Bluelink Family of health care plans

Medical News & Updates August 2019 I Volume 21 I Issue 4

What’s Happening? • Avoid Losing Access to CareFirst Direct — User Access Review Due Sept. 30

• BlueLink Tip — Home-Based Services Program

• CareFirst Offers Support for Members with Behavioral Health Needs

• Drug Prior Authorization Enhancement — NCCN Supported Regimen-level Review Coming in November

• Tell Us What You Think

Health Care Policy • Effective Dates, Current Procedural Terminology (CPT®) Codes and Policy Updates for

August

• New Medical Technology Updates for August

Claims and Billing • Helpful Tips to Avoid Claims Denials for Genetic Testing

• Complex Psychological Testing No Longer Requires Prior Authorization

• FEP Provides Advanced Benefit Determination for Some Specialty Drugs

• Avoid Claims Errors by Submitting the Correct Frequency Code

Provider Reminders • Stay Connected — It Matters for your Patients

• Come One, Come All…Lactation Consultants Can Participate in Our Medical Networks

• DME Providers — Time is Running Out, Join the CPAP Program Today

• Have You Made the Switch to the Enhanced ePA Tool? Make the Switch Today

For more information, visit carefirst.com/bluelink

Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA by: First Care, Inc.). First Care, Inc., CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association. CareFirst of Maryland, Inc. and The Dental Network underwrite products in Maryland only.

BlueLink

• Are You Up to Date on Best Practices and Quality Standards?

In Case You Missed It • ADHD and Narcolepsy Medications Subject to Quantity Limits

• Review the Latest Updates to Our Professional Provider Manual

• Updated Claims Information for Freestanding Substance Use Disorder Facilities

• Eleven Medications Added to the Prior Authorization List – Effective Sept. 1

What’s Happening?

Avoid Losing Access to CareFirst Direct — User Access Review Due Sept. 30

As part of the security updates implemented to CareFirst Direct in January, user administrators will need to begin to conduct user access reviews. Access review needs to be completed annually or the user will be locked out of their account.

The first annual review process was due on June 30, but an extension has been made to allow the review process to be performed until Sept. 30. Instructions on how to Manage User Access Requests are available online.

If you do not have a system administrator, the review process will not be implemented for you. For users who are unable to access the Provider Portal, please follow the normal process of calling the Help Desk.

If you have additional questions, please contact your Provider Relations Representative.

BlueLink Tip — Home-Based Services Program

CareFirst BlueCross BlueShield and CareFirst BlueChoice Inc. (CareFirst) has a suite of care support programs that offer your patients individualized services to help them achieve an optimal level of well-being and aim to reduce costly hospitalizations and readmissions. The Home-Based Services Program is one of our clinical programs where patients can receive an extra layer of support while being in the home setting. Watch this issue’s BlueLink Tip to learn more about our Home-Based Services program.

CareFirst Offers Support for Members with Behavioral Health Needs

CareFirst continues to focus on increasing access and improving support for our members, your patients, with behavioral health needs.

In 2018, CareFirst integrated all behavioral health and medical services to better support your patients when and where they need it most. This is especially important during recovery.

2 August 2019 I Volume 21 I Issue 4

BlueLink

Access If your patients have behavioral health needs, refer them to CareFirst services in one of the following ways:

• The physician or the patient can call the Mental Health/Substance Abuse number on the back of the patent’s CareFirst membership card: 800-245-7013.

o By calling this number, your patient is connected to the Intake, Appointment and Assessment unit. A team member will help your patients get appointments quickly and connect them to the services they need.

• For all patients with non-emergent behavioral health issues or care coordination needs, email your patient’s name and date of birth to CareFirst’s behavioral health triage team at PCMHBHreferrals@carefirst.com.

o A team member will connect your patient to a care coordinator who can help navigate your patient’s care.

• For all PCMH providers, reach out to your Regional Care Director if you have a patient who could benefit from behavioral health care coordination.

o A Behavioral Health Care Coordinator will help your patients find behavioral health providers, coordinate care, explain treatment options and/or connect them to any other needed behavioral health programs.

Recovery Our Substance Use Disorder Program is designed to improve patient recovery outcomes by quickly connecting CareFirst members with trusted providers of Intensive Outpatient Treatment. In this program, patients will receive specialized outpatient treatment for alcohol and drug addiction. This lower cost treatment option allows patients to remain in their community while getting the appropriate recovery support they need. More information on this program can be found here.

Drug Prior Authorization Enhancement — NCCN Supported Regimen-level Review Coming in November

Beginning in November, the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology will be integrated into our electronic prior authorization (ePA) tool for the treatment of breast, colorectal and lung cancer. NCCN is a not-for-profit alliance of leading cancer centers throughout the United States.

NCCN Prior Authorization Enhancement Benefits This enhancement gives providers an efficient tool to submit one drug prior authorization request and receive multidrug regimen options to improve patient quality and outcomes.

Providers receive the most up-to-date and nationally recognized guidelines when selecting cancer regimens for their patients and aids them to consider and choose an NCCN supported regimen option that is the most appropriate and cost-effective for their patients. The integration can help

3 August 2019 I Volume 21 I Issue 4

BlueLink

mitigate inappropriate and/or harmful drug combinations from being utilized that may not be caught via the traditional single-drug prior authorization process.

How does this work? When a prior authorization is submitted for members* with an eligible cancer diagnosis, the system will present all NCCN supported regimen options based upon the current standards of care for that cancer type. All NCCN supported regimen options and data that supports each recommendation will be available prior to selecting the most appropriate option.

When an NCCN supported regimen option is selected and meets clinical criteria, all the drugs that require a prior authorization within that regimen will be approved. Please note this regimen will include all recommended drugs for a patient’s care and may include drugs covered under the patient’s medical benefit and/or pharmacy benefit.

To learn more about the NCCN drug prior authorization enhancement, attend the ePA for NCCN Supported Cancer Regimens webinar. Sessions will be made available this fall at carefirst.com/cpet. For information on upcoming training, please continue to check your inbox for CareFirst provider news and updates. *This enhancement applies to members who have CareFirst medical and pharmacy benefits

Tell Us What You Think

How are we doing? How has BlueLink helped you? Are there topics you want to see covered in the future? Please tell us about your experience(s) with BlueLink. Let us know what you think – what we’re doing right and what we could do better. Our goal is to provide you with the best articles possible and your feedback is vital. E-mail your comments to newsletter.editor@carefirst.com.

Health Care Policy

Effective Dates, Current Procedural Terminology (CPT) Codes and Policy Updates for August

Our Health Care Policy department continuously reviews medical policies and operating procedures as new, evidence-based information becomes available regarding advances on new or emerging technologies, as well as current technologies, procedures and services.

The table below is designed to provide updates on changes to existing or new local policies and procedures during our review process. Each local policy or procedure listed includes a brief description of its status, select reporting instructions and effective dates. Policies from non-local accounts, such as NASCO and Federal Employee Program (FEP), may differ from our local determinations. Please verify member eligibility and benefits prior to rendering service through CareFirst on Call (Professional and Institutional) or CareFirst Direct.

4 August 2019 I Volume 21 I Issue 4

BlueLink

Note: The effective dates for the policies listed below represent claims with date of service processed on and after that date.

Medical Policy and/or Procedure Actions, Comments and Reporting Guidelines

Policy Status and Effective Date

1.01.030 Under policy guidelines, added updated 2019 Periodic review

Dynamic Splinting Systems rationale statement.

Report service using appropriate Healthcare Common Procedure Coding System (HCPCS) code.

Refer to policy for details.

and update

Effective 05/20/19

1.01.071 Policy placed in archived status. Refer to new Periodic review

Automated Oscillometer policy 1.01.077A. and update

Blood Pressure Monitors Under description and policy, added the archived for Home Use statement. Under policy guidelines, added

updated 2019 rationale statement.

Report service using appropriate HCPCS code. Refer to policy for details.

Effective 05/20/19

1.01.077A New medical policy operating procedure. An New Policy

Automated Blood Pressure automated blood pressure monitor is a non-

Monitoring for Home Use invasive, electronic device that displays a patient’s mean, systolic and diastolic blood pressure.

Report service using appropriate HCPCS code. Refer to policy for details.

Effective 05/20/19

1.03.001 Revised policy guidelines and cross references to Periodic review

Orthotic Devices and related policies and procedures sections. and update

Orthopedic Appliances Report service using appropriate HCPCS code. Refer to policy for details. Effective

05/20/19

1.03.003 Under policy guidelines, added updated 2019 Periodic review

Orthotic Foot Inserts rationale statement.

Report service using appropriate HCPCS code. Refer to policy for details.

and update

5 August 2019 I Volume 21 I Issue 4

BlueLink

Medical Policy and/or Procedure Actions, Comments and Reporting Guidelines

Policy Status and Effective Date

Effective 05/20/19

2.01.069

Non-Contact Low-Energy Ultrasound Wound Care Therapy

Under policy guidelines, added updated 2019 rationale statement.

Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 05/20/19

2.01.078

Amniotic Membrane and Amniotic Fluid Grafts and Injections

Fetal tissues have low immunogenicity and contain cellular components that promote healing. For these reasons, amniotic grafts and amniotic fluid injections are used in some medical procedures.

Amniotic grafts are considered medically necessary for diabetic foot ulcers and ophthalmic conditions.

Injections of amniotic fluid are considered experimental / investigational for all indications.

Report service using appropriate HCPCS code. Refer to policy for details.

New Policy

Effective 05/20/19

3.01.014 Revised benefits applications statement. Revision

Psychological Testing Report service using appropriate category I CPT code. Refer to policy for details. Effective

05/20/19

4.01.010

Lactation Consultations

Revised description and provider guidelines statements.

Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 05/20/19

5.01.023A Refer to medical policy operating procedure for details.

Periodic review and update

6 August 2019 I Volume 21 I Issue 4

BlueLink

Medical Policy and/or Procedure Actions, Comments and Reporting Guidelines

Policy Status and Effective Date

Drugs and Pharmaceuticals, Wastage and/or Discarded Amounts

Effective 05/20/19

7.01.062

Lung Volume Reduction Surgery for Palliation of Severe Emphysema

Under policy guidelines, added experimental/investigational criteria and an updated 2019 rationale statement.

Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 05/20/19

7.01.079

Laryngeal Denervation and Reinnervation for Laryngeal Dystonia

Under policy guidelines, added experimental/investigational criteria and an updated 2019 rationale statement.

Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 05/20/19

7.01.097 Under policy guidelines, added updated 2019 Periodic review

Gastric Electrical rationale statement. and update

Stimulation

Report service using appropriate category I CPT code. Refer to policy for details.

Effective 05/20/19

11.01.051 Under policy guidelines, added updated 2019 Periodic review

HIV Tropism Assay rationale statement.

Report service using appropriate category I CPT code. Refer to policy for details.

and update

Effective 05/20/19

11.01.053

Measurement of Antibodies to Biological Agents such as Infliximab and Adalimumab

Under policy guidelines, added updated 2019 rationale statement.

Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 05/20/19

7 August 2019 I Volume 21 I Issue 4

BlueLink

Medical Policy and/or Procedure Actions, Comments and Reporting Guidelines

Policy Status and Effective Date

11.01.061 Under policy guidelines, added updated 2019 Periodic review

Proteomic Testing for rationale statement. and update

Targeted Therapy in Non- Updated cross references to related policies and Small Cell Lung Cancer procedures section.

Report service using appropriate category I CPT code. Refer to policy for details.

Effective 05/20/19

2.01.004 Under policy guidelines, added Periodic review

Hyperbaric Oxygen experimental/investigational criteria and an and update

Therapy updated 2019 rationale statement.

Report service using appropriate category I CPT code. Refer to policy for details.

Effective 06/24/19

2.01.029

Carbogen Therapy for Idiopathic Sudden Hearing Loss

Under description, added no further review statement.

Under policy guidelines, added experimental/investigational criteria and an updated 2019 rationale statement.

Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

No further review scheduled

Effective 06/24/19

2.01.080 Infants less than 1500g of weight at birth are at New Policy

Pasteurized Donor Human increased risk for growth failure due to unmet

Milk high protein and caloric needs. Therefore, the use of human donor milk in low birth weight (LBW) infants < 1500g when mother’s milk is inadequate or lacking despite significant lactation support is encouraged.

The use of pasteurized donor human milk is medically necessary for LBW infants with documented birth weight of < 1500 grams when the mother’s own breast milk is unavailable or insufficient. Refer to policy for details.

Effective 04/01/19

8 August 2019 I Volume 21 I Issue 4

BlueLink

Medical Policy and/or Procedure Actions, Comments and Reporting Guidelines

Policy Status and Effective Date

2.02.014 Under policy guidelines, added updated 2019 Periodic review

Long-term Wireless rationale statement. and update

Ambulatory Cardiac

Rhythm Monitoring Report service using appropriate category III CPT code. Refer to policy for details.

Effective 06/24/19

2.03.007

Photodynamic Therapy

Under policy guidelines, added experimental/investigational criteria and an updated 2019 rationale statement.

Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update

Effective 06/24/19

6.01.039 Under policy guidelines, added updated 2019 Periodic review

Magnetic Resonance rationale statement. and update

Neurography Report service using appropriate category I CPT code. Refer to policy for details. Effective

06/24/19

7.01.048

Autologous Chondrocyte Implantation

Revised policy statement to include patella indication.

Under policy guidelines, added updated 2019 rationale statement on Autologous Chondrocyte Implantation/MACI for patella.

Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 06/24/19

7.01.095

Endoscopic Therapies for Gastroesophageal Reflux Disease

Updated description statements.

Under policy guidelines, revised 2017 rationale statement and added an updated 2019 rationale statement.

Report service using appropriate category I CPT code.

Updated cross references to related policies and procedures section. Refer to policy for details.

Periodic review and update

Effective 06/24/19

9 August 2019 I Volume 21 I Issue 4

BlueLink

Medical Policy and/or Procedure Actions, Comments and Reporting Guidelines

Policy Status and Effective Date

7.01.112 Under policy guidelines, added an updated 2019 Periodic review

Collagen Meniscus Implant rationale statement.

Report service using appropriate category I CPT code.

Updated cross references to related policies and procedures section. Refer to policy for details.

and update

Effective 06/24/19

7.01.133 The Transperineal (TP) Access System New Policy

Free-handed Transperineal (PrecisionPoint) allows a free-handed

Biopsy of the Prostate with transperineal approach to biopsy the prostate. Effective

a Transperineal Access The system is proposed to sample more regions 04/01/19 System (PrecisionPoint™) of the prostate with increased precision

compared with the standard transrectal approach.

Free-handed TP biopsy of the prostate with a TP access system (PrecisionPoint) is considered medically necessary for the diagnosis of prostate cancer and for use in men with low-risk disease (Gleason Score <7) in the active surveillance settings.

Report service using appropriate category I CPT code.

Refer to policy for details.

8.01.001 Revised policy statement. Periodic review

Physical Therapy Under policy guidelines, added an updated 2019 rationale statement.

Revised benefits application statement.

Report service using appropriate category I CPT code.

Updated cross references to related policies and procedures section. Refer to policy for details.

and update

Effective 06/24/19

8.01.004

Occupational Therapy

Revised policy statement. Periodic review and update

10 August 2019 I Volume 21 I Issue 4

BlueLink

Medical Policy and/or Procedure Actions, Comments and Reporting Guidelines

Policy Status and Effective Date

Under policy guidelines, added an updated 2019 rationale statement.

Revised benefits application statement.

Report service using appropriate category I CPT code.

Updated cross references to related policies and procedures section. Refer to policy for details.

Effective 06/24/19

11.01.077 Human microbiome analysis is the study of New Policy

Human Microbiome microbial communities found in and on the

Analysis human body and is used to determine the association of microbes with specific diseases.

Human microbiome analysis is considered experimental/investigational.

Report service using appropriate category I CPT code. Refer to policy for details.

Effective 06/24/19

New Medical Technology Updates for August

Our technology assessment unit evaluates new and existing technologies to apply to our local indemnity and managed care benefit plans. The unit relies on current scientific evidence published in peer-reviewed medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst criteria for coverage. Policies for non-local accounts like NASCO and Federal Employee Program may differ from our local determinations.

Please verify member eligibility and benefits prior to rendering services via CareFirst on Call (Professional or Institutional) or CareFirst Direct.

The technology assessment unit recently made the following determinations:

Technology Description CareFirst and CareFirst BlueChoice Determination

remedē® An implantable phrenic nerve stimulator for the treatment of central sleep apnea

Considered experimental/ investigational

CPT reporting codes(s) 0424T, 0425T, 0426T, 0427T, 0428T,

11 August 2019 I Volume 21 I Issue 4

BlueLink

Technology Description CareFirst and CareFirst BlueChoice Determination

0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T

Eustachian Tube Balloon Dilation

A tuboplasty procedure intended to improve the patency of the cartilaginous eustachian tube (i.e. Eustachian Tube Dysfunction)

Considered experimental / investigational

CPT reporting codes(s) 69799

BBDRisk DxTM A risk stratification tool for patients with atypical ductal hyperplasia and other hyperplasias of the breast.

Considered experimental / investigational

CPT reporting codes(s) 0067U

VenaSeal ClosureTM

System The closure system is indicated for the treatment of varicosities. The non-tumescent, non-thermal, non-sclerosant, endovenous procedure delivers a proprietary medical adhesive to close the vein.

Considered not medically necessary

CPT reporting codes(s) 36482, 36483

MiraDry® The miraDry System is indicated for the treatment of primary axillary hyperhidrosis and the removal of unwanted underarm hair. The system works by using miraWave™ technology to heat and destroy sweat and odor glands, and hair follicles.

Considered experimental / investigational

There is no CPT code specific to this service.

Claims and Billing

Helpful Tips to Avoid Claims Denials for Genetic Testing

Since February 1, we have required prescribing providers to request prior authorization for genetic testing before patients receive the testing. While many of our providers and their staff have been following the prior authorization process, there are still some providers who are not submitting a prior authorization which results in denial of genetic tests for patients.

To improve your patient’s experience and ensure they receive the right care at the right time, you are urged to start requesting prior authorizations for your patients before sending them for genetic testing. Please view the tip sheet to learn how to request a prior authorization.

12 August 2019 I Volume 21 I Issue 4

BlueLink

If you have questions or feedback, contact Provider Service.

Complex Psychological Testing No Longer Requires Prior Authorization

Effective for dates of service on or after August 1, Complex Psychological Testing will no longer require prior authorization. Providers will be able to offer Complex Psychological Testing without an authorization. If you have any additional questions, please contact Provider Service.

FEP Provides Advanced Benefit Determination for Some Specialty Drugs

As a courtesy to you, FEP offers an advanced benefit determination (ABD) for specific high-dollar, complex services such as high cost durable medical equipment or prosthetics with a billed amount greater than $5,000 or services for life-threatening illness.

Recently, FEP has added the following service type to this process: • Single specialty drug provided in an office or outpatient setting that would be billed as a

medical claim totaling $5,000 or more

What This Means for You This allows providers to receive a benefit determination on services and may bypass any medical review process that is required once the service is rendered and a claim is submitted. This does not include specialty drugs on the CVS Caremark* prior authorization list.

If you are interested in receiving an ABD for a drug that meets these criteria, please contact FEP Provider Service at 800-842-5975 (DC) or 800-854-5253 (Md.).

*CVS Caremark is an independent company that provides benefit management services.

Avoid Claims Errors by Submitting the Correct Frequency Code

When submitting claims, please ensure you are submitting the correct frequency code. By selecting a frequency code of 7, the claim is considered a replacement claim. If all charges are not resubmitted with the corrected frequency code, it may cause unnecessary accounts receivables to be sent.

For additional questions, please contact Provider Service.

13 August 2019 I Volume 21 I Issue 4

BlueLink

Provider Reminders

Stay Connected — It Matters for your Patients

Have new providers and office staff joined your practice? Make sure they sign up to receive Provider News and Updates. Signing up is easy. Visit carefirst.com/stayconnected. Also, to receive the news that’s most relevant to you, visit our website to update your subscriber preferences with your specialty. Important Subscription Notes:

• If you have multiple individuals checking an email address for your office, be sure to register separately with a unique email account. Do not register “role” or “practice” accounts that begin with sales@, info@, webmaster@, etc.

• To ensure that your computer does not block Provider News and Updates emails as spam, please add newsletter.editor@carefirst.com to your address book

• The information you provide for subscription will be used only for maintaining this email list. We will never use this information to sell or rent to others or for solicitation. Read our Privacy Statement

Come One, Come All… Lactation Consultants Can Participate in Our Medical Networks

Did you know CareFirst is now credentialing lactation consultants and listing them in our provider directory? If you are interested in joining the CareFirst network as a credentialed lactation consultant, please review the following requirements:

• You must be a licensed health care provider, in Md., DC, Va., (or W.Va., Pa., or Del. if treating patients in on contiguous county out of CareFirst’s service area) and licensed in the jurisdiction where the patient receives the service

• Be certified by the International Board of Lactation Consultant Examiners®, or be a Certified Lactation Counselor with the Academy of Lactation Policy and Practice

• Maintain professional liability insurance in the amounts of $500,000 per occurrence and $1,500,000 annual aggregate

To apply, visit provider.carefirst.com and search How To Apply under Join Our Networks.

DME Providers — Time is Running Out, Join the CPAP Program Today

If you want to be designated as a sleep apnea equipment program provider in the CareFirst provider directory, please respond to the letter that we recently sent to you.

To be designated as a sleep apnea equipment program provider, follow these simple steps:

14 August 2019 I Volume 21 I Issue 4

BlueLink

• Sign and return Attachment A-1 within 30 days of the date of the letter you received earlier this month to Monica Jenifer, contract manager, via email at monica.jenifer@carefirst.com or fax to 410-720-5987

• You must continue to actively monitor and report member compliance with their equipment using continuous positive airway pressure (CPAP) devices with built-in modems

• You should continue to provide guidance to members to ensure high levels of compliance with their CPAP equipment

To make the process a little easier for you and your office staff, you no longer need to submit quarterly compliance reports, however you must first sign and return Attachment A-1.

What If You Don’t Want to Participate in The Program? You can continue to set up and dispense CPAP equipment and supplies, however, you won’t be designated and listed separately in the CareFirst provider directory as a Sleep Apnea Equipment Program Provider.

Have You Made the Switch to the Enhanced ePA Tool? Make the Switch Today

In January, CVS Caremark upgraded its electronic prior authorization (ePA) submission process. The newly enhanced ePA tool, which is accessed through the Provider Portal, makes submitting prior authorization requests easier and more convenient. Currently you can toggle between the old version and the new version, however this functionally is being retired by the end of the third quarter. Beginning in October, you will only have access to the upgraded version. It is important that your office start to use the enhanced ePA tool now to ensure you have the best experience when submitting drug prior authorizations.

Training is Available To learn more about the enhanced tool, attend our ePA for Drugs-An Enhanced Authorization Experience webinar. This webinar will walk you through the new system and provide answers to many of the frequently asked questions we have received since the upgraded tool launched.

Are You Up to Date on Best Practices and Quality Standards? From recommending preventive care options to your patients or managing day-to-day office operations, the clinical resources on our provider website can be valuable, time-saving tools to help support your treatment plan for patients with chronic diseases.

CareFirst’s Quality Improvement Council annually reviews the clinical resources and adopts nationally recognized guidelines and best practices to make sure you are informed when information changes.

15 August 2019 I Volume 21 I Issue 4

----

BlueLink

Click on the links below for details on topics that can help you improve the care you provide to patients in your practice.

Quality Standards and Best Practices

General Guidelines and Survey Results Topic Website Link PDF Available CareFirst’s Quality Improvement Program Includes processes, goals and outcomes.

carefirst.com/qualityimprovement

Clinical Practice Guidelines Includes evidence-based clinical practice guidelines for medical and behavioral conditions.

carefirst.com/clinicalresources

Preventive Health Guidelines Includes evidence-based preventive health guidelines for perinatal care, children, adolescents and adults.

carefirst.com/clinicalresources

Accessibility and Availability of Appointments Includes medical and behavioral health accessibility and availability standards for routine care appointments, urgent care appointments and after-hours care.

carefirst.com/clinicalresources

Care Coordination Programs Topic Website Link PDF Available Access to Care Management Includes instructions for making referrals for both medical and behavioral health; or call 800-245-7013.

carefirst.com/providermanualsandguides

16 August 2019 I Volume 21 I Issue 4

-

-

-

BlueLink

Practitioner Referrals for Disease Management Includes information on how to use the services, how a member becomes eligible and how to opt in or opt out.

carefirst.com/clinicalresources

Pharmaceutical Management Topic Website Link PDF Available Pharmaceutical Management Includes the formulary, restrictions/ preferences, guidelines/policies and procedures.

carefirst.com/rx

Utilization Procedures Topic Website Link PDF Available Utilization Management Criteria Includes information on how to obtain utilization management criteria for both medical and behavioral health.

carefirst.com/bluelink > February 2019

Physician Reviewer Includes instructions on how to obtain a physician reviewer to discuss utilization management decisions for both medical and behavioral health.

carefirst.com/bluelink > February 2019

Decisions about Medical and Mental Health, and Pharmacy Includes affirmative statement for anyone making decisions regarding utilization management.

carefirst.com/bluelink > February 2019

Member Related Resources Topic Website Link PDF Available Quality of Care Complaints Includes policies and procedures for complaints involving medical issues or services given by a provider in our network.

carefirst.com/qoc

17 August 2019 I Volume 21 I Issue 4

------

BlueLink

How to File an Appeal Includes policies and procedures for members to request an appeal of a claim payment decision.

carefirst.com/appeals

Member’s Privacy Policy Includes a description of our privacy policy and how we protect our members health information.

carefirst.com/privacy

Member’s Rights and Responsibilities Statement Outlines responsibilities to our members.

carefirst.com/myrights

To request a paper copy of any documents listed above, please call 800-842-5975

In Case You Missed It August 1, 2019 — ADHD and Narcolepsy Medications Subject to Quantity Limits

July 24, 2019 — Review the Latest Updates to Our Professional Provider Manual

July 16, 2019 — Updated Claims Information for Freestanding Substance Use Disorder Facilities

July 11, 2019 — Eleven Medications Added to the Prior Authorization List — Effective Sept. 1

18 August 2019 I Volume 21 I Issue 4