

To reserve a seat or for more information, please contact your Electronic Solutions field consultant.

eSolutions field consultant Location Phone number

Will Farrish Charlotte (704) 561-2751

Nadean Jones Greensboro (336) 316-5346

John Hodges Greenville (252) 931-7223

Ashley Teeters Hickory (828) 431-3142

Anil Samuel Raleigh (919) 765-4658

Ann Marie Lorenz Wilmington (910) 509-0605

Dell computer discounts

BCBSNC is pleased to announce that the corporate discount for select Dell PC equipment is now being made available to BCBSNC network providers. This discount can be obtained by shopping at the BCBSNC/Dell provider Internet site at www.dell.com/bcbsncproviders or by calling the Dell dedicated toll-free line at 1-866-746-4977.

“We encourage network providers to submit their claims electronically,” said Morgan Tackett, Director of the BCBSNC Electronic Solutions department. “It only makes sense for us to pass on our purchasing discount in order for providers to be able to take advantage of the range of BCBSNC electronic connectivity options.”

For more information on the purchasing program, or any BCBSNC sponsored provider electronic connectivity option, contact your local EDI field consultant.

Electronic Solutions: Updates and reminders(continued from page 22)

23

An independent licensee of the Blue Cross and Blue Shield Association. ®, SM Marks of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina. U4807, 02/08

V i s i t u s on l ine at bcbsnc. com/prov ide r s

Editor: Howard BarwellPO Box 2291Durham, NC 27702-2291

Address Service Requested

PRSRT STDU.S. POSTAGE

PAIDBLUE CROSS ANDBLUE SHIELD OF

NORTH CAROLINA

Online member services We’ve been telling you about the benefits of Blue e and asking that providers visit our Web site for years now. But have you ever wondered about our online services for members?

BCBSNC also provides online services for members, including access to exclusive features designed to promote better health. BCBSNC members can register or log in to our Member Services site (bcbsnc.com/memberservices) to access their account information or take part in programs designed to encourage healthy living and reward physical activity.

With Member Services, members can also:

t Find a doctor

t Get details of their health plan

t Check your claims 24/7

t And much more

Plus, our new multimedia demo gives an up-close look at the new features available at Member Services. To learn more about our online services for members, visit bcbsnc.com/memberservices/public/demo today and take a site tour!

Blue Cross and Blue Shield of North Carolina

Colonoscopy benefit fact sheet

Colonoscopy is a covered benefit for Blue Cross and Blue Shield of North Carolina (BCBSNC) members. Below is a summary of the standard benefit for colonoscopy screening.

• The out-of-pocket cost of a colonoscopy done in an office based colonoscopy center is a member’s specialty co-payment for Blue Care, Blue Options and Blue Advantage members.

• Colon cancer screening is an enhanced preventive benefit for Blue Options HSA members. Screening must take place in an office location to meet the Blue Options HSA preventive benefits.

• Members can have a colonoscopy in a hospital or ambulatory care center, subject to deductible and coinsurance. Colonoscopy screening in a office based colonoscopy center can lead to significant out-of-pocket cost savings for members.

• Members can check their benefit booklets or call BCBSNC Customer Service to determine their benefits.

• Physicians who do colonoscopies in an office based colonoscopy center are listed in the provider directory at bcbsnc.com, under Find a Doctor (see illustration below).

You can get a list of office based colonoscopy centers by calling BCBSNC customer service or by visiting bcbsnc.com and clicking “Find a Doctor”

Select your county and choose “Colonoscopy/ office-based” under specialty

An independent licensee of the Blue Cross and Blue Shield Association. ® Mark of the Blue Cross and Blue Shield Association. SM Mark of the Blue Cross and Blue Shield of North Carolina. Flyer created 6/27/07 by Healthcare Development and Evaluation