Collective News
HCFA Coding for Place of Service
Do You Have Interpreter Services Available?
Formulary Update
New Technology Reviewed
Medical Policy for Non-Cosmetic Reduction Mammoplasty
Additional Payment for Multiple Birth Deliveries
CareFirst No Longer Uses Local Codes
Ambulatory Surgical Centers and Type of Bill Coding
Dental Billing for Infection Control
CareFirst's Depression Guidelines Now On-line
Physicians Must Obtain Injectables Administered in Offices

Indemnity News
BlueCard Point of Service is Growing
Provider and Staff Training
FEP Options for 2002

HMO News
BlueChoice: Telephone Numbers for Claims Status and Eligibility
LabCorp Reminders

HCFA Coding for Place of Service to be Used on All
CareFirst Claims

Recent review of HCFA1500 claims reveals that claims continue to be submitted with
invalid or missing Place of Service (POS) codes (Block 24B for paper claims). CareFirst BlueCross BlueShield (CareFirst) has historically required that claims be submitted using the most current version of the form and its instructions. This requirement is now being enforced for all CareFirst paper and electronic claims as a result of our adoption of a standard claim submission process and compliance with the State of Maryland’s uniform claim submission legislation now adopted under COMAR 31.10.11.

To avoid claims being returned and to assist you with proper POS coding, refer to the following tables which provide the proper HCFA/Medicare B value that you should use for submitting all paper and electronic claims. You will notice that the HCFA and Medicare B codes are the same (see Tables on Pages 2 & 3).

Please make any changes necessary to your billing processes and procedures to accommodate the use of HCFA/Medicare B values. It may be necessary for you to contact your vendor or clearinghouse to make these changes. If you have any questions, please contact your CareFirst Provider Claim and Benefit Inquiry Team.

Table I: The following table includes HCFA/Medicare B codes along with the comparable "old" CareFirst or National Standard Format (NSF) codes you may have been using.

Table II. The following table applies to CareFirst Maryland Region only and includes CareFirst and NSF values that have been used by providers submitting claims electronically. These NSF codes do not have a comparable HCFA value. This chart provides you with the HCFA replacement values that should be used for these types of claims for CareFirst Maryland Region only. These should not be used for CareFirst National Capital Region.

Do You Have Interpreter Services Available?

We urge all health care providers to be aware of their obligations under the Americans with Disabilities Act (ADA). Title III prohibits discrimination against individuals with disabilities by all places of public accommodation. Private health care providers, including private offices regardless of the size of the office or the number of employees, are considered public accommodations. Under this Title you must provide auxiliary aids and services to ensure effective communication with any individual with a hearing loss.

Auxiliary aids and services are defined as qualified interpreters, assistive listening devices, notetakers, written materials, television decoders, and telecommunication devices for the deaf (TDDs). A health care provider may not charge the deaf individual for the costs of providing the auxiliary aid or service directly or through the individuals insurance carrier. Costs are to be treated as part of the overhead costs of operating a business.

If you have specific questions, please contact the ADA Information Center for the Mid-Atlantic Region at 800-949-4232 or Provider Relations at 410-528-7103 or 800-228-8161.

Recent Formulary Additions

The Pharmacy & Therapeutics Committee announces the addition of the following drugs to the CareFirst formulary. For a hardcopy of the formulary, please call Provider Relations at 410-528-7103 or 800-228-8161.

2001 Formulary Review

The following is a list of generics that have been introduced as equivalents for brand name drugs and placed on our formulary during 2001. The brand names shown here are no longer preferred drugs and are considered 3rd tier; however, the generics are tier 1 (lowest co-payment).

The following generics are no longer available and have been replaced by the brand name drugs shown. These brand-name drugs are preferred (2nd tier) within our formulary.

New Technology Evaluated

CareFirst’s Technology Assessment Unit evaluates new and existing technologies for application to our indemnity and managed care benefit plans. The unit relies on current medical literature, local expert consultants, and physicians to determine our position on new technologies and whether those technologies meet our criteria for coverage. The Technology Assessment Unit recently made the following determinations:

Non-Cosmetic Reduction Mammoplasty is Considered Medically Necessary

Lipoplasty assisted breast reduction is considered medically necessary when performed for non-cosmetic reasons. Below is a review of CareFirst's medical policy regarding reduction mammoplasty.

Reduction mammoplasty, including lipoplasty assisted breast reduction (CPT code 19318), is considered medically necessary when performed to create symmetry post medically necessary mastectomy or when the following criteria are met:

Documentation of either of the following signs with or without musculoskeletal symptoms:

• Severe shoulder grooving, or
• Skin ulceration on shoulder or under the breast(s)

And either of the following:

• Submission of a pathology report for reduction mammoplasty documenting excessive tissue removal per the following weight parameters, or
• Submission of surgeon's report for lipoplasty assisted breast reduction documenting excessive tissue removal in cc's of supernatant fat* per the following criteria:

*Supernatant fat is described as the fat minus the fluid infused during the liposuction process.

For dates of service on or after December 1, 2001, CareFirst will make an additional payment to the professional provider for multiple birth deliveries. Additional benefits for antepartum or postpartum care for uncomplicated, multigestational pregnancies will not be provided.

• Multiple deliveries should be reported in addition to routine obstetrical care and delivery (billing code 59400, 59610, 59510, or 59618) by listing the applicable billing code for the delivery only (59409, 59514, 59612, or 59620) with modifier --22, and with a diagnosis code denoting multiple gestation (651.0 -- 651.9) or a multiple birth outcome of delivery (V27.2 -- V27.7).
• For multiple vaginal deliveries or multiple cesarean deliveries, the additional payment is 25% of the allowed benefit for the delivery only billing code reported. If a multiple birth consists of a vaginal delivery and a cesarean delivery, the cesarean delivery will be considered the primary procedure, and the additional payment will be 50% of the allowed benefit for the vaginal delivery only code reported. This is a single additional payment, which will not be increased for multiple births involving more than two deliveries on the same date of service.

CareFirst No Longer Uses Local Codes

As part of the uniform claims submission process, CareFirst no longer accepts local codes as of September 7, 2001. Please use the most recent version of the applicable code set and convert local codes to their corresponding codes. Acceptable code sets include: CPT, CDT, ICD-9-CM, HCPCS, ASA, NDC DSM-IV, UB-92, revenue codes approved by the HSCRC for hospitals in Maryland or revenue codes approved by the National Uniform Billing Data Elements Specifications for hospitals located outside of Maryland. For more information, contact your Provider Relations Representative.

Ambulatory Surgical Centers Use Code 831 for Type of Bill

Ambulatory surgical centers (ASC) should use Type of Bill code 831 in block #4 when submitting a paper UB92 claim. Also, be aware that ASC claims can now be submitted electronically to CareFirst. If you currently submit UB92 claims electronically, contact your vendor or clearinghouse for additional information. For providers who do not submit electronic claims, please contact WebMD at 800-241-4730 for details on the submission of these claims.

Dental Billing for Infection Control

Dental providers who bill for infection control using the local procedure code 1360 should discontinue this practice to avoid claims being returned. CareFirst does not provide a benefit for infection control as it is considered to be inclusive to the service being provided. In addition, the use of local codes has been discontinued throughout CareFirst with the adoption of uniform claim submission requirements effective September 7, 2001. For questions, please contact the Provider Inquiry Dental Team at 410-581-3541 or 800-272-1580.

Remember to Label Supporting Documentation

X-rays and medical records submitted in conjunction with claims or preauthorization requests should always include the patient's name, membership number and the related date of service.

CareFirst's Depression Guidelines Now On-Line

Primary care practitioners are reminded to screen for symptoms of depression during all visits. Screening tools, assessment guidelines, and treatment recommendations can be found in our Clinical Practice Guidelines for Depression in Adults in the Primary Care Setting, which is now available on-line at www.carefirst.com in the For Providers section.

If you would like a preprinted copy of the Guidelines, please call Provider Relations at 410-528-7103 or 800-228-8161.

Physicians Must Obtain Injectables Administered in Offices

Practitioners are required to obtain and bill for injectable medications administered in their offices. The patient should not be asked to get the medication from the pharmacy when it is to be administered in the medical office setting.

Please note the following exception: Depo-Provera, when used for contraception, is the only non-self administered injectable covered under the prescription drug benefit. As such, the patient may acquire it directly from the pharmacy and take it to the practitioner's office to be administered.

BlueCard Managed Care Point of Service is Growing

Effective January 1, 2002, several additional national accounts will be issued Maryland BlueCard Managed Care Point of Service (POS) ID cards with the appropriate three-character alpha prefix preceding their ID number (see the codes below). Please be sure that your patients, insured through the following employers, present their new ID cards (see the sample below).

Please note that the PCP name and telephone number will not appear on the ID cards issued for these new Maryland Point of Service (MPOS) accounts. If necessary, the patient's PCP selection can be validated on the monthly panel report.

Note: The BlueCard Managed Care/POS program is for members who reside outside of their BlueCross BlueShield Plan's service area. However, unlike other BlueCard programs, BlueCard Managed Care/POS members are actually enrolled in the MPOS network and are assigned a primary care physician (PCP). MPOS PCPs should apply the same referral practices and network protocols to these members that you would for any other MPOS member.

Upcoming Practitioner and Staff Seminars

CareFirst’s half-day seminars for practitioners and their office staff are designed to familiarize you with our newest programs, claims submission procedures, coordination of benefits, and vouchers/remittance notices. They also offer the latest information on BlueCard, HMO opt-out products, utilization management, BlueLine, ACCESS, and other topics. (CareFirst’s practitioner seminars do not include basic HCFA 1500 completion or coding training.

Seminars are held from 9:00 a.m. to 1:00 p.m. at our headquarters in Owings Mills. Please register in advance by calling 410-528-7103 or 800-228-8161. The next seminars will be offered:

• Tuesday, November 13, 2001

FEP Options for 2002

CareFirst would like to make you aware of changes the Blue Cross and Blue Shield Service Benefit Plan serving the Federal Employee Program (FEP) is making to its benefit offerings for 2002. In short, the Service Benefit Plan will continue to offer two options for federal employees and retirees in 2002. These choices will be Standard Option and Basic Option.

Here's what's new for 2002:

• The FEP Service Benefit Plan's High Option enrollees will be merged into Standard Option as of December 31, 2001. Currently, the Blue Cross and Blue Shield Service Benefit Plan offers two different benefit options - High Option and Standard Option. Research shows that many federal employees find the High Option no longer affordable and would prefer other health benefit options. Accordingly, at the end of 2001, the FEP Service Benefit Plan will merge High Option enrollees into the Standard Option.
  
  High Option and Standard Option FEP enrollees currently utilize CareFirst's Select Preferred Provider (SPP) and Participating (Par) networks for in-netowrk benefits. If you are a participant in our SPP or Par networks, you may continue to see any and all High Option enrollees who are merged into Standard Option for 2002.

• The FEP Service Benefit Plan will introduce a new option called Basic Option in 2002. This new benefit package has been specially designed based on comments received from federal employees and in recognition of the need for more affordable health plan choices in today's economic environment. Basic Option offers a lower premium and no deductibles. Basic Option will be offered along with Standard Option to FEP enrollees for 2002 during the upcoming open enrollment period of November 12 through December 10, 2001.

If you participate with our SPP network, you may see all enrolled FEP patients, including Basic Option enrolleees, in 2002 that you do today. FEP members who select Basic Option must seek care from a Select Preferred Provider to receive benefits. If you are a Participating Provider only, no benefits are available for services provided to Basic Option members. You will be able to identify Basic Option members by the plan's distinct ID card.

As of January 1, 2002, all CareFirst indemnity FEP members will be serviced exclusively by CareFirst's Par and SPP networks. To participate in either the Par or SPP regional provider networks, your practice needs to have completed an agreement with Group Hospitalization and Medical Services, Inc. Otherwise, as of January 1, 2002, you will no longer be eligible to see FEP members.

Look for a summary of 2002 Blue Cross and Blue Shield Service Benefit Plan benefits by option in the next issue of BlueLink. If you have questions, please call our FEP Provider Service Unit at 410-581-3568 or toll-free 800-854-5256. You may also visit the FEP Service Benefit Plan's Web site at www.fepblue.org.

Do you need to check claims status or eligibility on BlueChoice members?
Recently, CareFirst introduced CareFirst BlueChoice, Inc. to our CareFirst family of products as our regional HMO. Presently, you can check claims status by calling the Voice Response Unit (VRU) at 202-479-6560, 202-646-1270 or 800-842-5975. If you need to verify a patient's eligibility, however, you'll need to transfer out of the VRU by pressing 0 and speak directly to a Provider Services Representative.

LabCorp Reminders

To ensure your prompt receipt of patient lab reports from LabCorp, use a LabCorp Requisition form when ordering tests. To obtain Requisition Forms preprinted with your information, call LabCorp at 703-742-3167 or 888-859-0391.

Be sure to enter the member's birth date and membership number on the Requisition Form. An ICD-9 diagnosis code is also required. There is space on the form for your clinical comments and for you to request that report copies be sent to additional providers.

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