A newsletter for contracting institutional and professional providers
May 2017
Making the health care system work better, together.
Blue Cross and Blue Shield of Illinois (BCBSIL) is working every day to identify ways we can streamline, simplify and improve
processes that may affect your practice. That work includes examining how and in what ways we can work together with
providers to favorably impact care quality and affordability. To that end, we are designing new data and reporting capabilities
that may help providers gain deeper and broader insights into the health care needs of BCBSIL members.
Throughout this year and the next, BCBSIL will introduce new tools and technologies that we expect will help:
Make it easier for you to do business with us
Deliver actionable data to help you make more insightful patient treatment and practice management decisions
Enhance the value and quality of care our members receive
Modernization is essential. By offering more efficient online options, increased network participation opportunities and risk
models, and greater access to improved data and reporting tools, BCBIL is aiming to go above and beyond where we are
today so that we may continue to work with you in more innovative ways.
We invite you to join us in helping make the health care system work better, together. Keep reading future issues of the Blue
Review to find out what’s new.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Update: Uniform Coding for Habilitative and Rehabilitative Services
Rehabilitative and habilitative services and devices are one of the required Essential Health Benefits (EHBs) required to be
covered by health care plans. Recently, federal regulations further clarified how these benefits should be covered by defining
rehabilitative and habilitative services, requiring parity in coverage limits and requiring separate visit limits for each.1
Effective Jan. 1, 2017, visit limits for rehabilitative and habilitative services must not be combined. Providers that submit
claims for habilitative services may need to make a change to their billing practices by using the available Healthcare
Common Procedure Coding System (HCPCS) modifier SZ (habilitative services) when billing for habilitative services on
claims for Blue Cross and Blue Shield of Illinois (BCBSIL) and BlueCard® (out-of-area Blue Plan) members.
Rehabilitative and habilitative services need to be tracked separately for all members, including members accessing care in
another Blue Plan’s service area, to ensure visit limits are not combined. This billing requirement applies to both professional
(CMS-1500) and outpatient facility (UB-04) claims. For electronic professional claims, the modifier is coded in the SV1
segment and for electronic facility claims, the modifier is coded in the SV2 segment. Without the (SZ) modifier, the service
will be considered rehabilitative. Providers’ use of the code modifier allows BCBSIL to be able to track habilitative and
rehabilitative services separately, in order to comply with EHB requirements of the Affordable Care Act (ACA) regulations.
Current Procedural Terminology (CPT®) codes and Centers for Medicare & Medicaid Services (CMS) HCPCS Level II codes
are defined for rehabilitative services. Many of the procedure codes used for rehabilitative services are also used for
habilitative services, which do not have a separate set of procedure codes. In 2014, the HCPCS modifier SZ (habilitative
services) was created for providers to accurately specify when habilitative services are billed. Use of the (SZ) modifier is
supported by the situational rule for HIPAA-adopted claim transactions, which requires modifiers for procedure codes when
they clarify or improve the reporting accuracy of the associated procedure code.
This information is for educational purposes only. Providers are instructed to bill claims in accordance with BCBSIL and industry standards and based upon services rendered as
documented in the medical record.
1
See the regulation at 45 CFR § 156.115
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Provider Learning Opportunities
Blue Cross and Blue Shield of Illinois (BCBSIL) offers complimentary educational workshops and webinars with an emphasis on electronic options that can help create
administrative efficiencies for the independently contracted providers who conduct business with us. A snapshot of upcoming training sessions is included below. For additional
information, refer to the Workshops/Webinars page in the Education and Reference Center on our website at bcbsil.com/provider.
BCBSIL WEBINARS
To register now for a webinar on the list below, click on your preferred session date.
Descriptions:
Dates:
Session Times:
BCBSIL Back to Basics: ‘AvailityTM 101’
Join us for a review of electronic transactions, provider tools and helpful online resources.
May 9, 2017
May 16, 2017
May 23, 2017
May 30, 2017
11 a.m. to noon
Introducing Remittance Viewer
Have you heard? This online tool offers providers and billing services a convenient way to retrieve, view, save or print
claim detail information.
May 16, 2017
10 to 11 a.m.
iExchange® Training: New Enrollee Training
Learn how to gain access to and begin using our online benefit preauthorization/predetermination of benefits tool.
May 9, 2017
11 a.m. to 12:15 p.m.
BCBSIL PROFESSIONAL PROVIDER WORKSHOPS
Register via the Workshops page in the Education and Reference Center on our Provider website.
Description:
Locations:
Dates:
Questions? Contact:
Our Provider Network Relations team is offering specialized
training with a question-and-answer session to discuss current
areas of interest pertaining to independently contracted BCBSIL
providers.
Mt. Vernon
Drury Inn & Suites
May 17, 2017
Registration deadline:
May 12, 2017
Teresa Trumbley
[email protected]
618-246-5201
The session time for each workshop is 9:30 a.m. to noon.
Check-in will be held from 9 to 9:30 a.m.
New Lenox
Silver Cross Hospital
1900 Silver Cross Blvd
New Lenox, IL 60451
June 22, 2017
Registration deadline:
June 16, 2017
Aaron Nash
[email protected]
312-653-3274
Aurora
Rush-Copley Heart Institute
2088 Ogden Ave.
Aurora, IL 60504
June 27, 2017
Registration deadline:
June 23, 2017
Kathy Barry
[email protected]
312-653-4247
Arlington Heights
Northwest Community Hospital,
Auditorium
800 W. Central Rd.
Arlington Hts., IL 60005
July 19, 2017
Registration deadline:
July 14, 2017
Gina Plescia
[email protected]
312-653-4733
East Peoria
Par-A-Dice Hotel
21 Blackjack Blvd.
East Peoria, IL 61611
Sept. 14, 2017
Registration deadline:
Sept. 8, 2017
J’ne Erlenbush
[email protected]
217-698-5125
To register online: Visit the Workshops page in the Education and
Reference Center on our Provider website. Be sure to sign up by
the registration deadline so that we can be prepared to
accommodate all attendees.
145 North 44th St.
Mt. Vernon, IL 62864
AVAILITY WEBINARS
Availity also offers free webinars for their registered users. For a current listing of webinar topics, dates and times, registered Availity users may log on to the secure Availity
provider portal – the Live Webinar Schedule is located under the Free Training tab. Not yet registered with Availity? Visit their website at availity.com for details; or call Availity
Client Services at 800-AVAILITY (282-4548) for assistance.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. iExchange is a
trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party
vendors such as Availity and Medecision.If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Online Enrollment Options in AvailityTM
Blue Cross and Blue Shield of Illinois (BCBSIL) offers providers multiple enrollment opportunities for electronic
options through the Availity Web Portal, in addition to supporting utilization of standard administrative transactions
through Availity or your preferred vendor portal. Instead of faxing or mailing paper enrollment forms, you may
complete the online enrollment options listed below through Availity, at no cost. In addition, Availity provides single
sign-on access to several online tools, including those highlighted below. This feature offers you greater convenience
and security, without the need for another User ID and password.
Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA)
BCBSIL independently contracted providers* may enroll online for EFT and ERA and also make any necessary setup changes in Availity. The online enrollment process can be completed in near real-time. Providers will receive a
confirmation letter acknowledging the enrollment effective date and related information. Once an organization is
enrolled for ERA, providers and billing services also gain access to the Availity Remittance Viewer. This online tool
permits users to search, view, save and print remittance information, even if the ERA is delivered to an appointed
receiver.
*This excludes atypical providers who have not acquired a National Provider Identifier (NPI).
Benefit Preauthorization – iExchange® (Single sign-on access)
Once you are registered as an Availity user, you may enroll through the Availity Web portal for iExchange. This tool
supports online submission and electronic approval of benefits for inpatient admissions, as well as select outpatient
and clinical pharmacy services.** iExchange also offers you an alternative to calling to request status of most benefit
preauthorization requests. Additionally, iExchange accepts electronic medical record documentation for
predetermination of benefits requests. As a reminder, always check eligibility and benefits first to find out if benefit
preauthorization is required for a particular member. Please note that, for behavioral health services, you should
continue to use the current fax and telephone benefit preauthorization methods. If you have questions, contact the
number on the member’s ID card.
Electronic Refund Management (eRM) (Single sign-on access)
Registered Availity users also have the opportunity to gain access to eRM, an online tool that helps simplify the
overpayment reconciliation process. You will receive electronic notification of overpayments, with the option to deduct
from a future payment or pay by check. When you enroll for eRM, you also gain access to the Claim Inquiry
Resolution (CIR) tool, a method of online assistance that helps save your staff time by reducing the amount of calls
and specific written inquiries on finalized claims. Note: The eRM and CIR tools are not available for government
programs (Medicare Advantage and BCBSIL Medicaid) claims.
Learn more…
To learn more about these and other electronic tools and resources, visit the Education and Reference
Center/Provider Tools section of our website at bcbsil.com/provider. Also see the Webinars page for dates, times and
registration for online training sessions on a variety of topics. For assistance or customized training, contact a
BCBSIL Provider Education Consultant at [email protected].
Not yet registered with Availity? Visit availity.com and complete the online application today. If you need
registration assistance, contact Availity Client Services at 800-AVAILITY (282-4548).
**Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized is not a guarantee of payment. Benefits will be determined once a
claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date
services were rendered. If you have any questions, please call the number on the back of the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical
professionals. Availity provides administrative services to BCBSIL. iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care
management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party
vendors such as Availity or Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent
Blue Cross and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and
Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Benefit Information Accessible in Our Automated Phone System
Starting on Dec. 12, 2016, Customer Advocate assistance was removed for several common benefit categories within the Blue Cross and Blue Shield of Illinois (BCBSIL)
Interactive Voice Response (IVR) phone system. The IVR quotes the same level of patient eligibility and benefits information as the information a Customer Advocate provides.
Our Customer Advocates will continue to be available for more complex benefit quotes.
BCBSIL is committed to providing efficient and secure access to patient information. To better assist providers with understanding the recent IVR change, a list of the benefit
categories that are currently contained in the IVR is included below. This listing is continually reviewed and may vary across different BCBSIL networks, products and/or group
policies. Also included below is a separate category containment list for Federal Employee Program (FEP) members.*
*Note: These listings are not applicable to government programs (Medicare Advantage and BCBSIL Medicaid) member policies. For government programs eligibility and benefits
requests, please refer to the number on the member’s BCBSIL ID card.
IVR-Contained Benefit Categories
Office Visit
Hospital
Preventive Care
Colonoscopy
Allergy
Ultrasound
Coordinated Home Care
Laboratory
X-ray
Extended Care Facility
Mammogram
EKG
Physical Exam
Inhalation Therapy
Consultations
Pap Smear
Private Duty Nursing
Office Services
FEP IVR-Contained Benefit Categories
Accidental Injury
Maternity
Allergy
Office Visit
Chiropractic Services
Outpatient Physical, Occupational and Speech Therapy
Diagnostic – Lab, X-ray, Outpatient Diagnostic
Vision
Inpatient Benefits – Inpatient Hospital, Inpatient Surgery
When navigating the IVR to determine patient coverage or connecting with a Customer Advocate to request predetermination of benefits status, it is imperative that you select the
exact benefit category that will be rendered for the patient. This will help ensure that you receive the most accurate benefit information associated with your request.
Checking eligibility and benefits electronically through Availity™ or your preferred Web vendor is the quickest way to access information for BCBSIL members. To learn more
about online solutions, refer to the Education and Reference Center/Provider Tools section of our website at bcbsil.com/provider. For IVR navigational assistance, an Eligibility
and Benefits Caller Guide is available on the Tutorials/User Guides page of our Provider website.
Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage
applicable on the date services were rendered. If you have questions, please call the number on the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. eCare is the registered
trademark of Nebo Systems, a division of Passport Health Communications, Inc., an independent third party vendor. (Passport/Nebo Systems offers the NDAS Online product to independently contracted BCBSIL providers.) BCBSIL makes no endorsement,
representations or warranties regarding any products or services offered by third party vendors such as Availity and Passport Health Communications. If you have any questions about the products or services offered by such vendors, you should contact the
vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
iExchange® Adds Blue Cross Community Integrated Care Plan (ICP)SM and Blue Cross
Community Family Health PlanSM (FHP) Requests
We are pleased to announce that benefit preauthorization requests for ICP and FHP members can now be initiated through
iExchange. This is in addition to benefit preauthorization requests for Blue Cross Medicare Advantage (PPO)SM and Blue
Cross Community MMAI (Medicare-Medicaid Plan)SM members.
iExchange supports online submission and electronic approval of benefits for inpatient admissions, as well as select
outpatient and pharmacy services 24 hours a day, 7 days a week.* For behavioral health services, you should use the current
fax and telephone benefit preauthorization methods. iExchange also offers you an alternative to calling to request the status
of your benefit preauthorization requests.
REMEMBER TO CHECK ELIGIBILITY AND BENEFITS – FIRST
To determine if a benefit preauthorization is needed, confirm member eligibility and benefits first through AvailityTM, or your
preferred online vendor portal. As always, questions also may be directed to the Customer Service number on the member’s
ID card.
We have scheduled webinars through June 2017 to provide iExchange users with an overview of this online benefit
preauthorization tool. For upcoming dates and times and to register online, visit the Webinars page in the Education and
Reference Center on our website at bcbsil.com/provider.
For more information about iExchange, including how to gain access if you are not a current user, visit the Education and
Reference Center/Provider Tools section of our Provider website.
*With the exception of the third Sunday of the month from 11 a.m. to 2 p.m.
Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the
member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, please call the number on the
member’s ID card.
iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no
endorsement, representations or warranties regarding any products or services offered by third party vendors such as Medecision. If you have any questions about the products or
services offered by such vendors, you should contact the vendor(s) directly.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals.
Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendors
such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Update: New Medicaid and Medicare Benefit Preauthorization Requirements through eviCore
In February 2017, Blue Cross and Blue Shield of Illinois (BCBSIL) announced new benefit preauthorization requirements, beginning April 3, 2017, for BCBSIL members enrolled
in any of the following plans:
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
Blue Cross Community Integrated Care Plan (ICP)SM
Blue Cross Community Family Health PlanSM (FHP)
Blue Cross Community Managed Long Term Supports and ServicesSM (MLTSS)
Blue Cross Medicare Advantage (PPO)SM
The benefit preauthorization requirements will now be effective beginning June 1, 2017. eviCore healthcare (eviCore) will manage benefit preauthorization requests for the
specialized clinical services listed below. Please note that the list of services requiring benefit preauthorization beginning June 1, 2017, has been updated to exclude
Cardiac Rhythm Implantable Devices (Crid).
Outpatient Molecular Genetics
Outpatient Radiation Therapy
Musculoskeletal services
Chiropractic
Physical and Occupational Therapy
Speech Therapy
Spine Surgery (Outpatient/Inpatient)
Spine Lumbar Fusion (Outpatient/Inpatient)
Interventional Pain
Outpatient Cardiology & Radiology imaging services
Pediatric Abdomen Imaging
Pediatric Cardiac Imaging
Pediatric Chest Imaging
Pediatric Head Imaging
Pediatric Musculoskeletal Imaging
Pediatric Neck Imaging
Pediatric Oncology Imaging
Pediatric Pelvis Imaging
Pediatric Peripheral Nerve Disorders (Pnd) Imaging
Pediatric Peripheral Vascular Disease (Pvd) Imaging
Pediatric Spine Imaging
Abdomen Imaging
Cardiac Imaging
Chest Imaging
Cardiac Rhythm Implantable Device (Crid)
Head Imaging
Musculoskeletal
Neck Imaging
Obstetrical Ultrasound Imaging
Oncology Imaging
Pelvis Imaging
Peripheral Nerve Disorders (Pnd) Imaging
Peripheral Vascular Disease (Pvd) Imaging
Spine Imaging
Outpatient Medical Oncology
Outpatient Sleep
Post-Acute Care
Outpatient Specialty Drug
Services performed without benefit preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek
reimbursement from the member.
Providers may continue to use iExchange® for all other services that require benefit preauthorization.
Watch the News and Updates on our website at bcbsil.com/provider and also the Blue Review for additional information, including training opportunities, in the coming months.
Our goal is to support access to quality, affordable health care for our members. If you have any questions, please contact your assigned BCBSIL Provider Network Consultant
(PNC).
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL.
Please note that the fact that a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the
member’s certificate of coverage applicable on the date services were rendered.
iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services
offered by third party vendors such as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
City of Chicago Requires Second Surgical Opinion
Effective May 1, 2017, City of Chicago Blue Cross and Blue Shield of Illinois (BCBSIL) members with the alpha prefix CTY on
their member ID card and the group numbers 195500, 195501 or 195502 must call Telligen to obtain a second surgical
opinion before having surgery. If the member does not call Telligen before a scheduled surgery, the City will not authorize
BCBSIL to pay for any expenses related to the surgical procedure. This requirement applies to surgeries in the following
areas:
Hip/knee/shoulder
Neck/back/spine
Gall bladder
Uterine/vagina/cervix
Gastric bypass
This requirement does not apply to surgical procedures performed if the member was admitted through the emergency room
for emergency surgery.
There is no charge for the second opinion and the member is not expected to travel or be examined to complete the review.
Most members who are affected by this new requirement received a letter from the City of Chicago explaining the second
surgical opinion.
The benefit of this requirement is that the member will receive a confidential written report of the second opinion related to
the proposed surgery. The member makes the final decision on how to proceed with the proposed treatment plan. Telligen
will not share any information with the City of Chicago, the member’s treating physician or BCBSIL other than to verify that
the member met the requirement of the second surgical opinion. Members may call Telligen at 800-373-3727.
Always refer to the member’s ID card to verify prior benefit authorization requirements and appropriate contact information.
Telligen is an independent third party vendor that is solely responsible for the products and services they offer. BCBSIL makes no endorsement, representations or warranties
regarding any products or services offered by independent third party vendors. If you have any questions about the products or services they offer, you should contact the vendor(s)
directly.
The fact that a guideline is available for any given treatment, or that a service has been preauthorized, is not a guarantee of payment. Benefits will be determined once a claim is
received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If
you have any questions, please call the number on the member’s ID card.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Hospital Affiliations are Required for M.D.s and D.O.s when Joining PPO and Blue
Choice PPOSM Networks
New M.D. and D.O. PPO and Blue Choice PPO contracted providers must be affiliated with a network hospital provider to be
part of the Blue Cross and Blue Shield of Illinois (BCBSIL) PPO and Blue Choice PPO networks. Exceptions to this rule
include allergists, dermatologists, physiologists, rehabilitation specialists, ophthalmologists and PCPs who are part of a
hospitalist group.
Additional information on requirements for new providers seeking to join the BCBSIL PPO professional network is available in
the Network Participation/Contracting section of our website at bcbsil.com/provider.
As a reminder, existing providers can add hospital affiliations and/or make any other changes as needed using our online
demographic change form, which has recently been updated to help make your experience quick, efficient and user-friendly.
The form can be found in the Network Participation/Update Your Information section of our Provider website.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
National Drug Code (NDC) Billing Update for BCBSIL Medicaid Claims
Blue Cross and Blue Shield of Illinois (BCBSIL) is implementing Medi-Span® as its NDC validation source. This
implementation will help ensure that the BCBSIL system is aligned with the system adopted by the Illinois Department of
Healthcare and Family Services (HFS) to validate use of appropriate NDCs on Blue Cross Community OptionsSM, or BCBSIL
Medicaid, claims.
BCBSIL follows HFS billing guidance for outpatient services that relate to NDCs. A current list of services that require an
NDC can be found on the HFS website.
If you are a BCBSIL independently contracted provider who submitted a BCBSIL Medicaid claim that was denied recently for
invalid NDC, please resubmit your claim after validating that any NDC codes billed are appropriate for the services rendered
and also active for the date(s) of service. A timely filing waiver has been temporarily granted to allow impacted providers to
resubmit the claim(s).
This information is for educational purposes only. Providers are instructed to bill claims in accordance with BCBSIL and industry standards and based upon services rendered as
documented in the medical record.
Medi-Span is a registered trademark of Wolters Kluwer Clinical Drug Information, Inc., a separate and independent company that provides information and point of care solutions for
the health care industry. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by Wolters Kluwer Clinical Drug Information, Inc.
If you have any questions about the products or services they offer, you should contact the company directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Additional Code Auditing Software Implementation Rescheduled for May 21, 2017
On Dec. 21, 2016, Blue Cross and Blue Shield of Illinois (BCBSIL) published a News and Updates notification regarding
additional code auditing software that was originally scheduled for implementation as of April 23, 2017. BCBSIL has
rescheduled this additional code auditing software implementation for May 21, 2017.
As noted in the previous announcement, this software will further enhance the auditing of professional and outpatient facility
claims for correct coding according to Healthcare Common Procedure Coding System (HCPCS), Current Procedural
Terminology (CPT®) and Centers for Medicare & Medicaid Services (CMS) guidelines. Upon implementation, providers may
use the Claim Inquiry Resolution tool, available on the AvailityTM Web Portal, to research specific claim edits.
The above notice does not apply to government programs claims.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals.
Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendors
such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2017, and April 1, 2017
DRUG LIST (FORMULARY) CHANGES
Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some
additions, revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions were made to the Blue Cross and Blue Shield of Illinois (BCBSIL)
drug lists. Changes that were effective Jan. 1, 2017, and changes that were effective as of April 1, 2017, are outlined below.
Drug List Updates (Coverage Additions) – As of April 1, 2017
Preferred Brand1
Drug Class/Condition Used For
Basic (formerly known as Standard) Drug List
Invokamet XR
Diabetes
Soolantra
Topical/Rosacea
Enhanced (formerly known as Generics Plus) Drug List
Soolantra
Topical/Rosacea
Performance Drug List
Amlodipine Besylate/Atorvastatin Calcium 10-10 mg, 10-20 mg, 10-40 mg,
10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
High Blood Pressure
Clindamycin/Benzoyl Peroxide 1-5% gel
Acne
Clindamycin Phosphate 1% gel
Topical Anti-infective
Enstilar
Topical Steroid
Fenofibrate 40 mg, 120 mg tablet
High Cholesterol
Fenofibrate Micronized 200 mg capsule
High Cholesterol
Gatifloxacin 0.5 % ophthalmic solution
Ophthalmic Anti-infective
Hydrocodone Bitartrate/Acetaminophen 10-325 mg/15 mL solution
Pain
Invokamet XR
Diabetes
Pramipexole Dihydrochloride ER 3.75 mg
Parkinson’s Disease
Rayaldee
Hyperparathyroidism
Renvela
Kidney Disease
Rubraca
Oncology
Soolantra
Topical/Rosacea
Tretinoin 0.05% cream
Acne
Triamcinolone Acetonide 0.5% ointment
Topical Steroid
Performance Select Drug List
Acanya
Acne
Amlodipine Besylate/Atorvastatin Calcium 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg,
2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
High Blood Pressure
Belviq XR
Weight Loss
BromSite
Ophthalmic NSAID
Clindamycin/Benzoyl Peroxide 1-5% gel
Acne
Clindamycin Phosphate 1% gel
Topical Anti-infective
Edarbi
High Blood Pressure
Edarbyclor
High Blood Pressure
Enstilar
Topical Steroid
Fenofibrate 40 mg, 120 mg tablet
High Cholesterol
Fenofibrate Micronized 200 mg capsule
High Cholesterol
Gatifloxacin 0.5 % ophthalmic solution
Ophthalmic Anti-infective
Hydrocodone Bitartrate/Acetaminophen 10-325 mg/15 mL solution
Pain
Invokamet XR
Diabetes
Lomaira
Weight Loss
Metronidazole topical cream, gel and lotion (0.75%)
Topical Anti-infective
Onexton
Acne
Pramipexole Dihydrochloride ER 3.75 mg
Parkinson’s Disease
Rayaldee
Hyperparathyroidism
Rubraca
Oncology
Silenor
Insomnia
Soolantra
Topical/Rosacea
Taclonex
Topical Steroid
Tretinoin 0.05% cream
Acne
Triamcinolone Acetonide 0.5% ointment
Topical Steroid
Drug List Updates (Revisions/Exclusions) – As of April 1, 2017
Non-Preferred Brand1
Generic Preferred Alternative(s)2
Drug Class/Condition Used For
Preferred Brand Alternative(s)1,2
Basic (formerly known as Standard) Drug List Revisions
Daklinza
Hepatitis C
N/A
Harvoni, Epclusa, Sovaldi
Performance Drug List Exclusions
Daklinza
Hepatitis C
N/A
N/A
Sitavig
Antiviral
N/A
N/A
Performance Select Drug List Exclusions
Sitavig
Antiviral
N/A
N/A
Drug List Updates (Coverage Additions) – As of Jan. 1, 2017
Preferred Brand1
Drug Class/Condition Used For
Basic (formerly known as Standard) Drug List
Aubagio
Multiple Sclerosis
Avonex
Multiple Sclerosis
Axiron
Low Testosterone
Descovy
Antivirals/HIV
Epclusa
Hepatitis C
Genvoya
Antivirals/HIV
Odefsey
Antivirals/HIV
Otezla
Psoriasis/Psoriatic Arthritis
Stiolto Respimat
COPD, Emphysema
Vonvendi
Hemophilia
Enhanced (formerly known as Generics Plus) Drug List
Aubagio
Multiple Sclerosis
Avonex
Multiple Sclerosis
Axiron
Low Testosterone
Descovy
Antivirals/HIV
Epclusa
Hepatitis C
Genvoya
Antivirals/HIV
Odefsey
Antivirals/HIV
Otezla
Psoriasis/Psoriatic Arthritis
Stiolto Respimat
COPD, Emphysema
Vonvendi
Hemophilia
Xarelto
DVT, Stroke, Embolism Prophylaxis
Drug List Updates (Revisions/Exclusions) – As of Jan. 1, 2017
Non-Preferred Brand1
Drug
Class/Condition
Used For
Generic Preferred
Preferred Brand Alternative(s)1,2
Alternative(s)2
Basic (formerly known as Standard) Drug List Revisions
Androderm 2 mg/24hr, 4 mg/24hr
Low Testosterone
Testosterone
Axiron
Enhanced (formerly known as Generics Plus) Drug List Revisions
Androderm 2 mg/24hr, 4 mg/24hr
Low Testosterone
Testosterone
Axiron
Cuprimine
Wilson’s Disease,
Cystinuria
N/A
Depen
Roche Accu-Chek Active, Aviva, Aviva Plus,
Compact, Smartview, Roche Accutrend
Diabetic Supplies
N/A
Bayer Ascensia Autodisc,
Breeze2, Contour, ContourNext
DISPENSING LIMIT CHANGES
The BCBSIL prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on U.S. Food and Drug
Administration (FDA) approved dosage regimens and product labeling.
Effective April 1, 2017:
Drug Class and Medication(s)1
Dispensing Limit(s)
Basic (formerly known as Standard) and Performance Drug List Changes
Misc
Diclegis
120 tablets per 30 days
Rayaldee
60 grams per 180 days
PCSK9
Repatha 140 syringe
2 per 28 days
Repatha 140 autoinjector
2 per 28 days
Selective Serotonin Inverse Agonist (SSIA)
Nuplazid
60 tablets per 30 days
Therapeutic Alternatives
Doxepin 5% cream
45 grams per 180 days
levorphanol
120 tablets per 30 days
Vanatol LQ
1000 mLs per 30 days
Vanos
60 grams per 180 days
Enhanced (formerly known as Generics Plus) Drug List Changes
Therapeutic Alternatives
Doxepin 5% cream
45 grams per 180 days
Performance Select Drug List Changes
PCSK9
Repatha 140 syringe
2 per 28 days
Repatha 140 autoinjector
2 per 28 days
Selective Serotonin Inverse Agonist (SSIA)
Nuplazid
60 tablets per 30 days
Effective Jan. 1, 2017:
Drug Class and Medication(s)1
Dispensing Limit(s)
Basic (formerly known as Standard) Drug List and
Enhanced (formerly known as Generics Plus) Drug List Changes
Actinic Keratosis (Diclofenac/Fluorouracil/Imiquimod/Ingenol)
Carac/Fluorouracil
30 grams per 180 days
Efudex cream
240 grams per 180 days
Fluoroplex
60 grams per 180 days
Solaraze Gel
300 grams per 180 days
Tolak
40 grams per 180 days
Antifungal (Onychomycosis)
Jublia
4 mLs per 30 days
Kerydin
4 mLs per 30 days
Onmel
30 tablets per 30 days
Penlac
6.6 mLs per 30 days
Sporanox 100 mg
120 capsules per 30 days
Sporanox Oral Solution
1200 mLs per 30 days
Buprenorphine, Buprenorphine-Naloxone
Suboxone 4/1
30 films per 30 days
Zubsolv 2.9/7.1, 5.7/1.4, 11.4/2.9
30 tablets per 30 days
Fluocinonide
Vanos
120 grams per 180 days
Irritable Bowel Syndrome with Diarrhea
Lotronex 0.5 mg, 1 mg
60 tablets per 30 days
Northera
Northera 100 mg
450 tablets per 30 days
Northera 200 mg, 300 mg
180 tablets per 30 days
Opioid Antidote
Evzio
1 box (2 injectors) per 90 days
Pain
Xartemis QL
120 tablets per 30 days
Rayos
Rayos 1 mg, 2 mg, 5 mg
30 tablets per 30 days
Therapeutic Alternatives
Absorica
60 capsules per 30 days
Amrix
30 capsules per 30 days
Ativan 0.5 mg
30 tablets per 30 days
Ativan 1 mg, 2 mg
150 tablets per 30 days
Bupap
180 tablets per 30 days
Cambia
9 packets per 30 days
Cardizem CD
30 capsules per 30 days
Cuprimine
480 capsules per 30 days
Daraprim
73 per 28 days
Dexpak 6 day
21 tablets per 90 days
Dexpak 10 day
35 tablets per 90 days
Dexpak 13 day
51 tablets per 90 days
Durlaza
30 capsules per 30 days
Fortamet 500 mg
150 tablets per 30 days
Fortamet 1000 mg
60 tablets per 30 days
Glumetza 500 mg, 1000 mg
120 tablets per 30 days
Pandel
80 grams per 90 days
Primlev 5/300
360 tablets per 30 days
Primlev 7.5/300
240 tablets per 30 days
Primlev 10/300
180 tablets per 30 days
Sitavig
2 tablets per 180 days
Spritam 250 mg, 500 mg, 1000 mg
60 tablets per 30 days
Spritam 750mg
120 tablets per 30 days
Vivlodex
30 capsules per 30 days
Zyflo
120 tablets per 30 days
Zyflo CR
120 tablets per 30 days
UTILIZATION MANAGEMENT PROGRAM CHANGES
Effective April 1, 2017, the following changes were applied:
The Cox-2/NSAID-GI Protectant Step Therapy (ST) program changed its name to: Combination GI Protectant. All targeted medications and program criteria effective Jan.
1, 2017, remain the same.
Several drug categories and/or targeted medications were added to the current Prior Authorization (PA) and Step Therapy (ST) programs for standard pharmacy benefit
plans, upon renewal for most members. As a reminder, please review your patient’s drug list for the indicator listed in the Prior Authorization or Step Therapy column, as
not all programs may apply. Information on prescription drug lists is available on our public website at bcbsil.com under the Member Services tab. You may ask your patient
what drug list they have, or contact customer service using the number on the member’s ID card. Members may look up their own information on myprime.com.
Drug categories added to current pharmacy PA standard programs, effective April 1, 2017:
Targeted Medication(s)1
Drug Category
Basic (Standard), Performance and Performance Select Drug Lists
Regranex
Regranex
Selective Serotonin Inverse Agonist (SSIA)
Nuplazid
Strensiq
Strensiq
Targeted drugs added to current pharmacy PA standard programs, effective April 1, 2017:
Targeted Medication(s)1
Drug Category
Basic (Standard) and Performance Drug Lists
Therapeutic Alternatives
Doxepin cream, levorphanol, Vanatol LQ, Vanos
Drug categories added to current pharmacy ST standard programs, effective April 1, 20173:
Targeted Medication(s)1
Drug Category
Basic (Standard) and Performance Drug Lists
Gabapentin ER
Gralise, Horizant
Insulin Combination Agents
Soliqua, Xultophy
Methotrexate Injectable
Otrexup, Rasuvo
Performance Select Drug List
Gabapentin ER
Gralise, Horizant
Insulin Combination Agents
Soliqua, Xultophy
Effective Feb. 15, 2017, the Opioid Dependence PA program was discontinued. Drugs to treat opioid dependence, such as Suboxone, no longer require a PA.
Effective Jan. 1, 2017, the following changes were applied:
The Cox-2/NSAID-GI Protectant ST program removed the target drug Celebrex from the program. Grandfathering was also removed from the program criteria. Members
on a current drug regimen are included in program participation.
The Biologic Immunomodulators ST program became a standard PA program. Members on a current drug regimen were grandfathered from participation. Additionally, the
target drug Otezla from the old ST program became an independent standard PA program. Members with a recent prescription history for this medication are also
grandfathered from participation.
Several drug categories were removed from the Therapeutic Alternatives standard PA program and separated into independent standard PA programs:
Antifungal-Onychomycosis Agents (2016 drug targets - Onmel, Sporanox)
Topical Lidocaine (2016 drug targets – lidocaine ointment, Lidoderm)
Northera (2016 drug target – Northera)
Opioid Antidote (2016 drug target – Evzio)
Rayos (2016 drug target – Rayos)
PA and ST programs for standard pharmacy benefit plans correlate to the member’s drug list and not all standard programs may apply. Be sure to review your patient’s drug
list for the indicator listed in the Prior Authorization or Step Therapy column.
Several drug categories and/or targeted medications were added to the current PA and ST programs for standard pharmacy benefit plans, upon renewal for most members.
Drug categories added to current pharmacy PA standard programs, effective Jan. 1, 2017:
Drug
Category
Targeted Medication(s)1
Basic (Standard), Enhanced (Generics Plus) and Performance Drug Lists
Actinic
Keratosis
Aldara, Carac/Fluorouracil (2016 target in Therapeutic Alternatives PA), Efudex, Fluoroplex, Picato, Solaraze/generic
diclofenac gel (2016 target in Therapeutic Alternatives PA), Tolak, Zyclara
Effective Oct. 1, 2016, the Ocaliva PA program was added for standard pharmacy benefit plans, upon renewal for most members. This program includes the target drug
Ocaliva.
Targeted mailings were sent to members affected by basic drug list deletions, dispensing limit, prior authorization and the GI Protectant ST program changes per our usual
process of member notification prior to implementation. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our website at
bcbsil.com/provider.
1
Third party brand names are the property of their respective owners
2
These lists are not all inclusive. Other medications may be available in this drug class.
3
Members on a current drug regimen will be grandfathered from participation in the ST program.
Prime Therapeutics LLC, a separate company, is a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue
Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set
forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details,
including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Reminder: Pharmacy Program Benefit Changes, Effective Jan. 1, 2017
Blue Cross and Blue Shield of Illinois (BCBSIL) implemented pharmacy benefit changes on Jan. 1, 2017, for some members with prescription drug benefits administered through
Prime Therapeutics.*
Based on claims data, letters are being sent from BCBSIL to alert members who may be affected by one, or more, of the 2017 pharmacy benefit changes. A summary of the
changes, as outlined in the member letters, is included below for your reference.
Drug List Changes and Medication Coverage Revisions/Exclusions – Some members’ plans may now be based on a new drug list:
1. New Performance Drug List and Performance Select Drug Lists – Some members may have one of these new drug lists, which are closed drug lists, meaning they will list
covered medications only. As a result, some medications will move to a higher copay/coinsurance payment tier and select drugs/drug classes may be excluded from coverage.
Additionally, if your patient had a prior authorization approval for a drug that is now excluded from coverage, you can submit a drug list coverage exception request to BCBSIL.
Based on this change, your patient may ask you about therapeutic alternatives.
2. Enhanced Drug List (formerly known as Generics Plus Drug List) – Some members may move to this drug list, and as a result, select medications may move to a higher
copay/coinsurance payment tier. Based on this change, your patient may ask you about generics or lower cost alternatives.
3. Some members may also be affected by annual or quarterly drug list changes, such as drugs moving to a higher payment tier or excluded from coverage. Based on this
change, your patient may ask you about therapeutic or lower cost alternatives.
4. The Standard Drug List is now known as the Basic Drug List.
5. As a reminder, medications that have not received U.S. Food and Drug Administration (FDA) approval are not covered under the BCBSIL pharmacy benefit.
Utilization Management Program Changes – Some members’ plans may now be subject to new prior authorization and step therapy programs and/or dispensing limits. If your
patient is taking any of the selected medications included in these programs, your patient may need to meet certain criteria, such as an approval of a prior authorization request,
for coverage consideration. Additionally, these programs may correlate to your patient’s drug list. (For example, if a particular drug is not included on the member’s drug list, a
formulary exception request would need to be submitted, rather than a PA request, for coverage consideration.)
Medication Coverage Exclusions – Under the pharmacy benefit, some member’s plans may exclude from coverage the following: weight loss drugs, non-sedating
antihistamines, compound medicines, brand-name proton pump inhibitors (PPIs), drugs that have not received FDA approval and prescription drugs with an over the counter
(OTC) equivalent available.
Specialty Drug Changes – Starting Jan. 1, 2017, regardless of plan effective date, HMO individual benefit plans offered on/off the Illinois Health Insurance Marketplace now
require the member to obtain self-administered specialty medications from a specialty pharmacy included in the BCBSIL HMO specialty pharmacy network for coverage
consideration under the pharmacy benefit. To help your patients receive appropriate benefits, be sure their self-administered specialty medications are filled at a BCBSIL preferred
specialty pharmacy.
Starting Jan. 1, 2017, members with an individual benefit plan offered on/off the Illinois Health Insurance Marketplace who are using a drug manufacturer’s coupon or copay card
cannot have the specialty drug payment apply to their plan deductible or out-of-pocket maximum, unless the coupon is a permitted third-party cost sharing payment. Your patients
can contact BCBSIL if they have questions about this change.
Pharmacy Network Changes – Some members’ plans may experience changes to the pharmacy network:
1. CVS Exclusion – Effective Jan. 1, 2017, CVS pharmacies® and CVS pharmacies in a Target® store were removed from most members’ pharmacy networks.
2. New Pharmacy Networks – Some members’ plans may move to a preferred network where prescriptions filled at these preferred tiered independently contracted pharmacies
offer the lowest copay/coinsurance amounts. 90-day supplies can also be filled at either these preferred tiered pharmacies or through mail order for coverage consideration.
Members who continue to fill prescriptions at a pharmacy no longer in their network will pay more. In most cases, no action is required on your part for any of these pharmacy
network changes as members can easily transfer prescriptions to a nearby in-network pharmacy. If your office stores pharmacy information on your patients’ records, you may
want to ask your patient which pharmacy is their new in-network choice.
Retail and Mail Order Supply Limit Changes – Some members’ plans may include a 90-day supply limit for covered prescriptions filled at a retail pharmacy or through mail
order.
If your patients have questions about their pharmacy benefits, please advise them to contact the Pharmacy Program number on their member ID card. Members also may
visit bcbsil.com and log in to Blue Access for MembersSM for a variety of online resources.
*Changes to be implemented, as applicable, based on the member’s 2017 plan renewal, or new plan effective date, unless otherwise noted. These changes do not apply to members with Medicare Part D or Medicaid coverage.
Prime Therapeutics LLC, a separate company, is a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. In addition, contracting pharmacies are contracted
through Prime Therapeutics. The relationship between BCBSIL and contracting pharmacies is that of independent contractors. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
A “preferred” or “participating” pharmacy has a contract with BCBSIL or BCBSIL’s pharmacy benefit manager (Prime Therapeutics) to provide pharmacy services at a negotiated rate. The terms “preferred” and “participating” should not be construed as a
recommendation, referral or any other statement as to the ability or quality of such pharmacy. Please note that changes to participating pharmacies may be made in the future.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. The listing of any particular drug or classification of drugs
is not a guarantee of benefits. This is only a brief summary of some plan benefits. For more complete details, including benefits, limitations and exclusions, members should refer to their certificate of coverage. Regardless of benefits, the final decision about
any medication and pharmacy choice is between the member and their health care provider.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Insurers Required by Centers for Medicare & Medicaid Services (CMS) to Conduct Audit
for Affordable Care Act (ACA) Risk Adjustment Program
CMS requires an annual Initial Validation Audit (IVA) to ensure accurate data is used when assessing the payment transfers
for the ACA Risk Adjustment (RA) program. Therefore, to comply with the IVA requirement, BCBSIL is asking for the
cooperation and participation of all independently contracted providers in its networks.
Insurers are required to hire an independent auditor to perform the requirements of the IVA. Tactical Management
Incorporated (TMI) is the auditor selected by BCBSIL to retrieve medical records for the IVA, which is expected to begin in
June 2017. The RA program applies to all ACA-compliant individual and small group plans, including plans that are available
on and off the Exchange, and conducts a calculation based on enrollee risk. As a reminder, enrollee risk is calculated based
on the diagnosis codes submitted on a claim, as well as through supplemental codes captured through medical record
review. As BCBSIL independently contracted providers, you may be asked to provide medical records directly to TMI in order
to validate all of the diagnosis codes submitted on claims, which are then used in the RA calculation. Please respond to these
requests in a timely manner. It is important to have a successful audit to help improve the health care delivery system.
The IVA will be performed on a sample of members enrolled in ACA-compliant plans. TMI will seek to validate medical claims
of the sampled members from the previous calendar year. For example, this audit will be conducted in 2017, but will review
claims with dates of service in 2016. Please be aware some of these claims may have been paid in 2017 and are likely to be
included in the IVA sample.
We understand this is a very busy time. However, in an effort to comply with the CMS requirements, we appreciate your full
support and cooperation as you receive requests from TMI and deliver the requested medical record(s) in a timely manner.
We want to help ensure that the valuable care you provide to your patients every day is accurately reflected in the data you
provide to auditors for CMS records.
If you have any questions, please contact your assigned BCBSIL Provider Network Consultant (PNC).
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
ClaimsXtenTM Announces Software Version Upgrade
Beginning on or after July 17, 2017, Blue Cross and Blue Shield of Illinois (BCBSIL) will perform a system software upgrade
from version 4.4 to version 6.0 for ClaimsXten. Key enhancements related to this upgrade include, but are not limited to:
Version 6.0 uses XML formatting with flexibility at the header and line levels during claim processing.
The Clear Claim ConnectionTM (C3) tool will have a new look and feel with new data fields for greater claim specificity,
and the ICD code set default will be ICD-10.
Clinical edit clarifications and related sources will continue to be available.
An instruction document will be available by July 17, 2017, to assist users with learning the navigation in C3. Watch the News
and Updates for additional details and announcements.
For more information about ClaimsXten, including answers to frequently asked questions, refer to the Clear Claim
Connection page in the Education and Reference Center/Provider Tools section of our website at
bcbsil.com/provider.Information also may be published in upcoming issues of the Blue Review.
ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and
services.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
ClaimsXtenTM Quarterly Updates
New and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS)
codes are periodically added to or deleted from the ClaimsXten code auditing tool software by the software vendor on a
quarterly basis and are not considered changes to the software version. Blue Cross and Blue Shield of Illinois (BCBSIL) will
normally load this additional data to the BCBSIL claim processing system after receipt from the software vendor and will
confirm the effective date via the News and Updates section of the BCBSIL Provider website. Advance notification of updates
to the ClaimsXten software version also will be posted on the BCBSIL Provider website.
To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process,
you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool. Refer to the Clear Claim
Connection page in the Education and Reference Center/Provider Tools section of our Provider website for additional
information on gaining access to C3, as well as answers to frequently asked questions about ClaimsXten. Updates may be
included in future issues of the Blue Review.
ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and
services.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield Plans.
bcbsil.com/provider
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
© Copyright 2017 Health Care Service Corporation. All Rights Reserved.
A newsletter for contracting institutional and professional providers
May 2017
Has your information changed? Let us know!
When seeking health care services, our members often rely upon the information in our online Provider Finder®. In
particular, potential patients may use this online tool to confirm if you or your practice is a contracted in-network
provider for their health care benefit plan. Other providers may use the Provider Finder when referring their patients
to your practice.
We encourage you to check your own information in the Provider Finder – look for the link on our Provider website
Home page at bcbsil.com/provider. Is your online information accurate? If changes are needed, it’s important that you
inform BCBSIL as soon as possible.
USE OUR ONLINE CHANGE REQUEST FORMS
You can request most changes to your information online by using one of our electronic change request forms. Visit
the Network Participation/Update Your Information section of our Provider website to access instructions along with
links to each type of form. Currently, there are three different change request forms to help you organize your
information, as follows:
1. Request Demographic Information Changes
Use this form to request changes to your practice information currently on file with BCBSIL (such as address, email
or NPI). You may specify more than one change within your request as long as all changes relate to the same billing
(Type 2) NPI. As a participating provider, your NPI(s) should already be on file with BCBSIL. You may use this online
form to request changes, such as deactivation of an existing NPI.
2. Request Addition of Provider to Group
Use this form to notify BCBSIL when a new individual provider joins your practice. Please remember that new
providers are subject to credentialing review and will not be effective until the process is completed and the provider
is approved.
3. Request Removal of Provider from Group
Use this form to notify BCBSIL when an individual provider is leaving any or all of your practice locations.
Please note that changes are not immediate upon submission of an online change request form. Processing can take
a minimum of 30 business days. If you would prefer to mail or fax your changes to BCBSIL, there is a downloadable
Provider Information Change Request Form in the Network Participation/Update Your Information section of our
Provider website, under the Related Resources. If you have any questions or need assistance, contact Provider
Network Operations at [email protected].
EXCEPTIONS TO THE ONLINE REQUEST PROCESS
The following types of changes are more complex and require special handling:
Multiple changes, especially changes involving more than one billing (Type 2) NPI – These should be
submitted via email to [email protected].
Tax ID changes that may, or may not, involve Legal Business Name changes – This type of change often
requires a new contract. To request a contract application, visit the Network Participation/Contracting section of
our Provider website. You may also want to discuss this with your assigned Provider Network Consultant (PNC).
Ancillary provider changes – Skilled nursing facilities, home health agencies, hospice, home infusion therapy,
durable medical equipment (DME) suppliers, orthotics and prosthetics, dialysis centers, private duty nursing
agencies and other ancillary providers may request changes by sending details to [email protected],
or by calling 312-653-4820.
bcbsil.com/provider
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