Inside this edition

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

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November 2019 RecapThis publication contains articles previously published on our Provider News Center.

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Administrative ● Becoming a credentialed professional provider

● Medicare Outpatient Observation Notice submission guidelines

● Required lead time when updating your provider information

● Coverage for emergency ambulance response and treatment without transport

Billing & Reimbursement ● Avoid documentation cloning ● Focus on reducing risk adjustment and Stars care gaps for out-of-area group Medicare Advantage PPO members

● Enhanced claim edits to support correct coding principles and important information about Medicare Advantage

BlueCard®

● BlueCard® Medicaid claims cannot be processed without complete information

Medical ● Changes to precertification requirements for intravitreal VEGF products effective January 1, 2020

● Vaccinations recommended for adult Independence members

Medical (continued) ● Eleven new drugs added to the Dosage and Frequency Program

● View up-to-date policy activity on our Medical Policy Portal

Pharmacy ● BriovaRx Specialty Pharmacy and Infusion Services has become Optum Specialty Pharmacy and Optum Infusion Pharmacy

● Updates to the Blood Glucose Meter Program for commercial members

● Changes to opioid management for members under 18 years of age

● Independence drug program formulary updates

Products ● New! $0 Personal Choice 65SM Prime Rx PPO plan and Medigap plans

● New medical and pharmacy product portfolios available for 2020

Quality Management ● Independence offers language assistance services to help members and their beneficiaries communicate

● 2019 – 2020 Clinical Practice Guidelines Summary now available

● Our Quality Management Program promotes quality of care and service

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

Professional Facility Ancillary

Inside this edition

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IVE Becoming a credentialed professional provider

Published November 1, 2019

Independence requires credentialing of physicians and all other types of health care providers who provide services to Independence members and who are permitted to practice independently under applicable state law. Providers must be credentialed and contracted before they are allowed to provide care to Independence members.*

Information on our network credentialing process and credentialing criteria can be found on our Professional Provider Credentialing webpage or in the Quality Management section of the Provider Manual for Participating Professional Providers.

Submitting credentialing applicationsTo ensure that credentialing applications are managed in a timely manner, it is important for providers to adhere to the processes outlined below for provider credentialing.

All professional providers interested in becoming a participating provider must apply for credentialing by completing the Practitioner Participation Form.

To become credentialed in Pennsylvania, providers are also required to complete the Council for Affordable Quality Healthcare’s (CAQH) online credentialing application: CAQH ProView®.

If your practice contracts with multiple health plans, the CAQH ProView online application minimizes the administrative work needed to fill out multiple, redundant, and time-consuming forms.

If you have already been credentialed by Independence, there is no need to resubmit a Practitioner Participation Form or a CAQH ProView credentialing application.

Submitting requests not related to credentialingThe Practitioner Participation Form is used strictly for credentialing applications. If you need to make changes to your basic provider information (e.g., updating names, addresses, office hours, contact information associated with your practice), please use our Demographic Maintenance Guide.

Learn moreIf you have additional questions on the content of this article, please email our Provider Communications team at provider_communications@ibx.com.

* Behavioral health providers must be credentialed by and contracted with Magellan Healthcare, Inc., an independent company. Interested behavioral health providers can contact Magellan by selecting the “Join the Network” link or by contacting their Magellan Provider Services Line at 1-800-788-4005 for assistance.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.

Important credentialing notes: ● Any professional provider interested in participating in our network must complete the Practitioner

Participation Form and the CAQH ProView credentialing application. ● Any credentialing application request not received through the Practitioner Participation Form will be

returned with instructions to submit the request using the form. ● The Practitioner Participation Form is only for credentialing applications.

November 2019 | Partners in Health UpdateSM 4 www.ibx.com/pnc

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IVE Medicare Outpatient Observation Notice submission

guidelinesPublished November 12, 2019

The Centers for Medicare & Medicaid Services (CMS) require that all hospitals and critical access hospitals (CAH) provide the Medicare Outpatient Observation Notice (MOON) to beneficiaries in Original Medicare (fee-for-service) and Medicare Advantage enrollees who receive observation services as an outpatient for more than 24 hours. This notice informs beneficiaries that they are outpatients receiving observation services and are not inpatients of a hospital or CAH.

The hospital or CAH must issue the MOON no later than 36 hours after observation services as an outpatient begin.

This also applies to beneficiaries in the following circumstances: ● beneficiaries who do not have Part B coverage (as noted on the MOON, observation stays are covered under

Medicare Part B); ● beneficiaries who are subsequently admitted as an inpatient prior to the required delivery of the MOON; ● beneficiaries for whom Medicare is either the primary or secondary payer.

Learn moreTo access the MOON and completion instructions, please visit the CMS website.

Required lead time when updating your provider informationPublished November 21, 2019

Independence would like to remind you that submitting changes in a timely manner helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories.* In accordance with your Provider Agreement, the Provider Manual for Participating Professional Providers, and/or Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, as applicable, you are required to notify Independence whenever key provider demographic information changes.

Please review our dedicated webpage to review the specific lead-time requirements, exceptions, and/or additional information for:

● Professional providers ● Facility and ancillary providers ● Authorizing signature and W-9 Forms

Independence will not be responsible for changes not processed due to lack of proper notice. Failure to provide proper advance written notice to Independence may delay or otherwise affect provider payment.

If you have questions related to updating your provider information after reviewing the webpage, please email our provider communications team at provider_communications@ibx.com.

*Behavioral health providers contracted with Magellan Healthcare, Inc. (Magellan), an independent company, must submit any changes to their practice information to Magellan via their online Provider Data Change form by selecting the “Display/Edit Practice Info” link.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.

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IVE Coverage for emergency ambulance response and

treatment without transportPublished November 12, 2019

Effective January 1, 2020, Independence will cover emergency ambulance response and treatment without transport in accordance with the Commonwealth of Pennsylvania’s mandate (Act 103 of 2018) for members enrolled in Pennsylvania products that are subject to the mandate when all the following medical necessity criteria are met:

● the services provided are medically necessary to stabilize the individual’s medical condition; ● the responding emergency medical services (EMS) ambulance is Pennsylvania-licensed and rendering EMS

services in the Commonwealth of Pennsylvania; ● the responding EMS ambulance, in accordance with state regulations, is a specially designed and equipped

vehicle used to transport the sick or injured; ● the responding EMS ambulance, in accordance with state regulations, is staffed by state certified or qualified

staff who can provide basic life support or advanced life support services, as appropriate, at the treating location during the time of the emergency;

● the responding EMS staff provides on scene emergency evaluation and, if necessary, treatment to stabilize the individual’s medical condition, and it is subsequently determined that transportation to an acute care hospital or other emergency care facility for additional care is not required, or the individual declines transportation.

HCPCS code A0998 will be considered eligible for reimbursement in a situation where:1. EMS staff respond to an emergency call and provide on scene emergency evaluation. AND2. If necessary, provide treatment to stabilize an individual’s condition but does not provide transportation – either

because the medical issue has resolved or the individual declined transportation.

Updated policyMedical Policy #12.04.02i: Ground Ambulance Services (Emergency and Nonemergency) (Independence) was updated and posted as a Notification on October 3, 2019, and will go into effect January 1, 2020.

To view the Notification for this policy, visit our Medical Policy Portal.

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Avoid documentation cloningPublished November 1, 2019

Medical record reviews conducted by Independence’s Corporate and Financial Investigations Department (CFID) have shown that providers are billing higher levels of evaluation and management services based upon cloned documentation rather than the actual service provided. Cloned notes affect the integrity of the medical record.

What is cloning?Cloning is when identical or similar documentation is used in a note describing an encounter. Medical records must contain documentation showing specific differences for each visit according to the needs of the patient for that date of service. Electronic medical records (EMR) enable quick access to patient records for more coordinated, efficient care. However, all forms of identical or similar documentation that are defined as cloning are a result of certain EMR features like:

● copy and paste ● auto-fill and auto-prompts (overdocumentation) ● pulling forward ● macros and/or templates.

Medical records reflecting these patterns misrepresent the medical necessity required for reimbursement of services rendered and cause the accuracy of the documentation to be questioned.

Services that show evidence of cloning will not be considered for reimbursement because it is not possible to determine exactly how much work was performed during an encounter. Audit summaries that identify documentation associated with any form of cloning may result in recovery of overpayments.

Learn moreIf you have questions about the content of this article, please email our Provider Communications team at provider_communications@ibx.com.

Focus on reducing risk adjustment and Stars care gaps for out-of-area group Medicare Advantage PPO members Published November 26, 2019

Beginning January 1, 2020, the Blue Cross and Blue Shield Association, an association of independent Blue Cross® and Blue Shield® Plans, will begin a phased rollout of a new approach for care management for out-of-area group Medicare Advantage members.

The new arrangement will enhance the way Blue Plans support Medicare Advantage group members who live outside their designated service area.

In the first phase, other Blue Plans will engage Independence to connect with you, our providers, to close risk adjustment and Stars care gaps for their members living in our service area. In turn, we will share monthly reports with providers who render services to those out-of-area Medicare Advantage PPO members who have gaps in care and who receive care in the Independence service area.

How to retrieve and use the reportsProviders who are registered for the Provider Engagement Analytics and Reporting (PEAR) portal can retrieve their monthly reports through IndexProTM.

IndexPro is our new online, self-service, and on-demand reporting tool for participating providers. It delivers access to timely data and actionable incentive program reports, delivered through a secure connection.

Providers who are not yet registered for PEAR will receive their monthly reports by mail until their portal registration is completed.

We ask that you review the information in the reports and work with your patients to close the gaps in care.

Learn moreIndependence will regularly share updates on this new program through Partners in Health UpdateSM articles.

If you have questions about the program or how to access the reports, please email us at provider_communications@ibx.com.

Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.

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Enhanced claim edits to support correct coding principles and important information about Medicare AdvantagePublished November 20, 2019

As a reminder, claims received by Independence on or after June 10, 2018, are subject to a claim editing process during prepayment review to ensure compliance with current industry standards and support the automated application of correct national coding principles.* By applying these principles, we will be consistent with other payers in the region and will apply claim payment principles that are national in scope, simple to understand, and continue to comply with industry standard sources, including:

● Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines

● American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines ● CMS HCPCS LEVEL II Manual coding guidelines ● ICD-10 Instruction Manual coding guidelines

Please be advised that as guidelines from these sources are updated, our claim edits will be reviewed and additional claim edits will be implemented as applicable. In addition to the above, Medicare Advantage plans comply with the National Coverage Determinations (NCD).

*Self-funded groups have the option to not participate in the enhanced claim edits; therefore, prepayment review may vary by health plan.

Areas of focusThe enhanced claim editing process for our Medicare Advantage lines of business will continue to focus on ensuring compliance with CMS coverage policies and reporting guidelines. Medicare Advantage plans are subject to edits that comply with clinical and correct coding criteria as defined in CMS publications including but not limited to, the following:

● Medicare NCD Manual ● Medicare Claims Processing Manual ● Medicare NCD Coding Policy Manual and Change Report (ICD-10-CM): Clinical Diagnostic Laboratory

Services

In addition to the above, Independence enforces CMS rules on appropriate modifier usage including, but not limited to the following:

● KX ● AT ● Q0

With the implementation of these claim edits, claims submitted with inappropriate coding will be returned or denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim return or denial. Any returned claims must be corrected prior to resubmission. These changes should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.

Claim review requestsWe recognize there may be times when you have questions regarding the outcome of a claim edit. As with all claim review requests, these questions should be submitted using the Claim Investigation transaction on the NaviNet® web portal (NaviNet Open). Claim lines that have gone through the editor can be identified by the alpha-numeric codes and messages beginning with E8 on your Provider EOB or Provider Remittance.

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Refer to the box below for more information.

Identifying claims that went through the new claim editor processIf your claim was affected by one of the new claim edits, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. Should your claim line contain an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen in NaviNet Open. To view, hover your mouse over the service line and select View Additional Detail. If you see an E8XXX code/message, the line went through an edit. Only E8XXX codes/messages are part of the enhanced claim editor. All other codes/messages are unrelated to the enhanced claim editor. Many of these rejections can be resolved by sending a corrected claim submission. Please ensure it follows the procedures outlined in the Partners in Health UpdateSM article, Claim investigation and corrected claim submission procedures.

Automated claim editsHere are some examples of the higher volume enhanced claim edits we continue to see:

ICD-10 coding ● Excludes 1 Notes: Claim lines reported with mutually exclusive code combinations according to the

ICD-10-CM Excludes 1 Notes will be denied. − When a code from range H73.0 – H73.099 (Acute myringitis) is associated to the same claim line as a code

in either the range H65 – H65.93 (Nonsuppurative otitis media) or the range H66 – H66.93 (Suppurative and unspecified otitis media), then the claim line will be denied.

● Laterality: The Diagnosis-to-Modifier comparison assesses the lateral diagnosis associated to the claim line to determine if the procedure modifier matches the lateral diagnosis. If it does not match, the claim line will be denied.

− DIAG1: H60.332 (Swimmer’s ear, left ear) − CPT: 69000 (Drainage external ear, abscess, or hematoma; simple) − MOD: RT

● Primary diagnosis code reporting: Certain diagnosis codes cannot be reported as the only or primary diagnosis code on a claim. If one of the following codes is reported as the only or primary diagnosis, then the claim line will be denied:

− Manifestation codes − External causes (i.e., “V – Y” codes) − Secondary codes (e.g., Z33.1)

Evaluation and Management services ● Only one new patient visit will be allowed to the same group practice and specialty within three years. ● Only one initial inpatient hospital visit and inpatient hospital discharge will be allowed per hospital stay. ● Accurate reporting of initial, subsequent, and observation discharge care. Only the admitting physician is

eligible to bill the observation care.

Surgical services ● Accurate reporting of modifiers for the billing of surgical services rendered by one or more providers.

Learn moreFor questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on Independence NaviNet Open Plan Central or in the Quick Links section on the right-hand side of the Independence Provider News Center. The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please send an email to claimeditquestions@ibx.com.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

NaviNet® is a registered trademark of NantHealth, an independent company.

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BlueCard® Medicaid claims cannot be processed without complete informationPublished November 4, 2019

Through the BlueCard Program, providers can render services to patients who are enrolled in a Blue Cross® and Blue Shield® Plan – other than one offered by Independence – and patients can visit physicians or facilities within the Independence five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) for treatment.

Independence coordinates with other Blue Plans to process professional and institutional electronic billing for Host claims. We strive to pay claims in a timely manner, but missing details in a claim submission can delay the payment process or cause a claim rejection.

Common reasons for claim rejectionsBe sure to complete all information fields in the claim. The claim cannot be processed if it is missing:

● actual ambulance mileage; ● attending physician information, including National Provider Identifier, name, tax ID, and physical address; ● medical record number; ● name, dosage, and National Drug Code number; ● occurrence date or from and to date, code, and span code; ● operating physician number and qualifier; ● service facility location state and ZIP code; ● value amount and code.

More informationIf you have questions about electronic claim submission guidelines, refer to the Independence Blue Cross HIPAA Transaction Standard Companion Guide, available on the Trading Partner Business Center.

For more information about the BlueCard Program, visit the BlueCard section of the Provider News Center or email us at provider_communications@ibx.com.

Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.

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Changes to precertification requirements for intravitreal VEGF products effective January 1, 2020Published November 1, 2019

As previously communicated in a Partners in Health UpdateSM article, effective January 1, 2020, Avastin® and its biosimilars (i.e., Mvasi™, Zirabev™) will be the preferred intravitreal vascular endothelial growth factor (VEGF) products for Independence commercial and Medicare Advantage members.* We will continue to cover the other intravitreal VEGF products, but they will be approved only for members who have demonstrated failure, contraindication, or intolerance to Avastin or an Avastin biosimilar.

Currently, there are six intravitreal VEGF products that treat ophthalmologic conditions such as neovascular (wet or exudative) advanced macular degeneration and diabetic macular edema:

● Avastin® (bevacizumab) ● Eylea® (aflibercept) ● Lucentis® (ranibizumab) ● Macugen® (pegaptanib) ● Mvasi™ (bevacizumab-awwb) ● Zirabev™ (bevacizumab-bvzr)

Updates to VEGF precertification requirements for ophthalmologic indicationsRequests for intravitreal Avastin or its biosimilars do not require precertification approval from Independence.

All new requests for Eylea, Lucentis, or Macugen received on or after January 1, 2020, will require precertification approval for all Independence members.

Members who have received Eylea, Lucentis, or Macugen in the past 12 months will continue to be approved to receive treatment with these drugs.

Learn moreThe following commercial and Medicare Advantage medical policies will be updated to reflect the new step therapy criteria:

● Commercial: #08.00.74m: Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and related biosimilars

● Medicare Advantage: #MA08.073f: Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and related biosimilars

Additional information on these changes will be published in a future Partners in Health Update article.

These changes will also be reflected in an updated precertification requirement list, which will be posted to our website.

*As additional biosimilars to Avastin receive approval from the U.S. Food and Drug Administration, these products will also be designated as preferred products for Independence members.

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Vaccinations recommended for adult Independence membersPublished November 5, 2019

The flu shot is not the only vaccine adults need. Encourage your adult Independence patients to get vaccinated and help us ensure they are fully immunized for other health risks.

Patients should get up to date with their vaccinationsStudies by the Centers for Disease Control and Prevention (CDC) indicate that the vaccination rates are extremely low among adults.1 In fact, most adults are not aware that they need vaccinations, or which vaccines are appropriate for them, until speaking with a health care professional. This highlights the importance of discussing vaccinations with your patients and assessing their vaccination status.

The CDC provides an Adult Vaccine Assessment Tool for patients to evaluate their immunization status.1 Patients can access the tool through the Vaccine Information for Adults section of the CDC website. The tool informs the patient what vaccinations are needed according to their age, gender, and medical conditions. Patients can discuss the results with their health care provider.

What providers should do for their patientsThe CDC also recommends a set of practice standards for providers.2 Providers should:

● Assess the immunization status of all adult patients at every clinical encounter. ● Recommend vaccines that patients need. ● Administer or refer patients to a vaccination provider (other provider that offers vaccines you do not stock). ● Document vaccines received by your patients.

By encouraging your Independence patients to stay up to date on their vaccinations, you are helping to reduce potential health risks that are preventable or minimized by vaccines.

Learn moreFor more information on vaccines and immunizations, providers can visit the CDC website, and the Internet Resources section on our website. 1 Centers for Disease Control and Prevention/Immunization Schedules. “The Adult Vaccine Assessment Tool.” 2019. Available from: https://www.cdc.gov/vaccines/adults/.

2 Centers for Disease Control and Prevention/Adult Vaccination Resources. “Standards for Adult Immunization Practice.” 2013. Available from: https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/.

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Eleven new drugs added to the Dosage and Frequency ProgramPublished November 15, 2019

As of January 3, 2020, the Independence Dosage and Frequency Program will expand to include 11 new drugs. Most of these medical benefit drugs are used to treat pulmonary arterial hypertension or are biosimilars to antineoplastic agents that are already part of this program.

The following is the list of new drugs that will be added to this program: ● Flolan® (epoprostenol sodium) ● KanjintiTM (trastuzumab-anns) ● Krystexxa® (pegloticase) ● Remodulin® (treprostinil) ● Revatio® (sildenafil) ● RuxienceTM (rituximab-pvvr) ● Tyvaso® (treprostinil) ● Veletri® (epoprostenol) ● Ventavis® (iloprost) ● Xembify® (immune globulin subcutaneous, human-klhw) ● ZirabevTM (bevacizumab-bvzr)

Learn moreFor more information on the dosage and frequency guidelines, please refer to the medical policies for each drug in the program. To access these policies, visit our Medical Policy Portal.

The complete list of all 71 drugs on this program can be found on our website.

If you have any questions about this program, please call the Independence Clinical Services department at 1-800-ASK-BLUE (1-800-275-2583).

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View up-to-date policy activity on our Medical Policy Portal Published November 21, 2019

Changes to Independence medical and claim payment policies for our commercial and Medicare Advantage Benefit Programs occur in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity section of our Medical Policy Portal to stay up to date with changes to our policies.

The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics include:

● Notifications ● New Policies ● Updated Policies ● Reissued Policies ● Coding Updates ● Archived Policies

For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference.

To access the Site Activity section, go to our Medical Policy Portal and select Accept and Go to Medical Policy Online. From there you can select Commercial or Medicare Advantage under Site Activity to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage tab from the top of the page. To access policies from the NaviNet® web portal (NaviNet Open), go to Independence NaviNet Open Plan Central and select Medical Policy Portal under Quick Links in the right-hand column.

NaviNet® is a registered trademark of NantHealth, an independent company.

CPT Copyright 2017 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association.

Medical codes for services that require precertificationA list of services that require preapproval/precertification from Independence prior to being performed for our members is available for providers on our Medical Policy Portal. This list, Services that require precertification, includes the CPT® and HCPCS codes, where applicable, that correlate with the services and injectable drugs that are included on our Preapproval/Precertification List.

To access Services that require precertification, visit our Medical Policy Portal. Links to Services that require precertification can also be accessed from the Quick Links section on the right-hand side of the Independence Provider News Center.

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Y BriovaRx Specialty Pharmacy and Infusion Services has become Optum Specialty Pharmacy and Optum Infusion PharmacyPublished November 5, 2019

As of October 1, 2019, and continuing throughout 2020, FutureScripts®, our pharmacy benefits manager, will be changing the names of their specialty pharmacy and infusion services programs from BriovaRx to Optum® Specialty Pharmacy and Optum® Infusion Pharmacy. These programs will continue to be administered through FutureScripts. This rebranding effort will only affect the program names and logos. The member and provider experience of how medications are ordered and delivered will remain the same. As you may know, FutureScripts already provides mail-order services for our members, your patients, under the Optum name.

Where you will see the name changeWe are currently identifying all channels that mention the BriovaRx name and will be updating them throughout 2020. During that time, the name will be updated on our website and printed materials, including the Provider Manual for Participating Professional Providers.

QuestionsIf you have any questions regarding this change, please call the pharmacy benefits number listed on the back of the member’s identification card.

FutureScripts is an independent company that provides pharmacy benefits management services.

Updates to the Blood Glucose Meter Program for commercial membersPublished November 13, 2019

At Independence, we are always looking for ways to provide our members with greater value for high quality health care. Based on this, we are changing our preferred test strips and monitors available for members who have been diagnosed with diabetes to use in monitoring their disease.

Effective January 1, 2020, Independence is changing the preferred test strips for diabetic care for commercial members to the OneTouch Verio® test strips. These replace the current preferred test strips provided by Ascensia Diabetes Care (formerly Bayer Health Care LLC) and Abbott Laboratories, both independent companies.

Free meters and information for membersWith the changes in preferred test strips, Independence is offering a free OneTouch Verio® or OneTouch Verio Flex® meter. The new meters can be used with the preferred brand OneTouch Verio® test strips. Members affected by this change will receive a letter regarding the change, as well as details on how to obtain a free meter and starter kit.

Learn moreIf you have any questions regarding the change in preferred test strips and meter, call FutureScripts at 1-888-678-7012. You may also view the informational flyer members received.

FutureScripts is an independent company that provides pharmacy benefits management services.

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YChanges to opioid management for members under 18 years of agePublished November 13, 2019

Independence remains committed to fighting the opioid epidemic in our region. Since implementing the five-day supply limit for members, based on claims data, Independence has seen a 45 percent reduction in opioid prescriptions, as well as a 36 percent reduction in opioid users.

In an ongoing effort to reduce the risk of substance use disorder in members under 18 years of age, while helping to ensure access to acute pain treatment, Independence is implementing the following limits effective January 1, 2020:

Note: A prior authorization is needed if additional days’ supply is required.

Learn moreIf you have any questions concerning the prior authorization process, please contact FutureScripts® at 1-888-678-7012.

FutureScripts is an independent company that provides pharmacy benefits management services.

Opioid product Days’ supply limitShort-acting opioids and opioid-containing cough and cold products Two 3-day fills within 60 days

Opioid-containing headache products One 3-day fill within 30 days

Independence drug program formulary updatesPublished November 20, 2019

Effective January 1, 2020, Independence will make changes to its Select Drug Program® Formulary and Value Formulary.

● Select Drug Program Formulary. This formulary-based prescription drug benefit program is available to commercial members. It includes all generic drugs and a defined list of brand-name drugs. All drugs on the formulary have been approved by the U.S. Food and Drug Administration (FDA) and were chosen for formulary coverage based on their medical effectiveness, safety, and value. Independence’s Pharmacy and Therapeutics Committee reviews the formulary periodically to ensure its continued effectiveness.

● Value Formulary. This is a restricted formulary managed by Independence and is available to commercial members. The selection of drugs for inclusion in the Value Formulary is similar to the Select Drug Program Formulary. All drugs on the formulary have been approved by the FDA and were chosen for formulary coverage based on their medical effectiveness, safety, and value. Drugs not included on the formulary (non-formulary drugs) have covered equivalents and/or alternatives used to treat the same condition.

In addition, new and updated prior authorization, morphine milligram equivalent (MME) limit, age limit, and quantity limit requirements will be applied to certain drugs on the formularies.

● Prior Authorization. Prior authorization requirements help ensure that prescribed drugs are medically necessary and are being used appropriately.

● MME Limit. The MME limit is designed to help with safe and appropriate opioid use. ● Age Limit. Age limits help ensure drugs are used in the appropriate age group in furtherance of patient safety. ● Quantity Limit. Quantity limits are designed to allow a sufficient supply of medication based upon the

maximum daily dose and length of therapy approved by the FDA for that drug. This also includes a day supply limit, which is based on the day supply of a prescription and not the quantity.

Please review the Select Drug Program Formulary and Value Formulary changes that go into effect January 1, 2020. For additional information on pharmacy policies and programs, visit our website.

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New! $0 Personal Choice 65SM Prime Rx PPO plan and Medigap plansPublished November 13, 2019

Independence is offering the NEW $0 Personal Choice 65 Prime Rx PPO plan to our beneficiaries in our five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties). Medicare beneficiaries can enroll now for January 1, 2020, coverage. Benefits of this product include:

● $0 monthly premium; ● $0 Preferred Provider copay*; ● access to the full PPO network – including 100% of area hospitals plus coverage when members travel in

37 states and one territory; ● no Part D deductible and no in-network medical deductible; ● no referrals – less red tape for members to work through; ● prescription drug coverage with a custom formulary.

*Preferred PCPs in the HMO networks are not necessarily providers in the Personal Choice 65 Prime Rx PPO preferred tier.

Tiered copaymentsThere are two in-network levels of copayments for select medical services in the Personal Choice 65 Prime Rx PPO plan. Providers can verify the appropriate copayment through the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal (NaviNet Open).

Medical services will have a “Preferred” or “Standard” copayment include: ● primary care provider visits ● specialist visits ● inpatient hospital care ● inpatient mental health care ● outpatient surgery ● outpatient hospital observation stays

Medigap plan expansionsIn addition to the new Medicare Advantage plan, Independence will modify its Medigap plan offerings.

● MedigapFreedom: Plan G-HD will be added for individual and group members. ● MedigapSecurity: Plans D, G, and G-HD will be available if requested by a group.

ID card samplesSee below for sample ID cards of these new plans:

Personal Choice 65 Prime Rx PPO MedigapFreedom

Learn moreIf you have questions about these new offerings, please call Provider Services at 1-800-ASK-BLUE (1-800-275-2583).

NaviNet® is a registered trademark of NantHealth, an independent company.

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New medical and pharmacy product portfolios available for 2020Published November 27, 2019

As previously communicated in a Partners in Health UpdateSM article, Independence has introduced new medical and pharmacy product portfolios that will be available to Pennsylvania large group (51+) standard plans for 2020. The new portfolio options will be offered to new and renewing customers beginning with January 1, 2020, effective dates.

Medical benefitsListed below are details of new and updated medical benefits:

● Cost effective site-of-service benefit differentials. New site-of-service benefits allow members to save on cost-sharing (i.e., copayment, deductible, and coinsurance) when accessing care, based on where that care is received. Additional services that members can save on include:

− biotech/specialty injectable drugs − infusion therapy

● Observation room copayment. An observation room copayment, equal to the emergency room copayment in most cases, is being added to certain plans when that service is part of an emergency room visit or an inpatient stay. The member will not have more than two copayments when the observation room copayment is applied.

● Multiple copayments in an office setting. When multiple services are performed in an office setting, a copayment will be applied to each clinical service. For example, if an X-ray is taken during an office visit, the member will have one copayment for the office visit, and one copayment for the X-ray.

Telemedicine benefits Telemedicine provides easy access to members when their primary care physician (PCP) is not available. Updates include:

● MDLIVE®. Members have access to board-certified physicians 24 hours a day, 7 days a week. Cost-share amounts will be lowered on most plans for this service beginning January 1, 2020.

● Penn Medicine OnDemand. Independence has partnered with Penn Medicine to bring a virtual primary care pilot to fully insured commercial members.* Advantages to this new pilot include:

− easy registration through the myPennMedicine app or online; − access available as audio only or with video; − results of each encounter can be shared with the member’s PCP.

*This benefit is available only to fully insured commercial members in the tri-state area.

Pharmacy benefitsMembers can get up to a 90-day supply of maintenance medications at Walgreens pharmacies for the same cost-sharing as mail order.

Learn moreAdditional information about these benefit additions and changes will be communicated in future Partners in Health Update articles.

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ENT Independence offers language assistance services to help

members and their beneficiaries communicatePublished November 4, 2019

We recognize that some Independence members may face communication challenges because they are differently abled, or English is their second language. For these members who are your patients, Independence provides free language assistance services through CyraCom® International, Inc., an independent company.

Your Independence patients (or their friends or family members) who speak languages other than English can call the Customer Service number on the back of their member ID card and follow the prompts to speak with a Customer Service representative in their language (e.g., Spanish, Chinese, Italian, etc.).

Independence also offers resources for members who are hearing, vision, or speech-disabled. These resources help members access plan information, communicate with Customer Service, and access information on web pages. These resources include:

● information available in braille ● large print materials ● print materials in other languages ● sign language interpreters with video conferencing ● audio recordings ● free telephone relay services via TTY/TDD: 711

Members can customize the size of website content and use enhanced search functions to find information on the website. These tools can provide members and their beneficiaries with equal access to their programs and benefits. Members can request alternate formats by calling the number on the back of their ID card.

Eliminating barriers to accessibility will enhance your patient’s perception of the care and information they are receiving. Be sure to discuss these options with your patients and their beneficiaries during their next appointment. If patients are interested in language assistance services in alternate formats, please encourage the member to call the number on the back of their ID card.

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ENT 2019 – 2020 Clinical Practice Guidelines Summary

now availablePublished November 18, 2019

We recently updated our 2019 – 2020 Clinical Practice Guidelines Summary, which provides sources and references to support your clinical decision-making. The revised summary includes a listing of all Clinical Practice Guidelines adopted by Independence that are considered accepted standards of care. Adherence to these guidelines may assist in improving patient outcomes.

Medical health guidelines are available for the following conditions:

● asthma ● chronic obstructive pulmonary disease (COPD) ● diabetes ● heart disease ● obesity

Behavioral health guidelines are adapted based on national peer reviewed information developed by our delegate, Magellan Healthcare, Inc. (Magellan). The 2019 – 2020 Clinical Practice Guidelines Summary includes information on how to access the behavioral health guidelines on Magellan’s website.

Guidelines are available for, but not limited to, the following conditions:

● anxiety ● attention deficit hyperactivity disorder ● autism spectrum disorders ● depression ● eating disorders ● substance use disorder

Changes in the 2019 – 2020 Clinical Practice Guidelines SummaryBased on provider feedback, changes in the 2019 – 2020 Clinical Practice Guidelines Summary include the following additions, updates, and deletions:

Additions ● Asthma

− Global Strategy for Asthma Management and Prevention (GINA Reports). Diagnosis and Management of Difficult-to-treat and Severe Asthma in Adolescent and Adult Patients (2018).

● Heart Disease − 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/

APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.

− Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents (2017).

Updates ● Asthma

− Global Initiative for Asthma (2018): Full Report, Appendix to Full Report, and Pocket Guide.

● COPD − Global Strategy for the Diagnosis, Management,

and Prevention of COPD: Full Report and Pocket Guide (2018).

● Diabetes − American Diabetes Association Standards of

Medical Care in Diabetes (2019).

Deletions ● Asthma

− Asthma, COPD and Asthma COPD Overlap Syndrome: In 2018 GINA and GOLD overlap was not a single disease but a range of different underlying mechanisms.

● Heart Disease − 2015 AHA/ACC/ASH Guideline on the Treatment

of Hypertension and CAD. This reference has been updated.

Guidelines are updated annually based on changes made to nationally recognized sources. Changes are reviewed by internal and external clinicians, including network physicians, quality committees, and others.

You can access the 2019 – 2020 Clinical Practice Guideline Summary on our website. Paper copies of the guidelines can be ordered by submitting an online request.

Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members.

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ENT Our Quality Management Program promotes quality of care

and servicePublished November 26, 2019

Independence is dedicated to enhancing the health and well-being of the people and communities we serve. Our Quality Management Program regularly reviews the care and service our members receive and promotes clinical, network, and service quality through its activities. Examples include member safety and wellness initiatives, disseminating clinical practice guidelines and standards of care, collecting member feedback on their care, and investigating quality-of-care and service concerns. As a participating provider, you have agreed to cooperate with, participate in, and abide by Independence’s Quality Management Program.

Standards of careAs a health care provider in our network, you are responsible for ensuring that our members receive quality care. Please review our standards of care in our Quality Management Program with your staff to confirm your office is meeting our standard of care requirements:

● Access and availability standards. To ensure our managed care networks meet the needs of our members, we provide standards for appointment access, the minimum number of office hours per practice per week, the maximum number of patients scheduled per hour per physician, and availability after hours. Our access and availability standards are in accordance with applicable regulatory requirements.

● Member rights and responsibilities. All Independence members have defined rights and responsibilities, including the right to be treated with respect, and the right to voice dissatisfaction about the quality of care or service they received to their health plan.

● Privacy and confidentiality. Independence, our contractors, and our affiliates are required to protect the privacy and confidentiality of our members’ personal and health information in accordance with applicable state and federal laws and regulations.

● Medical record keeping standards. Appropriate clinical documentation is fundamental to facilitating continuous and coordinated care. Medical records should be current, detailed, and organized as required by applicable regulatory requirements. We regularly review compliance with these standards and monitor the processes and procedures used to facilitate the delivery of effective and appropriate plans of care.

● Utilization review. Our utilization review process is intended to promote appropriate health care resource management and minimize clinically inappropriate interventions. Utilization review decisions are evidence-based and include a standardized review of the medical necessity of health care services and supplies related to the benefits available under the member’s coverage. We encourage peer-to-peer discussion by giving physicians direct access to Independence Medical Directors to discuss coverage decisions based on medical necessity. Additionally, clinical review criteria are available upon request.

Member safety and wellness initiativesThe following member safety and wellness initiatives aim to promote efficient utilization of services, facilitate coordination of care, promote adherence to the plan of care, and help to improve outcomes:

● Complex case management. Members with complex medical conditions like diabetes, asthma, high risk pregnancy, etc. may be eligible for case management programs. You can refer members online or by calling 1-800-313-8628.

● Drug Utilization Review. Targeted drug utilization reports are generated annually to identify opportunities for education related to prescribing and care coordination practices. Reports are sent via mail to your practice.

● Occurrence investigation. Our clinical staff, with Medical Director oversight, review all reported occurrences for quality issues. Our staff will request and review pertinent medical records, perform a detailed analysis, and request a corrective action plan from the facility or provider, if necessary. Please cooperate with all requests as outlined in your contract.

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● Blue Distinction® Specialty Care. Our Quality Management Program is responsible for recognizing facilities as Blue Distinction® Centers and Blue Distinction® Centers+ through the Blue Distinction® Specialty Care program when they meet stringent, objective national criteria for excellence in outcomes. Our members can see this designation in our online Commercial and Medicare Advantage Find a Doctor tools.

Learn moreFor more information about our Quality Management Program, including our goals and activities, visit our website or call Customer Service at 1-800-ASK-BLUE (1-800-275-2583).

Information can also be found in the Provider Manual for Participating Professional Providers and/or the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, which are available through the NaviNet® web portal (NaviNet Open). Paper copies of the manuals can be ordered online.

NaviNet® is a registered trademark of NantHealth, an independent company.

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Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (Independence) created to provide valuable information to the Independence-participating provider community that provides Covered Services to Independence members. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the Covered Services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with Independence. Refer to the Provider News Center to stay up to date on news and information from Independence.

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2016 www.dreamstime.com. All rights reserved.This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.The third-party websites mentioned in this publication are maintained by organizations over which Independence exercises no control, and accordingly, Independence disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.

NaviNet® OpenThe NaviNet web portal (NaviNet Open) is our secure, online provider portal that gives you and office staff access to critical administrative and clinical data. To help you navigate the portal and various transactions, we have created a central location for a variety of NaviNet Open resources, including user guides, webinars, and a communications archive.

NaviNet Open

Utilization ManagementCertain utilization review activities are delegated to different entities. Here you will find detailed information on our utilization management programs and common resources used among them.

Utilization Management

Opioid AwarenessWe have created a repository of tools and resources to assist you in managing your patients who are prescribed opioid medications.

Opioid Awareness Resources

Quick Links ● Bulletins ● Demographic Maintenance Guide ● Forms ● Frequently Asked Questions ● Medical Policy ● NaviNet Open Login ● Provider Home ● Services that require precertification

− Commercial − Medicare Advantage

Archives ● Partners in Health Update past edition PDFs ● Cumulative Index ● ICD-10 Transition

Email sign up ● Sign up for email from Provider Communications

Contact numbersPlease visit the Contact Information section of the Providers section of our website for a complete list of important telephone numbers.

Websites

Provider CommunicationsIndependence Blue Cross

1901 Market Street 28th Floor

Philadelphia, PA 19103

provider_communications@ibx.com