To the Provider Community: We Hear You and Will Continue to Provide Solutions

At CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice), we continue to look for easier and more efficient ways for you to interact with us. We have enhanced and expanded the capabilities of our FirstLine and BlueLine Voice Response Units (VRU) that enable you to get benefit information and responses to routine claims questions.

While we recognize that a provider may at first be apprehensive to use the VRU, we want to assure you that CareFirst and CareFirst BlueChoice stand behind the accuracy of the information provided and continually look for ways to make its usage more effective and efficient for our provider community.

Reasons to use the VRU:

• It saves time
• It gives accurate and consistent information
• It is available from 7 a.m. to 11:45 p.m. Monday through Friday
• No waiting on hold
• Complete multiple transactions within one call at your convenience
• Allows you more time to focus on other tasks
• More than 100 new benefit codes are available to providers through the FirstLine VRU
• Denial reasons are available by accessing claims denial

As part of CareFirst's Provider VRU - CareFirst Direct Campaign, effective Nov. 1, 2005, Provider Service Representatives at our CASCI, UCP and Red Run locations began to re-route provider calls back into the VRUs for calls that could otherwise be resolved through one of our self-service options.

Provider Service Representatives are available to assist you with:

• Accessing the VRU and providing step-by-step instructions on how to utilize the system, as needed
• Assistance with appeals
• Provide assistance with Administrative Services Only (ASO) accounts
• Assistance for out-of-area providers
• Materials to familiarize your staff on proper usage self-service options
• Assistance with difficult claims issues

The Provider Services Representatives do not need to verify the information on the VRU since these tools access the same databases available to CareFirst and CareFirst BlueChoice associates, and we stand behind these self-service options.

CareFirst and CareFirst BlueChoice are committed to creating initiatives to enhance our service and technology to make it easier for you and your staff, and to provide even more accurate eligibility, claims and benefit information. We invite you and your staff to try these self-help tools and experience how convenient and easy they are to use.

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Clarifying How to Use CPT® 96110, The Developmental Screening Test

To all pediatricians, pediatric providers, family practitioners and practice managers:

In response to inquiries from pediatric practices, CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) is clarifying the use of CPT® 96110.

Screening for developmental delays in motor, language and social interaction has been an important and integral part of monitoring children’s health for many years. Although there is a wide range of “normal” at any point in a child’s development, it is important to identify children who show signs of significant developmental delay so that more intensive efforts at diagnosis are initiated, followed by appropriate interventions. Although most children fall within the normal range, pediatricians are specially trained and highly experienced in the norms of developmental progress and in their ability to identify incipient delays in a child’s development.

Developmental assessment is a two-step process: firrst, a screening procedure to identify children in need of more indepth assessment; and second, developmental diagnosis, to better characterize the developmental problems and their significance in the context of a child’s biological, psychological and social strengths, and vulnerabilities.1

This developmental surveillance is an important technique used by pediatricians and family practitioners and is defined as a continuous process of skilled observations of a child during the provision of health care, including eliciting and responding to parental concerns, obtaining a relevant developmental history, accurate and informative observations of the child, and discussions with other relevant professionals.2

The American Academy of Pediatrics (AAP) recommends developmental/behavioral assessment of children at every preventive health visit, accomplished by history and appropriate examination, and if suspicious, by additional objective developmental testing.3 Consistent with this recommendation, CareFirst’s Preventative Services Guidelines include developmental assessment as part of each visit from birth through age 20.4

There are a number of formal and informal screening methods used by pediatricians and family practitioners to improve the sensitivity of screening methods. Pediatricians often use age-appropriate developmental checklists and parent questionnaires during preventive care visits as part of developmental surveillance. However, merely using a developmental checklist or administering a developmental history questionnaire is not the same as actually administering a timeintensive, structured developmental screening test. Such formal tests are carried out in a controlled environment by someone specially trained in the techniques of that particular test. The results and interpretation of such a developmental screening test must be comprehensive and include appropriate historical background, pertinent physical examination results, testing conditions, pertinent results of the test and recommendations for subsequent diagnostic and therapeutic measures.

CPT® 96110 is appropriate for the ensuing formalized testing of a child who has been found, through routine developmental surveillance, to be at risk for a significant delay in development. Therefore, it is not appropriate for pediatricians or family practitioners to submit a claim for CPT® 96110 for prescreening procedures done routinely during health maintenance.

In summary, CareFirst and CareFirst BlueChoice strongly support and encourage developmental screening services for children. However, that developmental screening is appropriately considered part of routine preventive health care, and thus is not paid as a separate service. A claim for CPT® 96110 should therefore only be submitted if the physician or another trained person under physician supervision and professionally licensed actually administers a formal, time-intensive structured developmental screening test, reports the results and interprets those results in light of the conditions of that particular child’s biological, psychological and social status.

1. Nelson’s Textbook of Pediatrics, 16th edition, p. 61, 2000
2. Developmental Surveillance and Screening of Infants and Young Children. American Academy of Pediatrics Committee on Children With Disabilities, Pediatrics 108:1, p.192-196, 2001
3. Recommendations for Preventive Pediatric Health Care. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Pediatrics 105: p. 645 – 646, 2000
4. CareFirst Preventative Services
   1. Guidelines, http://www.carefirst.com/providers/attachments/BOK5079.pdf
   Note: Current Procedural Terminology (CPT)® codes and descriptions are copyrights of the 1966 American Medical Association. All rights reserved.

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CareFirst and CareFirst BlueChoice to Launch Temporary Card Effort

As part of an ongoing effort to make access to health care easier, CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. will launch a "Temporary ID Card" initiative this summer in which members can obtain and use a temporary identification card.

The initiative should help ease concerns for new members who have not yet received their permanent card as well as existing members who have lost their cards. Providers should be prepared to accept this paper copy as proof of health insurance.

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News for Standard and Basic Options of FEP

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 precertification by CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. 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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Appropriate Reporting of Electrical Stimulation Modalities

A recent CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) study found that a majority of claims were errantly reported with CPT 64550 instead of CPT 97014 or CPT 97032.

In several CPT® Assistant newsletter articles, CPT® describes the appropriate reporting of codes 97014 and 97032. Refer to the published reference material on these particular codes in the Summer 1995 issue and the April 2002 issue.

CareFirst and CareFirst BlueChoice consider services reported with CPT® 64550 experimental/investigational (E/I), as providing a home Transcutaneous Electrical Nerve Stimulator (TENS) unit does not meet the evidence based CareFirst Technology Assessment Criteria criteria #2, 3 and 5. For additional information, refer to CareFirst and CareFirst BlueChoice Medical Policy 1.01.10, Transcutaneous Electrical Nerve Stimulators (TENS), at www.carefirst.com > Providers & Physicians > Medical Policies.

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

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Timely Filing Limit Now 365 Days After Date of Service

In an effort to make doing business with us easier, CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. will implement a consistent timely filing policy across all lines of business.

Effective July 1, 2006, providers will have a timely filing limit of 365 days from the date of service for care rendered on or after January 1, 2006. Each provider received formal notifi cation of this change, which applies to Group Hospitalization and Medical Services, Inc. and CareFirst of Maryland, Inc., collectively doing business as CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.

This timely filing policy does not override any federal, state or locally mandated timely filing periods for claims from participating providers.

Please note that after the timely filing limit, or 365 days after the date of service, providers are not eligible for reimbursement by CareFirst and CareFirst BlueChoice. Also after the timely filing limit, providers may not bill members for covered services that were not submitted within the timely filing period.

We hope you find this change to the timely filing limit to be beneficial to you and your office staff.

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Naltrexone Extended Release Injection Is Not A Covered Benefit

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. have determined that naltrexone (e.g., Vivitrol™), an extended-release injection for the treatment of alcohol dependence, will not be a covered benefit, effective immediately. There is no scientific evidence that this new formulation improves outcomes.

If you have questions, please contact your Provider Services representative.

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Annual Update for Freestanding Ambulatory Surgery Centers

Effective March 1, 2006, CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) formulated and implemented the annual update for all participating Freestanding Ambulatory Surgery Centers (ASC). Services rendered as a Participating Freestanding ASC Provider with CareFirst and CareFirst BlueChoice on and after March 1, 2006 will be governed by the agreement, as amended, effective that date. The purpose of the amendments are as follows:

• Updated the CPT®-4 Codes to reflect 2006 additions and deletions made by the American Medical Association (AMA).
• Incorporated changes made by Medicare to the listing of ambulatory surgery codes.
• Deleted CPT® Code 50590 from Attachment A-1. Approved ASC Procedure Codes and Payment Groups. Corporation will be contracting directly with Lithotripsy Providers for all Lithotripsy Services.
• Added to the list of surgeries are those eligible for payment in ASC CPTCodes that have not yet been added by Medicare. The additional CPT® Codes eligible for payment are: 15170, 15171, 15175, 15176, 50382, 50384, 50387 and 50389.
• Clarified language that payments for Extraordinary Supplies, Implants and Prosthetics are equal to 100 percent of the Medicare Maryland DMERC rates for 2006. Attachment A-2 reflects these amounts and specifies related quantities.
• All future annual reviews and updates performed by CareFirst and CareFirst BlueChoice shall be changed from March 1 of each calendar year to May 1 of each calendar year, effective May 1, 2007.

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

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FDA's Black Box Warnings to Appear on CareFirst Web Site

As part of the CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) patient safety initiative, Black Box Warnings issued by the Food and Drug Administration (FDA) will be posted on the CareFirst Web site, www.carefirst.com, as they become available.

Black Box Warnings are the FDA’s strongest warnings and are required to be placed on prescription drug labels to indicate that the product may cause serious adverse effects. The warning means clinical studies or serious animal toxicity indicate the drug carries “Special problems, particularly those that may lead to death or serious injury,” according to the FDA. The FDA requires some prescription drugs to include a Medication Safety Guide each time the medication is dispensed.

To access the warnings on the CareFirst Web site, click here. Notice of Black Box Warnings are also available via e-mail to those who are registered to receive e-mail from CareFirst and CareFirst BlueChoice.

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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:

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

Category III CPT® Reporting Codes Effective Jan. 1, 2006

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

Category III CPT® Reporting Codes Effective July 1, 2006

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Medical Policy Updates

The 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 identifying 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
1.02.03 Enteral Nutrition Therapy
1.04.01 Prosthetics

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

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PCPs Dissatisfied with Lack of Discharge Information

A recent survey by the CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. Quality Improvement department found that many primary care physicians (PCPs) are dissatisfied with the lack of discharge information from acute and skilled nursing facilities.

To facilitate improved continuity of care, PCPs are encouraged to instruct their patients to request the attending physician and/or facility to forward a copy of their discharge summary to their PCP.

PCPs may also request discharge information regarding an Emergency Room visit and/or any inpatient admission directly from a hospital or skilled nursing facility.

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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.

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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Hospital Seminars

Date and Time Location Room Tuesday, September 26, 2006 10 a.m. to 1 p.m. Hospital Quarterly Arlington Hilton and Towers 950 North Stafford St. Arlington, Va. 22201 Gallery Ball Room

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Professional Seminars

Date and Time Location Room Wednesday, September 13, 2006 10 a.m. to 1 p.m. B to B Sibley Memorial Hospital 5255 Loughboro Road Washington, D.C. 20016 Renanissance Conference Room Thursday, June 29, 2006 1 p.m. to 4 p.m. B to B Upper Chesapeake Medical Ctr. 500 Upper Chesapeake Drive Bel Air, Md. 21014 Chesapeake Conference Room

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Ancillary Seminars

Date and Time Location Room 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. 21401 Room 250A Tuesday, July 11, 2006 10 a.m. to 1 p.m. DME Holiday Inn Express 241 Railway Lane Hagerstown, Md. 21740 Conference Room Wednesday, July 26, 2006 9 a.m. to noon ASC Easton Memorial Hospital 219 S. Washington St. Easton, Md. 21601 Health Education Center, Rooms C & D Wednesday, July 26, 2006 1 p.m. to 4 p.m. SNF Easton Memorial Hospital 219 S. Washington St. Easton, Md. 21601 Health Education Center, Rooms C & D Tuesday, August 1, 2006 1 p.m. to 4 p.m. ASC Holiday Inn Express 241 Railway Lane Hagerstown, Md. 21740 Conference Room

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Phone Numbers and Address

See Where to File a Claim (Phone Numbers)

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Find Your Professional Provider Relations Representative

Not sure who your provider representative is or what number to call to reach him/her?

• Find your Professional Provider Relations Representative
  
  
• Find your Institutional Provider Relations Representative

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CLARIFICATION An article in the March/April 2006 edition of BlueLink titled “Medicare Advantage Overview” was not an announcement of a plan available through CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. However, Medicare Advantage products are available to members of other BlueCross BlueShield plans, and participating providers may encounter patients with this type of coverage.

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