1. Presented By: Lenora Ballard and Robin Lewis

2. Agenda  2016 Policy Updates, Guidelines and Highlights  New Web Portal  Maximizing Incentive Opportunities  Fee Schedule and Impact Reports  Cost Effectiveness and Clinical Efficiency Scores  How To Increase Your Incentives  The Physician Performance Assessment (PPA)Tool  Patient Health Snapshot (PHS) 2016 Incentive Programs  PCP Select/VBP Incentive Program  Blue Advantage Incentive Program

3. Lenora Ballard

4.  Effective September 1, 2015, pass-through billing is no longer permitted for laboratory tests.  Pass-through billing occurs when an ordering provider requests and bills for laboratory tests, but the tests are not actually performed by the ordering provider.  The performing provider should bill for these services directly.

5. Select “Physician-Administered Drug Policies and Forms” under Pharmacy Resources. Blue Cross offers a new, paperless predetermination service that will streamline the authorization process for physician-administered drugs.

6. Access this online predetermination service from ProviderAccess in Eligibility and Benefits:

7. Physicians should review draft policies. We appreciate your feedback!

8. In 2016, two new individual plans will be available on and off the health insurance exchange Blue Cross Select Gold, a Multi-State Plan Blue Cross Select Silver, a Multi-State Plan

9. These plans will require that each member designate a Primary Care Select physician, who will be responsible for coordination of care via referrals to specialists. The primary care designation and referral process will be required in order for services to be paid.

10. Physicians currently participating in our Primary Care Select Program are recognized as “Primary Care Select” doctors within “Doctor Finder” on our Blue Cross website. Primary Care Select Physicians

11. Referrals must be made through ProviderAccess on our website. A physician under the same provider tax ID with a primary care specialty will automatically be considered by Blue Cross as one of the covering physicians. Physician assistants and nurse practitioners are not automatically considered as “covering” and should be manually added to the covering list. Primary Care Select physicians will be able to designate covering physicians to care for their patients in their absence. The Primary Care Select provider can update this information via ProviderAccess.

12. 1.Visit AlabamaBlue.com/providers. 2.Log in through ProviderAccess. 3.Select “Provider Functions.” 4.Under “Primary Care Select Physician.” 1.Visit AlabamaBlue.com/providers. 2.Log in through ProviderAccess. 3.Select “Provider Functions.” 4.Under “Primary Care Select Physician.”

13. Due to the variety of products available on and off the exchange, individual or group coverage and varying levels of complexity, a provider should always check Eligibility & Benefits for each Blue Cross and Blue Shield of Alabama member.

17.  A discounted copayment for office visits at a member’s designated primary care physician’s office.  A discounted copayment for office visits to a specialist if a Primary Care Select physician has referred the member to that specialist prior to the visit.  A discounted copayment for OB/GYN visits (with no referral required) if a member has a designated primary care physician. Primary Care Select: Discounted Copay Product

20.  The primary laboratory for this network is Quest Diagnostics, a leading provider of diagnostic testing, information and services. Several specialty laboratories are also included.  Coverage will still be provided for limited in-office clinical laboratory services (Exhibit I) for these members.  All other laboratory services for members with the Select Lab Network benefit must be referred to Quest Diagnostics unless they are medically necessary laboratory services unavailable through Quest.

21. (Exhibit I) is located on the website under “Provider Resources” in the Provider Manual.

23. Services provided by a Preferred Provider Lab (PPL) will be considered out of network for members according to their contract benefits. Contact information for Quest Diagnostics: 1-866-MY-QUEST (1-866-697-8378)1-866-MY-QUEST (1-866-697-8378)

24. Robin Lewis

25. Does your documentation support the evaluation and management (E&M) codes you are choosing? It is important that you choose the right codes when dealing with high-level care. These Current Procedural Terminology (CPT) codes are often misused: 99205 99215

26. CPT code 99205 is used for high-level care of a new patient. The following 3 components must be present: High-complexity medical decision-making Comprehensive examination Comprehensive history

27. CPT code 99215 is used for high-level care of an existing patient. It can be used if 2 of these 3 components are present: High-complexity medical decision-making Comprehensive examination Comprehensive history

29. For both codes, moderate-to-high complexity decision- making is required in order to use them. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or other agencies should show consistent information with the nature of the problem. With code 99205, typically 60 minutes are spent face to face with the patient and/or family. With code 99215, typically 40 minutes are spent face to face with the patient and/or family.

30. Medicare – CMS www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html www.roadto10.org/ American Academy of Professional Coders – AAPC www.aapc.com/icd-10/icd-10-codes.aspx American Health Information Management Association – AHIMA www.ahima.org/icd10/ Blue Cross and Blue Shield of Alabama www.AlabamaBlue.org/providers/ICD10.cfm