Inside This Issue...

Sent to: CAP and Oral Surgeons

January 22, 2002 S-01-02

Questions: Contact your Professional Relations Representative, or the Professional Relations Hotline in Topeka at 785-291-7060 or 1-800-432-3587.

OUR WEB ADDRESS: http://www.bcbsks.com

The Blue Shield Report is

published by your Professional Relations

Department.

Communication Coordinator

Larry Callahan

Inside This Issue… FEP Benefit Changes for 2002 ............................................................. Pg. 1 Discontinued Products for 2002............................................................ Pg. 1 Provider Networks for 2002.................................................................. Pg. 2 New Benefit Coverage as of January 1, 2002....................................... Pg. 3 New to Standard Option in 2002 .......................................................... Pg. 3 Highlights of Standard and Basic Options............................................ Pg. 4 Questions and Answers About FEP 2002 Benefits............................... Pg. 5 New and Revised Remark Codes.......................................................... Pg. 7 FEP Benefits Chart ......................................................................... Attached

FFEEPP BBeenneeffiitt CChhaannggeess ffoorr 22000022 The Federal Employee Program (FEP) benefits has changed effective January, 2002. This change is an accommodation to FEP member requests for the best coverage possible at an affordable premium. FEP members expressed concern that High Option premiums have become too expensive. Plans were requested to engineer a health plan that is lower in cost than the 2001 Standard Option. The resulting benefits for 2002 have taken into account FEP member feedback and High Option will not be offered in 2002. Members will have the choice of Standard Option or Basic Option, which became effective January, 2002. The following pages outline the 2002 FEP benefits. For more information, you can access the FEP website at www.fepblue.org or call 1-800-432-0379.

Discontinued Products for 2002

• High Option is no longer available; it has been merged into the Standard Option.

• The Point of Service (POS) pilot program has been discontinued.

Blue Shield Report S-01-02 January 22, 2002


PROVIDER NETWORKS FOR 2002 STANDARD OPTION Under Standard Option, FEP has expanded their definition of preferred providers to include the following as of January 1, 2002:

• Ambulance • Nurse Anesthetist (CRNA) • Audiologist • Nurse Practitioner (ARNP) • Certified Diabetic Counselors • Occupational Therapist • Durable Medical Equipment Supplier • Physical Therapist • Home Infusion • Speech Therapist • Independent Laboratories

When members use preferred providers, they receive the highest level of benefits from FEP and have less out of pocket expense for themselves. FEP continues to consider physician assistant services billed under the physician assistant’s number to be considered non-preferred. Therefore, when services are provided and billed under the physician assistant’s provider number as the performing provider for a Standard Option member, the benefit payment is reduced to 75 percent of the charge, or maximum allowable payment (MAP), whichever is less, with 25 percent coinsurance and any applicable deductible or copayment being the patients responsibility. Our guidelines from Policy Memo Number 1, page 9, section 11, paragraph B, allows you to bill under the employing physician’s number when a physician assistant services were provided adjunct to (incident to) the services of the employing physician, thus resulting in payment at the FEP preferred benefit level. Blue Cross and Blue Shield of Kansas (BCBSKS) follows the Medicare Part B definition of “incident to” for consistency. The guidelines under section 11 paragraph B, also addresses when services are not adjunct to (incident to) the physician services. When this occurs you must bill Blue Shield using an individual physician assistant’s number. Under FEP, this will trigger member benefits to pay at the reduced level as previously described. PLEASE NOTE: Under Standard Option, there continues to be no FEP member chiropractic benefits. BASIC OPTION For Basic Option 2002, FEP considers preferred providers as those providers who contract with BCBSKS, including physician’s assistants. Thus, physician assistant services, either billed under their own provider number or services adjunct to (incident to) the physician’s services, result in the same level of FEP benefits to the member. Under Basic Option, FEP members only receive benefits when they use preferred providers. There is no benefit payment if a member uses a non-preferred provider and the financial responsibility for those services lies entirely with the patient. However under the Basic Option, FEP has a special set of chiropractic benefits, which are detailed on page three of the FEP 2002 Benefits Chart.



New Benefit Coverage as of January 1, 2002: • Services performed in contracting facilities by non-contracting radiologists,

anesthesiologists, CRNAs, pathologists, and emergency room physicians will be covered at the highest level of benefit.

• Benefits are provided for routine screening for chlamydial infection. • Benefits are provided for organ/tissue transplants to include autologous stem cell support for

amyloidosis. • Benefits provided for organ/tissue transplants in clinical trials to include nonmyeloablative

allogeneic stem cell transplants for chronic myelogenous leukemia, acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia, advanced Hodgkin’s lymphoma, advanced non-Hodgkin’s lymphoma, advanced forms of myelodysplastic syndromes, multiple myeloma, chronic lymphocytic leukemia, early stage (indolent or non-advanced) small cell lymphocytic lymphoma, and renal cell carcinoma.

• Smoking cessation services are now treated similar to other medical or mental health/substance

abuse services and are not limited to $100 of coverage per lifetime. Cessation drugs are not limited to one course of treatment per year, but additional courses require prior approval and participation in a smoking cessation program.

• Benefits are provided for dental accidental injury, but only when treatment is started promptly and

completed within 12 months of the accident.

New to Standard Option in 2002

• Ambulance services provided in connection with, and within 72 hours after, an accidental injury are covered in full.

• Mail Service Prescription Drug Program copayments have changed to $10 for generic drugs

and $35 copayment for brand-name drugs.



Highlights of Basic

and Standard Options

Standard Option • $250 per person /$500 per family deductible • $5,000 maximum copayment • $15 copay for professional services, with no deductible • $100 copay per inpatient admission • Pre-certification admission required • 10% coinsurance on selected services (see benefit chart)

Basic Option • No Deductible • Must use contracting providers to receive any benefits • $20 copay for primary care physician (PCP) types (family practice,

general practice, internal medicine, pediatrician, OB/GYN, and ancillary services ordered by PCP type)

• $30 copay for specialist services • $100 per day copay for inpatient admission, up to a $500 maximum

copay • Pre-certification admission required • Benefits for chiropractic services

• Prior approval required for all mental health & substance abuse care except emergencies



Q: What happens if a member came into my office in 2001 and showed the new

card with a 2002 effective date? A: The 2001 benefits remained in effect for the member through December 31, 2001. The new 2002 benefits became effective January 1, 2002.

Q: What happens to a High Option or Point-of-Service member who does not

make a change to their enrollment during open season? Does this mean that the patient will be uninsured? A: The member will be automatically enrolled under the Standard Option coverage for 2002.

Q: Is there a different card for Basic Option?

A: Yes, Basic Option has a different card and different codes. The new codes are: Self and family is 112 and self only is 111.

Q: Will members have to change providers?

A: Members obtaining treatment with Competitive Allowance Program (CAP) providers contracting with BCBSKS do not need to change providers.

Q: Who are covered providers for Basic Option?

A: All contracting providers currently eligible under Standard Option are considered covered in Basic Option. Chiropractors are also considered covered for limited services.

Q: Which contracting physicians are considered primary care providers and eligible for the $20 office visit copay?

A: Internal medicine, family practice, general practice, pediatricians, and obstetricians/gynecologists are all considered primary care providers.

Q: Are non-contracting providers ever paid? What are the payment exceptions

and how are providers paid. A: There are some exceptions in which non-contracting providers are covered, such as certain non-contracting hospital-based providers (i.e. radiologists, anesthesiologists, CRNAs, pathologists, assistant surgeons, and emergency room physicians) are paid at 100 percent of BCBSKS allowance when services are rendered in a contracting facility, or a non-contracting emergency room. Members may be financially responsible for the difference between BCBSKS allowance and the provider’s charges.

Q: Currently, precertification is required for all inpatient stays, except maternity

and when Medicare is the primary payer. Will this be required under Basic Option? A: Yes.

About FEP 2002 Benefits



Q: Do all mental health and substance abuse (MHSA) services require prior

approval for Basic Option members? A: In Basic Option, the mental health and substance abuse benefit is a more managed benefit than Standard Option. Prior approval is required, except in emergencies. Members must call HMS/Value Options before receiving any MHSA care. An MHSA professional will triage the call and provide a list of appropriate contracting providers from which the member may select and an initial number of visits may be approved. Thereafter, the provider will coordinate with HMS/Value Options to ensure that proper authorizations are received. If a contracting MHSA provider is not available, HMS/Value Options will assist the member in obtaining appropriate services that will be covered at the in-network level.

Q: What are the treatment plan requirements for Basic Option MHSA services

under Basic Option? A: When necessary, HMS/Value Options will request a treatment plan from the contracting provider. A written treatment plan is necessary to determine that the care is appropriate and medically necessary. The member must call the MHSA number before receiving care. During the initial telephone call, the member will be triaged to determine the best type of provider and what type of care would most likely produce the best results. The member will be given several names of providers from which to choose and an initial number of visits. Once the member selects a provider, HMS/Value Options will work with that provider to ensure that the member receives all the covered services necessary to increase the chance of obtaining a positive outcome. In most cases, the provider will send HMS/Value Options the necessary information and additional visits will be approved. In difficult or complicated cases, HMS/Value Options may request a formal treatment plan from the provider to evaluate the course of treatment being applied. Unlike Standard Option, a treatment plan will not have to be submitted by a certain visit.

Q: Will prior approval be required for certain prescription drugs?

A: Yes, prior approval for certain prescription drugs will be necessary for Basic Option as it does today under Standard Option.

Q: What services require prior approval?

A: The same services that require prior approval under Standard Option require prior approval under Basic Option, with the addition of all mental health and substance abuse services. These services are:

• cardiac rehabilitation • home hospice • organ transplants • certain prescription drugs • mental health and substance abuse (intensive outpatient and partial hospitalization are only

covered under Standard Option)



Q: What happens if my patient is receiving home health care as of December 31,

2001? A: Standard Option and Basic Option do not provide benefits for home health care, other than home nursing care.

Q: I am a chiropractor. Are benefits available for chiropractic care? A: For Basic Option, benefits are available for covered services provided by network chiropractors. Covered services include the initial office visit, spinal manipulations and the initial set of X-rays. There is a $20 copayment for each visit. Benefits are limited to 20 manipulations per year. Standard Option does not have any chiropractic benefits.

Q: How are benefits coordinated with Medicare?

A: For members with Medicare Parts A and B as the primary payer, copayments and coinsurance are waived when contracting providers are used. Prescription drug cost sharing is not waived. Members with Medicare who do not use contracting providers will be responsible for their coinsurance and deductibles.

Q: What happens if prior authorization is not obtained for MHSA? A: The contracting provider must write-off any care not authorized.

New and Revised Remark Codes You may discover some new remark codes printed on your remittance advice for FEP claims. Below is a list of the new codes, along with some established codes that have undergone an adjustment to the nomenclature. N4 Non-covered chiropractic services – Basic Option

NA Accidental injury – dental services incurred more than 12 months after the accident date

NB Prior approval not obtained for mental health and substance abuse services – Basic Option

NT Dental sealants not covered for patients over age 16

OH Out of network provider rendering services to Basic Option member

PE Dental sealants limited to one per molar – Basic Option

T7 Maximum benefit provided for chiropractic services

UJ Maximum benefits provided for intra-oral x-rays

January 22, 2002 Pg. 1 BCBSKS

Federal Employee Program 2002 Benefit Chart MEDICAL SERVICES AND SUPPLIES PROVIDED BY PHYSICIANS AND OTHER HEALTH

CARE PROFESSIONALS. NOTE: The calendar year deductible applies to almost all Standard Option benefits on the chart. It is indicated when the deductible does not apply to a specific service. There is no deductible under Basic Option.

MEDICAL SERVICESMEDICAL SERVICESMEDICAL SERVICESMEDICAL SERVICES ..................................................................................................Pg. 3

• Allergy Care.......................................................................................................................Pg. 3

• Alternative Treatments.....................................................................................................Pg. 3

• Chiropractic.......................................................................................................................Pg. 3

• Diagnostic and Treatment Services .................................................................................Pg. 4

• Educational Classes and Programs .................................................................................Pg. 4

• Family Planning ................................................................................................................Pg. 5

• Foot Care ...........................................................................................................................Pg. 5

• Hearing Services................................................................................................................Pg. 5

• Home Health Services .......................................................................................................Pg. 6

• Inpatient Professional Services ........................................................................................Pg. 6

• Maternity Care..................................................................................................................Pg. 6

• Preventative Care, Adult..................................................................................................Pg. 7

• Preventative Care, Children ............................................................................................Pg. 7

• Vision Services...................................................................................................................Pg. 8

SURGICAL SURGICAL SURGICAL SURGICAL SERVICESSERVICESSERVICESSERVICES ................................................................................................Pg. 9

• Reconstructive Surgery ....................................................................................................Pg. 9

• Surgical and Anesthesia Services.....................................................................................Pg. 9

LAB AND XLAB AND XLAB AND XLAB AND X----RAY SERVICESRAY SERVICESRAY SERVICESRAY SERVICES .............................................................................Pg. 10

• Lab, X-ray, and Other Diagnostic Tests .......................................................................Pg. 10

FEDERAL EMPLOYEE PROGRAM BENEFITS 2002


THERAPY SERVICESTHERAPY SERVICESTHERAPY SERVICESTHERAPY SERVICES ...............................................................................................Pg. 11

• Occupational and Speech Therapies .............................................................................Pg. 11

• Physical Therapy.............................................................................................................Pg. 11

• Treatment Therapies ......................................................................................................Pg. 11

HOME MEDICAL EQUIPMENT AND MEDICAL SUPPLIESHOME MEDICAL EQUIPMENT AND MEDICAL SUPPLIESHOME MEDICAL EQUIPMENT AND MEDICAL SUPPLIESHOME MEDICAL EQUIPMENT AND MEDICAL SUPPLIES........Pg. 12

• Home Medical Equipment..............................................................................................Pg. 12

• Medical Supplies .............................................................................................................Pg. 13

• Orthopedic and Prosthetic Devices ............................................................................... pg. 13

DENTAL SERVICESDENTAL SERVICESDENTAL SERVICESDENTAL SERVICES ....................................................................................................Pg. 14

MENTAL HEALTH AND SUBSTANCE ABUSE SERVICESMENTAL HEALTH AND SUBSTANCE ABUSE SERVICESMENTAL HEALTH AND SUBSTANCE ABUSE SERVICESMENTAL HEALTH AND SUBSTANCE ABUSE SERVICES.......Pg. 15

• Mental Health and Substance Abuse ............................................................................ pg. 16

• Inpatient Professional Visits ..........................................................................................Pg. 16

• Inpatient Services Provided and Billed by a Hospital or Other Covered Facility ....Pg. 16

• Outpatient Services Provided and Billed by a Hospital or Other Covered Facility .Pg. 16

• Professional Services.......................................................................................................Pg. 17

• Professional Charges for Outpatient Diagnostic Tests................................................Pg. 17

• Other Services ................................................................................................................. Pg. 17

• Not Covered .....................................................................................................................Pg. 17

• HMS/Value Options Outpatient Diagnostic Treatment Report for

Medication Management..........................................................................................Pg. 18

• HMS/Value Options Outpatient Diagnostic Treatment Report .................................Pg. 19



Medical Services

MEMBER RESPONSIBILITY Preferred/Contracting Benefits Standard Option Basic Option

Allergy Care • Testing and treatment, including

materials (such as allergy serum) • Allergy injections

10% coinsurance $20 visit copayment for primary care provider $30 visit copayment for specialty provider Note: Services billed by an independent lab or radiologist requires a separate $20 copayment.

Alternative Treatments Acupuncture – when performed and billed by a physician or physical therapist, for:

• pain relief, and • as a modality of physical therapy

10% coinsurance $20 copayment per visit for primary care provider $30 copayment per visit for specialty provider

Chiropractic • Initial office visit • Spinal manipulations (Only CPT 98940,

98941, and 98942 covered) • Initial set of x-rays

Member responsible for full charges

$20 copayment per visit, up to 20 manipulations per calendar year.




Diagnostic and treatment services • Outpatient consultations • Outpatient second surgical opinions • Office visits • Home visits • Initial examination of newborn needing

definitive treatment when covered under a family enrollment

• Pharmacotherapy • Neurological testing

$15 office visit copayment. No deductible.

$20 office visit copayment per visit. primary care provider types (FP, GP, PED, IM, OB/GYN) $30 specialist office visit copayment per visit

Educational classes and programs • Smoking cessation

$15 copayment for the office visit charge. No deductible 10% coinsurance for all other services (deductible applies)

$20 visit copayment for primary care $30 visit copayment for specialty provider

• Diabetic education when billed by a covered provider

Note: Covered providers are diabetic educators who bill independently only as part of a certified diabetic education program.

10% coinsurance $20 visit copayment for primary care provider $30 visit copayment for specialty provider




Family Planning A broad range of voluntary family planning services limited to:

• Depo-Provera • Diaphragms • IUDs • Norplant • Oral contraceptives • Voluntary sterilization

10% coinsurance $20 visit copayment for primary care provider $30 visit copayment for specialty provider Note: Services billed by an independent lab or radiologist requires a separate $20 copayment.

Foot Care Routine foot care when under active treatment for a metabolic or peripheral vascular disease, such as diabetes

$15 visit copayment No deductible

$20 visit copayment for primary care provider $30 visit copayment for specialty provider

Hearing Services (testing, treatment and supplies) Hearing tests related to illness or injury

10% coinsurance

$20 visit copayment for primary care provider $30 visit copayment for specialty provider




Home Health Services (limited to home nursing care only) Home nursing care for two (2) hours per day, up to 25 visits per calendar year, when:

• A registered nurse (RN) or licensed practical nurse (LPN) providers the service and,

• Service is ordered by a physician.

10% coinsurance

$20 visit copayment per visit. Any provider.

Inpatient professional services • During a hospital stay • Services ordered by attending

physicians • Consultations when ordered by

attending provider • Concurrent care (medically necessary) • Physical Therapy by other than the

attending provider • Initial exam of newborn needing

definitive treatment when covered under a family enrollment

• Neurological testing • Second surgical opinion

10% coinsurance

Member pays nothing

Maternity Care Complete maternity (obstetrical) care including related conditions resulting in childbirth or miscarriage when provided or ordered and billed by physician.

Member pays nothing. No deductible.

$100 delivery copayment. Member pays nothing for prenatal and postpartum care.




Preventative care, adult Home and office visits for routine (screening) physical exams. Under Standard Option, benefits are limited to the following when performed as routine physical exam:

• History and risk assessment • Chest x-ray • EKG • Urinalysis • Basic or comprehensive metabolic panel

test • CBC • Cholesterol tests • Chlamydial infection test

Under Basic Option, benefits are provided for all of the services listed above and other appropriate screening tests and services. Note: These benefits do not apply to persons under age 22. Cancer Screening

• Colorectal cancer screening, including -fecal occult blood test -sigmoidoscopy

• Prostate cancer screening (PSA) test • Cervical cancer screening • Breast cancer screening (routine

mammogram)

$15 visit copayment for the exam. No deductible Note: One routine physical examination every three calendar years for members under age 65. Members over age 65, one routine exam per year. Note: Screening services billed separately from the routine physical examination, may be assessed an additional copayment for each office visit billed.

$20 visit copayment for primary Care provider $30 visit copayment for specialist Note: Services billed by an independent lab or radiologist requires a separate $20 copayment.

Preventative care, children • All healthy newborn visits including

routine screenings (inpatient or outpatient)

• The following services are recommended by the American Academy of Pediatrics up the age of 22

-Routine physical exam -Routine hearing tests -Laboratory tests -Immunizations -Related office visits

Member pays nothing No deductible

$20 visit copayment for primary Care provider $30 visit copayment for specialty provider Note: Services billed by an independent lab or radiologist requires a separate $20 copayment.




Vision Services (testing, treatment and supplies)

• One pair of eyeglasses, replacement lenses, or contact lenses to correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery.

• Eye examinations related to a specific medical condition (routine eye exams are NOT covered)

• Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 12

10% coinsurance




Surgical Services


Reconstructive Surgery • Surgery to correct a functional defect • Surgery to correct a congenital anomaly

– a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.

• Treatment to restore the mouth to a pre-cancer state

• All stages of breast reconstruction surgery following a mastectomy, such as:

- surgery to produce a symmetrical appearance on the other breast

- treatment of any physical complications, such as lymphedemas

10% coinsurance $100 copayment per performing physician

Surgical and Anesthesia services A comprehensive range of services provided or ordered and billed by a physician.

10% coinsurance $100 copayment per performing physician Note: Services of a co-surgeon, member pays a second $100 copayment. No additional copayment applies to services of an assistant surgeon.



Lab and X-ray Services


Lab, X-ray, and other diagnostic tests Diagnostic tests provided, or ordered and billed by a physician, such as:

• Blood tests • CT scans/MRIs • EKGs and EEGs • Laboratory tests • Pathology services • Ultrasounds • x-rays • Laboratory and pathology services

billed by an independent lab

10% coinsurance

$20 visit copayment for primary care provider $30 visit copayment for specialist provider Note: Services billed by an independent lab or radiologist requires a separate $20 copayment.



Therapy Services


Occupational and Speech Therapies Occupational and speech therapy when performed by an occupational therapist, speech therapist, or physical therapist.

10% coinsurance Note: Benefits limited to 25 visits per person, per calendar year for occupational therapy or speech therapy or a combination of both. Note: Visits paid while meeting the calendar year deductible count toward the 25 per person limit.

$20 visit copayment for primary care provider $30 visit copayment for specialty provider Note: Benefits are limited to 50 visits per person per calendar year for physical, occupational, or speech therapy, or a combination of all three.

Physical Therapy When performed by a physical therapist or physician:

• Physical therapy • Acupuncture as a physical therapy

modality


Treatment Therapies Outpatient treatment therapy

• Renal dialysis – hemodialysis and peritoneal dialysis

• Intravenous (IV) infusion therapy – home IV or infusion therapy

Note: Home nursing visits associated with home IV/infusion therapy are covered as shown under the Home health services.

• Pharmacotherapy • Outpatient cardiac rehab. Prior approval

required. Inpatient treatment therapy

• Chemotherapy and radiation therapy • Renal dialysis – hemodialysis and

peritoneal dialysis • Pharmacotherapy

10% coinsurance 10% coinsurance

$20 visit copayment for primary care provider $30 visit copayment for specialty provider Note: Member pays 30% of the plan allowance for drugs and supplies related to outpatient treatment therapies. Member pays nothing



Home Medical Equipment and Medical Supplies


Home Medical Equipment (HME) Home medical equipment is equipment and supplies that:

• Are prescribed by the attending physician;

• Are medically necessary; • Are primarily and customarily used only

for a medical purpose; • Are generally useful only to a person

with an illness or injury; • Are designed for prolonged use; and • Serve a specific therapeutic purpose in

the treatment of an illness or injury. Coverage is available for rental or purchase at the option of FEP, includes repair and adjustments of home medical equipment. Covered under this benefit is:

• Home dialysis equipment • Oxygen equipment • Hospital beds • Wheelchairs • Crutches • Walkers • Other items determined by FEP to be

HME

10% coinsurance 30% coinsurance




Medical Supplies Medical foods for children with inborn errors of amino acid metabolism

• Medical foods and nutritional supplements when administered by catheter or nasogastric tubes

• Ostomy and catheter supplies • Oxygen and catheter supplies • Oxygen, regardless of provider • Blood and blood plasma except when

donated or replaced, and blood plasma expanders

10% coinsurance

30% coinsurance

Orthopedic and prosthetic devices Orthopedic braces and prosthetic appliances such as:

• Artificial limbs and eyes • Functional foot orthotics when

prescribed by a physician • Rigid devices attached to the foot or a

brace, or placed in a shoe • Replacement, repair, and adjustment of

covered devices • Following a mastectomy, breast

prostheses and surgical bras, including necessary replacements.

10% coinsurance

30% coinsurance



Dental Services


Dental Care: Note: The FEP PPO Dental Network is applicable for both Standard and Basic Options. Note: See the 2002 FEP dental benefits newsletter for a complete listing of the dental service codes applicable to these separate benefit programs.

Scheduled allowances for diagnostic and preventive services, fillings, extractions; regular benefits for dental services required due to accidental injury and covered under oral and maxillofacial surgery

$20 copayment for 2 exams, x-rays, cleanings per year, and sealants for children up to age 16 $20 copayment for dental services due to accidental injury Medical benefits are applicable for covered oral and maxillofacial surgery.



Mental Health and Substance Abuse Services MHSA Treatment Plan Requirements under Standard Option: The provider must submit a written treatment plan to HMS/Value Options prior to the member’s ninth outpatient visit. HMS/Value Options will approve or deny additional services based on the information on the treatment plan. If a treatment plan is not submitted and/or approved, the services will be denied as provider write-off. If the member changes providers after their ninth visit, a treatment plan will be necessary from the new provider of care. Treatment plan forms are available on the www.bcbsks.com Website, under provider services and in the “Forms” area. Samples of the forms are located at the end of this document. The medical criteria used to evaluate the treatment plans may be found on the HMS/Value Options web site, www.ValueOptions.com. Approval of MHSA Services under Basic Option: The member is responsible for contacting HMS/Value Options for triage, approval of care, and to receive the number of approved visits prior to seeking care. Several names and phone numbers of contracting providers will be provided for the member to schedule care with the provider of their choice. Benefits are allowed only when the member seeks care from a contracting provider. Otherwise services are not covered. Under Basic Option, a treatment plan must be submitted from the initial visit. This can be a verbal report, but in certain situations, a written treatment plan may be required.

Highlight of the MHSA Benefits for Standard and Basic Options Standard Option

• Maximum of 25 visits per year for office visits combined in-network and out of network. • Unlimited visits with an approved treatment plan. • In-network benefits are payable when the care is clinically appropriate for the patient’s

condition and when received as part of an approved treatment plan. • Applicable deductibles and copayments

Basic Option

• Must use in-network providers • Members must call HMS/Value Options for triage and care approval • No calendar year deductible

Precertification for all inpatient hospital and intensive outpatient treatment plan stays is required for both Standard Option and Basic Option. A $500 penalty will be applied if precertification is not obtained.



MEMBER RESPONSIBILITY Preferred/Contracting Benefits

Standard Option Basic Option Mental Health and Substance Abuse (MHSA) All diagnostic and treatment services contained within the approved treatment plan. The treatment plan may include services, drugs, and supplies.

Deductible and co-insurance applies. Note: A treatment plan is required before the 9th visit.

Applicable copayment(s) Note: HMS/Value Options may contact the provider and request a treatment plan.

Inpatient professional visits (MHSA)

10% coinsurance Note: Must obtain prior approval for service.

Member pays nothing.

Inpatient services provided and billed by a hospital or other covered facility (MHSA) Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services and diagnostic tests Note: Precertification is required for all inpatient stays. Failure to obtain precertification will result in a $500 penalty.

$100 copayment per admission. No deductible

$100 copayment per day up to $500 per admission.

Outpatient services provided and billed by a hospital or other covered facility (MHSA)

• Diagnostic tests • Services in the following approved

treatment programs: - partial hospitalization - facility-based intensive outpatient treatment

10% coinsurance $30 copayment per day per facility




Professional services (MHSA):

• Individual or group therapies • Office or home visits • In a hospital outpatient department

(except for ER)

$15 copayment for the visit, up to two hours (no deductible)

$20 copayment $30 copayment for services billed by an outpatient facility. Note: All care must be pre-certified by HMS/Value Options

Professional charges for outpatient diagnostic tests (MHSA)

10% coinsurance

$20 copayment per visit

Other Services (MHSA): • Pharmacotherapy (medication

management)

• Psychological testing

10% coinsurance deductible applies Note: Other services are not subject to the two-hour limit.

$20 copayment per visit with primary care provider or other health care professional $30 copayment per visit with specialist Note: $30 copayment for outpatient services billed by a facility.

Not covered (MHSA): HMS/Value Options Not Involved in the following:

• Services not approved • Educational or training services • Psychoanalysis or psychotherapy

credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present.

• Psychotherapy for smoking cessation

Member responsible for all charges

Member responsible for all charges

HMS/ValueOptions MANAGED MENTAL HEALTH CARE NETWORK

OUTPATIENT DIAGNOSTIC TREATMENT REPORT FOR MEDICATION MANAGEMENT

THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND RETURNED TO HMS FOR ADDL AUTHORIZATION. FAILURE TO DO SO MAY RESULT IN A DENIAL OF CLAIMS PAYMENT.

Subscriber:_____________________________________ ____________________ _____________

Last Name First MI Insured ID # Group # Patient:________________________________________ ____________________ _____________

Last Name First MI DOB Sex 1. Diagnosis: Use DSM-IV Codes Only (All 5 axes are mandatory) Axis I: ___________ ____________ Axis III:___________ Axis V: Current:____________

___________ Axis II:____________ Axis IV:___________ Highest PY:_____________

3. Please indicate current medications, with dosage and frequency, used to treat patient. 4. # of sessions requested over next year? ___________ 5. Expected Termination Date: __________________ 6. Yes ____ No _____ Are you providing services in addition to medication mgmt or 20-30 min psychotherapy

with medication mgmt? If so, please utilize the standard 2-page outpatient treatment form to request additional sessions of mental health services.

7. Yes ____ No _____ Are you coordinating care with the client’s Primary Care Physician? Client Refused ____ 8. Yes ____ No _____ Is there a need for additional services besides medication mgmt? If so, please describe

on the back of this form. By signing below, I certify that the information provided herein is accurate and truthful to the best of my knowledge. In addition, I attest that these services have been provided by me. ___________________________________ ____________________ Provider's Signature Date

Mail or Fax to: HMS/ValueOptions _______________________________ 107 SW 6th St., Topeka, KS 66603 Full Name (Please Print) Fax #: (785) 233-1209 03/01/01

2. Current Functional Assessment Identify all areas where patient currently demonstrates impaired functioning. Indicate the degree of severity by placing a check mark in the applicable box. None Mild Moderate Severe Description of Dysfunction/ Impairments a. Occupation/Education/Work ! ! ! ! Comments

b. Marital/Family ! ! ! !

c. Interpersonal/Social ! ! ! !

d. Control of Drives/Impulses ! ! ! !

e. Adult Daily Living Skills ! ! ! !

f. Neurovegetative Functions ! ! ! ! (eating, sleeping, energy level, etc.) g. Psychological Well being ! ! ! !

Health Management Strategies International, Inc. MANAGED MENTAL HEALTH CARE NETWORK

OUTPATIENT DIAGNOSTIC TREATMENT REPORT

THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND RETURNED TO HMS FOR ADDL AUTHORIZATION. FAILURE TO DO SO MAY RESULT IN A DENIAL OF CLAIMS PAYMENT.

Subscriber:_____________________________________ ____________________ _____________

Last Name First MI Insured ID # Group # Patient:________________________________________ ____________________ _____________

Last Name First MI DOB Sex 1. Diagnosis: Use DSM-IV Codes Only (All 5 axes are mandatory) Axis I: ___________ ____________ Axis III:___________ Axis V: Current:____________

Axis II:____________ Axis IV:___________ Highest PY:_____________

3. Describe patient's condition/dysfunction (associated with the diagnoses above) that the patient presented with at the beginning of this episode of treatment, or from the last continued stay review. Onset of Illness (date): 4. Previous Treatment (check all that apply) Patient's Response to Treatment Interventions ! Inpatient/Partial Hospital Dates ! Outpatient Psychotherapy Dates: ! Medications (names/ dosage) ! Other

2. Current Functional Assessment

Identify all areas where patient currently demonstrates impaired functioning. Indicate the degree of severity by placing a check mark in the applicable box. None Mild Moderate Severe Description of Dysfunction/ Impairments a. Occupation/Education/Work ! ! ! ! Comments

b. Marital/Family ! ! ! !

c. Interpersonal/Social ! ! ! !

d. Control of Drives/Impulses ! ! ! !

e. Adult Daily Living Skills ! ! ! !

f. Neurovegetative Functions ! ! ! ! (eating, sleeping, energy level, etc.) g. Psychological Well being ! ! ! !

5. Treatment Plan Formulation. Based on the patient's chief complaint and initial symptom presentation, indicate the focus(es) of treatment. For individual or family tx, please indicate current specific goals of tx including discharge criteria. For med mgmt, please indicate med, dosage, and frequency. 6. Progress to date. Please indicate progress client has shown during the treatment process, or from the last

continued stay review. # of Sessions Requested: ______________________ Frequency of Tx: _______________________________ Date of next appt:______________________ Expected Termination Date: _________________ . 7. Is there a need for an additional referral, i.e., psychological evaluation, medication evaluation, etc.? 8. Yes ____ No _____ Are you coordinating care with the client’s Primary Care Physician? Client Refused ____ By signing below, I certify that the information provided herein is accurate and truthful to the best of my knowledge. In addition, I attest that these services have been provided by me. _____________________________________________ ____________________ Provider's Signature Date

________________________________________ Full Name (Please Print)

Address City State Zip Mail or Fax to:

Health Management Strategies, Inc. 107 SW 6th Street, Topeka, KS 66603

Topeka, KS 66603 03/01/01 FAX: (785) 233-1209

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