Blue Cross of Idaho uses our One to One newsletter to notify and highlight upcoming important information or actions that may be required by the provider community.

The information is categorized in three parts: Informational (for education only), actions (requires action on your part) or reminders (notification or reminder of events or deadlines).

Topics in this edition of the provider newsletter include:

Informational• Clinical quality outreach and value-

based contracting

• Direct electronic health record messaging

• Electronic funds transfer registration /updates

• Health benefits of vaccinations

• New faces

• Return of external provider relations representatives

• Idaho Medicaid Plus – launching in Ada and Canyon counties

Actions• Billing services identification when

calling Blue Cross of Idaho

• Diabetes prevention program

• Osteoporosis – your perception matters

• Using our provider portal is quick and easy

Reminders• Contracting versus credentialing

• Medicare Advantage glasses after cataract surgery

• Medical policy updates

• Provider portal training webinars

M E D I C A L | S U M M E R E D I T I O N

One to One Newsletter

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER2

Informational

Clinical Quality Outreach and Value-Based ContractingCombating the rising cost of healthcare is at the forefront of conversations among providers and payers throughout the nation. The transition to value-based or pay-for-performance models are quickly becoming the leading platform to help reduce the cost of healthcare while improving quality of care and patient health outcomes. We, at Blue Cross of Idaho, are no different.

The Healthcare Operations Clinical Quality Outreach team was developed to provide support, guidance and best practice interventions with networks and providers who currently participate in a value-based agreement. The Provider Network Management team works with the Clinical Quality Outreach team and providers to establish quality measures in value-based contracts that are meaningful, impact the overall cost of care and have challenging but obtainable goals. Clinically integrated networks and provider groups are participating in value-based agreements across the state, positively impacting the quality and cost of care for a majority of Blue Cross of Idaho’s members across all product lines.

These provider groups and networks have access to an inventory of reporting tools, including a monthly gap in care report, to identify patients that need preventive screenings and condition-based care, such as laboratory monitoring or medications. They also receive a monthly quality scorecard that captures their member volume as well as quality metrics compliance rates. The Clinical Quality Outreach team helps to facilitate and ensure the timeliness and integrity of the quality metrics reports.

A positive and productive working relationship is a key factor to the success of value-based payment. The Clinical Quality Outreach and Provider Network Management teams are aiming to breakdown the historical culture of division between payers and providers.

These collaborative efforts will result in tangible improvements in the overall health of our communities. We also know that social determinants of health play a role in preventing people from getting the care they need. The Clinical Quality Outreach team is dedicated to partnering with healthcare professionals to identify barriers to care and coordinate with providers to ensure Idahoans have the access to health care they need.

In addition, the Outreach team reviews the submission of non-standard supplemental data from the networks and providers. This data is processed and reviewed for compliance per the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) Technical Specifications. We work with offices to provide education regarding care gaps and HEDIS measures. Resources available to support coding include The HEDIS Resource Guide, information for compliance to close gaps administratively through claims. The Non-Standard Supplemental Data- Guidelines for Submission is the step-by-step process for submitting patient charts to close care gaps.

As the quality outreach program continues to cultivate, we are looking to our providers to communicate to Blue Cross of Idaho the tools they need to continue to provide high quality healthcare. The goal of the Clinical Quality Outreach team is to assist, support and collaborate with the networks and providers to identify, develop and define opportunities to better serve patients. Our hope is that these efforts will result in substantial improvements in the overall health of our communities.

For more information call 986-224-4692 or email qualityoutreach@bcidaho.com.

SUMMER 2019 3

Direct Electronic Health Record Messaging We are excited to announce that, through our partnership with Pareto Intelligence, we now have the capability to leverage direct messaging technology to communicate patient-specific information directly with you through your electronic health record (EHR).

What is Direct Messaging? Direct messaging is like an email except messages are exchanged directly within the EHR account rather than an outside email server. Messaging directly within the EHR allows protected health information (PHI) be sent and received in a secure and HIPAA-compliant manner. Most EHRs offer a free direct messaging account.

Why direct message versus traditional email?Direct messaging allows us to communicate patient-specific information with you during your daily workflow within the EHR, eliminating the need to manually enter this information into your EHR from other sources, such as suspected condition lists.

What information will Direct Messages from Blue Cross of Idaho contain?All messages from Blue Cross of Idaho will come from BCIRiskAdjustment@paretointeldirect.com. Messages will be sent for qualified health plan (QHP) patients with risk documentation gaps. Risk documentation gaps are chronic conditions that have been reported in prior years but have not yet been evaluated in the current year.

Using the information within the message, providers will be able to easily identify these gaps and determine if ongoing evaluation and management is needed for the chronic condition during the patient encounter.

What to expect next: Expect to receive additional information in the mail, by email or by a direct message within your EMR. Clinics with patients who have a risk documentation gaps will also be contacted directly by their area provider engagement specialist to determine the best messaging options. To expedite direct messaging with Blue Cross of Idaho, please reach out to your area Provider Engagement Specialist or email us at riskadjustment@bcidaho.com.

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER4

Sharing the Health Benefits of VaccinationsAs a healthcare professional and a parent’s trusted source of education, you have an important role in successfully communicating to parents the health benefits of vaccinations for their children.

Parents who have considered delaying vaccination or are uncertain whether to have their child vaccinated still look to their child’s healthcare provider for guidance. Often, vaccine education can be limited when you are also examining the patient for physical and cognitive milestones. During those exams, remember to bring up vaccinations. Here are a few key, best practices to help you ensure that families make the right decisions regarding vaccinations1:

Assume parents will vaccinate• Research has found that using a

presumptive approach, parents are more accepting to vaccinate their child.

• Use language like, “Your child needs three shots today” or “Your child needs DTaP, Hib and Hepatitis B shots today.”

Give your strong recommendation• Talk about the importance of vaccines

and how they will protect their child from potentially life-threatening diseases.

• Use language like, “These shots are very important to protect him/her from serious diseases.”

Listen to and respond to parents’ questions

• Listen to the questions that parents have regarding vaccinations as they could indicate why they might be hesitant in vaccinating their child.

• Seek to understand a parent’s concerns and provide information when asked.

Parents may still refuse to vaccinate• Continue the conversation about vaccines

during the next visit If parents decline immunizations after a conversation on the health benefits.

• Inform the parents of an unvaccinated child that if the child is ill, healthcare professionals will need to take precautions to protect others. Explain that those too young to be fully vaccinated and those who have a weakened immune system will be at risk should their child not be fully vaccinated and are presenting with a preventable disease.

Finishing the conversation• Agree to leave the door open for future

conversations on the vaccines. If a parent declines a vaccine once, it does not mean they always will.

• Encourage the vaccine-hesitant parents to read educational materials you provide them.

• Schedule an appointment to answer their questions and to vaccinate their child if they agree.

1https://www.cdc.gov/vaccines

SUMMER 2019 5

Return of External Provider Relations RepresentativesBlue Cross of Idaho is pleased to announce the return of external provider relations representatives! The team will conduct in-office trainings, offer customized large-group and specialty-specific informational seminars and host online training webinars.

There will be total of four external reps who will cover the various regions of the state. Two representatives will serve the western/central area, which includes Riggins, Twin Falls, Sun Valley, the Treasure Valley and the contiguous Oregon counties. One representative will cover Northern Idaho including the upper Idaho border to Grangeville, as well as contiguous Washington and Montana counties and one representative will cover Southern Idaho including Burley to Preston to Saint Anthony as well as contiguous Nevada, Utah and Wyoming counties. All representatives will live in their respective areas and will be on hand to visit provider offices and promptly answer questions.

These external representatives work with our internal provider relations team who currently address incoming provider emails and phone calls. They will also conduct credentialing site visits and Centers for Medicare & Medicated Services-required new Medicare Advantage provider visits. They will also hold yearly mandatory training seminars for cultural compliance, fraud, waste and abuse and anti-discrimination education.

Western Central Idaho Reps: Heather Beard, CPC, CPB, CRC, CEMC, CGIC PRexternalreps@bcidaho.com P: 800-274-4018 Ext 5776 P: 986-224-5776

Makenzie Ekman PRexternalreps@bcidaho.com P: 800-274-4018 Ext 6927 P: 986-224-6927

Counties: Ada, Adams, Blaine, Butte, Camas, Canyon, Custer, Elmore, Gem, Lemhi, Owyhee, Payette, Twin Falls, Valley, Washington and contiguous Oregon counties

Southern Idaho Rep: Nicole Stosich PRexternalreps@bcidaho.com P: 800-274-4018 Ext 6671 P: 986-224-6671

Counties: Bannock, Bear Lake, Bingham, Bonneville, Caribou, Cassia, Franklin, Fremont, Gooding, Jefferson, Jerome, Lincoln, Madison, Minidoka, Oneida, Power, Teton and contiguous Nevada, Utah and Wyoming counties

Northern Idaho Rep: Tammy Fortune PRexternalreps@bcidaho.com P: 800-274-4018 Ext 6677 P: 986-224-6677

Counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce, Shoshone and contiguous Montana and Washington counties

We invite you take part in a brief, 10-minute survey to tell us about what learning formats you prefer and what topics you want to learn more about. Your response will guide 2019 education plans including provider groups and/or provider types (e.g., primary care providers, specialists, dentists, chiropractors, etc.) and give insight on provider website enhancements.

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER6

Electronic Funds Transfer (EFT) Registration Blue Cross of Idaho has implemented a dual-validation process for any new, updated or terminated EFT transaction made through our provider portal. This new validation process has been implemented to protect our providers’ financial transactions. During this process, providers will receive one call from Provider Relations and a second call from our Finance department. Please note that during this process there is a 10-day prenote bank verification for new or updated registrations. In addition, all payments are held until all validations can be completed to ensure payments are being made to correct providers.

New FacesHealthcare Solutions

• Stephen Kuchta – Solutions manager

Provider Relations

• Nicole Stosich – Provider relations representative

• Jodi Mastas – Provider relations representative

Government Funding Operations

• Stacy Dahl – Provider engagement specialist

SUMMER 2019 7

Idaho Medicaid Plus – Launching in Ada and Canyon CountiesIdaho Medicaid Plus is a plan for individuals who are eligible for both Medicare and full Medicaid services. The plan coordinates most of their Medicaid benefits through a single health plan. The Idaho Department of Health and Welfare (IDHW) is partnering with two health plans to administer the program, Molina Healthcare of Idaho and Blue Cross of Idaho. Developmental disability services, medical transportation and dental are all available through Idaho Medicaid Plus.

The enrollment into Idaho Medicaid Plus is mandatory if the dually eligible beneficiary lives within one of the assigned counties and has not enrolled in the Idaho Medicare-Medicaid Coordinated Plan (MMCP). There are some groups of people that are excluded from mandatory enrollment, including tribal members, pregnant women and individuals on the Adult Developmental Disabilities Waiver program.

Idaho Medicaid Plus covers most medically necessary* Medicaid benefits and services for a dually eligible participant, including:

• Hospital costs after Medicare payment

• Medical costs after Medicare payment

• Behavioral health, including community-based rehabilitation services

• Nursing home costs after Medicare payment

• Aged and Disabled (A&D) Waiver

• Personal care services

• Care coordination

*Please see member handbook for a full list of benefits.

The table below outlines the counties that already have Idaho Medicaid Plus available and counties that will launch the program.

Counties Effective DateTwin Falls November 1, 2018

Bannock, Bingham and Bonneville April 1, 2019

Bonner, Kootenai and Nez Perce June 1, 2019

Ada and Canyon August 1, 2019

ContractingWe encourage all providers to review their contract status with Blue Cross of Idaho. To learn more or to begin contracting, please call our Provider Network Management team at 986-224-3116 or email ProviderAncillarySpecialist@bcidaho.com. MMCP/Idaho Medicaid Plus Provider enrollment packets are located at: https://providers.bcidaho.com/forms-and-resources/MMCP/provider-packet-mmcp.page.

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER8

Action

Billing Services Identification When Calling Blue Cross of IdahoTo ensure that Blue Cross of Idaho is securing and protecting the patient and provider protected health information (PHI), we require that billing services calling for eligibility, claims, authorization or other information identify themselves by using their legal business name then the name of the provider they are calling on behalf of.

For faster service, we encourage billing services to use our 24/7, self-service provider portal. There you can find information about eligibility, claims, authorization and more. Visit www.providers.bcidaho.com to register or log in. Go to Forms & Resources, select Forms then Billing Service Access to locate the Billing Service Agreement form for each clinic/facility you need access to. A security verification call will be made to each clinic/facility to verify access.

Preventive Service — Diabetes Prevention ProgramBlue Cross of Idaho patients at risk for Type 2 diabetes have access* to the National Diabetes Prevention Program (NDPP).

The NDPP has been proven by the National Institutes of Health (NIH) in a randomized controlled trial to greatly reduce the progression of prediabetes to Type 2 diabetes.1 Services are delivered by trained lifestyle coaches and organizations recognized by the Centers for Disease Control and Prevention (CDC).

Criteria for eligibility are:

• At least 18 years old and Body mass index (BMI) greater than 25 or greater than 23 if Asian

• Blood screening (optional, if available):

• Hemoglobin A1C: 5.7–6.4 percent, or• Fasting plasma glucose: 100–125 mg/dL, or• Oral glucose tolerance Test: 140–199 mg/dL

• Exclusions: no previous diagnosis of end-stage renal disease, Type 1 or Type 2 diabetes; not pregnant (previous gestational diabetes is not an exclusion)

Refer qualified patients today to get started. Qualified members can enroll through our program administrator, Solera Health, by visiting solera4me.com/bcidaho or by calling 602-734-7435 (TY 711), Monday through Friday from 7 a.m. – 7 p.m. MST.

*Access and eligibility are based on risk assessment and Blue Cross of Idaho plan; not all plans include the Diabetes Prevention Program. Members will need to check plan benefits.

1 https://www.cdc.gov/diabetes/prevention/prediabetes-type2/preventing.html

SUMMER 2019 9

Diabetes Prevention Program for Medicare MembersEffective April 2018, the Diabetes Prevention Program (DPP) expanded to include Medicare members. The model is a structured intervention with the goal of preventing progression to Type 2 diabetes in individuals with an indication of pre-diabetes. The Medicare DPP (MDPP) helps participants learn to eat healthier, resulting in weight loss, increase their activity and reduce their risk for Type 2 diabetes.

The program consists of a minimum of 16 core sessions over six months using the approved curriculum from Centers for Disease Control and Prevention (CDC). The program is in a group-based, classroom-style setting allowing for enhanced interpersonal support and encouragement. MDPP also provides a lifestyle health coach to help set goals and keep participants on track. After completing the core sessions, monthly follow-up meetings will help ensure that participants maintain healthy behaviors.

The primary goal for the first year is for participants to obtain at least a 5 percent weight loss.

Aside from the first-year core services, the MDPP also includes second-year maintenance sessions for those who achieve the 5 percent weight loss goal and attend a minimum of two sessions per three-month period.

Patients are eligible for the program if they meet all five requirements:

1. Enrolled in Medicare Part B

2. Body mass index (BMI) greater than 25 (or greater than 23 if self-identified as Asian)

3. No previous diagnosis of Type 1 or Type 2 diabetes (history of gestational diabetes will not impact eligibility)

4. No history of end-stage renal disease (ESRD)

5. One of the following lab results within the past 12 months:

• A1C between 5.7–6.4 percent

• Fasting plasma glucose 110–125 mg/dL

• 2-hour plasma glucose 140–199 mg/dL (oral glucose tolerance test)

If eligible, MDPP is a covered, preventive benefit with no cost-sharing to the patients. This is a once in a lifetime benefit.

Blue Cross of Idaho has partnered with Solera Health to provide the MDPP benefit. Qualified members can enroll through our program administrator, Solera Health, by visiting solera4me.com/bcidaho-medicare or by calling 602-734-1799 (TY 711), Monday through Friday from 7 a.m. – 7 p.m. MST.

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER10

Osteoporosis – Your Perception MattersYour patients rely on you as the expert for their health, and this includes discussions about bone health – especially after having suffered a fracture.

Many women consider osteoporosis to be normal wear and tear associated with aging and many times do not link the condition to a fracture they may have sustained.1 According to the International Osteoporosis Foundation, approximately 80 percent of individuals at high risk and who have had at least one osteoporotic fracture have not been identified or received treatment.2 Your patients are listening to you when it comes to their bone health.

How well are we doing here in Idaho with osteoporosis management? We could improve and you can help. The following information shows Blue Cross of Idaho’s Healthcare Effectiveness Data and Information Set (HEDIS) ranking for initiating treatment for osteoporosis compared to the National Committee for Quality Assurance (NCQA) Medicare Quality Compass Benchmark:

Osteoporosis Management in Women Who Had a Fracture in 2017

Eligible Population 2018 (Data Year 2017) Blue Cross of Idaho’s Rate

National Benchmark 75th Percentile

Medicare HMO 24.55% 62.6%

HEDIS measure for women 67-85 years old, who experienced fragility fractures, treatment initiation is identified as:

• The presence of a bone mineral density test within six months post fracture, or

• Osteoporosis medication prescribed within six months post fracture

What can you do to help?

Discuss bone health even before a fracture occurs. Provide patient education about osteoporosis and listen to concerns regarding diagnosis and treatment options. Your patients are listening. If your patients hear their bone health is important to you, it becomes important to them.

1https://doi.org/10.1371/journal.pone.0158365

2https://www.iofbonehealth.org/facts-statistics#category-14

Formulary changes happen periodically. Please review the appropriate member formulary for the most up-to-date version.

SUMMER 2019 11

Using Our Provider Portal is Quick and Easy!Do you need information on a pending claim, want to see how a claim is processed or why one was denied? You can now find this information along with many helpful tools on our secure, self-service provider portal. Your questions can be answered with a few keystrokes and no more waiting.

Here’s what you can find or do in the provider portal:

• Patient eligibility status

• Benefit information

• Claim status

• Remittance advices

• Allowances

• Prior authorizations

• Provider Administrative Policies (PAPs)

• Direct Claims Entry (DCE) that lets you enter a claim

• Verify BlueCard patients

PAPs are a great tool for Blue Cross of Idaho claims submission requirements that may help reduce certain claim denials. We encourage providers to review these PAPs to ensure that claims are correct and accurate. For example, our PAP 206 has all information needed to submit a corrected or voided claim. A corrected or voided claim has different requirements than a first-time claim. Missing some of these vital requirements could result in a claim being denied. The website will list PAPs for each line of business such as Commercial, Dental, Medicare Advantage and Medicare-Medicaid Coordinated Plans.

• Log in to the portal at provider.bcidaho.com

• Find the Policies and Procedure tab

• Choose the line of business from the drop-down menu under Provider Administrative Polices

• Read the Use and Disclosure of Data on this page and select Continue if you agree

• Choose the appropriate section for your needs from the Table of Contents page. Most common is 200-299 General Billing/Information.

Looking for a remittance advice? You can quickly find that on the provider portal. On your check, there is a payment reference number that consists of 16 digits. The first 4 digits is the year and the next 4 digits is the date of the check. This coincides with the date of the remittance advice for the payment. As an example: the payment reference number on the check is 2019060312345678. The date of the remit is taken from the first 8 digits, 20190603. Your corresponding remittance date is 06/03/2019. You can use this date to find your remit through our remittance display.

The Direct Claims Entry (DCE) tool is a helpful link that can help eliminate missed or incorrect information submitted through EDI that may cause denials or delays in processing. The DCE tool can also accept attachments where EDI currently does not. There are printable instructions available that

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER12

will walk you through entering the claim and how to send attachments such as primary explanation of benefits (EOB), auto insurance EOB’s, Medicare opt-out forms or signed advanced beneficiary notices (ABNs). Using our DCE is a way to enter claims directly into our claims processing system and may help eliminate the question of if a claim was received by Blue Cross of Idaho.

• Log in to our portal at providers.bcidaho.com

• Navigate to the Eligibility and Claims tab at the top of the screen

• Choose Direct Claims Entry from the drop-down menu

• Print and read the instructions that are available on this screen for your information

• Select Launch

• Read the Terms and Conditions on this page and select Accept if you agree

• Select Create New Claim

• Follow the instructions that you printed to enter the claim

With the self-service provider portal, you have direct access to a host of information and tools that can reduce the need to call or email Blue Cross of Idaho, ultimately saving you time.

Blue Cross of Idaho is pleased to announce the return of our external provider relations representatives. We encourage you to contact the new team to schedule an in-office provider portal training visit. Our external provider relations representatives are here to help you and answer questions!

Western Central Idaho Reps: Heather Beard, CPC, CPB, CRC, CEMC, CGIC PRexternalreps@bcidaho.com P: 800-274-4018 Ext 5776 P: 986-224-5776

Makenzie Ekman PRexternalreps@bcidaho.com P: 800-274-4018 Ext 6927 P: 986-224-6927

Counties: Ada, Adams, Blaine, Butte, Camas, Canyon, Custer, Elmore, Gem, Lemhi, Owyhee, Payette, Twin Falls, Valley, Washington and contiguous Oregon counties

Southern Idaho Rep: Nicole Stosich PRexternalreps@bcidaho.com P: 800-274-4018 Ext 6671 P: 986-224-6671

Counties: Bannock, Bear Lake, Bingham, Bonneville, Caribou, Cassia, Franklin, Fremont, Gooding, Jefferson, Jerome, Lincoln, Madison, Minidoka, Oneida, Power, Teton and contiguous Nevada, Utah and Wyoming counties

Northern Idaho Rep: Tammy Fortune PRexternalreps@bcidaho.com P: 800-274-4018 Ext 6677 P: 986-224-6677

Counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce, Shoshone and contiguous Montana and Washington counties

SUMMER 2019 13

Reminders

Contracting Versus CredentialingAs a reminder, in order to be contracted with Blue Cross of Idaho you must first complete credentialing. It’s important to remember that contracting and credentialing are not the same. Credentialing is a review of qualifications and other relevant information pertaining to a healthcare practitioner who seeks a contract with Blue Cross of Idaho. Credentialing is required for practitioners who provide services to members and who are permitted to practice independently under state law. If you have questions, please reach out to Provider Relations at PRProviderRelations@bcidaho.com or 866-283-5723, option 4.

Medicare Advantage Billing Reminder – Glasses After Cataract SurgeryHardware following cataract surgery is reimbursed under the medical benefit and will be allowed for True Blue and Medicare-Medicaid Coordinated Plan (MMCP) members only if purchased from a contracting provider, unless a prior authorization is obtained from a non-contracting provider. For Secure Blue no Rx (PPO), the benefit will be considered in-network for contracting providers and out-of-network for non-contracting providers.

Please do not send these types of claims for hardware following cataract surgery into VSP. Routine vision benefits for True Blue Rx (HMO), True Blue Rx Option II (HMO), True Blue Rx Option I (HMO) and Secure Blue are processed through VSP.

Provider Portal Training WebinarsDid you know Blue Cross of Idaho offers provider portal training webinars on a monthly basis? The live trainings cover all aspects of the provider portal. Examples of portal trainings are dental, medical, Medicare-Medicaid Coordinated Care (MMCP) including information regarding Idaho Medicaid Plus (BCIMP), authorizations/notifications/referrals, medical drug, musculoskeletal/spine surgery and joint surgery/pain management.

There’s no need to register. Just review the webinar schedule and follow the instructions to participate in the training that interests you. To view the schedule, visit the provider portal at providers.bcidaho.com and select the Webinar Schedule link found under Live Provider Portal Training Webinars. If you have questions about these monthly webinar trainings, contact your Provider Relations Representative at 866-283-5723 or PRproviderrelations@bcidaho.com.

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER14

Policy # Title Summary of Changes to Policy Statement New Policies2.02.31 Myocardial Strain Imaging Added to medical policy library, effective June 14,

2019: Myocardial strain imaging is investigational.

5.01.30 Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients

Added to medical policy library, effective May 15, 2019: Patisiran and inotersen are considered medically necessary when specific clinical criteria are met.

5.01.654 Provider Administered Drugs – Site of Care Guidelines

Added to medical policy library, effective July 15, 2019: This guideline addresses the criteria for consideration of allowing hospital outpatient facility specialty medication infusion services. Alternative sites of care, such as non-hospital outpatient infusion, physician office, ambulatory infusion or home infusion services are well accepted places of service for medication infusion therapy. If an individual does not meet criteria for outpatient hospital facility infusion, alternative sites of care are to be used.

7.01.105 Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis

Added to medical policy library, effective May 15, 2019: Use of a catheter-based inflatable device (balloon ostial dilation) in the treatment of chronic rhinosinusitis is considered investigational.

7.01.155 Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Added to medical policy library, effective May 15, 2019: The use of functional endoscopic sinus surgery in the treatment of chronic rhinosinusitis is considered medically necessary for patients with chronic rhinosinusitis when specific clinical criteria are met.

Medical Policy ChangesMedical policies updates effective since the last provider newsletter are summarized below. See the specific medical policy referenced for complete information.

Medical Policies provide general guidance for applying Blue Cross of Idaho benefit plans and do not constitute medical advice. Any person applying a Medical Policy must identify member eligibility, the member specific benefit plan, and any related policies or guidelines prior to applying a Medical Policy. If there is a conflict between a member specific benefit plan and Blue Cross of Idaho’s standard benefit plan, the member specific benefit plan supersedes Medical Policy. Blue Cross of Idaho Medical Policies are designed for informational purposes only and are not an authorization, explanation of benefits or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the member specific benefit plan coverage. Blue Cross of Idaho reserves the sole discretionary right to modify all its Policies and Guidelines at any time.

SUMMER 2019 15

Revised Policies1.01.30 Artificial Pancreas Device

SystemEffective July 15, 2019: The age criterion changed in the first medically necessary statement; medically necessary statement added on FDA-approved automated insulin delivery system (artificial pancreas device system) designated as hybrid closed loop insulin delivery system in patients with Type 1 diabetes who meet specified criteria; and investigational statement added on use of an automated insulin delivery system (artificial pancreas device system) for individuals who have not met specified criteria.

2.04.114 Genetic Testing for Idiopathic Dilated Cardiomyopathy

Effective May 15, 2019: Policy statements changed from investigational to medically necessary when criteria are met. Title updated.

2.04.500 Diagnostic Tests for Allergic and Immune Deficiency Diseases of Uncertain Efficacy

Effective July 15, 2019: Removed Prausnitz Kustner and Rebuck Skin Window tests as they are no longer in use. Removed CPT 83516.

2.04.502 Salivary Hormone Testing Effective June 14, 2019: Policy statement regarding Cushing’s disease removed. No change to investigational policy statement.

5.01.611 Complement Inhibitors: Eculizumab (Soliris) and Ravulizumab (Ultomiris)

Effective July 15, 2019: Policy statement added stating Ravulizumab (Ultomiris) may be considered medically necessary when specific criteria are met. References 17-20 added. Policy title changed from

“Eculizumab (Soliris)” to “Complement Inhibitors: Eculizumab (Soliris) and Ravulizumab (Ultomiris).”

7.01.149 Amniotic Membrane and Amniotic Fluid Injections

Effective July 15, 2019: EpiCord add to medically necessary statement for diabetic lower extremity ulcers. Sutured and non-sutured amniotic membrane may be considered medically necessary for specified ophthalmic conditions.

7.01.25 Spinal Cord and Dorsal Root Ganglion Stimulation

Effective July 15, 2019: The second policy statement was changed from investigational to medically necessary: "Dorsal root ganglion neurostimulation is considered medically necessary for the treatment of severe and chronic pain of the trunk or limbs."

7.01.524 Treatment of Varicose Veins/Venous Insufficiency

Effective May 15, 2019: Added statement for cyanoacrylate adhesive as medically necessary. Added statement regarding medical necessity of concurrent treatment of great or small saphenous veins when criteria for each vein is met.

BLUE CROSS OF IDAHO | MEDICAL NEWSLETTER16

9.01.501 General Coverage Guidelines

Effective July 15, 2019: Policy format and criteria order updated to align with Blue Cross of Idaho standards.

Archived Policies1.03.05 Patient Controlled

End Range of Motion Stretching Devices

Effective July 15, 2019: Policy will no longer be used and was archived from the medical policy library.

6.01.54 Dopamine Transporter Imaging with Single Photon Emission Computed Tomography

Effective May 15, 2019: Policy will no longer be used and was archived from the medical policy library.

s

Any Questions?MEDICAL MANAGEMENT Questions regarding managed health care/review, preadmission/admission certification or individual benefits management and case management:

• Call: 208-331-7535 or 800-743-1871 (voicemail available after office hours and on holidays and weekends)

MEDICAL POLICY Questions regarding medical policy and clinical criteria:

• Email: HCOMedicalPolicy@bcidaho.com

BLUE CROSS OF IDAHO HELP DESK Questions regarding electronic billing errors, error and acceptance reports:

• Email: edihelpdesk@bcidaho.com

PROVIDER CONTACT CENTER Questions regarding benefits, coverage and authorization:

• Call: 208-286-3656 or 866-482-2250 between 7 a.m.-7 p.m. MT Monday-Friday, EXCEPT closed 2-3 p.m. MT Thursday

For post-service claim questions, log on to our secure website at providers.bcidaho.com and select Contact Us.

PROVIDER RELATIONS Questions regarding coding, contracting or need website training:

• Call: 866-283-5723 or 208-286-3602 • Email: PRproviderrelations@bcidaho.com

FRAUD, WASTE AND ABUSE We encourage anyone who suspects possible fraudulent activity to report it to us. You have the option to remain anonymous. Call the fraud hotline at 800-682-9095 or email fraudreporting@bcidaho.com.