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Blue Ink - Wellmark Blue Cross and Blue Shield

Tips for reducing“denied” or“pending”authorizationrequestsPage 2St Luke’s sharesearly adoptionexperiencePage 5Blue Distinction®designation helpsconsumers identifyhigh‐performinghospitalsPage 12April 2013Information for Iowa and South DakotaPhysicians, Hospitals, and Health Care ProvidersStay current with the latest news from Wellmark® Blue Cross® and Blue Shield®Visit our website at Wellmark.com.Current Procedural Terminology (CPT) is copyright 2012 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT.The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT ® is a registered trademark of the American Medical Association.


Table of ContentsFeatureFeatureHow can you reduce “denied” or “pending”authorization requests? . . . . . . . . . . . . . . . 2Important dates for your calendar . . . . . . . . . 4I received a denial. What do I do? . . . . . . . . . 4Utilization Management tool is putinto action. . . . . . . . . . . . . . . . . . . . . . . 5Administration & PolicyAlways use current enrollment, credentialingand contracting documents . . . . . . . . . . . . 8Claims & CodingDo you make house calls?. . . . . . . . . . . . . . 9Send credentialing, enrollment materialsto Des Moines . . . . . . . . . . . . . . . . . . . . 9Online PCRs coming soon . . . . . . . . . . . . . 9Accessing benefit accumulation online justgot easier . . . . . . . . . . . . . . . . . . . . . . . 9Patient waivers for certainservices require careful attention . . . . . . . . 10Denied claim or payment change?. . . . . . . . 10Easily indicate whether a claimwas work-related. . . . . . . . . . . . . . . . . . 11File claims for Tyson Foods, Inc.,members promptly . . . . . . . . . . . . . . . . 11Clinical QualitySubmit new claim when you receiveF or X denial messages . . . . . . . . . . . . . . 11Wellmark congratulates local hospitals onreceiving Blue Distinction ® Centerdesignation for quality and efficiency . . . . . . 12New accountable care organization (ACO)to improve outcomes . . . . . . . . . . . . . . . 13PQM scores available for reviewApril 15 . . . . . . . . . . . . . . . . . . . . . . . 13Education & TrainingUpcoming Wellmark webinars for providers . . 13Iowa OnlyBlue Zones Project . . . . . . . . . . . . . . . . 14Iowa jumps to No. 9!. . . . . . . . . . . . . . . . 14Medical PolicyNew, revised and retired medical policies . . . 15Telehealth services . . . . . . . . . . . . . . . . 15PHARMACYCorrection — Anesthesia modifiers . . . . . . . 15TRICAREBig thanks from TriWest. . . . . . . . . . . . . . 15WELLNESSHow well are your patients?. . . . . . . . . . . . 162 | blueInk April 2013How can you reduce “denied” or“pending” authorization requests?Save time with these tips for using the online UM toolLate last year, Wellmark introduced our new online Utilization Management(UM) tool. Powered by McKesson’s Clear Coverage product, this tool allowsproviders to submit authorization requests for designated procedures,DME, and out-of-network referrals. You can also use the tool to completeinpatient admission notifications and precertification requests, and submitdischarge notifications.Throughout the first few months of using the new system, Wellmark staffcollected feedback from providers about how the new tool was working. In thisarticle, we’ll provide some tips to enhance your experience and improve yourbusiness flow.While working through the medical review questions, knowwhen (and when not) to click the boxes marked “Other.”Because our UM tool uses preset algorithms to determine if the clinicalinformation provided meets medical necessity criteria, clicking the “Other” boxautomatically puts the request in “Pending” status. This results in a manualreview. Therefore, unless you believe additional information is absolutelypertinent to determining medical necessity, DO NOT click the “Other”boxes. If you do select “Other,” be sure to attach or submit the pertinentdocumentation. If no additional information is provided, our clinical teamhas no information to review in order to support the medical necessity for theprocedure to be performed.Submit multiple procedure codes in the initial requestas appropriate.If there is a chance that the procedure may change, please submit allpertinent codes. For example, you may choose to enter the code for a totalknee replacement as well as the code for a unicondylar knee procedure. Thisis important, as failure to authorize the code for the service that was actuallydelivered will result in a denied claim. Please refer to page 20 in the UserGuide. (On Wellmark.com, go to Provider > Medical Policy Authorizations > Pre-Service Review Changes.)Make sure to click “Submit” to completeyour request.Wellmark has noticed that a number of providers are stopping short ofcompleting their request once the UM tool returns a “Recommended” or “NotRecommended” message at the conclusion of the medical review portion ofthe process. “Recommended” and “Not Recommended” messages only referto whether or not the clinical information submitted meets medical necessitycriteria. Unless you take the next step and click “Submit,” your request willremain in an incomplete status. Please know that Wellmark does not receiveincomplete requests. That is, we cannot see them on our side of the system.Remember that a “Pending” status does not mean therequest has been denied.A big advantage to our UM tool is the ability to check the real-time status ofyour request. This saves having to call or send an inquiry to Provider Service. Ifyou receive a “Not Recommended” message, for example, simply follow up by


Featuresubmitting any additional documentation to support your request.This is required for authorization to be approved. The next step lieswith our clinical UM nurses or, in some cases, a medical director.The nurse or physician will review your documents to determinemedical necessity. If the request is denied and additionalinformation is available, a provider inquiry or appeal can besubmitted for further review. Just follow the steps outlined in theaccompanying article, “I received a denial. What do I do?”Save time by knowing when to submitadditional documentation.If your request meets medical necessity and the UM tool shows a“Recommended” determination, there is no need to submit furtherdocumentation with a note, by attachment, or by fax. Simply click“Submit,” and the request will likely be automatically authorized. Ifyour request did not meet medical necessity criteria, as indicatedby the “Not Recommended” determination, you may still submitthe request. Just be sure to include additional clinical informationto support medical necessity. Start by entering information in the“Notes” section. You may attach documentation directly to therequest, or send a fax using the cover sheet available in the tool.Please note that in order to recognize an attached document, thesystem requires an entry in the “Notes” section.Do not schedule nonemergent procedures prior toreceiving an approval.If the situation is a medical emergency, perform the services andsubmit the claim per the normal process. We will respond to urgentrequests within 72 hours for Iowa members and 24 hours forSouth Dakota members. For nonemergent requests, Wellmark willrespond within 15 calendar days. However, our normal turnaroundtime is usually within a week.Can’t find the “Submit” button? Scroll to the bottom of your screen or hit the F11 key to see the entire window on one screen.April 2013 blueInk | 3


FeatureApril 17Important datesfor your calendarWebinar:Save Time with Online PCRsMay 8Webinar:Overview of Enhanced AmbulatoryPatient Groupings (EAPG) Base RatesMay 31Deadline for clinicians to review theirPhysician Quality Measurement (PQM)scores at Wellmark.com.June 12Webinar:Wellmark Contracts and AddendumsJuly 1Providers are required to use currentversions of documents for enrollment,credentialing, and contracting.I received a denial. What do I do?Navigating the pre- and post-service denial review processGood question! Let’s look at two types of denials – those for pre-servicereview requests and those for a post-service claims review. They differin a number of ways, including whether you need member consentto proceed.preservicereviewrequestIf the pre-service review request isdenied and additional information is available, you canstart by submitting a provider inquiry through any of thefollowing:• Submit a secure online Provider Service Inquiry (OnWellmark.com at Provider > Claims and Payment >Appeals and Inquiries).• Use the Provider Inquiry Form at Wellmark.com(Provider > Forms > Provider Claim Review Forms).• Call Provider Service−−800-362-2218 IA Providers−−800-532-1537 for FEP−−800-774-3892 SD ProvidersThrough an inquiry, additional medical documentationcan be submitted, or a peer-to-peer consultation canbe requested.If the provider completes the inquiry process and thedecision is not overturned, the provider can move forwardwith the appeal process. In this case, the membermust provide consent for the provider toappeal. Click here.For more information on pre-service appeals, click hereor visit Wellmark.com (Member > Using Your Benefits >Member Appeals and External Reviews).postserviceclaimdenialFor a post-service claim denial, either theprovider or member can request a review. Here’s how:• Providers must first complete the inquiry process asoutlined above. Inquiries must be submitted within18 months of the date of the provider’s remittance onwhich the original claim in question appeared.• If the inquiry process is completed and the decision isnot overturned during that process, the provider canmove forward with the appeal process. In this case,member consent is not needed.For more information on post-service appeals, click hereor visit Wellmark.com (Provider > Claims and Payment >Appeals and Inquiries).4 | blueInk April 2013


FeatureSt. Luke’s Hospital Utilization Management department. Pictured left to right are: Breana Klein, precertification specialist, Marilinne Staub, utilizationmanagement specialist, and Suzie Lange, senior revenue cycle analyst.Utilization Management tool is put into actionSt. Luke’s shares early adoption experience and advice for other providersOn Dec. 15, 2012, Wellmark launched the new online UtilizationManagement tool for providers. The online tool enables providersto complete authorization requests for designated proceduresand DME, inpatient notification/precertification, and dischargenotifications, as well as out-of-network referrals.When Wellmark initiated the selection of today’s UtilizationManagement tool, it made sense to work collaboratively withthe providers who would be relying on the online tool day in andday out. Understanding how providers use these tools was keyin delivering a product that saved them time and eliminatedinefficient steps.Beginning in July 2012, Wellmark reached out to a handfulof willing providers from Iowa and South Dakota to become earlyadopters of this new process.Along the way, Wellmark’s teams carefully monitored usage andengaged in a series of weekly feedback meetings with theseproviders in an effort to craft the most efficient, effective onlinetool process.Marilinne Staub,RN, BSN, CCMUtilization management specialist,Marilinne Staub, RN, BSN, CCM, withSt. Luke’s Hospital — one of six earlyadopters — shares her experience withWellmark’s Vice President and ChiefMedical Officer Timothy R. Gutshall, M.D.Dr. Gutshall: As a process improvement principle, Wellmarkwanted to work with some providers as a small test of change tolearn about the good, the bad, and the ugly regarding lessonslearned in implementing this new tool prior to expanding its useto the entire network.How long has St. Luke’s Hospital been using the tool?Ms. Staub: St. Luke’s Hospital participated in the early adopterinitiative and started using the tool on Oct. 22, 2012.Utilization Management tool— continued on Page 6April 2013 blueInk | 5


FeatureUtilization Management tool— continued from Page 5Dr. Gutshall: Changing any process within a complexorganization can be a challenge due to the interplay of manyworkflows. Describe your experience with using the new tool tocomplete the authorization process.Ms. Staub: After resolution of some initial glitches and withincreased use, we have found the tool easy to use. We haveboth nonclinical and clinical staff coordinating efforts to providetimely and accurate information to complete the authorizationsfor our patients.Dr. Gutshall: To modify and enhance the tool’sfunctionality, Wellmark leaned on your experiences andfeedback as early adopters. What was it like being a part of thatdevelopment process?Ms. Staub: We found the early adopter period to be bothchallenging and rewarding. We are willing to participate in newprocesses when improvement, efficiency and accuracy are theultimate goal. We enjoyed the networking opportunities and thechance to gain efficiencies for both parties.Dr. Gutshall: Comparing the process now to the process youpreviously used to complete a request, what is the differencein the average length of time required using the new tool? Whatwere some stumbling blocks?Ms. Staub: Considering the Precertification/Notification role,utilizing the tool has not resulted in any increase in the timeto complete a request. It is comparable. Unfortunately, not allinpatient requests can be completed on the tool. Those thatcannot be completed on the tool are taking longer due to therequirement to phone in those requests. Examples include NICUadmissions and behavioral health admissions. We are hopefulthat future enhancements to the tool will allow for electronicsubmission for these as well as other types of admissions. Also,the ability to interact with the Procedures and DME module toobtain preauthorization results would be ideal.As it relates to the Utilization Review role, the tool did add time tothe UR process in that we now perform the criteria review twicefor some patients (those requiring an admission criteria reviewon the tool), due to our decision to continue our internal criteriareviews for these patients as well. Aside from that, the clinicalstaff does not need to interact with the tool for the majorityof patients because the plans require only timely notification.Adding the discharge date and disposition added a very smallamount of time as well, as we previously had a daily fax sentfrom our system. However, the discharge process on the tool isextremely quick and easy.Timothy R. Gutshall, M.D.Wellmark Vice President and Chief Medical OfficerA native of Ohio, Dr. Gutshall earned his undergraduate and medical degrees from the Universityof Iowa. He completed his Family Medicine residency at Wake Forest University in Winston-Salem,North Carolina, in 1986.Timothy R.Gutshall, MDWellmark VicePresident and ChiefMedical OfficerWith experience running his own primary care clinic practice, Dr. Gutshall became an original partner inthe formation of the Iowa Physicians Clinic in 1988. In 1995, he transitioned to the emergency room as afull-time staff physician at Iowa Methodist.In 2007 Dr. Gutshall became the Senior Clinical Director of Telligen, formerly Iowa Foundation for MedicalCare. He has lectured in more than 70 hospitals and in multiple national venues, including the Institute ofHealthcare Improvement. He became Chief Medical Officer at Telligen in 2010 and continued in that roleuntil joining Wellmark in March of 2012.Dr. Gutshall is a member of the Iowa Medical Society, American College of Emergency Physicians, and theAmerican Medical Association. He is currently on the board of the Free Clinics of Iowa and is a past boardmember of the Iowa Healthcare Collaborative and Health Access Partnership.6 | blueInk April 2013


FeatureDr. Gutshall: As with any change in process workflows, thereis a learning curve. Even at this early stage, do you think the newtool is improving the response time for getting your authorizationrequest outcome?Ms. Staub: Generally, yes! The response time from requestto authorization is much quicker for those who do not requirean admission criteria review. For those requiring a review, theresponse time from submission to authorization decision iscomparable. I believe this will continue to improve as the clinicalstaff becomes savvier with adding supporting documentationwhen criteria are not initially met.Dr. Gutshall: It is our express purpose here at Wellmark toprovide great communication and educational support for thistype of network change. Tell me about the education or processchanges your hospital implemented to get your administrative orclinical teams on board with the new tool.Ms. Staub: We attended the webinars, onsite training andfollow‐up teleconferences to learn about the tool, get updateson issues, and garner tips on best practices. We also utilizedan internal staff member as a subject matter expert to provideone-to-one support. Our processes did not change significantly,except for the obvious change from phone/fax to the tool.However, an unexpected positive effect was improved use of ournew electronic health record (EHR) tools to communicate theauthorization status.Dr. Gutshall: The new tool is designed to create efficienciesfor both you and Wellmark. What is most helpful about theUtilization Management tool, now that you have fully adoptedusing it?St. Luke’s HospitalCedar Rapids, IowaSt. Luke’s is a fully accredited, 532-bedhospital serving a five-county area surroundingCedar Rapids, Iowa. Founded in 1884 as CedarRapids’ first hospital, today it offers a wide range ofpatient care services with strengths in cardiac care,obstetrics, neonatology, pediatrics, rehabilitation,behavioral health, general surgery, trauma careand senior services. St. Luke’s Hospital is nationallyrecognized as a five-time winner of the TruvenHealth Analytics 100 Top Hospitals Award and isalso a Magnet Hospital.Ms. Staub: The tool allows all staff involved with theauthorization to see at a glance the current state ofthe authorization, the criteria used, and the workingreference number.Dr. Gutshall: We know from the process improvement worldthat change management is essential but oftentimes painful.What advice might you lend to other providers hesitant to makethe transition to the new Utilization tool?Ms. Staub: Electronic health care transactions are already apart of our daily work and are quickly replacing nonelectronicmethods of health care business. We encourage providers toparticipate knowing there will be difficulties with the change, butthat they will also find opportunities to improve processes andfind efficiencies while providing excellent patient care.April 2013 blueInk | 7


Administration & PolicyAlways use current enrollment,credentialing and contractingdocumentsOnly current versions accepted after July 1Wellmark has various documents for providers to use when requestingparticipation in Wellmark networks and for maintaining demographic andpractice information once approved. It is important that providers use currentversions of applications, the addendum, and supporting documents. Althoughyou may save copies for your convenience, we advise that you update yourcopies at least annually, as Wellmark requires the most current versions.Beginning July 1, 2013, Wellmark will only accept the most current versionof applications, addendums, and contracts. If a noncurrent document issubmitted after July 1, Wellmark will return all documents to the requestorunprocessed with explanation.It is importantthat providers usecurrent versionsof applications,the addendum,and supportingdocuments.Use the Statewide Universal Practitioner/Facility Application when:1. It is the provider’s first time applying for participation; this is true whetherthe provider wants to be listed in the Wellmark directory or not, except forhospital-based providers. (See the Professional Provider Application belowfor additional information.)2. A hospital-based provider is adding a non-hospital-based location with theintent to provide non-hospital-based services.3. A facility or entity wants to provide services eligible for benefitconsideration, but does not want to participate in Wellmark’s networks as aparticipating provider.Use the Professional Provider Application (short application) when:1. The provider is already credentialed with Wellmark and is enrolling at anadditional location, whether under the same or a different tax ID.2. The provider is enrolling with Wellmark as an emergency departmentprovider and practicing as an ED physician.3. A hospital-based provider 1 does not wish to be listed in theWellmark directory.4. A non-credentialed provider wishes to submit claims, but does not wish toparticipate in any networks.A Wellmark addendum is required each time a Universal Application issubmitted. Both documents should be submitted together.Access current application forms, addendums and contracts at Wellmark.com(Provider >Credentialing and Enrollment)1To be considered hospital-based, the provider should practice exclusively at a hospital or afreestanding facility. For details, see the “Contracts and Credentialing” section of the WellmarkProvider Guide at Wellmark.com (Provider > Billing Guides).8 | blueInk April 2013


Claims & CodingDo you make house calls?New code for PTs introduced for treatment at worksitesThe American Physical Therapy Association’s (APTA) request for a new placeof service (POS) code to indicate that a physical therapist (PT) deliveredservices at a patient’s worksite was recently granted by the Centers forMedicare and Medicaid Services (CMS). POS codes are 2-digit codes placedon health care claims to indicate the setting in which a service was provided.The new code became available for use effective Jan. 1, 2013. For Medicaidclaims, it became effective April 1, 2013.The new code, POS 18, is named “place of employment-worksite.” Per thedescription, the code should be used when physical therapy is delivered at“a location, not described by any other POS code, owned or operated by apublic or private entity where the patient is employed, and where a healthprofessional provides ongoing or episodic occupational medical, therapeuticor rehabilitative services to the individual.”Examples of situations in which POS 18 can be used include, but are notlimited to:iiJob-site analysis to identify potential accommodations — patientpresent and participating in the service.iiJob coaching to improve biomechanics at the worksite — patientpresent and participating in the service.iiPhysical therapy evaluation and treatment at the worksite.iiFunctional capacity evaluations at the worksite to determine theworker’s ability to perform specific job duties.Currently, PTs are likely to report POS 99, known as “other place ofservice,” when delivering services at the worksite.Wellmark accepts POS 18, but determined that services billed appropriatelywith POS 18 will not be covered, as these services are specific tooccupational issues and are not covered under the member’s health plan.CMS maintains POS codes used throughout the health care industry. Foradditional information about POS codes and to obtain an updated list ofcodes, visit the CMS website, CMS.gov.Send credentialing, enrollmentmaterials to Des MoinesDelivering to the wrong address delays the processCredentialing materials and applications for participation in Wellmark’snetworks, both in Iowa and South Dakota, are processed at our DesMoines office and should be mailed to the address on the forms:Wellmark Blue Cross and Blue Shield of IowaPO Box 14509Des Moines, IA 50306-3509Please do not deliver or mail these materials to our South Dakota orregional Iowa offices.Online PCRs coming soonPaper versions to be eventually phased outThe days of wasting paper and time dealingwith hard copy provider claims remittanceinformation will soon come to an end. Providerstold us they wanted an electronic solution andWellmark listened. Here’s what you need to knowabout our upcoming Online PCRs:iiWellmark will soon add a feature to theProvider portal on Wellmark.com, whichallows providers to access Online PCRs.iiWe think you’ll like the electronic option. Thenew Online PCRs will be available as fullysearchable PDF documents. Even better, theymay be downloaded and saved locally.iiYou will also be able to use the website to stopdelivery of paper PCRs.iiEventually, paper-based PCRs will no longerbe mailed or faxed. Instead, providers willonly be able to access Online PCRs throughWellmark.com.The new Online PCR feature is just one morereason to register with Wellmark.com! Thank youto all the providers who encouraged us to addthis Web enhancement.Accessing benefit accumulationsonline just got easierPhysical medicine providers need fewerclicks to get the information they needWe recently discovered that the “View MoreAccumulations” button on the “Check PatientEligibility & Benefits” section of our Providerportal was a bit tricky to find. To make it easierfor the physical medicine specialists who relymost on this function, we recently set this pageto automatically expand the list of accumulatedbenefits. Whether you’re a physical therapist,occupational therapist, speech therapistor chiropractor, you now have fewer clicksto find what you’re looking for. In addition,providers can now print or download a record ofaccumulated benefits for their patients.April 2013 blueInk | 9


Claims & CodingPatient waivers for certain services require careful attentionFollow these tips to help avoid confusion about paymentProviders may seek payment from the member for experimental orinvestigational services, and services that do not meet Wellmark’sdefinition of medical necessity if:iithe provider explains verbally and in writing to the member,prior to the signing of the waiver, that the specific services inquestion are experimental or investigational, or do not or maynot meet Wellmark’s medical necessity criteria;iithe provider gives a cost estimate to the member for thespecific services in question;iithe member signs a valid waiver form before the services areperformed; andiithe provider bills such services with the GA modifier.MODIFIERGADEFINITIONWaiver on fileBy including a GA modifier with a procedure code, you indicatethat a patient has agreed to accept financial liability for a servicethat Wellmark may consider experimental or investigational, ora service that does not meet Wellmark’s definition of medicalnecessity. It also indicates that you have met Wellmark’srequirements for an appropriate waiver, and that a signed waiveris on file.The GA modifier does not affect a claim’s processing in any way.If the service is denied as not medically necessary, the charge willappear on your remittance and on the member’s statement asprovider liability. If you’ve met the waiver requirements, you maybill the member for the service.The provider will not attempt to collect from members anypayment reduction resulting from the provider’s failure to followWellmark’s Utilization Management procedures, such as obtaininga required prior approval or precertification.Blanket or generic waivers, intended or attempting to include anyand all services which the provider may render to the member,will not be considered valid waivers with respect to non-medicallynecessary, experimental, or investigational services.Elements of a valid patient waiver formThe patient waiver form must contain the following:iithe date,iithe place of service,iithe description of the service,iia cost estimate of the service,iia summary of Wellmark’s medical policy or an attachedcopy of the policy,iia statement that you have met with and explained to themember that the service provided for that condition may beconsidered experimental, investigational, or not medicallynecessary by the member’s health insurance policy orcoverage manual and therefore, may not be covered by hisor her health insurance contract benefits, andiiverification that the member agrees to be financiallyresponsible for the services.REMINDERS:iiDo not file the waiver with the claim. Instead, keep waivers withthe member’s medical record.iiThe claim form should include a GA modifier with theappropriate procedure code.You’ll find complete information about patient waivers in the“Claims Filing” section of the Wellmark Provider Guide,Wellmark.com (Provider > Billing Guides)Denied claim or payment change?Check online for faster serviceA recent enhancement to Wellmark’s online Check Claim Status tool can help you avoidunnecessary and time-consuming calls to Provider Service. Instead of picking up the phoneto find out why a claim was denied or payment changed due to iCAP (Improve the ClaimsAdjudication Process) processing, just log in to Wellmark.com. Here’s how it works.iiWithin the Check Claims Status tool, go to the “Claim Lines” header on the Claim SummaryInformation screen.iiIn the table under the “Message” column, click on claims with a denial code starting with “I.”iiThen, you will see the claim message information that includes the policy scriptand rationale.Prior to this enhancement,providers only received ahigh-level description such as:“Payment adjusted becauseinformation submitted doesn’tsupport this level of service.” Thisimprovement to our onlineservices is just one more reasonto get registered at Wellmark.com.10 | blueInk April 2013


Claims & CodingClinical QualitySubmit new claim when youreceive F or X denial messagesA claim denied for missing information mustbe resubmitted as a new claimEasily indicate whether a claim was work-relatedUse Wellmark.com to get claims decisions fasterWe all aim for accuracy, but ensuring accuracy can add time delays. Thisincludes delays in processing claims. For example, some claims are rejectedor placed in pending status due to lack of information about whether theinjury or illness was work-related. A new feature on Wellmark.com can helpresolve this issue.iiWellmark recently started giving providers the opportunity to submit a“yes” or “no” response for possible work-related injury or illness claims.This questionnaire appears on both rejected and pending claims.iiOnly providers registered with Wellmark.com can take advantage of thisnew self-service feature. The Wellmark Provider Services team cannotaccept requests to mark the injury or illness as work-related.iiPlease know that information we get from the member regarding whetheran injury or illness is work-related takes precedence over informationsubmitted by the provider. For claims that occurred prior to March 1, themember must contact Wellmark to indicate whether an injury or illnesswas work‐related.Not registered yet? It’s easy! Just follow these simple steps:1. Designate a security coordinator in your organization.2. Visit Wellmark.com (Provider/Register.aspx) to print an access agreement.3. Mail your completed agreement to the address provided.If you submit a paper claim that is missinginformation, we reject the services on yourProvider Claim Remittance (PCR) with an F orX code. The F or X code message will tell youto resubmit the claim with corrected or addedinformation. At that point, you should edit theoriginal submission and send to our office as youwould if filing a brand-new claim.Remember, do not mark the resubmission as a“corrected claim,” and do not attach the claimto a provider inquiry form. Both indicate thatyou are submitting a request for an adjustment.Because the original submission did not passWellmark’s initial processing edits, theseclaims have not gone through Wellmark’sentire claims processing system, and thereforecannot be adjusted. Wellmark will return suchresubmissions with a letter asking you to file as anew claim.iiThe resubmitted claim can besubmitted electronically, evenif the first submission was apaper claim.iiResend the completed claim assoon as possible to avoid timelyfiling issues.iiWhenever possible, please submitclaims electronically.For a list of F and X denial code messages, seethe “Claims Filing” section of the WellmarkProvider Guide.File claims for Tyson Foods, Inc., members promptlyCoverage moved to Arkansas BlueCross BlueShieldAdministration of claims for services provided to members with Tysoncoverage moved to Arkansas BlueCross Blue Shield Jan. 1, 2013.Wellmark will be processing claims incurred prior to that date only throughJune 30, 2013.We encourage providers to file any claims incurred prior to Jan. 1, 2013, byJune 1, 2013, to avoid delays.For questions related to services for Tyson members provided afterJan. 1, 2013, call Arkansas BlueCross BlueShield at 800‐452‐6199.April 2013 blueInk | 11


Clinical QualityWellmark congratulates local hospitals on receivingCenter designation for quality and efficiencyBlue Distinction designation helps consumers identify high‐performing hospitalsWellmark® Blue Cross® and Blue Shield® congratulates 13 Iowahospitals and two South Dakota hospitals for being recognized bythe Blue Distinction Centers for Specialty Care® program in theareas of Spine Surgery and Knee and Hip Replacement.Since 2006, consumers, medical providers and employershave relied on the Blue Distinction program to identify hospitalsdelivering quality care in Bariatric Surgery, Cardiac Care, Complexand Rare Cancers, Knee and Hip Replacements, Spine Surgery,and Transplants.The Blue Distinction Centers for Specialty Care program wasrecently expanded to include new cost-efficiency measures, aswell as more robust quality measures focused on improved patienthealth and safety. Three facilities in Iowa and South Dakota arerecognized as Blue Distinction Centers for their expertise indelivering quality specialty care in Spine Surgery or Knee and HipReplacement, and 10 are recognized as Blue Distinction Centers+(Plus) for their expertise in quality and cost efficiency in deliveringspecialty care. Quality is key: only facilities that first meet BlueDistinction’s nationally established, objective quality measures areconsidered for additional Blue Distinction Centers+ designation.“The Blue Distinction Center designation places a high value onresearch and evidence-based health outcomes,” says TimothyGutshall, M.D., Wellmark vice president and chief medical officer.“It also celebrates and affirms the excellence and commitmentof the physicians and staff of these health systems in combiningstate-of-the-art surgery with state-of-the-art care.”Research confirms that the newly designated Blue DistinctionCenters and Blue Distinction Centers+ demonstrate betterquality and improved outcomes for patients, with lower rates ofcomplications and readmissions than their peers. Blue DistinctionCenters+ are also more than 20 percent more cost-efficient.Additional categories will be opened up in the future. Interestedfacilities should contact their Wellmark Network EngagementBusiness Partner to learn more.For more information about the Blue DistinctionProgram and to see a list of Blue DistinctionCenters in your area, please visitbcbs.com/bluedistinction.Blue Distinction Center and Blue Distinction Center+ designations in Iowa and South Dakota include:Iowa Provider/Health System City Spine Surgery Knee/Hip ReplacementAlegent Health Mercy Hospital Council Bluffs N/A Blue Distinction Center+Covenant Medical Center Waterloo Blue Distinction Center+ N/AGenesis Medical Center Davenport Blue Distinction Center+ Blue Distinction Center+Iowa Lutheran Hospital Des Moines N/A Blue Distinction Center+Iowa Methodist Medical Center Des Moines Blue Distinction Center+ N/AMary Greeley Medical Center Ames Blue Distinction Center+ Blue Distinction Center+Mercy Hospital Iowa City Blue Distinction Center+ Blue Distinction Center+Mercy Medical Center Cedar Rapids Blue Distinction Center+ Blue Distinction Center+Mercy Medical Center Des Moines Blue Distinction Center+ Blue Distinction Center+Mercy Medical Center Dubuque N/A Blue Distinction Center+Methodist West Hospital West Des Moines Blue Distinction Center+ Blue Distinction Center+Mercy Medical Center Sioux City Blue Distinction Center+ N/ASt. Luke’s Methodist Hospital Cedar Rapids Blue Distinction Center+ Blue Distinction Center+The Finley Hospital Dubuque N/A Blue Distinction Center+Trinity Bettendorf Bettendorf N/A Blue Distinction Center+University of Iowa Hospitals and Clinics Iowa City Blue Distinction Center Blue Distinction Center +South Dakota Provider/Health System City Spine Surgery Knee/Hip ReplacementAvera McKennan Hospital Sioux Falls Blue Distinction Center Blue Distinction CenterSanford Medical Center Sioux Falls Blue Distinction Center Blue Distinction Center+12 | blueInk April 2013


Clinical QualityEducation & TrainingNew accountable care organization (ACO) toimprove outcomesWellmark collaborates with Wheaton Franciscan Healthcare IowaWellmark Blue Cross and Blue Shield of Iowa recently announcedcollaboration with Wheaton Franciscan Healthcare Iowa in Waterloo to createan ACO. The new ACO will focus on coordinating patient care to improvequality, provide greater value, and slow increases in health care costs.John Forsyth, Wellmark chairman and CEO, says, “This ACO was createdto help healthy people maintain good health and improve outcomes for ourmembers when they need care. Wellmark is pleased to enter into this ACOagreement with Wheaton Franciscan Healthcare Iowa to improve the healthcare experience, and to help slow the rate of cost increases.”In an ACO, providers assume responsibility for managing a population ofpatients no matter where in the system the patients receive care. Wellmarkoffers the providers financial incentives if they reach established qualitygoals and slow the rate of increase in health care spending. At the same time,providers will not earn their financial incentive if their quality declines or theircosts run higher than expected.To read the full news release, please visit Wellmark.com. To learn aboutACOs, visit Wellmark.com/Member/HealthInsurance101/ACO.aspx.PQM scores available for review April 15Review and approve your score by May 31Primary care clinicians will be able to review their Physician QualityMeasurement (PQM) scores on Wellmark.com between April 15 and May 31,2013. Secure access to this site is required. Unless the provider requestsotherwise, his or her scores will be uploaded for display this summer on theNational Doctor & Hospital Finder, a tool on the Blue Cross and Blue ShieldAssociation website. Physicians affected include only primary care clinicians(MDs, DOs, NPs, and PAs with primary care declared as their specialty) whomeets the 30-attributed member denominator requirement set by the NationalQuality Forum-endorsed Healthcare Effectiveness Data and InformationSet (HEDIS®) 1 .The PQM program collects and displays physician quality measures toassist Blue members in making health care decisions. The program annuallyincorporates selected HEDIS physician measures. Performance scores are theresult of measurements administered by Wellmark Blue Cross and Blue Shield ofIowa and South Dakota as part of its measurement and improvement program.To review your score by May 31, log on to Wellmark.com using your currentcredentials. Then, click on “Physician Quality Measurement (PQM) Program”under Quality & Transparency.Not registered yet? It’s easy! Just follow these simple steps:1. Designate a security coordinator in your organization.2. Visit Wellmark.com (Provider > Registernow.aspx) to print anaccess agreement.3. Mail your completed agreement to the address provided.1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).Upcoming Wellmarkwebinars for providersAttend provider educationWellmark is offering free webinars to providersand their staff. The one-hour webinars will beheld the second Wednesday of each month, fromnoon – 1 p.m. CT.Upcoming webinar scheduleDATE TOPIC PRESENTERApril 17May 8June 12Save Time withOnline PCRsOverview ofEnhancedAmbulatory PatientGroupings (EAPG)Base RatesWellmark Contractsand AddendumsJoey Davis, NetworkAdministrationoperationscoordinatorLuke Speltz,NetworkEngagementbusiness partnerJuwon Buckner,NetworkAdministrationGo to Wellmark.com (Provider > Communication& Resources > Education > Calendar of ProviderWebinars) to:iiRegister by noon the day before thewebinar so we can email you informationabout connecting to the webinar.iiObtain the “Request for ProviderEducation” form if you have a topic you’dlike to see presented at a future webinar.April 2013 blueInk | 13


Iowa OnlyIowa increased 0.7 pointsto 68.1 in overall well-beingin 2012, moving the statefrom No. 16 to No. 9 inthe rankings.Blue Zones ProjectNew educational videos now availableThe Blue Zones Project was launched in September 2011. Since then theexcitement has spread rapidly throughout Iowa, igniting a community-bycommunitywell-being transformation where people live and work together inBlue Zones Communities for a better life.The Blue Zones Project supports Wellmark’s overriding strategy to minimizehealth care inflation and bring cost increases in line with the ConsumerPrice Index.Two new videos were produced to continue building awareness andunderstanding of the project. In the first video, retired WHO-TV 13 anchor JohnBachman breaks down for viewers what it’s about, why it’s important to thefuture of Iowa, and what viewers can do to join the movement! In the secondvideo, he talks about the main drivers of health care costs and what Wellmark isdoing to improve trends, including bringing the Blue Zones Project to Iowa.Want to learn more? Visit Wellmark’s YouTube channel at youtube.com/wellmarkvideo and click on Uploaded Videos under the FeaturedPlaylists section.If you wish to view the videos on your smartphone or tablet, scan the QRcodes below. For a refresher on the Blue Zones Project in general, go toWellmark.com/bluezonesproject.Video 1: Blue ZonesProject 101Video 2: Understanding themain drivers of health careIowa jumps to No. 9!The 2012 Gallup-Healthways Well-Being Index® (WBI) report was releasedand we’ve learned that Iowa increased 0.7 points to 68.1 in overall well-beingin 2012, moving the state from No. 16 to No. 9 in the rankings. The Gallup-Healthways Well-Being Index is the official measurement tool of the Blue ZonesProject and Iowa’s Healthiest State Initiative.Check out the reports by visiting well-beingindex.com.14 | blueInk April 2013


Presorted StandardU.S. PostagePAIDWellmark Blue Crossand Blue ShieldIndependent Licensees of the Blue Cross and Blue Shield AssociationMail Station 3W741PO Box 9232Des Moines, IA 50306-9232M-2164 04/13WELLNESSBlue Ink is published by Wellmark BlueCross and Blue Shield’s Corporate andMarketing Communications Department.Editors:Don McCormickMicholyn FajenContributing Editor:Marie QuanbeckGraphic Designer:Elisa ConklinIf you have questions about informationin this newsletter, please contactProvider Service:in Iowa515-376-4688 or800-362-2218in South Dakota800-774-3892Blue Cross ® , Blue Shield ® , the Cross ® andShield ® symbols, and Blue Advantage ®are registered marks and Blue Ink SMis a service mark of the Blue Cross andBlue Shield Association, an Association ofIndependent Blue Cross and Blue ShieldPlans. Wellmark ® is a registered mark ofWellmark, Inc.Wellmark is not providing any legaladvice with regard to compliance withthe requirements of the Affordable CareAct (ACA) and Mental Health Parityand Addiction Equity Act (MHPAEA).Regulations and guidance on specificprovisions of the ACA and MHPAEA havebeen and will continue to be provided bythe U.S. Department of Health and HumanServices (HHS) and/or other agencies. Theinformation provided reflects Wellmark’sunderstanding of the most currentinformation and is subject to change withoutfurther notice. Please note that plan benefits,rates, renewal rate adjustments, and ratingimpact calculations are subject to change andmay be revised during a plan’s rating periodbased on guidance and regulations issuedby HHS or other agencies. Wellmark makesno representation as to the impact of planchanges on a plan’s grandfathered statusor interpretation or implementation of anyother provisions of ACA or MHPAEA. Anyquestions about Wellmark’s approach to theACA or MHPAEA may be referred to yourWellmark account representative.How well are your patients?Wellmark offers new WebMD tools and programs to help patientsunder your care improve their health and well-beingGood news! New resources will soon be available from Wellmark to encouragepatients to take better care of themselves. Wellmark is teaming with WebMD tooffer a collection of tools and programs to help inspire healthy changes, and helpthem become permanent.Some WebMD tools will be standard with allWellmark fully insured health plans; otherofferings will be purchased by employers forworkplace wellness promotions.The new offering includes access to aWebMD wellness center on myWellmark.com. Participants self-assess the generalstate of their health, and then engage in andtrack positive initiatives, including exerciseand healthy eating.Employers may purchase other servicesto encourage employees to engage inhealthy lifestyles, including wellness(biometric) screenings, phone and onlinehealth coaching, and incentive programsthat encourage participants to completehealthy actions.Wellmark plans to launch the WebMD platformin the second half of the year.Wellnessassessmentsby doctors can:1. Raise positive healthconsciousness.2. Assess patient interest inand capability to do morefor their own health.3. Spark wellness initiativesthat can lead to betterhealth and quality of life.“For providers, wellness tools and services are a way we [Wellmark] can supportthe doctor/patient relationship,” says Jason Bobst, Wellmark’s director ofwellness services. “These tools enable us to recognize how to help individualsto the extent they need, and link those individuals back to the supportiveinfrastructure that exists to help them have the best health andlife possible.”216 | | blueInk April 2013

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