Consumer-Directed Health Plans Available to Individual Members

Over the last few years, insurers such as CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) have started to offer Consumer-Directed Health (CDH) plans. A CDH plan allows consumers to better manage their health care costs by giving them increased financial responsibility and empowering them with information on managing those costs.

Generally, CDH plans are administered in the same manner as other PPO plans and feature a deductible of at least $1,050. Members with a CDH plan have a combined deductible for medical services and prescription drug coverage.

On March 1, CareFirst and CareFirst BlueChoice began offering two CDH options to our individual members. One plan offers a $1,200 deductible and the other features a $2,700 deductible. CDH cards look very similar to PPO cards. The line “$1,200 DED PPO/DRUG” indicates an in-network combined deductible of $1,200 that applies to medical services and prescription drug coverage.

As always, please determine the member’s benefits and eligibility prior to rendering services by calling BlueLine or FirstLine.

Billing Suggestions

• Send claims to the address on the back of the member’s ID card.
• We strongly encourage you to submit claims for processing before billing the member. The CareFirst and CareFirst BlueChoice payment voucher will indicate the dollar amount for which the member is responsible.
• Keep in mind that if you choose to collect payments at the time of service, you may need to refund the member for any overpayments you collected.

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Teaching Dental Professionals to Spot Abuse

Hoping to end the abuse of children and vulnerable adults, CareFirst BlueCross BlueShield (CareFirst) has given the Mid-Atlantic coalition, Prevent Abuse and Neglect Through Dental Awareness, (PANDA) a $30,000 grant.

The goal of PANDA is for dentists, dental hygienists and other health care professionals to recognize the signs and symptoms of abused or neglected patients, according to Dr. Gary A. Colangelo, CareFirst’s Dental Director.

“Recognizing abuse or neglect can save a child’s life, ease the suffering of a battered spouse and restore the quality of life for an elder,” Colangelo said.

Statistics show that one in four girls and one of eight boys will be sexually abused before their 18th birthday, while one of every 20 children is physically abused each year. An alarming 2.5 million cases of child abuse and neglect are reported each year.

In addition, 551,001 people aged 60 or older experienced abuse, neglect and/or self-neglect in 1998, according to studies – and in 90 percent of the cases the culprit is a family member.

As many as 75 percent of physical abuse cases involve head and neck injuries – areas of the body in which dental professionals have immediate access – and the PANDA effort hopes to teach dental professionals how to recognize signs of abuse and what to do about it.

Since the CareFirst grant in 2001, more than 700 dental personnel have been trained, the teaching curriculum has been expanded and PANDA has partnered with the Maryland Coalition Against Domestic Violence (MedChi) and the Maryland Network Against Domestic Violence.

Colangelo believes that dental care workers are well-suited to spot the abuse of children and vulnerable adults because children are more likely to have regular dental preventive care and abusers often avoid the same physicians but return to the same dental office.

“Dentists and dental hygienists are legally and ethically required to report suspected cases of child or vulnerable adult abuse to the appropriate social services agency,” Colangelo said.

The local PANDA program is a two-hour presentation that uses case studies and discussion to provide the basic information dental personnel need to recognize abuse and neglect.

Although child abuse cases are found throughout the Mid-Atlantic region, Colangelo called Washington, D.C. the “epicenter of child abuse.”

“We want them [dental professionals] to be aware that this is a problem and you’re going to see it,” Colangelo said.

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Refer Members to Other CareFirst BlueChoice Participating Providers

Providers, please remember to refer members to other CareFirst BlueChoice Inc. (CareFirst BlueChoice) providers for non-Primary Care Services as stated in the Referrals For Non-Primary Care Services section of your contract.

The contract states:

If Provider reasonably determines that a Member requires non-Primary Care Services, Provider will refer the Member to an appropriate CareFirst BlueChoice Provider. Provider will follow established CareFirst BlueChoice referral procedures, as set out in the CareFirst BlueChoice Provider Manual, including use of a properly completed CareFirst BlueChoice referral form. Provider will not refer Members to a non-CareFirst BlueChoice Provider unless the required medical services are not available in a medically appropriate manner through any other CareFirst BlueChoice Provider and the referral is authorized in advance by Corporation.

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Receive Important News Via E-Mail

E-mail is the fastest and most efficient way to communicate for many busy professionals, and now you have the option to receive timely news via-e-mail from CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice Inc. (CareFirst BlueChoice). E-mail updates are sent in addition to regular postal mailings (e.g., letters, contract updates, provider newsletters). E-mail news includes quick updates regarding changes in claims and billing procedures, links to online provider newsletters, product and benefit information, provider seminar announcements and more.

You may specify the networks you participate in and select your medical specialty (up to three specialty types or you may choose to receive information about all specialties). You will only receive e-mails that match your selected criteria.

To add your e-mail address to our list, visit the Providers & Physicians section of www.carefirst.com and click on Electronic Services, then select E-mail Registration. Please pass this information along to others who may wish to register, including your employees and billing agents.

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Provider Overhead Practice Expenses

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. follow the Medicare (CMS) guidelines in terms of what is included in the practice expense for each procedure code. A portion of a procedure code’s relative value unit (RVU) and associated reimbursement allowance is “practice expense.” The practice expense portion includes medical and/or surgical supplies and equipment commonly furnished in a practice, and that are a usual part of the surgical, medical,anesthesiology, radiology, or laboratory procedure or service. This includes, but is not limited to:

• Syringes/biopsy and hypodermic needles (e.g., HCPCS A4206-A4209, A4212-A4215)
• IV catheters and tubing (e.g., A4223)
• Gowns/gloves/masks/drapes (e.g., A4927-A4930)
• Scalpels/blades
• Sutures/steri-strips
• Bandages/dressings/tape (e.g., A4450-A4452, A6216-A6221)
• Alcohol/betadine/hydrogen peroxide (e.g., A4244-A4248)
• Sterile water/saline (e.g., A4216-A4218)
• Thermometers (e.g., A4931-A4932)
• Trays and kits (e.g., A4550)
• Oximetry and EKG monitors
• Blood pressure cuffs (e.g., A4660-A4670)

Therefore, additional charges for routine supplies and equipment used for a procedure, service, or office visit, and reported with CPT® code 99070, HCPCS code A4649 and any other code that describes these supplies or equipment, are considered incidental to all services and procedures. This is applicable whether or not the supply is reported with other procedures/services or is reported alone. Incidental services are not eligible for reimbursement, and subscribers may not be balance-billed for them. While we may have on occasion inadvertently paid for some of these supply items, effective July 1, 2006, we will no longer do so.

In addition, since surgical trays (A4550) are also included in the practice expense of procedures, effective July 1, 2006, we will consider these incidental to all procedures and will no longer reimburse for these trays.

You may view the components of the practice expense through the CMS Web site at:
http://new.cms.hhs.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage , and selecting “CMS-1502-P (2006).”

If you have additional questions, please contact Provider Services.

Note: Current Procedural Terminology (CPT)® codes and descriptions only are copyright of the 1966 American Medical Association. All rights reserved.

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National Provider Identifiers in 2007

Effective May 23, 2007, the use of a National Provider Identifier (NPI) is required for all providers who conduct business electronically. The NPI will ultimately replace all individual provider numbers from the various health plans, including CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice).

You can apply for an NPI through the Centers for Medicare & Medicaid Services (CMS) by:

• Completing the online application at https://nppes.cms.hhs.gov.
• Completing a paper copy of the application. To obtain a copy, call 800-465-3203 or visit https://nppes.cms.hhs.gov to print a copy.

Please note that CareFirst and CareFirst BlueChoice cannot accept the NPI as your provider number at this time. We are working with our clearinghouses to ensure that, together, we are prepared for the various electronic transactions that contain the NPI. Our goal is to make the NPI implementation as seamless as possible for you. Meanwhile, please continue to use your existing CareFirst and CareFirst BlueChoice provider numbers.

For more information on the NPI regulations, you can visit the CMS Web site at http://www.cms.hhs.gov/NationalProvIdentStand/.

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Presbyopia-Correcting Intraocular Lens Not a Covered Benefit

CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) have determined that the insertion of a presbyopia-correcting, accommodating intraocular lens, in conjunction with cataract surgery, is considered a patient convenience and not a covered benefit. Please refer to Medical Policy Operating Procedure 7.01.20A, Surgical Correction of Refractive Errors, which can be found in the online Medical Policy Reference Manual. To access the manual, visit the Providers & Physicians section of www.carefirst.com and select Medical Policies. This policy is effective May 1, 2006 for all CareFirst and CareFirst BlueChoice members.

When a CareFirst or CareFirst BlueChoice provider recommends the presbyopia-correcting intraocular lens, the member should be advised of their responsibility for the difference in charges between the standard/conventional intraocular lens and the accommodating intraocular lens and the cost of those charges. CareFirst or CareFirst BlueChoice should not be billed for any services specifically performed in conjunction with the accommodating lens.

CareFirst and CareFirst BlueChoice consider the standard intraocular lens professional charges to be eligible for reimbursement according to the terms of the member’s contract. The professional provider should continue to bill for the standard intraocular lens in cases where the member has elected to receive the accommodating intraocular lens.

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Updates to the CareFirst BlueChoice In-Office Procedure List

Effective March 1, 2006, services defi ned by CPT® procedure codes 71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034 and 71035* can be performed by pulmonologists in a physician office setting (in addition to contracted radiology facilities). Be sure to verify member eligibility and coverage prior to rendering services, as benefit limitations and medical policy requirements still apply.

A complete list of in-office codes is located in the Benefits section of the CareFirst BlueChoice Provider Manual. To access the manual online, visit the Providers & Physicians section of www.carefirst.com and select Administrative Guides in the Solution Center.

*For descriptions of these services, please refer to the current edition of the CPT® code book.

Note: Current Procedural Terminology (CPT)® codes and descriptions only are copyright of the 1996 American Medical Association. All rights reserved.

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Verifying Blue Member Eligibility Now Easier

At CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc., provider satisfaction is our top priority. We understand you need the right tools and resources to provide the best care to Blue members. So, to help you obtain member eligibility more quickly, we have enhanced our electronic services. For both CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. members and out-of-area Blue members, you can:

• Submit eligibility requests electronically
• Receive real-time responses to your eligibility requests

Plus, we’ve extended our service hours for you. We now process your electronic eligibility requests Monday through Saturday, 6 a.m. to midnight Central Time.

To submit electronic eligibility requests for Blue members, follow these three easy steps:

(enter appropriate steps) e.g.,

• Log in to www.carefirst.com
• Go to Solutions Center under Providers & Physicians
• Click on Claim Status & Eligibility
• Enter user ID and password
• Submit your request

In addition to receiving eligibility verifications electronically, you can always call BlueCard® Eligibility line at 1.800.676. BLUE (2583)

Your satisfaction is very important to us and we are committed to improving our service to you. In the coming year, you will see several additional enhancements in the electronic services arena, including the availability of more detailed eligibility information for Blue members.

If you have any questions, don’t hesitate to contact us:

• Visit us online at: www.carefirst.com
• Talk to your Provider Relations Representative.

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Medicare Advantage Overview

“Medicare Advantage” is the new program alternative to standard Medicare Part A and Part B fee-for-service coverage (generally referred to as “traditional Medicare”). Medicare Advantage is an outgrowth of the former Medicare + Choice program. It offers Medicare beneficiaries several product options (similar to those available in the commercial market), including health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS) and private fee-for-service (PFFS) plans. All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits, but many offer additional covered services as well (e.g., enhanced vision and dental benefits). On Jan. 1, 2006, many Medicare Advantage plans began offering Medicare prescription drug coverage for their members under the new Medicare Part D benefit program.

Medicare Advantage plans may allow in-and out-of-network benefits, depending on the type of product selected. For instance, Medicare Advantage HMO plans typically require members to obtain health care services through in-network providers, except in urgent or emergency care situations. By contrast, Medicare Advantage PPO and POS plans offer added flexibility by allowing members to select out-of network providers at additional member cost. While POS plans may limit available out-of-network benefits to those services specified by the plan, PPO plans must offer all covered services through both in and out-of-network providers. As a result, coverage for out-of-network claims may vary depending on the Medicare Advantage product type and plan selected by the member. Providers should confirm the level of coverage for all Medicare Advantage members prior to providing service since the level of benefits, and coverage rules, may vary depending on the Medicare Advantage plan.

Several Blue Plans offer Medicare Advantage products of the type mentioned above (e.g, HMO, PPO, POS and PFFS plans). The Blue Plan is typically (but not always) the primary payer for health care services provided to their Medicare Advantage members. Since Medigap policies are designed to supplement benefits under traditional Medicare (and not Medicare Advantage plans), such policies generally have no applicability in the Medicare Advantage context.

Types of Medicare Advantage Plans

Medicare Advantage HMO

A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals. Generally (except in urgent or emergency care situations), medical services are only covered when provided by in-network providers. The level of benefits, and the coverage rules, may vary by Medicare Advantage plan.

Medicare Advantage POS

A Medicare Advantage POS program is an option available through some Medicare HMO programs. It allows members to determine – at the point of service – whether they want to receive certain designated services within the HMO system, or seek such services outside the HMO’s provider network (usually at greater cost to the member). The Medicare Advantage POS plan may specify which services will be available outside of the HMO’s provider network.

Medicare Advantage PPO

A Medicare Advantage PPO is a plan that has a network of providers, but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers. Required member costsharing may be greater when covered services are obtained out-of-network. Medicare Advantage PPO plans may be offered on a local or regional (frequently multi-state) basis. Special payment and other rules apply to regional PPOs.

Medicare Advantage PFFS

A Medicare Advantage PFFS plan is a plan offered by an organization that pays physicians and providers on a fee-forservice basis. Enrollees can obtain services from any licensed physician or provider in the United States who is qualified to be paid by Medicare and accepts the plan’s terms of payment. The Plan must provide the same coverage as Medicare Part A and Part B, but may offer additional services.

Medicare Advantage Claims

Members who enroll in Medicare Advantage products may on occasion seek services out-of-network. As noted, coverage rules are likely to vary by product type and Medicare Advantage plan. When you furnish services to an enrollee in a Medicare Advantage Plan:

Ask for the member ID card. Members will not have a standard Medicare card; instead, a Blue Cross and/or Blue Shield logo will be visible on the ID card. The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards:

Verify eligibility by contacting 1-800-676-Blue (2583) and providing the alpha prefix. Be sure to ask if Medicare Advantage benefits apply. If you experience difficulty obtaining eligibility information, please record the alpha prefix and report it to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.

Submit claims to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. Do not bill Medicare directly for any services rendered to a Medicare Advantage member. Payment will be made directly by a Blue Plan.

Based upon the Centers for Medicare and Medicaid Services (CMS) regulations, if you are a provider who accepts Medicare assignment and you render services to a Medicare Advantage member for whom you have no obligation to provide services under your contract with a Blue Plan, you will generally be considered a non-contracted provider and be reimbursed the equivalent of the current Medicare payment amount for all covered services (i.e., the amount you would collect if the beneficiary were enrolled in traditional Medicare). This amount may be less than your charge amount. Special payment rules apply to hospitals and certain other entities (such as skilled nursing facilities) who are noncontracted providers. Providers should make sure they understand the applicable Medicare Advantage reimbursement rules.

Other than the applicable member cost sharing amounts, reimbursement is made directly by a Blue Plan. In general, you may collect only the applicable cost sharing (i.e. co-payment) amounts from the member at the time of service, and may not otherwise charge or balance bill the member. Special rules apply, however, in the PFFS context where balanced billing may be permitted under some plans.

You can make claim status inquiries through CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.

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Helpful Q&As and Quick Tips for Claims Filing

In CareFirst BlueCross BlueShield’s and CareFirst BlueChoice Inc.’s ongoing efforts to better service you, we are providing information to help make filing your Medicare claims easier. If you are a provider who accepts Medicare assignment and renders care to members from other Blue Plans, please note the following Q&As:

What are Blue Cross and/or Blue Shield Medicare-related claims?

These are claims for coverage that is secondary/supplemental to Medicare and is provided by a Blue Cross and/or Blue Shield Plan.

Examples include:

• Medigap (also called Medicare Supplemental, Medicare Complementary and Medicare Extended)
• Medicare Carve-out

How do I identify a member with a Medicare-related Policy?

Often, members will carry more than one identification (ID) card. Member’s current ID card, when Medicare is the primary payer, should be a standard Medicare card without a Blue Cross and/or Blue Shield logo. Members may also present a separate ID card with a Blue Cross and/or Blue Shield logo for Medicare secondary coverage.

Where do I submit Blue Cross and/or Blue Shield Medicare-related claims?

If the member has secondary coverage, submit the claim to your local Blue Plan. When Medicare is primary, submit claims to your Medicare intermediary and/or Medicare carrier.

It is essential that you enter the correct Blue Plan name as the secondary carrier, which may be different from the local Blue Plan. Check the member’s ID card for additional verification. The member ID will include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and coverage and key to facilitating prompt payments.

After receipt of the explanation of payment, or Medicare Remittance Notice from Medicare, look to see if the claim has been automatically forwarded (crossed-over).

If the remittance shows 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. You can make claim status inquiries through CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.

If the claim was not crossed-over, submit the claim to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. with the MRN. For claim status inquiries, contact CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.

Reminders for Remittance Advice:

Do not submit Medicare-related claims to your local Blue Plan before receiving a Medicare Remittance Notice from the Medicare intermediary and/or Medicare carrier. Duplicate claims submissions can delay claim processing and create administrative inefficiencies for you and the insurance plan.

If you have any questions, please contact Provider Services.

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Acute Inpatient Rehabilitation Now Covered for FEP Members

The 2006 Federal Employees Program (FEP) for Standard and Basic Options have an acute rehabilitation benefit. Under the FEP Service Benefit Plan this type of admission requires pre-certification by CareFirst. Failure to do so will result in a $500 penalty. If the stay does not meet criteria of medical necessity there will be no reimbursement. If the member is being discharged to an acute rehabilitation unit you must call the hospital assigned Utilization Review Nurse with the clinical information to support the medical necessity of the admission to facilitate the precertification.

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Reminder: Blue Member ID Cards Do Not Include Social Security Numbers

Blue Plans are sensitive to member concerns about identity theft and support legislative efforts toward protecting members’ privacy.

As of 2006, nearly all Blue Plans have replaced Social Security numbers on member ID cards with an alternate, unique identifier.

The new identifier begins with the three-character alpha prefix, which identifies the member’s Blue Plan and is critical for eligibility/benefits verification and claims processing, and may be followed by up to fourteen more characters, any combination of letters and numbers. Although the majority of member ID numbers still use only nine characters following the alpha prefix, some numbers will be shorter and some will be longer.

As a provider servicing out-of-area members, you may find the following tips helpful:

• Ask the member for the most current ID card at every visit. Since new ID cards may be issued to members throughout the year, this will ensure that you have the most up-to-date information in your patient’s file.
• Verify with the member that the ID number on the card is not his/her Social Security number. If it is, call the BlueCard® Eligibility line 1-800-676-BLUE to verify the ID number.
• Make copies of the front and back of the member’s ID card and pass this key information on to your billing staff.
• When filing the claim, always enter the identification number exactly as it appears on the member’s card, including the three-character alpha prefix.
• The member ID will always include the alpha prefix in the first three positions. The alpha prefix must be included, as part of the member ID number on the claim.
• Following the three-character alpha prefix, the ID number may include any combination of letters or numbers up to a maximum length of 17 characters total. This means that you may see cards with ID numbers between 6 and 14 numbers/letters following the alpha prefix.

Examples of ID numbers:

Remember: member ID numbers must be reported exactly as shown on the ID card and must not be changed or altered. Do not add or omit any characters from the member ID numbers.

If you have any additional questions, please contact Provider Services.

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New Technologies Evaluated

Our Technology Assessment Unit evaluates new and existing technologies to apply to our local indemnity and managed care benefit plans. The unit relies on current medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) criteria for coverage. Policies for non-local accounts like NASCO and FEP may differ from our local determinations. Please verify member eligibility and benefits prior to rendering services via BlueLine, FirstLine or CareFirst Direct. The Technology Assessment unit recently made the following determinations:

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Medical Policy Updates

Our Health Care Policy Department reviews medical policies and operating procedures on a consistent basis as new, evidence-based information becomes available regarding advances in new or emerging technologies, as well as current technologies, procedures and services.

The table below is a new guide designed to provide updates on any changes to existing or new local policies and procedures during our review process. Each local policy or procedure listed includes a brief description of its status, select reporting instructions and effective dates. Policies for non-local accounts such as NASCO and FEP may differ from our local determinations. Please verify member eligibility and benefits prior to rendering services via BlueLine, FirstLine or CareFirst Direct.

POLICIES UNCHANGED FROM LAST REVIEW
3.01.09 Attention Deficit Disorder (ADD) with or without Hyperactivity
8.01.11A Habilitative Services (Maryland Mandate)
9.01.02A Intravenous Patient Controlled Analgesia (IV-PCA)
Note: Current Procedural Terminology (CPT)® codes and descriptions only are copyright of the 1966 American Medical Association. All rights reserved.

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Practitioner and Staff Training Seminars

CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) offer half-day seminars designed to familiarize professional and institutional providers and office staff with CareFirst and CareFirst BlueChoice policy and provider-oriented procedures. We offer a variety of seminars to appeal to the needs of our versatile provider community. These seminar types are listed below, accompanied by a brief description and its identification code to assist in the selection of the appropriate seminar to meet your needs.

B to B - Back to Basics - designed to introduce professional providers to CareFirst’s and CareFirst BlueChoice’s full portfolio of products, claims submission procedures, coordination of benefits, administrative policies, quality improvement, the latest information on BlueCard and more. This seminar is an excellent “new provider staff” or “provider refresher” tool. Attendance will accredit primary care providers for CareFirst BlueChoice, Inc. Primary Care Physician Recognition Program.

Hospital Quarterly - designed to provide hospital staff with updated information on changes at CareFirst and CareFirst BlueChoice and may include special presentations on select topics.

Ancillary - designed to provide ancillary providers (Dialysis, SNF, DME, HIT, ASC, Hospice, Home Health and Mental Health) with updated information on changes at CareFirst and CareFirst BlueChoice and may include special presentations on select topics.

eFocus - designed to provide professional and institutional providers with information related to electronic claims solutions that are available through electronic claims submission, CareFirst Direct and www.carefirst.com. Representatives will also provide a high-level presentation on basic and updated CareFirst products and procedures. Attendance will accredit primary care providers for CareFirst BlueChoice, Inc. Primary Care Physician Recognition Program.

emf - eSystems Mini Fairs - designed to provide professional and institutional providers with more detailed information on electronic claim solutions by meeting with representatives from many of the large vendors who will showcase their products and answer specific questions. CareFirst and CareFirst BlueChoice representatives will also be available to review CareFirst Direct, www.carefirst.com and more. This is a new event for 2006.

eoh - eSystems Open House - designed to provide professional and institutional providers with more in-depth information on electronic claims solutions. This event will be a larger and more detailed event than our Mini Fairs and will be presented on Oct. 4, 2006 at the Columbia Hilton in Columbia, Md. More details and enrollment will be made available during the 2nd quarter of 2006.

Update - “Update Me” Seminars - designed to update professional and institutional providers about CareFirst and CareFirst BlueChoice changes. As a result of their popularity with our provider community in 2005, CareFirst “Update Me” seminars will return in 2006. Locations, dates and times will be announced later in the year and will take place during the 4th quarter of 2006. Attendance will accredit primary care providers for CareFirst BlueChoice, Inc. Primary Care Physician Recognition Program.

To register for any of these seminars, visit the Providers & Physicians section of www.carefirst.com for a full list of 2006 seminars and select “Register for a Seminar” in the Solution Center. If you do not have internet access, call the Provider Seminar Registration Line at 877-269-2219. Below is a list of upcoming seminars. Please note: Sign-in for seminars begins 15 minutes prior to the scheduled start time.

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Professional Seminars

DATE AND TIME LOCATION ROOM Tuesday, April 18, 2006 10 a.m. to 1 p.m. emf Sacred Heart Hospital 900 Seton Drive Cumberland, Md. 21502 Auditorium Thursday, April 27, 2006 10 a.m. to 1 p.m. B to B Virginia Hospital Center 1701 N. George Mason Drive Arlington, Va., 22205 Auditorium Wednesday, May 3, 2006 10 a.m. to 1 p.m. B to B Easton Memorial Hospital 219 South Washington St. Easton, Md. 21601 Health Education Center A,B,C & D Wednesday, May 17, 2006 10 a.m. to 1 p.m. B to B Doctors Community Hospital 8118 Good Luck Road Lanham, Md. 20706 DSE Room Wednesday, May 17, 2006 10 a.m. to 1 p.m. emf Ramada Inn 300 South Salisbury Blvd. Salisbury, Md. 21801 Devon Room Wednesday, June 14, 2006 10 a.m. to 1 p.m. B to B Montgomery General Hospital 18101 Prince Phillip Drive Olney, Md. 20832 Community Learning Center Thursday, June 29, 2006 1 p.m. to 4 p.m. B to B Upper Chesapeake Med. Ctr. 500 Upper Chesapeake Drive BelAir, Md. 21014 Chesapeake Conference

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Ancillary Seminars

DATE AND TIME LOCATION ROOM Tuesday, April 18, 2006 10 a.m. to 1 p.m. emf Sacred Heart Hospital 900 Seton Drive Cumberland, Md. 21502 Auditorium Wednesday, April 19, 2006 1 p.m. to 4 p.m. Mental Health CareFirst BlueCross BlueShield 6731 Columbia Gateway Drive Columbia, Md. 21046 Redwood Rom Tuesday, April 25, 2006 10 a.m. to 1 p.m. ASC CareFirst BlueCross BlueShield 10455 Mill Run Circle Owings Mills, Md. 21117 MPR LL03 Wednesday, May 3, 2006 10 a.m. to 1 p.m. HIT CareFirst BlueCross BlueShield 6731 Columbia Gateway Drive Columbia, Md. 21046 Redwood Room Tuesday, May 16, 2006 1 p.m. to 4 p.m. SNF Southern Maryland Hospital 7503 Surratts Road Clinton, Md. 20735 Library Wednesday, May 17, 2006 10 a.m. to 1 p.m. emf Ramada Inn 300 South Salisbury Blvd. Salisbury, Md. 21801 Devon Room Tuesday, May 23, 2006 1 p.m. to 4 p.m. Hospice CareFirst BlueCross BlueShield 10455 Mill Run Circle Owings Mills, Md. 21117 MPR LL03 Wednesday, June 21, 2006 10 a.m. to 1 p.m. Home Health CareFirst BlueCross BlueShield 6731 Columbia Gateway Drive Columbia, Md. 21046 Redwood Room Tuesday, June 27, 2006 10 a.m. to 1 p.m. Mental Health Anne Arundel Medical Center 2002 Medical Parkway Annapolis Md. Room 250 A & B Tuesday, July 11, 2006 10 a.m. to 1 p.m. DME Holiday Inn Express 241 Railway Lane Hagerstown, Md. 21740 Conference Room

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Hospital Seminars

DATE AND TIME LOCATION ROOM Tuesday, April 18, 2006 10 a.m. to 1 p.m. emf Sacred Heart Hospital 900 Seton Drive Cumberland, Md. 21502 Auditorium Thursday, May 11, 2006 10 a.m. to 1 p.m. Hospital Quarterly Providence Hospital 1150 Varnum St. N.E. Washington, D.C. 20017 Ross Auditorium Wednesday, May 17, 2006 10 a.m. to 1 p.m. emf Ramada Inn 300 South Salisbury Blvd. Salisbury, Md. 21801 Devon Room Thursday, May 25, 2006 9 a.m. to 1 p.m. DRG Virginia Hospital Center 1701 N. George Mason Drive Arlington, Va. 22205 Auditorium Tuesday, June 13, 2006 10 a.m. to 1 p.m. Hospital Quarterly Holiday Garden Inn 4770 Owings Mills Blvd. Owings Mills, Md. 21117 Garden Room

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Annual Criteria Review Complete

The CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) medical directors and a panel of active practitioners met on Oct. 26, 2005 for the Annual Criteria Review. The panel, which included primary care physicians and practitioners from various specialties, reviewed and approved the 9th edition Milliman Care Guidelines, the Modified AEP Criteria, and the Apollo Managed Care Physical Therapy, Occupational Therapy, and Rehabilitation Criteria. The Magellan Behavioral Health Medical Necessity Criteria was also reviewed and approved. The panel recommended a number of exceptions (i.e., longer lengths of stay) to the Milliman Care Guidelines Goal Lengths of Stay. The changes took effect Jan. 1, 2006 and are shown in the charts below.

To obtain a copy of the 9th edition Milliman Care Guidelines, please call Milliman USA at 610-687-5644. A copy of any of the mentioned criteria can be obtained or reviewed by calling the CareFirst and CareFirst BlueChoice Utilization Review Dept. at 410-528-7041.

CareFirst and CareFirst BlueChoice make available physician reviewers to discuss utilization management decisions. Physicians may call 410-528-7041 or 1-800-367-3387 x 7041 to speak with a physician reviewer. All cases are reviewed on an individual basis.

Important note: Utilization Management decision-making is based only on appropriateness of care and service and existence of coverage. CareFirst and CareFirst BlueChoice do not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Furthermore, utilization decision-makers do not receive any financial incentives that would encourage decisions that result in underutilization.

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BlueLink is published bimonthly by CareFirst BlueCross BlueShield’s Corporate Communications Department. Chief Medical Officer and Sr. Vice President of Medical Affairs Eric R. Baugh, M.D. Editor Robert Hilson newsletter.editor@CareFirst.com

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