Provider Update July 2024

Medical

New Medical Policy 

• Monaural Hearing Aids RP-P-017

Recent updates to policies

• Anesthesia Guidelines RP-X-009
• Telehealth GP-X-016
• Timely Filing Limit GP-X-046

The following medical policies had changes effective June 1, 2024:

• I.212 Sympathetic Nerve Blocks
• I.195 Botox
• III.237 Treatment of Lymphedema and Lipedema
• IV.81 Radiology
• VIII.2 Contact Lens and/or Glasses

G0109 (Group Diabetic Education) was added to our telehealth policy effective July 1, 2024 

G0109 follows the same guidelines as other telehealth codes and requires modifier 95 with a place of service 02 or 10. In addition, the service must be billed by an approved telehealth provider.

Denials for non-FDA Approved Treatments 

^{Updated May 24, 2024} 
  
BCBSNE will no longer cover Q0224 and M0224. While these drugs had received emergency use authorization, these drugs are not FDA approved. Additionally, any drug or service that is not FDA approved will be denied by BCBSNE as benefit plans do not provide coverage. Claims submitted would be denied as provider liability.

Dental

Submitting Corrected Dental Claims

To submit a corrected dental claim, simply send a Reconsideration with the changes needed or the requested EOB. If a new claim is submitted rather than a Reconsideration, it will automatically deny as duplicate since dental claims do not have XX7/XX8 claims like medical claims.

Medicare Advantage

BCBSNE’s Medicare Advantage plan is moving in-house for 2025

We’re excited to announce that in 2025, we will bring the operations of our Medicare Advantage (MA) program fully in house, providing key benefits for you, our health care provider partners.

What’s changing? 

Currently, BCBSNE works with a third-party vendor to manage our MA program. Effective Jan. 1, 2025, we will bring the operations our MA program fully in-house. This change will enable us to better support you, our health care provider partners, in serving your patients who have a BCBSNE MA plan. Key benefits will include:

Utilization Management: 

• Providers will be able to submit MA preauthorizations via NaviNet^®. These preauthorizations can be tracked in the same way as our commercial members' preauthorizations.
• The types of preauthorizations able to be submitted for via NaviNet will be expanded for MA plans.
• Discharge planning will be managed directly by BCBSNE.

Claims processing: 

• BCBSNE will process MA claims directly. You can expect the claims process for MA to mirror BCBSNE’s familiar commercial claims process. This will allow BCBSNE to provide you with an enhanced experience, as our Provider Executive team will have increased visibility into claims and be able to support you should you have questions.

Enhanced customer service experience: 

• BCBSNE will have a Nebraska-based customer service team available to answer MA questions once the transition is complete. Please note: The customer service phone number for MA will not change. Please continue to call 888-505-2022 for BCBSNE MA member eligibility, benefits and claims questions.

Access to Medicare Advantage on NaviNet: 

• After the transition is completed on Jan. 1, 2025, providers will have access to claims, eligibility, benefits, preauthorization and other items available on NaviNet for the Medicare Advantage line of business.

We will share more information about this change soon. If you have any questions in the meantime, please reach out to your Provider Executive. 

Medicare Advantage Access Standards

BCBSNE establishes provider access standards in accordance with the Centers for Medicare and Medicaid Services (CMS) regulations for BCBSNE Medicare Advantage members. The following standards apply to BCBSNE Medicare Advantage Primary Care and Behavioral Health in-network providers for BCBSNE Medicare Advantage. Providers who do not meet the standards may be required to complete a Corrective Action Plan (CAP).

Provider Type	Appointment Type
Primary Care Provider General Practice Family Practice   Internal Medicine Pediatric Medicine Obstetrics and Gynecology practitioners	Routine and Preventive care must be provided within 30 business days of patient request. Non-Urgent care requiring medical attention must be provided within seven business days of patient request.  Emergent Care for urgently needed services must be provided immediately.
Behavioral Health Provider Psychology Psychiatry  Mental Health and Substance Abuse practitioners	Routine and Preventive care must be provided within 30 business days of patient request. Non-Urgent care requiring medical attention must be provided within seven business days of patient request.  Emergent Care for urgently needed services must be provided immediately.
After-Hours Access to Care
CMS requires that the hours of operation of its practitioners are convenient for and do not discriminate against members.     Practitioners must provide coverage for their practice 24 hours a day, seven days a week with a published after-hours telephone number (to a practitioner’s home or other relevant location), pager or answering service or a recorded message directing members to a physician for after-hours care instruction.     Note: Recorded messages instructing members to obtain treatment via emergency room for conditions that are not life threatening is not acceptable. In addition, primary care physicians must provide appropriate backup for absences.

Best Practices for Medication Adherence

According to the Centers for Disease Control and Prevention, it’s estimated that “approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency and duration.” 

That’s why there are three Medicare Advantage star measures to help determine success with patients ages 18 and older for filling prescriptions to cover 80% or more of the time they are supposed to be taking the medication. The measures are medication adherence for: 

• Diabetes Medications (Non-Insulins) 
• Hypertension (RAS Antagonists) 
• Cholesterol (Statins) 

Medication adherence may be unintentional or intentional. It’s important for patients to trust their providers and understand that providers only want to better understand potential or current barriers without judgement.

Tips for talking with patients include:

• Provide short and clear instructions for all prescriptions.  
• Emphasize the benefits of taking the medication and the risks of not taking the medication. The benefits should outweigh the risks. 
• At each visit, ask your patients about their medication habits, including the average number of doses they may miss each week. Continue with open-ended questions to identify barriers to taking medications: 
  • What side effects have you had from the medication, if any? 
  • How many doses have you forgotten to take? 
  • Are there any financial barriers preventing you from obtaining your prescriptions? 
  • What issues prevent you from refilling your prescription? 
  • What OTC vitamins or supplements, herbs or essential oils are you taking, if any?  
• Offer recommendations for improvement: 
  • Recommend weekly or monthly pillboxes, smart phone apps with medication reminder alerts and placing medications in a visible area (but in properly closed containers and safely out of reach of children or pets) for patients who forget to take their medications. 
  • Encourage patients to call your office if they experience side effects to discuss alternative medications. 
  • Refer patients to their health plan to learn about mail order options for their prescriptions. 

Read the Medication Adherence tip sheet for more tips for success and information about the measures including which medications are included and exclusions. 

Manage osteoporosis to limit disability 

Musculoskeletal conditions are the leading contributor to disability, according to the World Health Organization.  
 
The Osteoporosis Management in Women who had a Fracture (OMW) HEDIS^® star measure assesses women 67–85 years of age who suffered a fracture and had either a bone mineral density test or received a prescription to treat osteoporosis within six months of the fracture.  
 
Read the OMW tip sheet to learn more about this measure and the information to include in medical records.   
 
^{Source: Musculoskeletal health (who.int)
Healthcare Effectiveness Data Information Set (HEDIS®) is a registered trademark of the National Committee for Quality Assurance (NCQA).}

Importance of statin therapy for patients with cardiovascular disease and diabetes

According to the National Committee for Quality Assurance, cardiovascular disease is the leading cause of death in the United States. People with diabetes also have elevated cardiovascular risk, thought to be due, in part, to elevations in unhealthy cholesterol levels. This places people with diabetes at significant risk for developing Atherosclerotic Cardiovascular Disease (ASCVD). 
 
American College of Cardiology and American Heart Association (ACC/AHA) guidelines state that statins of moderate or high intensity are recommended for adults with established clinical ASCVD. The American Diabetes Association and ACC/AHA guidelines also recommend statins for primary prevention of cardiovascular disease in patients with diabetes, based on age and other risk factors. Guidelines also state that adherence to statins will aid in ASCVD risk reduction in both populations. 
 
The Centers for Medicare & Medicaid Services (CMS) has two star measures to support statin therapy’s importance. To learn more about these measures, read these tip sheets: 
 
Statin Therapy for Patients with Cardiovascular Disease (SPC)
Statin Use in Persons with Diabetes (SUPD) 

^{Source: Statin Therapy for Patients With Cardiovascular Disease and Diabetes - NCQA} 

What’s new for HEDIS MY2024

There are no new measures for HEDIS MY2024, but below are a few highlights of changes to existing HEDIS Measures for MY2024.

Cervical Cancer Screening (CCS)

• Replaced references to “women” with “members recommended for routine cervical cancer screening.”  
• Added criteria for “members recommended for routine cervical cancer screening” to the eligible population. 
• Added an exclusion for members who were assigned male at birth. 

Glycemic Status Assessment for Patients with Diabetes (GSD) 

• Updated the measure title from Hemoglobin A1C Control for Patients with Diabetes (HBD)
• Added glucose management indicator as an option to meet numerator criteria. 

There are two ways to identify members with diabetes: by claim/encounter data and by pharmacy data. 

• Claim/encounter data. Members who had at least two diagnoses of diabetes on different dates of service during the measurement year or the year prior to the measurement year. 
• Pharmacy data. Members who were dispensed insulin or hypoglycemics/ antihyperglycemics during the measurement year or the year prior to the measurement year and have at least one diagnosis of diabetes during the measurement year or the year prior to the measurement year. 

Security Corner

Breach Notifications by Business Partners

In some cases, your clinic’s HIPAA Business Partners may send breach notifications to your patients. For example, if a breach occurs at a clearinghouse or electronic health record (EHR) vendor that your clinic uses.

While these notifications may not be coming from your clinic directly, your patients will no doubt have questions. Be sure to provide a communication plan and any applicable details to your frontline staff so they can effectively field these questions for concerned patients.