Fall 2009

Our vision for the future of retail health care

The Blue Cross and Blue Shield of Florida, Inc. (BCBSF) vision of retail health is focused on partnering with individual consumers to help them make the best health and financial choices for themselves and their families. We are committed to being the leading consumer-oriented health care company in Florida. "Our goal is to create a completely new consumer experience to provide the trusted advice and guidance that our members have come to rely on. This innovative concept will allow members to take more control over their health care through one-on-one consulting services and education," said Craig Thomas, vice president and chief marketing officer. "It will allow us to bond with our members as true health care partners to help simplify the system and control their personal costs."

BCBSF is unveiling a series of programs and services based on consumer feedback. Last year, BCBSF began promotion of The Power of the Human Voice. Through that campaign, we gained valuable insight into the services and capabilities that consumers want. As a company, we believe we play a unique role in the health and well-being of Floridians. Giving voice to consumers—and really listening to them—offered us an opportunity to respond with more affordable, innovative products and services that more closely fit their lives and budgets. What's more, it enabled us to honor our commitment to continue to develop solutions that members can rely on for their unique health care coverage needs.

Our Blueprint for Health^® programs and services are a great response. Included in this initiative are online tools, new worksite health clinic, pre-paid health cards and retail centers.

Online Tools

Whether a member is already healthy and they want to stay that way, feeling under the weather, has a chronic condition they want to get better control of or is experiencing a health care crisis they didn't see coming, BCBSF offers many free resources – on the web, over the phone or in person. "Members are having an increasingly difficult time understanding the growing complexities of the health care system," says Diane Kelley, vice president, Contact Process. "In addition, the prevalence of plans with higher cost sharing places greater responsibility and choice in the hands of the members as a consumer of health care. For many of our members, this is a new experience and they need information and resources to choose well."

MyBlueService, our self-service website for BCBSF members, is continuously being updated to provide more helpful and easily accessible information to your patients. By using MyBlueService, and everything it offers, BCBSF members will become more empowered to take control of their overall health, including their health costs and outcomes. Benefits information is just a click away, so if members have any questions about their coverage, they can get their answers 24/7. MyBlueService offers members more than just health plan information. Much of what it offers is personalized to the individual to make it even more valuable.

Some examples include:

• The member's network now automatically populates the provider directory so there's no confusion about whether a provider is participating.
• A pharmacy price comparison shopping tool links to other drug-related information including requirements for prior authorization, quantity limitations and step therapies where indicated – all based on what drug the member chooses.
• Health management program is a personalized actionable plan recommended based on a member's personal health assessment results.

MyBlueService is more than an information site; it is an important tool for managing personal health information. Members can organize all their health-related documents into a single secure location. They can permit their physicians and care providers to access their Personal Health Record (PHR) when appropriate. Members can save time completing new patient paperwork by printing their PHR and taking it with them to their doctor visits. This ensures consistent and complete data without the challenge of remembering dates and services.

BCBSF recently added Lifestyle Improvement Programs to our suite of WebMD tools available through MyBlueService. The Lifestyle Improvement Programs provide a personalized, engaging and highly interactive way for members to address and improve their risk factors at their own pace by providing information, planners, tips and tools in the key areas of emotional health, exercise, nutrition, smoking cessation, stress management and weight management.

Our Care Consultant Team (CCT) offers members truly personalized service by understanding their treatment options and comparing the cost and quality of care – whether it be a simple prescription or something much more complicated. The CCT uses tools like the pharmacy comparison shopping tool and Care Comparison.

Earlier this year, we introduced Care Comparison, a new transparency-related tool to assist our members as they navigate through the health care delivery system. Care Comparison is designed to allow members to evaluate the total estimated cost of approximately 40 specific medical procedures (bundles) performed at hospitals, ambulatory surgical centers or imaging centers. For more detailed information about Care Comparison see the article in this issue.

Worksite Health Clinic

Another component of Blueprint for Health is BCBSF's own worksite health clinic which opened the end of June 2009 and focuses on prevention and intervention. The first clinic – a pilot – is available to BCBSF employees located at or traveling to the Jacksonville, Florida-based home office. It offers low cost, high quality health care for minor illnesses and enables our employees to adopt healthy behaviors through in-person support, incentives and lifestyle improvement programs.

Pre-paid Health Cards

With 95% of U.S. households purchasing or receiving gift cards annually, the pre-paid health cards are an innovative way to make health insurance conveniently available at neighborhood Winn-Dixie and CVS stores in Florida. The cards will be promoted in Winn-Dixie, beginning in September, and CVS, beginning in October. To use the pre-paid health cards, consumers simply call the number on the back of the card to activate and enroll. For detailed information about Pre-paid Health Cards see the article in this issue.

Retail Centers

In 2006, we opened the first of our Florida Blue retail stores. The stores were designed to provide easier access to health care for Floridians. To improve on this concept, we are taking it a step further—now creating consumer health centers—offering decision making support and services to communities. An exciting new idea for the industry, our first center is scheduled to open in Tampa in January, 2010.

Florida Blue consumer health centers provide physicians a place to send their patients to learn more about their BCBSF health plan coverage, wellness services and, if they need it, to buy health coverage. They will provide a one-stop shop for our members where a staff of knowledgeable friendly service, medical professionals and sales associates are dedicated to helping members maximize their health plan benefits while empowering them to make smart health care decisions for themselves and their families. Florida Blue consumer health centers can relieve physicians of having to be the expert on their BCBSF patient’s health plan benefits and programs allowing them to focus on providing care.

In addition to being able to learn about and purchase insurance plans, consumers can work with our care consultants to research providers, treatment options, quality and costs. A focus will be placed on wellness and preventive care, teaching members how to utilize the tools available to them through MyBlueService. Also, members will be able to take personal health assessments and participate in educational forums. The new Florida Blue centers will have seminar areas, a health library and will be Wi-Fi enabled for public use.

Fall 2009

Talk to your patients about advance directives

Blue Cross and Blue Shield of Florida, Inc. (BCBSF), State of Florida and Centers for Medicare & Medicaid Services (CMS) recognize the right of a competent adult to make an advance directive.

BCBSF encourages physicians to have end of life conversations with their patients 18 years and older about the plan of care to ensure that the person's choices regarding when to accept or refuse medical treatment are honored. Documentation of the existence of an advance directive or copy in a prominent part of an individual's medical record allows end of life wishes to be carried out as a result of later physical or mental incapacity.

The four types of advance directives recognized in Florida:

• Living Will

• Healthcare Surrogate Designation

• Durable Power of Attorney for Healthcare

• Do-Not-Resuscitate (DNR) Order

Advance directive handouts are available in English and Spanish. Visit www.bcbsfl.com, click Physicians & Provider, Tools & Resources, then Forms and scroll down to Member Forms. Additional information can be found in the Manual for Physicians and Providers, which is available on the Manuals & Billing Instructions page under Tools & Resources on our website.

Thank you for supporting this initiative, which facilitates communication, coordination and continuity of care for our members. For questions regarding advance directives, please contact Joanne Keenan, R.N., at (800) 555-8228, ext. 87329.

Fall 2009

Helping to manage urinary 
incontinence in older adults

Urinary incontinence remains significantly under-reported and under-diagnosed for adults age 65 and older, according to the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). Behavioral and pharmacotherapy strategies can make tangible differences in improving outcomes for patients.

As part of your routine screenings, initiate a dialogue with your patients about urinary incontinence for early identification at the earliest possible stage when pharmacologic or other treatments are most effective. For women, make it a part of the comprehensive screening that they already undergo for breast cancer, cervical cancer and diabetes. For men, make it part of a regular screening program for prostatitis, benign prostatic hyperplasia, prostate cancer and diabetes.

Here are five simple questions that you can use with your patients to help assist with your assessment and diagnosis of urinary incontinence and/or related problems:

1. Many people experience problems with urinary incontinence, the leakage of urine. In the past 6 months, have you accidentally leaked urine?
2. How much of a problem, if any, is the urine leakage for you?
3. How have you been dealing with your urinary incontinence?
4. Would you like to talk more about your urine leakage problem?
5. Would you like to discuss ways to treat it?

The 2008 Medicare Health Outcomes Survey indicated 54.6 percent of respondents who had urine leakage problems reported that they discussed their problem with their providers and only 38.8 percent of respondents reported they received treatment for their urine leakage problem.

Urinary urgency, frequency and incontinence are important symptoms that may be indicative of other serious diseases including diabetes, benign prostatic hyperplasia, prostatitis, prostate cancer, bladder cancer, urinary tract infections and an overactive bladder. Urinary incontinence may also cause a wide range of morbidities including cellulites, pressure ulcers, urinary tract infections, falls with fractures, sleep deprivation, social withdrawal, depression and sexual dysfunction. Many men and women experience urologic symptoms but fail to seek medical help for them because of embarrassment or the misconception that urologic changes are normal and an inevitable part of aging.

If you have any questions, call Joanne Keenan at (800) 555-8228, extension 87329.

Fall 2009

Realize financial savings 
through electronic adoption

There are real financial gains to be realized for acquiring and using electronic health records (EHRs) and other electronic tools. As seen in recent headlines, federal stimulus incentives will be offering physicians up to $44,000 over five years for the adoption of EHR and other electronic tools. But even if you are not yet ready for a full-blown recalibration of your practice, you can take smaller steps that can result in sizeable financial savings and position your practice for larger future change. Here's how:

1) Run the numbers. There are industry calculating tools on the internet that allow you to compare costs of your current manual processes with more streamlined electronic processes. You'll find exactly how much money you can save on postage, envelopes, labor and paper—even the time and fuel it takes to drive to the bank to make manual deposits—simply by using electronic tools. To get started, visit www.ushealthcareindex.com or access the Savings Calculator at http://www.emdeon.com/support/document_library.php.

2) Start slow and at no cost to you. Rome wasn't built in a day. Ease into making the larger-scale change to EHRs by accessing administrative, financial and clinical tools that are simple to use and easily accessible now, at no cost. Check out the menu of electronic self-service tools Blue Cross and Blue Shield of Florida, Inc. (BCBSF) offers providers through the Availity^®1 Health Information Network by visiting our website, www.bcbsfl.com, clicking on Physicians & Providers, Online Services, then e-Capabilities & Health Information Technology. Start using one or two, then escalate to using them all. This will allow you to pocket the extra cash. Visit www.availity.com or call (800) 282-4548 (AVAILITY) for more information.

3) Develop a technology-savvy staff. Financial incentives offered to electronic users today will turn into financial penalties for non-users tomorrow. Your staff will be key to realizing big returns for your practice. So help them become technology-savvy now by incorporating electronic tools in day-to-day processes. Your staff can learn how to use most tools in an afternoon and be that much more "tech-y" when it's time for larger-scale change. To learn more about stimulus money physicians can earn under the American Recovery & Reinvestment Act of 2009, click here.

Fall 2009

Eligibility & Benefits transaction has new features

The Availity^®1 Health Information Network Eligibility and Benefits (E&B) transaction provides real-time benefit results such as coverage status, copay, deductible, coinsurance amounts, member data and some lower level benefits. E&B can assist providers by eliminating or reducing phone calls to health plans as well as providing quick access to other capabilities through Availity (i.e., CareProfile^®, CareCalc^®, CareCollect^sm).

Effective July 18, 2009, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) began including the following enhancements to the E&B transaction.

• Additional out-of-network benefits — Availity will display out-of-network benefits for all BCBSF health plans when applicable. This includes out-of-network benefits when they are the same as in-network benefits.
• Suppressed individual deductible — To eliminate confusion as to when the individual deductible does not apply on a family plan, Availity will not display the individual deductible for family Health Savings Account (HSA) plans when the family deductible is the same. The individual information field for these plans will be suppressed by BCBSF.
• Consolidated other party liability — BCBSF will provide existing other party liability information to Availity. The consolidated information will be displayed on one screen.
• Display deductible and copay information on all service types — Availity will display the deductible and copayment on any applicable service type.

Fall 2009

Availity security upgrade offers greater flexibility in managing user accounts

In order to offer greater flexibility in managing account permissions on the Availity^®1 Health Information Network, Availity is upgrading its security platform in a series of two phases that will be completed by January 2010.

In addition to a new "look and feel," the planned enhancements will establish time-saving self-service functionality so administrators can easily manage their Availity account(s) permissions and organizational maintenance functions online.

Once complete, the upgrade will enable streamlined account administration workflows and simplified delegation processes, by allowing administrators to apply unique Availity user roles. Roles will be organized to reflect connected business processes, allowing Primary Access Administrators (PAAs) to assign a group of permissions to a user, in addition to the individual settings currently available.

Initial changes currently in place

The first phase of the upgrade, delivered in August, included changes to the Availity portal login page, the Forgot My Password page and other login-related pages. New security controls aim to minimize password sharing and call attention to individual account ownership responsibilities (e.g., retiring old usernames and passwords from ex-employees).

Since August, users have been unable to log in or reset their passwords if they have entered an invalid password five consecutive times. In this situation, Availity locks the account and users must contact the PAA or Availity Client Services for a password reset.

More changes coming in January

In response to customer feedback, broader changes to the Availity portal will simplify account administration workflows. Since these changes may impact specific provider operations, more detailed information will be communicated to you closer to January 2010. Administrators should be prepared to update and verify account information and user profiles at some point in the future.

What you can do now: Verify your access administration

In preparation for the full security upgrade in January 2010, you are encouraged to verify the PAA and Primary Controlling Authority (PCA) information for your organization by clicking the Who Controls My Access link, located at the top of the screen when you log in to the Availity portal. If this information is not accurate, click either of the following two links on the Availity screen to access the appropriate change form:

• Complete the change request form to change your PAA
• Complete the change request form to change your PCA

For more information, contact an Availity Client Services Representative by calling (800) 282-4548 (AVAILITY), Monday – Friday, 8:00 a.m. - 7:00 p.m. (EST) or by completing the Contact Availity page on their website. If you are not currently using Availity, you can register at www.availity.com.

Fall 2009

Care Comparison, new online tool for members, now available

Care Comparison, a new education tool from Blue Cross and Blue Shield of Florida, Inc. (BCBSF) for BlueOptions members, will help educate members on options to consider before seeking elective care. The tool provides broad cost ranges for approximately 40 common procedures performed in hospitals, (both inpatient and outpatient hospital services), ambulatory surgical centers and imaging centers.

The cost ranges combine facility and physician allowed amounts. The combined costs are grouped into broad groupings, so members can educate themselves on the general costs for a procedure at area facilities, such as a breast biopsy or mammography. BlueOptions members can now access this information through MyBlueService^SM, a secure members-only web portal. CareComparison is a welcome addition to MyBlueService which provides secure access to member information, online provider directories, health and wellness information and much more. BlueOptions members can also discuss this same information today with a Care Consultant.

The data is based on one year's worth of BCBSF claims and is updated monthly. Hospital quality information is provided, based on publicly reported data from the Agency for Health Care Administration (AHCA), Centers for Medicare & Medicaid Services (CMS), WebMD^® and The Leapfrog Group.

BCBSF is working to provide Care Comparison access to providers through Availity^®1 Health Information Network in 2010.

Fall 2009

CareCalc^® pilot underway 
for some BlueCard^® plans

Blue Cross and Blue Shield of Florida, Inc. began a pilot program on September 21, 2009 that provides member cost sharing information for some out-of-state members through CareCalc. CareCalc for BlueCard^® will provide some other Blue plan information to CareCalc and CareCalc Real-Time Claims Adjudication (RTCA) transactions.

The initial pilot will involve Blue Cross and Blue Shield of South Carolina and Health Care Services Corporation (HCSC) for Illinois and Texas. The pilot will only include professional CareCalc and CareCalc RTCA, not Institutional CareCalc.

Fall 2009

Enhancements made to Claim Reconciliation Tool (CRT)

The Claim Reconciliation Tool (CRT) is a web-based tool built by Blue Cross and Blue Shield of Florida, Inc. (BCBSF) to enable providers to view a summary of claims that have previously been paid, rejected or pended. The CRT is offered exclusively by BCBSF and accessed through the Availity^®1 Health Information Network. It provides additional information that is not available on the standard HIPAA-compliant Availity claims status capability, allows providers to view multiple claims on multiple members, provides our proprietary reason codes and descriptions.

Since the implementation of CRT, providers have identified various improvement opportunities. We have recently expanded the patient responsibility column to include Patient Co-Ins (coinsurance). We will also populate the Amount Paid and Allowed Amount columns for claims paid to the subscriber. There are additional enhancements scheduled for December and details will be provided in the next issue of BlueLine.

Fall 2009

Enhancements to BlueChoice
and BlueOptions plans

This past June, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) enhanced the benefits of existing Individual, Under-65 BlueChoice and BlueOptions products. Most recently, our predictable cost, Health Savings Account (HSA) compatible, and Integrated Health and Dental plans have been enhanced with new benefit levels. Enhancements include the following:

• Adult Wellness services no longer have an annual maximum for services provided by an in-network physician.
• Mail order drugs are now available with HSA-compatible plans.
• Drugs purchased at an out-of-network pharmacy are subject to a deductible plus 50% coinsurance. The member will pay the full amount at the time of purchase and then submit a claim to BCBSF for reimbursement.
• Self-administered drugs are excluded from medical coverage when administered in a provider’s office. They will be covered under the prescription drug benefits.

BCBSF has a variety of BlueChoice and BlueOptions plans including: limited benefit, lower-cost, HSA-compatible, predictable cost and plans with tax incentives. Members have access to our provider networks and comprehensive support services to complement their coverage, including personalized care programs and tools important for making informed health care decisions.

Members are easily identified by the product name (e.g., BlueChoice, BlueOptions) which is clearly displayed in the upper right corner of their BCBSF magnetic stripe identification (ID) cards.

To confirm benefits, submit an Eligibility and Benefits transaction through the Availity^®1 Health Information Network. If your office is equipped with a card reader compatible with Availity’s card-processing program, CareRead^®, you can simply swipe the member’s ID card to access real-time benefit information.

Fall 2009

Changes to mental health and substance abuse benefits for Publix PPO members

Effective July 1, 2009, Publix members with Blue Cross and Blue Shield of Florida, Inc. (BCBSF) mental health and substance abuse benefits must obtain pre-certification for outpatient behavioral health services.

All Publix BCBSF PPO members, including members currently receiving outpatient treatment from a mental health or substance abuse specialist, must request pre-certification by contacting Companion Benefit Alternatives (CBA) at (800) 868-1032. CBA is an independent company that manages behavioral health benefits on behalf of Publix members. Failure to request outpatient pre-certification for behavioral health services will result in denial of all charges.

Identifying Publix Group Members

Publix group members are easy to identify. Copayment information is displayed on the front of the card. Alpha prefix PBB is displayed in front of the member ID number.

Eligibility, Benefits and Claims Filing Information

Providers should use the Availity^®1 Health Information Network to verify eligibility and benefits, file claims and check claim status.

For questions or additional information, call the BCBSF Publix Dedicated Customer Service Unit at (866) 782-5495.

Fall 2009

BlueSelect now available in additional counties

In July 2009, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) expanded the BlueSelect plans to Broward, Charlotte, Hernando, Pasco and Polk counties. BlueSelect was introduced in Hillsborough and Pinellas counties in January 2009, as part of BCBSF's continuing effort to provide all Floridians access to affordable health care solutions.

A network of hospitals, physicians and providers was developed in the expansion counties. "We have partnered with local hospitals and other providers to develop BlueSelect for those who are uninsured or may soon become uninsured," said Craig Thomas, vice president of Marketing Operations. "By working with these community health care providers, compared to other networks, we can keep costs down and offer yet another affordable health plan option to Floridians." As part of this progressive product rollout, BlueSelect will be expanded to additional markets/counties in the coming months.

BlueSelect plans offer support services, personalized care, comprehensive prevention and wellness programs that use a community-based network without reducing benefits. The network covers all medical specialties and secondary providers, but consists of a smaller number of providers compared to other networks.

BlueSelect's coverage is comparable to traditional plans with a higher level of benefits for in-network services and a lower level of benefits for out-of-network coverage. In addition, the plans offer valuable discounts on programs and services such as weight and stress management, alternative medicine and vision and hearing care.

Members will have a unique member identification (ID) card. BlueSelect is clearly identified in the upper-right corner of the card. Providers can verify eligibility and benefits of BlueSelect members using the Availity^®1 Health Information Network.

For more information on BlueSelect plans, visit our website at www.bcbsfl.com.

Fall 2009

How can the Network Management Service Unit assist you?

Do you want to join a Blue Cross and Blue Shield of Florida, Inc. (BCBSF) network? Are you an existing provider, wanting to expand the products you service? First you have to find out if BCBSF is accepting applications for the networks that support those products.

Assistance is one call away! Contact the Network Management Service Unit at (800) 727-2227, say "More Choices" then "Network Management." A network representative will be able to tell you whether or not we are accepting new applications in your area.

The Network Management Service Unit also handles:

• Contract issues

• Credentialing status inquiries

• Fee schedule requests

To request a fee schedule or allowance for specific codes, complete the Fee Schedule Request Form by visiting www.bcbsfl.com, clicking Physicians & Providers, Tools & Resources, then Forms. Once you've completed the form, fax it to (904) 997-5716.

Fall 2009

BCBSF offers new priority call process

In July, 2009, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) began offering priority service to providers who utilize the Availity^®1 Health Information Network for Eligibility and Benefits (E&B) Inquiry transactions.

New Fast Path Priority Call Process

1. Complete an electronic E&B inquiry and document the Fast Path code (Transaction Id) located in the upper left-hand corner of the results screen.

2. If you need additional benefit information for that specific member, call the Provider Contact Center at (800) 727-2227. You will be prompted to enter the Fast Path code before you hear the main menu options.

3. Your call will be automatically routed to the appropriate area as a priority call.

Note: The Fast Path code is associated with a specific member and your call is routed accordingly, therefore you will only be able to obtain their benefit information. Fast Path codes are active for three days.

Member Exceptions

Although a Transaction Id will display for BlueCard and Federal Employee Program (FEP) members, the Fast Path code will not be utilized to prioritize calls regarding those members.

• BCBSF does not provide telephonic detailed benefits for BlueCard members, so providers should continue to call the BlueCard Eligibility Line at (800) 676-BLUE (2583).

• FEP has a dedicated unit and their current call process will not change.

Fall 2009

FHCP is now an affiliate of Health Options

In June 2009, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and Health Options, Inc. announced that Florida Health Care Plan, Inc. (FHCP), a Florida licensed HMO, became an affiliate of Health Options. FHCP will continue to operate as a community-based, locally managed health plan.

FHCP directly employs physicians, both primary care and specialists, which in addition to those directly contracted by FHCP, constitute the FHCP provider network. However, with the exception of FHCP’s Medicare Advantage benefit plans, there are occasions when members may require services outside the FHCP provider network.

If you provide covered services to FHCP commercial and Healthy Kids members the following guidelines apply:

• All FHCP members who access covered emergency, urgent or pre-authorized services from you should be treated as Health Options members and you will be paid based upon the Health Options negotiated rates.
• To request authorization or pre-certification of non-emergency services, follow the directions on the back of the FHCP ID card.
• Send all FHCP member claims to the address on the back of the FHCP ID card. Do not send your claim to BCBSF/Health Options. FHCP will process the claim applying the applicable member benefits at the Health Options negotiated rate.

This process does not apply to FHCP's Medicare Advantage benefit plans. Call the telephone number listed on the back of the member's FHCP ID card for all inquiries related to FHCP Medicare Advantage benefits.

If you have any questions, call the Network Management Service Unit at (800) 727-2227, say "More Choices," then "Network Management."

Fall 2009

Start preparing now for the ICD-10 transition

The Department of Health and Human Services has announced an implementation date of October 1, 2013, for the transition to the new ICD-10 code set standards from the current ICD-9 coding system and January 1, 2012, for the transition to version 5010 of the Health Insurance Portability and Accountability Act-Administrative Simplification (HIPAA-AS) standard electronic transactions. All standard covered HIPAA-AS electronic transactions are changing including claims, eligibility and claim status inquiries, referral and authorization requests and remittance advices.

The American Health Information Management Association offers an ICD-10 preparation checklist to help health care organizations begin planning for the transition. You can download the checklist at http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht.

For additional information related to ICD-10, go to www.cms.hhs.gov/ICD10.

Fall 2009

Submitting medical records 
for BlueCard^® members

Are you familiar with how to submit medical records related to BlueCard members to Blue Cross and Blue Shield of Florida, Inc. (BCBSF)? Submit your records to the BlueCard fax number at 
(904) 361-0711.

The members' identification (ID) cards will have a suitcase logo and alpha prefix. Our BlueCard Fast Tracker lists the five steps to follow when providing services to a BlueCard member, which includes the BCBSF networks they may use while in Florida with balance billing protection (e.g., BlueCard HMO members use the Traditional/PPS/PHS).

Suitcase Logos

 A "PPO" inside the logo identifies PPO members. These members use the PPO network for the lowest out-of-pocket costs; in Florida that is BCBSF's PPC network. PPO members may also use the Traditional/PPS/PHS network, but will usually have higher out-of-pocket costs.

 A "blank" suitcase logo identifies Traditional, Indemnity, POS, HMO and some Medigap (Medicare Complementary/Supplemental) members. These BlueCard members use the Traditional/ PPS/PHS network while in Florida.

In July, the fax number was updated in the BlueCard^® Program Manual on page 18. That page also includes the following information:

Helpful Hints

• If the records are requested following submission of the claim, forward all requested medical records to BCBSF.

• Follow the submission instructions given on the request. Fax the specific records requested and a copy of the request to (904) 361-0711. Only send BlueCard documentation to this fax line.

• Include the cover letter you received with the request when submitting the medical records. This is necessary to make sure the records are routed properly once received by BCBSF.

• Submit the information to BCBSF within ten business days to expedite processing.

• Only send the information specifically requested. Quite often, complete medical records are not necessary.

• Please do not proactively send medical records with the claim. Unsolicited claim attachments may cause claim payment delays.

• Status inquiries should be directed to BCBSF at (800) 727-2227.

The BlueCard fast tracker and manual are available on our website, www.bcbsfl.com; click Physicians & Providers, Tools & Resources, then Fast Trackers or Manuals & Billing Instructions.

Fall 2009

New guidelines for BlueCard^®
Medicare crossover claims

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) recently streamlined its provider service procedures, decreasing hold times for BlueCard Medicare Crossover Claims. If the member has Medicare primary insurance and a Blue Cross and/or Blue Shield plan as secondary insurance, providers should first submit the claim to Medicare. Medicare will process the claim, then route the claim to the member's supplemental Blue Plan for processing. You will receive payment or processing information from the member's supplement plan after they receive proof of Medicare payment.

Follow these steps before calling BCBSF:

• Verify the Medicare Remittance Notice states “Claim information forwarded to: (Name of secondary payer).” which indicates the claim was forwarded for processing.
• If the claim did not crossover electronically, then submit the claim to BCBSF with the remittance notice attached (BCBSF, P.O. Box 1798, Jacksonville, FL 32231-0014).

  Note: If more than one claim appears on the Medicare Remittance Notice, please indicate the specific claim you are filing.

• Please allow 45 days from the Medicare payment date for the secondary claim (Medicare supplemental coverage) to process.
• If calling about multiple claims, then sort them by the secondary payer for efficient processing.
• The total claim charge (not the balance owed) is required for research purposes.

Inquiries

Direct inquiries on secondary claims to BCBSF's Provider Contact Center at (800) 727-2227 unless the member's Blue Plan has requested specific information from you on a particular claim. Inquiries received on secondary claims by BCBSF will be coordinated with the member's Blue Plan for resolution.

BCBSF Resources

We have informational Medicare Crossover documents on our website, www.bcbsfl.com. Click Physicians & Providers, Tools & Resources, then Tips & Frequently Asked Questions.

• Medicare Crossover for Other Blue Plan Members (CMS-1500)
• Medicare Crossover for Other Blue Plan Members (UB-04)

Fall 2009

Educating patients about osteoporosis prevention

Osteoporosis continues to be a threat for about 55% of Americans (mostly women) age 50 and older.¹ It's estimated that approximately 10 million already have osteoporosis and 34 million may be at risk because of low bone mass.

In an ongoing effort to educate our members, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) sends osteoporosis educational letters to female members who are age 50 and older and recently had a fracture. The letter advises the member to speak with her physician about osteoporosis testing. Please discuss osteoporosis and bone density testing with your elderly and at risk patients.

Our Healthcare Effectiveness Data and Information Set^® (HEDIS) results for BlueMedicare HMO have improved more than 5 percentage points since 2008. This measures the percentage of women 67 years and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture.

For more information on BCBSF Medical Policies for bone mineral density studies, refer to the Medical Policies (Medical Coverage Guidelines) on our website at www.bcbsfl.com.

For more information on osteoporosis, you can also visit the Centers for Medicare & Medicaid Services at http://www.cms.hhs.gov/BoneMassMeasurement/01_Overview.asp#.

Fall 2009

BCBSF continues to promote colorectal cancer screening test

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) continues to educate and remind targeted member populations annually about the importance of colorectal cancer screening. Thank you for taking the time to discuss this very important screening with your patients. Most patients will not get tested unless advised by their physician to do so. The Healthcare Effectiveness Data and Information Set^® (HEDIS) screening rate for BCBSF BlueMedicare HMO has reached a new high of nearly 70% and BlueCare of 58%.

Screening tests are accurate and relatively simple and the survival rate is higher when the cancer is identified early. Please continue to discuss this screening with your patients -- with your help more lives can be saved.

For more information, visit the following websites:

http://www.cms.hhs.gov/ColorectalCancerScreening/

http://www.medicare.gov/health/coloncancer.asp

For more information on BCBSF Medical Policies for colorectal cancer screening, refer to the Medical Policies (Medical Coverage Guidelines) on our website at www.bcbsfl.com. Medical Policies are available under the heading of Medical Information on the Physicians & Providers page.

Fall 2009

Research links oral health
and cardiovascular disease

Following up with the Spring 2009 BlueLine article, Focus attention on oral health link to overall health, current research now indicates that infections from the mouth may be a factor in heart disease and stroke. There are one and one half million heart attacks and approximately 600,000 strokes in the United States each year. Half of these individuals will have known risk factors for heart disease and stroke while the other half will appear to be healthy with normal or low cholesterol levels. This has led to an investigation of other factors that may be involved with heart disease and stroke that were not previously identified.

Heart disease is related to a thickening of the walls of the arteries in the body, a condition called atherosclerosis. The thickening of the arteries is believed to be aggravated by damage to the artery wall caused by an inflammatory process leading to the development of an atheroma or plaque. These atheromas may rupture leading to a heart attack or stroke in the individual or simply narrow the opening of the blood vessel. One hypothesis is that this process may be aggravated by bacteria from the mouth which make their way into the bloodstream and contribute to this inflammation.

This connection between oral health and coronary artery disease through the inflammatory process appears to be supported by the literature. A cumulative analysis of all studies done to date suggests that periodontal disease is an independent risk factor for coronary artery disease, raising the additional risk by approximately 30% independent of other factors.

This association has caused the American Journal of Cardiology and the Journal of Periodontology to issue a consensus statement to their respective members recommending treatment and referral guidelines to their patients with either or both conditions. The position paper can be found at http://www.joponline.org/doi/pdf/10.1902/jop.2009.097001. These guidelines are meant to make dentists and physicians co-therapists in oral health management of their patients at risk for heart disease.

Look for the following warning signs of gum disease to help determine if you or your patient is someone at risk:

• Bleeding and tender gums
• Bad breath
• Receding gums or spaces developing between the teeth
• Changes in the bite or tooth mobility

Over the last year, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and its affiliate, Florida Combined Life Insurance Company, Inc. (FCL), has developed an outreach program to educate our members at-risk for heart disease and diabetes of the connection between improving oral health and reducing risks for heart disease and stroke. Stay tuned for future updates about this exciting program.

Fall 2009

Women health screenings save lives

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) remains committed to preventive screenings and educating our very diverse population of their importance. Help us by promoting these preventive health screenings with your female patients: annual gynecological exams, regular mammography screening, cervical cancer screening and Chlamydia screening. And please reinforce to young women that Gardisil does not protect against all types of cervical cancer and appropriate screenings should continue.

While our Health Healthcare Effectiveness Data and Information Set^® (HEDIS) rates for breast cancer screening remains stable, our Chlamydia screening rate improved significantly from 35% to 44%. Conversely, cervical cancer screening continues to decline to about 81%.

Our HEDIS rates are:

Did you know?¹

• While the incidence and mortality rate of cervical cancer continues to decline, African American women still have an incident rate of 32% higher and mortality rate twice that of white women. The death rate from cervical cancer is about 50% higher in Hispanic women than non-Hispanic white women.

• Breast cancer remains the second leading cause of death in African American women. It’s also the most commonly diagnosed cancer among Hispanic women and is less likely to be diagnosed at an early stage.

Fall 2009

2009 Documentation of Care review reveals three areas for improvement

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) recently conducted the 2009 annual medical record review of primary care physicians (PCPs) participating in our HMO network, Health Options, Inc. The monitoring of documentation of patient care takes steps to assess and improve medical records--keeping practices to promote patient safety and improve continuity and quality of care.

The program is consistent with efforts to respond to customer expectations and accreditation requirements by the National Committee for Quality Assurance (NCQA), Agency for Health Care Administration (AHCA) and Centers for Medicare & Medicaid (CMS). A statistically random sample of Health Options HMO members was pulled from the statewide Health Plan Employer Data and Information Set (HEDIS^®) dataset. A comparison over the last three years is shown on Table 1.

Our 2009 Documentation of Care review identified three areas of opportunity for improved compliance. The three indicators were:

Documentation for 14 years of age and older inquiry/counseling regarding alcohol/substance abuse in baseline history or physical

The best chance for a physician to detect a problem with alcohol and drug abuse is in the context of routine medical care. Screening provides an opportunity for the clinician to intervene early and impact a patient's overall health. According to National Institute on Drug Abuse (NIDA) using the 5 A's of Intervention (Ask, Advise, Assess, Assist and Arrange) can be a useful framework in encouraging patients to quit drugs. You can find more information at www.nida.nih.gov.

Pediatric and adolescent immunization records complete and up to date for children 16 years of age and older

The physician office documents if immunizations are up-to-date and requests the parents to provide a copy for the medical records. Physicians are encouraged to enroll in the Florida State Health Online Tracking System (SHOTS) program by clicking on the link at the Availity website (www.availity.com) to track and secure a complete patient immunization file. Refer to the current Centers for Disease Control and Prevention (CDC) immunization schedule at www.bcbsfl.com, by clicking Physicians & Providers, Medical Information, then Preventive Services Guidelines.

Advance Directives

Federal and state law regulations mandate that HMOs require contracted providers to document whether or not HMO members 18 years of age and older have an advance directive. A yes or no is sufficient and should be found at an easily accessible location in the medical record. It is recommended that practitioners place a question about the existence of advance directive on their new patient history form or registration form.

The Documentation of Care review showed significant improvement in five indicators from the previous year as shown below: 

Your help in implementing change is critical to facilitating improved communication, coordination and continuity of care. If you would like a copy of the Documentation of Care tool packet, please call Joanne Keenan at (800) 555-8228, ext. 87329.

Fall 2009

Are you familiar with the BCBSF's medication guides?

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) maintains medication guides for providers and members that reflect the current BCBSF and Health Options, Inc. formularies, which include the prescription drugs, insulin and diabetic supplies that reflect the current BCBSF and Health Options, Inc. formularies.

All of our commercial formularies are updated on a quarterly basis including Healthy Kids. There are separate medication guides for Group and Individual members under 65, BlueMedicare member, BlueSelect members with a pharmacy benefit and Healthy Kids members. Links to the three medication guides as well as the quarterly medication guide updates can be located at www.bcbsfl.com, by clicking Physicians & Providers, Pharmacy, then Medication Guides.

Fall 2009

Unlisted HCPCS codes claim submission process for physicians and physician extenders

Unclassified HCPCS codes are to be used only when there is not a specific HCPCS code available for the drug being billed. Submitting a claim using an unclassified HCPCS code where there is a specific HCPCS code for a drug will result in the claim being denied and returned to the provider to resubmit with the appropriate HCPCS code. Unclassified HCPCS codes are to be used only when there is not a specific HCPCS code available for the drug being billed.

Each unclassified drug code submitted must include the associated National Drug Code (NDC) number and NDC quantity. Submitting a claim using an invalid or missing NDC number and NDC quantity will result in the claim being returned. If multiple unclassified drug codes are submitted on the same claim, each unclassified code and associated NDC number/quantity is to be listed on a separate claim line following the instructions specified in the Unclassified Drugs topic of the Coding and Filing Claims section of the Manual for Physicians and Providers. The section can be accessed by visiting www.bcbsfl.com and clicking Physicians & Providers, Manuals & Billing Instructions, then Coding and Filing Claims.

The following are guidelines for submitting unclassified drug codes:

• Use the appropriate unclassified drug HCPCS code (e.g., J3490, J3590, J8999, etc)
  • Electronic claims - Enter in Loop 2400, Segment SV1, Element SV101
  • Paper claims - Enter in lower, non-shaded area of Block 24D
• NDC Qualifier (N4)
  • Electronic claims - Enter in Loop 2410, Segment LIN, Element LIN02
  • Paper claims - Enter in the shaded area of Block 24A
• NDC Code - Report the NDC Code in an FDA recognized 11-digit numeric format (e.g., 99999999999)
  • Electronic claims - Enter in Loop 240, Segment LIN, Element LIN03
  • Paper claims - Enter in the shaded area of Block 24A after the N4 qualifier
• NDC Quantity using a metric decimal quantity (reported in the HCPCS unit field - Block 24G) as exact amount administered to the member
  • Electronic claims - Enter in Loop 2400, Segment SV1, Element SV10
    Note: NDC Quantity is required in this Element
  • Paper claims - NDC Quantity is provided in the HCPCS units Block 24G
• NDC Description (optional)

For compounded drugs, each NDC number and quantity must be submitted on a separate claim line with the unclassified drug code J3490.

Claims submitted without the correct information, as outlined in the Coding and Filing Claims section of the provider manual, are required for processing and will be denied and returned to the provider for correction. The Availity^®1 Health Information Network includes the required NDC fields on its input screens. If your practice management system does not accommodate this requirement, please contact your vendor to coordinate changes.

Fall 2009

Contracting home infusion providers with a licensed Ambulatory Infusion Suite

On July 1, 2009, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and Health Options Inc. began contracting with home infusion providers who maintain a licensed Ambulatory Infusion Suite. Benefits to physicians include:

• Safe and convenient site offering infusion therapy services for select medications
• Infusion-trained registered nurses providing personalized care for your patient
• Assistance with patient education
• Close monitoring of patient clinical responses
• Assistance with determining benefits and obtaining required authorizations for medications

Note: As the member's physician, you will still have primary accountability for obtaining referrals or prior authorizations to the Ambulatory Infusion Suite, according to the member's benefits.

To locate a participating Ambulatory Infusion Suite provider, access the Physicians & Providers page on BCBSF's website, www.bcbsfl.com, and click the following:

• Provider Directory
• Advanced Search
• Support Service (under Step 1: Doctor or Facility Information)
• Select Medical Services (under Services Provided)
• Other Provider (from the drop-down menu)
• Ambulatory Infusion Suite
• Continue

If you have any questions or need further information on accessing services through an Ambulatory Infusion Suite, please call the Provider Contact Center at (800) 727-2227.

Fall 2009

Are you in compliance? Complete the online diagnostic imaging quality assessment

Physicians who provide CT, MR, PET and Nuclear Cardiology services must complete the online OptiNet^SM, diagnostic imaging quality assessment through the American Imaging Management's (AIM) provider portal, https://www.providerportal.com/.

Registering to complete the survey is easy. Just enter your BCBSF provider number. Once you have accessed the OptiNet website, you will find the survey under the Profile Manager tab by clicking Register My Site. If you need additional information, please refer to the frequently asked questions available on BCBSF's website, www.bcbsfl.com, by clicking on Physicians & Providers, Tools & Resources, then Tips & Frequently Asked Questions.

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) is committed to elevating and promoting patient safety in outpatient settings and wants to assure that members receive services at sites where equipment, physicians and technologists meet national industry standards.

If you have already completed OptiNet, confirm that your information is correct and that certifications and accreditations are current. The current established minimum score required for each modality is 70. Please note that effective January 2010, the minimum score will be raised to 80.

Access the following websites to register or review your modality scores on OptiNet:

• BCBSF — Visit www.bcbsfl.com, click Physicians & Providers, then Online Services.
• Availity^®1 Health Information Network — Log in to www.availity.com, click Payer Resources, then BCBSF, then Tools.
• AIM — https://www.providerportal.com/

This initiative is identified as a quality assurance program and either your individual or group physician agreement requires compliance. Therefore, we urge you to take the necessary steps to successfully complete the assessment.

Beginning fourth quarter 2009, non-compliance with these quality assurance program requirements may impact your participation status unless you agree to the removal of advanced imaging services from your fee schedule and agree not to provide such services to our members.

If you have questions about completing the survey or improving your score, call AIM's customer service center at (800) 252-2021. For information about your specific contract, call your network manager. If you don't know your network manager's name or phone number, call the Network Management Service Unit at (800) 727-2227, say "More Choices," then "Network Management."

Fall 2009

BCBSF reconfigures DME and MS network

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) is making changes to its Durable Medical Equipment (DME) and Medical Supplies (MS) network for our Preferred Patient Care (PPC), Network Blue, Traditional and Medicare Advantage PPO networks. Beginning July 1, 2009, BCBSF started the process of reconfiguring our DME/MS network such that it consists of specialized providers whose core business is dedicated to specific DME and MS sub-specialties.

Providers who may have been participating in the past may not be participating in this new network configuration. However, effective November 1, 2009, BCBSF will have over 50 DME and MS companies contracted representing over 125 locations statewide. The network will continue to offer our members the choice to use large statewide or national providers or small local or niche providers.

As a result of this network change and to assist members in maximizing their medical benefits, members requiring new equipment and supplies should be referred to one of the participating providers based on the services or equipment needed.

Note: Please consult the communication that was faxed to your office during late September for details about the new DME/MS network and for instructions on transitioning your patients appropriately prior to November 1, 2009.

Affected members will also receive a communication in late September. Either your office or the member may begin the transition by locating a participating DME or MS provider in BCBSF's online provider directory.

Thank you for your assistance in transitioning members to our new DME and MS network. If you have questions, please call the Network Management Service Unit at (800) 727-2227, say "More Choices," then "Network Management."

Fall 2009

BCBSF offering a new easy way to buy affordable health insurance

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) now makes it even easier for Floridians to buy the health insurance they need for themselves, their family and friends at a price they can afford. Currently BCBSF is offering two innovative products through CVS and Winn-Dixie stores throughout Florida: the $59 Gift of Health Care card and the $19 FamilyBlue Discount card.

This innovative retail channel allows BCBSF to reach a broader audience already familiar with pre-paid products. 94% of U.S. households purchase or receive pre-paid products annually. Just like these other gift and pre-paid cards, consumers can now pick up a BCBSF pre-paid health card located in the pharmacy area of both retailers and call to activate them at their convenience. Once enrolled, they receive their member ID card that they use to present to providers.

The $59 Gift of Health Care cards can be used to purchase one of our health insurance plans. The card is featuring GoBlue; however it can be applied to other products like BlueOptions, based on the level of coverage that is needed. There are some exceptions covered in the terms and conditions of the card. Although this card is not insurance, it gives consumers the ability to use it to purchase the health insurance coverage they are looking for.

The $19 FamilyBlue Discount card gives Floridians access to deep discounts at providers throughout the state. FamilyBlue is not health insurance, but does provide an entire family with discounts on health services and products including dental, prescription and vision for three months for only $19.

We have educated the customers to follow the activation process before they visit a provider. However, you may occasionally get a customer that presents the pre-paid health card they have purchased in the local store. Please direct them to call the number on the back of the card and follow the activation steps in order to receive their member ID and become a member in BCBSF systems.

The cards will be available in Winn-Dixie at the end of September 2009 and CVS at the end of October 2009.