Important National Provider Identifier Update

CareFirst and CareFirst BlueChoice are committed to providing information to assist you with the National Provider Identifier (NPI) implementation process.

To ensure that claims processing and payment continue smoothly up to and after the May 23, 2007 NPI implementation date, we are providing detailed guidance on how to manage this transition. To minimize any impacts on our ability to serve you during this period, we have outlined five specific steps for doing business with CareFirst and CareFirst BlueChoice:

1) Send your NPI directly to CareFirst/CareFirst BlueChoice

Providers should provide CareFirst/CareFirst BlueChoice with their NPI as soon as it is received. We are adding NPI information to our records and will link the NPI to your legacy ID (your provider ID number(s) assigned by CareFirst/CareFirst BlueChoice). NPIs cannot be extracted from claims. As a result, you must submit your NPI information directly to our Provider Information & Credentialing Department. Please send your NPI as soon as possible. Also, be sure to share your NPI with other health care providers (and payers) with whom you do business.

To submit your NPI, visit www.carefirst.com > Providers & Physicians > National Provider Identifiers (NPI) > Submission Form and follow the instructions provided online. If you do not have Internet access, please call Provider Services to obtain a copy of the NPI submission form or refer to the January/February 2007 BlueLink for other ways to submit your NPI. You will receive a confirmation via e-mail or by mail verifying that we received your NPI information.

2) Submit Legacy IDs and NPIs on 837 Electronic Claims

Industry reports suggest that providers, billing systems, clearinghouses and health plans may not be ready to fully implement NPI on May 23, 2007. As a contingency to avoid delays in claim submission and claim processing, CareFirst and CareFirst BlueChoice strongly recommend that providers continue to submit legacy ID numbers, along with the NPI. This is considered a “dual use” approach.

For more information, please refer to our NPI Dual Use Companion Guide. Visit www.carefirst.com > Providers & Physicians > Electronic Services > EDI Services > EDI Manuals to find the NPI Dual Use Guide

3) Test with your electronic claim vendor/ clearinghouse before May 23rd

Providers should share their NPI with their vendor/clearinghouse immediately for testing purposes. Electronic claim vendors should test 837 claim submissions with CareFirst/CareFirst BlueChoice prior to the compliance date. Please check with your vendor/clearinghouse to determine if they currently test with us on your behalf.

4) Submit Legacy IDs on Paper Claim Forms

We will accept the new CMS 1500 as of April 10, 2007 and the UB04 as of May 23, 2007 when submitted with legacy provider ID numbers. NPI will be considered optional. Claims submitted with an NPI only will be returned. For additional details, refer to the article “What you Need to Know about the CMS 1500 08/05 Claim Form” in this issue of BlueLink. You may also visit the National Uniform Claim Committee Web site at www.nucc.org. To order the CMS 1500 forms, please call the Government Printing Office at 202-512-0455. For information regarding the UB04, visit the National Uniform Billing Committee Web site at www.nubc.org.

5) Continue to Use Legacy ID Numbers for Inquiries and Referrals

Providers must continue to use their legacy ID numbers when submitting paper claims, writing referrals, and accessing BlueLine and FirstLine Voice Response Units, CareFirst Direct, iEXCHANGE and IASH.

CareFirst and CareFirst BlueChoice are working diligently to ensure a smooth transition to the NPI for our providers. We appreciate your cooperation in reviewing this information and for doing your part to prepare for the May 23, 2007 NPI compliance date.

If you have any questions about NPI, please send an e-mail to NPI@carefirst.com or contact Provider Services.

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Big Changes in CareFirst Direct

Major changes to CareFirst Direct will make it easier for you to do business with CareFirst and CareFirst BlueChoice.

Starting in April, you will notice a new look in the online tool. The Welcome screen will offer details about CareFirst Direct to help you navigate and quickly find the information you need.

The main changes to CareFirst Direct are in the eligibility and benefits sections:

• When you search for a member, use the membership number and either the member’s date of birth or name.
  
  
• Membership information will be displayed on the new eligibility screen, where you will also be able to review the coverage details for various products (medical, dental, pharmacy, vision). On the eligibility screen for out-of-area members, providers will find effective dates with a “from date” and possibly a second date. The second date not does not necessarily indicate a termination date but may indicate coverage through the date provided.
  
  
• The new screen will allow you to limit your search to specific benefits. To find inpatient hospital benefits, you will have the ability to search directly for inpatient hospital benefits. The new benefit screen will supply you with greater detail. For example, the new screen displays benefit limitations (number of visits, age restrictions, etc.).
  
  
• Please also be aware that FEP and NASCO members will be treated like Out-Of-Area members in terms of eligibility and benefit searches. You will need to provide the member’s name and relationship information when searching for these members to improve the accuracy of the response.

In addition to these changes, CareFirst Direct will now be available on Sundays from 9 a.m. to 4 p.m. We hope that these changes will enhance your CareFirst Direct experience.

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What You Need to Know about the CMS 1500 08/05 Claim Form

The National Uniform Claim Committee (NUCC) revised the CMS 1500 paper claim form to accommodate the use of the National Provider Identifier (NPI). Visit the NUCC Web site at www.nucc.org to find:

• The CMS 1500 Reference Instruction Manual for 08/05 version
• A copy of the new form available for downloading and printing
• How to order the new forms
• A “change log” detailing all adjustments to the new form (e.g., expanding certain fields to allow for future changes to billing codes, new fields added, etc.)
• Frequently Asked Questions

CareFirst and CareFirst BlueChoice will accept the CMS 1500 08/05 as of April 10, 2007 when submitted with your legacy provider ID number. After the May 23rd compliance date, legacy ID numbers will still be required on paper claims and NPI will be optional until further notice. Paper claims submitted with an NPI only will be returned.

For professional providers, please remember that a claim should report the services of only one practitioner. If more than one provider in your practice renders services for a given member, separate claims must be submitted to ensure quick and accurate claims processing.

Below are some changes that impact the way you submit the CMS 1500 claim form to CareFirst/CareFirst BlueChoice:

If you have any questions about the requirements for the CMS 1500 08/05 form, please contact Provider Services.

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Magellan's Tristate Office to Manage Health Care Benefits

On April 2, 2007, Magellan Behavioral Health (Magellan) will transition the management of CareFirst members’ behavioral health care benefits to its Tristate Care Management Center in Cincinnati, Ohio. Other than a few new voices on the other end of the phone, you should not experience any changes to how you access Magellan.

• The customer service line for providers and members will not change; continue to call Magellan at 800-245-7013 for all authorization requests and questions.
• Both appeals and treatment plans will continue to be faxed to 800-365-5030, as this fax number will be redirected to the Tristate Center.
• Continue to send correspondence to the post office boxes you use today or, as of April 2, correspondence can be sent to the new location (see address below).
• Your Magellan field network contacts, account manager, medical director and compliance functions will remain in Maryland and be available at their current phone numbers and mailing addresses.

CareFirst associates will continue to process claims, customer service requests, provide benefit quotes and eligibility verifications.

If you have any questions or concerns, please call your Provider Services Representative.

Tristate Care Management Center:
Magellan Behavioral Health
10101 Alliance Road Suite 201
Cincinnati, Ohio 45242

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Changes to Medical Records and Practitioner Office Standards

The CareFirst and CareFirst BlueChoice Quality Improvement Council (QIC) recently made changes to the Medical Records Documentation Standards and Performance Measures. The overall performance goal for compliance with the standards was increased from 80 to 90 percent.

The QIC also updated the Practitioner Office Standards and Performance Measures. The following were added:

• Standard for a smoke-free environment
• Standard related to automated external defibrillator maintenance and function checks
• Standard for destroying outdated or unusable narcotics
• Standard for electronic medical record security, data integrity, confidentiality and privacy
• New references, as applicable

To view the current standards, visit www.carefirst.com > Providers & Physicians > Resources and Seminars. To obtain a paper copy of the standards, please call 410-528-7997 or 800-323-4472.

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Cultural Diversity Program for Physicians

CareFirst and CareFirst BlueChoice are pleased to introduce an on-line learning tool to provide health care professionals with skills and techniques to more effectively communicate with patients of various cultural backgrounds.

Quality Interactions uses a patient-based approach that focuses on common clinical and cross-cultural scenarios, and includes web links to clinical guidelines, references and other relevant information.

Developed by the Manhattan Cross Cultural Group, the two-hour online course is easy and convenient, and network physicians earn 2.5 hours of Continuing Medical Education (CME) credit upon completion of the program.

Selected CareFirst and CareFirst BlueChoice physicians will be contacted this month and offered an opportunity to participate in the Quality Interactions program. For more information about the training program, please contact providercmes@carefirst.com or 410-605-2677 or 800-323-4472.

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Case Management - Assistance to Take Charge of Your Health Care Needs

CareFirst’s Case Management services can enhance your overall care by providing an organized, comprehensive and holistic approach to your health care needs. This will reduce the frustration of fragmented care that those with complex care requirements often face. Your case manager can help navigate the complex health care maze by coordinating your medical care services and help you to better understand what is happening to your health. Our specialty programs include:

Generalist – Our generalist case management team of registered nurses with diverse clinical background for patients with acute and chronic disease processes.

Pediatrics - Our pediatric case managers are experienced pediatric clinicians. They manage referrals for children ages 0 to 17 years with simple to complex health care needs. Our pediatric program also includes oncology education and support.

Oncology – Our oncology case management team is comprised of registered nurses with oncology experience and expertise to assist patients with a cancer diagnosis.

Great Beginnings – A case manager will contact you during each trimester of your pregnancy to provide supplemental support for expectant mothers, family members and physicians to enhance optimal maternal-infant outcomes.

When you enroll in the Case Management program, a case manager will contact you to review your medical history and identify important factors that may affect your health.

Your case manager is available to answer questions Monday through Friday, 8 a.m. to 4:30 p.m.

To enroll in Case Management or fi nd out more information about our programs call 888-264-8648.

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Updates to the CareFirst BlueChoice In-Office Procedure List

Effective March 1, 2007, the following procedure codes may be performed 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 in the Benefits section of the CareFirst BlueChoice Provider Manual. To access the manual online, visit www.carefirst.com > Providers & Physicians > Solution Center > Provider Manuals.

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Requirements for Mental Health and Substance Abuse Treatment

A treatment plan for outpatient mental health and substance abuse must be submitted by the provider prior to the ninth outpatient visit in order for the member to receive maximum benefits. In addition, effective Jan. 1, 2007, a treatment plan is required for FEP members with Medicare as their primary coverage.

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New Technologies Evaluated

Our Technology Assessment Unit evaluates new and existing technologies that 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 and 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.

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Medical Policy Updates

Our Health Care Policy Department continually reviews medical policies and operating procedures 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 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 benefi ts prior to rendering services via BlueLine, FirstLine or CareFirst Direct.

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

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Annual Criteria Review Complete

CareFirst’s and CareFirst BlueChoice’s medical directors and a panel of active practitioners met on Nov. 14, 2006 for the Annual Criteria Review. The panel, which included primary care physicians and practitioners from various specialties, reviewed and approved the 10th 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 were also reviewed and approved. The panel recommended no changes to the previous exceptions (i.e., longer lengths of stay) to the Milliman Care Guidelines Goal Lengths of Stay. The changes took effect Jan. 1, 2007 and are shown in the accompanying charts.

To obtain a copy of the 10th 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 410-528-7041.

CareFirst makes available physician reviewers to discuss utilization management decisions. Physicians may call 410-528-7041 or 800-367-3387 x 7041 to speak with a physician reviewer. All cases are reviewed on an individual basis. Important Note: CareFirst affirms that all Utilization Management (UM) decision-making is based only on appropriateness of care and service. We do not reward practitioners or other individuals conducting utilization review for denials of coverage or service. In addition, financial incentives for UM decision-makers do not encourage denials of coverage or service.

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Practitioner and Staff Training Seminars

CareFirst and 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 diverse provider community. Seminar offered by CareFirst and CareFirst BlueChoice are listed below accompanied and are accompanied by a brief description to assist in selecting of the appropriate seminar to meet your needs.

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 15 minutes prior to the scheduled start time.

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Hospital Seminars

Date and Time	Location	Room
Tuesday, April 3, 2007 8 a.m. to 1 p.m. emf	The Plaza 1718 Underpass Way Hagerstown, Md. 21740	Ballroom
Thursday, April 12, 2007 10 a.m. to 1 p.m. Hospital Quarterly	Hilton Garden Inn 4770 Owings Mills Blvd. Owings Mills, Md. 21117	Garden Room
Thursday, April 19, 2007 10 a.m. to 1 p.m. Hospital Quarterly	Martins Crosswinds 7400 Greenway Center Drive Greenbelt, Md. 20770	Posted in Lobby
Wednesday, May 16, 2007 1 p.m. to 4 pm. Hospital Quarterly	Ramada Inn 300 S. Salisbury Blvd. Salisbury, Md.	Devon Room
Thursday, May 24, 2007 8 a.m. to 1 p.m. emf	Hyatt Regency 100 Heron Blvd at Route 50 Cambridge, Md. 21613	Chesapeake Ballroom
Wednesday, June 6, 2007 10 a.m. to 1 p.m. DRG	Washington Hospital 110 Irving St. N.W. Washington, D.C. 20010	Siegel Auditorium

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Ancillary Seminars

Date and Time	Location	Room
Thursday, March 22, 2007 11 a.m. to 1 p.m. Hospice	Easton Memorial Hospital 219 S. Washington St. Easton, Md. 21601	Health Education Rooms C&D
Tuesday, April 3, 2007 8 a.m. to 1 p.m. emf	The Plaza 1718 Underpass Way Hagerstown, Md. 21740	Ballroom
Tuesday, April 10, 2007 11 a.m. to 1 p.m. ASC	CareFirst Owings Mills 10455 Mill Run Circle Owings Mills, Md. 21117	MPR LL03
Tuesday, April 17, 2007 11 a.m. to 1 p.m. HH	CareFirst Owings Mills 10455 Mill Run Circle Owings Mills, Md. 21117	MPR LL03
Wednesday, April 18, 2007 11 a.m. to 1 p.m. HIT/DME	Ramada Inn 300 S. Salisbury Blvd. Salisbury, Md.	Devon Room
Thursday, April 26, 2007 10 a.m. to 1:30 p.m. Sub/Mtl	CareFirst Columbia Gateway 6731 Columbia Gateway Drive Columbia, Md. 21046	Redwood Room
Tuesday, May 8, 2007 11 a.m. to 1 p.m. SNF	Shady Grove Adventist 9901 Medical Center Drive Rockville, Md. 20850	Willow Room
Wednesday, May 9, 2007 11 a.m. to 1 p.m. Hospice	CareFirst Owings Mills 10455 Mill Run Circle Owings Mills, Md. 21117	MPR LL03
Thursday, May 10, 2007 11 a.m. 1 p.m. HIT	CareFirst Columbia Gateway 6731 Columbia Gateway Drive Columbia, Md. 21046	Redwood Room
Tuesday, May 15, 2007 10 a.m. to 1 p.m. Sub/Mtl	Comfort Inn 8523 Ocean Gateway Easton, Md. 21601	Cambridge Room
Thursday, May 24, 2007 8 a.m. to 1 p.m. emf	Hyatt Regency 100 Heron Blvd. at Route 50 Cambridge, Md. 21613	Chesapeake Ballroom
Tuesday, June 5, 2007 11 a.m. to 1 p.m. ASC	Easton Memorial Hospital 219 S. Washington St. Easton, Md. 21601	Boardroom

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Professional Provider Seminars

Date and Time	Location	Room
Tuesday, March 20, 2007 10 a.m. to 1 p.m. B to B	CareFirst Owings Mills 10455 Mill Run Circle Owings Mills, MD 21117	MPR LL03
Tuesday, March 27, 2007 10 a.m. to 1 p.m. B to B	Franklin Square Hospital 900 Franklin Square Drive Baltimore, MD 21237	Redwood Room
Tuesday, April 3, 2007 8 a.m. to 1 p.m. emf	The Plaza 1718 Underpass Way Hagerstown, MD 21740	Willow Room
Wednesday, April 11, 2007 10 a.m. to 1 p.m. Update Me	Anne Arundel Community College 101 College Park Arnold, MD 21012	Cade 219
Tuesday, April 24, 2007 10 a.m. to 1 p.m. B to B	Holiday Inn Express 241 Railway Lane Hagerstown, MD 21740	Conference Room
Tuesday, April 24, 2007 10 a.m. to 1 p.m. emf	University of Maryland Medical Center 22 S. Greene Street Baltimore, MD 21201	Shock Trauma
Tuesday, May 1, 2007 10 a.m. to 1 p.m. B to B	Sacred Heart 900 Seton Drive Cumberland, MD 21502	Auditorium
Wednesday, May 9, 2007 1 p.m. to 4 p.m. Update Me	St. Agnes Hospital 900 Caton Ave. Baltimore, MD 21229	Community Room
Tuesday, May 22, 2007 10 a.m. to 1 p.m. B to B	Courtyard by Marriott 8506 Fenton Street Silver Spring, Md. 20910	Community Room
Thursday, May 24, 2007 8 a.m. to 1 p.m. emf	Hyatt Regency 100 Heron Blvd. at Route 50 Cambridge, Md. 21613	Ballroom

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Find Your Institutional Provider Relations Representative

Not sure who your provider representative is or what number to call to reach him/her? This information, as well as institutional provider representative information, can be found in the Providers & Physicians section of www.carefirst.com by clicking on Professional or Institutional under Find My Provider Representative in the Solution Center.

• Find your Institutional Provider Relations Representative

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Phone Numbers and Address

See Where to File a Claim (Phone Numbers)

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New Quantity Limits

Drug	Quantity Limit
Asmanex®	1 inhaler (0.24 grams)/30 days or 3 inhalers (0.72 grams)/90 days
Diabetic test strips (various brands)	3 boxes (#300 test strips)/30 days or 9 boxes (#900 test strips)/90 days
Migranal®	8 ampules per 34 days
Nuvaring®	1 ring/28 days or 3 rings/84 days
Oxycontin®	extended release 120 tablets (combined total of all strengths) per 34 days

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New Generics

The following drugs now have generic equivalents. As a result, the brand-name drug has moved to non-preferred (tier 3) and the generic alternatives are now available at tier 1.

The following drugs now have generic equivalents. As a result, the generic alternative is available as a tier 1 or generic drug. The brand-name drug remains on tier 3 or non-preferred.

For the most current preferred drug list, prior authorization forms and pharmaceutical management procedures, visit www.carefirst.com > Prescription Drugs. For a paper copy of the formulary and pharmaceutical management procedures, call 877-800-3086.

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Change in Prior Authorization Process for Self-injectable Drugs

On March 1, 2007, CareFirst and CareFirst BlueChoice simplified the prior authorization and medication fulfi llment processes for the following self-injectable drugs:

New prior authorization forms will be used for the medications noted above. These forms can be obtained from the Providers & Physicians section of www.carefirst.com by selecting Prescription Drugs, then Prior Authorization in the Solution Center or by calling CareFirst Pharmacy Management at 877-800-3086. The new forms will be used to request authorization AND medication fulfillment for all CareFirst and CareFirst BlueChoice patients. The forms include a prescription field, so once the form has been completed and signed it will be used as the patient's prescription. Completed forms should be faxed directly to our preferred specialty pharmacy vendor, ICORE Healthcare, at 866-546-2925 (as indicated on the forms). ICORE Healthcare will notify you and the member of approval within two business days. In addition, ICORE Healthcare will fill the medication and contact the patient for coordination of delivery and payment. With this new process, no separate prescription will be required for the patient. To avoid filling duplications of the medication, please do not provide a prescription to the patient.

For additional information, please contact CareFirst Pharmacy Management at 877-800-3086, or ICORE Healthcare at 866-522-2486.

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Formulary Changes

Effective April 1, 2007, Nasonex® and Rhinocort® will move to non-preferred (tier 3) status on our preferred drug list, resulting in a higher co-payment for members who are currently using these drugs .The lowest co-payment will be available with the use of formulary alternatives fluticasone and flunisolide, which are available as tier 1 or generic drugs.

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What's the Big Deal About Coding - Besides Getting Paid?

"It’s easier and takes less of my time to code abdominal pain, a code we use all the time, rather than look up the code for cholelithiasis."

"I’m not going to waste my time with all these codes. I’m being paid to take care of patients, not to be an expert coder."

These are comments from practitioners and their office staff upon hearing pleas for accurate coding from health insurance plans. The inaccurate codes are often discussed when practitioners call to learn why their claims were rejected or they were reimbursed lower than expected.

Submitting accurate claims to insurance companies for proper reimbursement is perhaps your most important reason to pay attention to the codes you use, but there are other ways code usage can have an impact on your practice.

The Problem
An article in the March 2005 Physicians Practice magazine states that the use of CPT codes is beset with a 45 to 55 percent error rate – and interventional radiologists’ coding was wrong 82 percent of the time. Since some codes change as frequently as quarterly, it is important to keep up-to-date with the CPT, HCPCS and ICD-9 codes.

Diagnosis codes (ICD-9-CM) have to be documented for each CPT/HCPCS code to verify medical necessity. The diagnosis codes should be as specific as possible to support the procedure or evaluation performed.

The current state of health care delivery demands more and better information to make decisions. The amount of information will not diminish in the near future and the mechanism for retrieving this valuable source of information – claims -- will continue until a novel, improved method takes its place. Since practices are impacted in multiple ways by how they code claims, it is best for those practitioners to pay close attention to how this process is performed in the office.

Monitoring Trends in Care
Health insurance plans, the government and researchers are some of the entities that use claims data to monitor trends in health care utilization and costs. Plans want to make projections about medical conditions that are on the rise and cost more to support in order to adequately allocate resources. Federal and state governments undertake similar activities, and also use the information to develop programs to address community needs, such as promoting appropriate planning and space for enhanced physical activity to fight obesity in areas where heart disease and diabetes are prevalent. Researchers use claims data in many projects to obtain large sample sizes, which are often resource prohibitive when using alternative methods like surveys and medical record reviews. Many of these studies are published in peer reviewed journals read by the community’s practicing physicians, and the findings are at times integrated into the way those practitioners deliver medicine. So how claims are coded has a greater impact on health care delivery than just providing a mechanism for reimbursement.

Quality of Care Measurement
Measurements of quality health care delivery are frequently conducted using claims data by organizations such as health insurance plans, the National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS). The results of those measurements are used in public reporting to assist consumers in making choices about where to receive their health care (report cards), and in various programs that have an impact on practitioners’ finances, such as Pay for Performance (P4P), variable reimbursement based upon performance compared to peers and tiered network selection.

Recent focus has been upon measures that assess not only the quality of health care delivered -- such as the receipt of HbA1c tests and eye exams in diabetes patients, as well as the outcomes and complications of those patients - - but also much more on the utilization of resources in managing patients’ clinical conditions. Health Maintenance Organizations and other health plans have used this cost measure for years, and is now tested by NCQA and CMS for use in their programs. This measure is known by several names like “cost efficiency” and “relative resource utilization.”

Detection of Inappropriate Billing Practices
Mining of claims is performed by health plans and government programs to detect fraud and abuse by providers filing for reimbursement. There are many software programs available that have algorithms to detect abnormal patterns and flag for closer scrutiny by knowledgeable health care delivery personnel. Consequently, significant sums of money have been returned to payers as a result of this activity, and providers are subject to legal ramifications if they knowingly participate in this type of activity.

Limitations of Claims Data
Claims data lack the robust clinical information found in other sources of medical information like medical records, i.e., physical findings and co-morbid conditions. There are limitations to the number of diagnoses that most practitioners code. When assessing outcomes of care, risk adjustment is needed to account for the sicker patients a practice might see compared to their peers. If the severity of the illness and other co-morbid conditions are not documented in the coding, the clinical condition being studied probably will not be adequately risk adjusted using claims. Although medical records are best for the rich clinical information, this process is very resource intensive – financial, time commitments and availability of qualified personnel to perform data abstraction.

Poor coding as to specificity of diagnosis and procedures is a frequent complaint of using claims data by those conducting the analysis and, indirectly by the practitioners that may be negatively impacted by the use of the ultimate analysis results. Practitioners admit to not coding well and say they have no urgent need to improve on this administrative function.

Movements to Address Some Concerns
Multiple quality improvement and measurement organizations, such as the National Quality Forum (NQF), NCQA and CMS, are confronted with the dilemma of being held accountable for promoting valid quality measurements over a broad spectrum of providers, but have a lack of data to perform the measurement. Several potential solutions have been proposed whereby more detailed information is captured through the coding process.

Medicare implemented the Physician Voluntary Reporting Program (PVRP) in 2006 to promote data collection and measurement by practitioners on 36 evidence-based clinically valid measures that have been endorsed by the physician community. This program is currently voluntary with discussions touching on perhaps using results in P4P and/or “Pay for Participation” programs down the line. This is a Medicare program and not a commercial insurance program.

The measures in this program use Medicare developed Gcodes, which are HCPCS codes that supplement the usual claims with clinical information demonstrating the quality of services delivered to Medicare beneficiaries. CPT Category II codes can also be used for some of these measures. This is considered an interim step on the way to electronic data submission through EMRs when they are widely adopted. An example of G codes that might be used for a patient with a history of a prior myocardial infarction that is being seen in the office and included in that practice’s measurement follows:

• G8033: Prior myocardial infarction: coronary artery disease patient documented to be on beta-blocker therapy
  
  
• G8034: Prior myocardial infarction: coronary artery disease patient not documented to be on beta-blocker therapy
  
  
• G8035: Clinician documented that prior myocardial infarction – coronary artery disease patient was not an eligible candidate for the beta-blocker therapy measure or the patient had no prior myocardial infarction

There is no additional reimbursement from Medicare for inclusion of the G codes, and many health plans, including CareFirst, do not recognize these codes.

Use of more detailed diagnositic codes has also been proposed. The ICD-9 codes are being updated to the ICD-10 codes, which are alphanumeric and have seven digits. The newer codes are more specific and increase the number of codes from ~13,000 diagnosis codes for ICD-9 to 120,000 for ICD-10, while the number of procedure codes increases from 11,000 to 87,000. Other countries have used the updated codes for several years. One reason cited for the update was enhancing data needs for health researchers and statistical analysis.

An example is a change from the sole code used for a sports injury resulting from being struck to the new 24 codes that list what object caused the impact – cleats, diving board, football, baseball, softball, soccer ball, golf ball, hockey puck, ice skate blades, etc. After protest by many concerned parties, including health insurance plans, Congress now targets the implementation of the ICD-10 codes for 2010. Training and understanding this new coding scheme will have a signifi cant impact on practices.

What Can You Do?

Basic steps that practices can take include employing a certified, experienced coder to complete insurance claims, and keeping current with coding changes. Ways to maintain currency include attendance at coding seminars and/or referencing updated provider coding manuals from the relevant health plans with which the practice contracts.

Some state and specialty medical societies offer or promote coding seminars to maximize reimbursement, but those methods may not be acceptable and reimbursable by health plans if they are not consistent with nationally recognized coding manuals and payers’ policies. In addition, because a code is found in a coding manual does not mean that a procedure or service will be reimbursed. This view is stated in the CPT manual - "Inclusion or exclusion of a procedure does not imply any health insurance coverage or reimbursement policy." If you are unsure, check with the health plan’s provider manual and contact the plan representative to determine what the specific insurance product covers.

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CareFirst BlueChoice to Introduce BlueChoice Advantage

To provide members more choices and easier access to health care, on April 1, 2007, CareFirst BlueChoice will introduce “BlueChoice Advantage,” a new product that offers members the freedom to choose their own doctor and/or specialist. With BlueChoice Advantage, members do not have to choose a primary care provider and referrals are not necessary to see specialists.

All CareFirst BlueChoice, PPO and Par providers should treat patients who present a CareFirst BlueChoice ID Card with “Advantage” printed on the front.

BlueChoice Advantage allows members access to three tiers of care:

Tier 1: Members receive care from a CareFirst BlueChoice network practitioner, specialist, hospital or other providers who participate in CareFirst BlueChoice’s provider network. Members receive the highest level of coverage at the lowest out-of-pocket expense.

Tier 2: Members receives care from any CareFirst participating provider and are responsible for all deductibles and co-insurance.

Tier 3: Members receive care from a non-participating provider and are responsible for all deductibles and co-insurance. Members must also pay the non-participating provider’s charges in full and receive reimbursement allowed under the contract directly from CareFirst BlueChoice.

CareFirst BlueChoice providers should continue to direct members to LabCorp for lab services. CareFirst BlueChoice contracted providers should be utilized for radiology, physical, occupational and speech therapies and chiropractic services for members to pay the lowest out-of-pocket cost. The product is designed to encourage members to use CareFirst BlueChoice providers, as their benefi ts will not be subject to deductibles or co-insurance. Deductibles and co-insurance will apply to members using PPO or PAR providers.

Providers may begin seeing CareFirst BlueChoice Advantage identifi cation cards in April, as new members join the plan. For easy identifi cation, CareFirst BlueChoice Advantage members will have the Prefi x XIH on their membership card. If you have questions, please contact your Provider Relations Representative.

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