This material is considered part of the Provider ManualMedical Mutual of Ohio, Consumers Life Insurance Company and Carolina Care Plan

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Volume 2/Issue 1 • 1st Quarter 2009

Mutual NEWS

NEWeBusiness UpdatesMedical Mutual and our Family of Companies are excited to share information regarding continuous enhancements to our Web sites, as well as the emergent transformation of our advancing eBusiness.

Our secure ePortal is designed to give providers quick access to important and individualized information, tools and services and the choice to receive various provider publications such as Mutual News electronically.

By enrolling in Electronic Funds transfer (EFt), providers are able to have claims payments deposited directly into their account and have an electronic history of deposits.

In 2009, an added feature will be the option to have Electronic Remittance Advice (eRAs) electronically accessible at the same time funds are deposited, in addition to the standard 835 transaction.

The NEW ePortal provides:

· Fee Schedule lookup

· Electronic Funds transfer

· Electronic Remittance advice

· Instant access to your demographic information

· Electronic access to various provider publications

Future Mutual News mailings will alert providers of new features and advancements to the ePortal that will simplify services and provide important information when you need it.

Visit the Provider section of MedMutual.com, ConsumersLife.com and CarolinaCarePlan.com for more information!

American Board of Pain Medicine ..................................2CPT Codes for Prenatal and Postpartum Care ...............2Submitting Claims Falling Under a Pre-existing Clause ..3 Submitting Itemized Bills ...............................................3Leading ePrescribing Networks Coalesce ......................4

Updating Provider Information ......................................4Updates to Prior Approval Coverage & Requirements ......5Electronic Coordination of Benefits ..............................5 2009 Updated Provider Manual .....................................6 Semi-Annual Review of Fees for Immunizations ...........6 Provider Contracting Offices ..........................................7

Index

This material is considered part of the Provider Manual Medical Mutual of Ohio, Consumers Life Insurance Company and Carolina Care Plan

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The criteria for providers listed as Pain Management specialists has been revised.

The Credentialing Committee has expanded the criteria to include a physician’s current certification from the American Board of Pain Medicine (ABPM) as appropriate evidence of the professional skill base to be listed in our directory as a Pain Medicine specialist.

Providers currently certified by the ABPM who were previously denied listing as Pain Medicine can now reapply.

To access the ABPM diplomate public directory please visit http://www.association-office.com/

abpm/etools/publicdir/search.cfm and select the pertinent state for a list of all providers currently certified, which includes addresses and phone numbers.

Please contact your local contracting representative with any questions.

American Board of Pain Medicine

CPT Codes for Prenatal and Postpartum Care

CPT Code 0503F: Postpartum Care Visit (Category II Code) Please use CPt Code 0503F to report performance of the Postpartum Care Visit between 3 to 8 weeks after delivery.* The postpartum visit should include the date of the visit and documentation of at least one or more of the following:

• Pelvic exam or• Evaluation of weight, blood pressure, breasts and abdomen

*HEDIS Technical Specifications 2008

Two CPT Category II Codes for the Initial Prenatal Care Visit and Postpartum Care Visit are now recognized to permit reimbursement for both in addition to the global obstetrical payment. Using these Category II Codes allows for greater reimbursement for you and notifies us that timely prenatal and postpartum care visits have occurred.

CPT Code 0500F: Initial Prenatal Care Visit (Category II Code)Use CPT Code 0500F to report performance of the Initial Prenatal Care Visit within the first 12 weeks of pregnancy.* This visit should include the following:

• History • Blood work• Physical examination • Pregnancy risk assessment• Pelvic exam

CPT Code 0500F may be used only after pregnancy has been confirmed. CPT Code 0500F also is eligible for reimbursement past the first trimester if a member transfers from one provider to another.

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The Free of Care Form is generated for received claims that meet certain criteria and fall under a pre-existing clause per a Covered Person’s policy. To ensure Covered Persons receive the maximum benefit allowed under their policy, complete the Free of Care Form sent to your service location and return it to the address that appears on the form. A pre-existing clause can limit benefits for a condition that was treated prior to the effective date of the policy. Policies sold with a pre-existing clause may have limitations applied.

Contact your local contracting representative with any questions.

Submitting Claims Falling Under aPre-existing Clause

Submitting Itemized Bills

If you receive a rejected claim with a remark code of CHN requesting an itemized bill for the date of admission through discharge, please be sure to mail the requested documents to the Post Adjudication Review Department at:

Itemized bills should NOt be sent with the Provider Action Request (PAR) form or to the address listed on the PAR form.

ATTN: Post Adjudication Review DepartmentMedical Mutual of OhioP.O. Box 94719Cleveland, OH 44101-4719

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Leading ePrescribing Networks Coalesce

SureScripts and RxHub have merged to collaborate with retail pharmacies and benefit managers to pursue an efficient, patient-safe technology. SureScripts-RxHub seeks to create a single, safe and secure platform for nationwide ePrescribing.

ePrescribing helps reduce prescribing errors and speeds the prescribing process while reducing costs.

SureScripts-RxHub, will act as a communication channel with pharmacies to increase productivity and enhance the quality of care.

Watch for upcoming information regarding our partnering with SureScripts-RxHub to further advance ePrescribing.

To ensure your information is the most up-to-date, we are encouraging our providers to check their data via our ePortal.

Updating your records through the ePortal allows you to quickly and efficiently add, edit or remove providers associated with your practice, as well as identify any changes to your service location(s) and reimbursement address(es).

Enrolling in the new ePortal is easy and secure for efficient, time-saving management of your data. Visit the provider section of MedMutual.com, ConsumersLife.com and CarolinaCarePlan.com to register.

If you have not yet registered on our ePortal and prefer to check and update your information manually, you will need to:

Check the most recent directory (available in the • Provider section of our Web sites)Fill in a Provider Information Form (PIF) (available in the •Provider, Tools & Resources, Forms, Update Your Records section of our Web sites) for each individual update (e.g. one PIF to delete an old address, then a second PIF to add a new address)

For organizations holding a delegated addendum with the company, updates must be made via the delegated roster process.

Your local contracting department needs to be notified in writing at least 90 days prior to the effective date of any intent to close, limit or reopen your practice.

Updating Provider Information

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Update Your Records

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Prescription medications Remicade (Infliximab®) and growth stimulating drugs, including Somatrem (Protropin®), Somatropin (Humatrope®, Nutropin®, Serostim®, Saizen®, Norditropin®, Genotropin®, Tev Tropin®, Zorbtive™, Omnitrope™), Sermorelin acetate and Mecasermin (Increlex™, IPLEX™), will require prior approval when the services are provided under the member’s medical benefit.

Growth stimulating drugs will no longer be covered for treatment of idiopathic short stature (non-growth hormone deficient short stature) or constitutional delayed growth. If a course of treatment has already been initiated prior to the date of this notification, members currently taking growth stimulating drugs for the treatment of idiopathic short stature (non-growth hormone deficient short stature) or constitutional delayed growth will continue to receive benefits based upon reimbursement policies in place at the time the course of treatment was approved.

When these services are provided under a member’s pharmacy benefit, providers should refer to the prior approval requirements of the pharmacy benefit manager, as indicated on the back of the member’s identification card.

Additionally, vagus nerve stimulation for treatment of major depressive disorder will be considered investigational and not medically necessary.

The prior approval process is not intended to infer benefits or coverage for a specific member. Benefit determinations and coverage decisions are subject to all the terms and conditions of the applicable benefit plan, including definitions, specific inclusions or exclusions, and applicable state or federal laws.

For more information regarding prior approval requirements and other Corporate Medical Policies, visit the Providers, Tools & Resources, Care Management section of MedMutual.com, ConsumersLife.com and CarolinaCarePlan.com.

Updates to Prior Approval Coverage and Requirements ...Effective April 1, 2009

Electronic Coordination of Benefits

For ease and efficiency, providers can electronically submit Coordination of Benefits (COB) information through the 837 electronic claims transaction and are not required to submit a paper Explanation of Benefits when COB claims are submitted electronically. Electronic dental COB is not currently supported.

Electronic COB is supported for all commercial claims, both professional and institutional. Additionally, Medicare secondary claims are accepted electronically.

For further information, contact your clearinghouse vendor or the Medical Mutual Provider Inquiry department at 800/362-1279.

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Semi-Annual Review of Fees for Immunizations

No aquious cote inside of this white area

08-MMU01-004 12/18/08

2009 Updated Provider ManualMedical Mutual and our Family of Companies have recently updated the Provider Manual and are in process of distributing the 2009 interactive CD-ROM version, as well as providing online availability.

The NEW Provider Manual will replace previous versions of the Professional Provider Manual and Hospital Reference Manual and is the first edition to incorporate material relevant to Professional and Institutional providers.

For easier navigation, improved features were employed. Specifically, the Table of Contents is divided into four informational segments, which are highlighted by a different color: All Provider (gold), Professional Provider (teal), Institutional Provider (blue) and Plan Guidelines (orange). Each segment is further detailed to keep topical material together.

The updated electronic version also contains bookmarks, thumbnails and direct links within the Provider Manual.

Coinciding with the CD-ROM distribution, look for the 2009 Provider Manual available in the Provider section of our Web sites at MedMutual.com, ConsumersLife.com and CarolinaCarePlan.com.

In response to feedback from the provider community, the commercial fee schedule for immunizations, currently reviewed on an annual basis, will be reviewed on a semi-annual basis.

By moving to a semi-annual review, fees for immunizations can more quickly reflect current market rates and accommodate the introduction of new drugs.

Any updates to immunization fees based on these semi-annual reviews will be effective for dates of service January 1 and July 1 of each year.

Contact your local contracting representative with any questions.

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Phone: 800/677-8028Fax: 678/742-9170

Phone: 888/258-3482Fax: 419/473-7024

Central (Columbus)Phone: 800/235-4026Fax: 614/932-7254

Northeast (Cleveland)Phone: 800/625-2583Fax: 216/687-7994

Northwest (Toledo)Phone: 888/258-3482Fax: 419/473-7024

Southwest (Cincinnati/Dayton)Phone: 800/589-2583Fax: 513/684-8121

Ohio Ancillary ProvidersPhone: 216/687-7466Fax: 216/687-1450

Phone: 800/625-2583Fax: 216/687-7994

ColumbiaPhone: 800/868-6734Fax: 803/561-7772

GreenvillePhone: 864/281-7465Fax: 864/297-7888

Provider Contracting Offices

Indiana

Ohio

Pennsylvania

South Carolina

Georgia

2060 East Ninth Street • Cleveland OH 44115-1355X7902 R1/09

This material is considered part of the Provider ManualMutual News, Volume 2, Issue 1, 1st Quarter 2009

Published by the Provider Communications Department • 2060 E. Ninth Street, Cleveland, OH 44115-1355Medical Mutual of Ohio, Consumers Life Insurance Company and Carolina Care Plan

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