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BLUE ReviewIssue 6 – 2008 • November/December

Blue Review going paperless in 2009As a part of our corporate “Blue Goes Green” initiative,we are collecting e-mail addresses of the more than10,500 contracting providers in our networks.* We willuse these e-mails to launch our electronic-only versionof Blue Review in 2009. We invite you to join us in“Blue Goes Green” by choosing to receive your BlueReview via e-mail.

By e-mailing communications to our providers, we canreduce paper use significantly, thereby acknowledgingour responsibility as corporate citizens to safeguard natu-ral resources and the environment. “Losing the paper”will give you quicker access to BCBSNM informationand make distribution easier – just forward the newslet-ter to your staff. Also, when you get your newsletter viae-mail, you’ll receive quick links to other new items onour provider website.

Beginning with issue 1, 2009, the next issue, Blue Reviewwill be a monthly publication available at bcbsnm.com.To find it, click the Blue Review button on the Providershome page. During the first quarter of 2009, we will mailpostcards to all contracted providers informing themthat the latest issue is available and what some of thekey articles are. If you do not have Internet access,please contact Network Management at 800-567-8540to continue receiving Blue Review by mail.

To sign up for Blue Review via e-mail, click the UpdateYour Contact Information button at bcbsnm.com/providers and submit your e-mail address. Pleaseinclude your NPI.

*BCBSNM is aware of your privacy concerns and ensures that youre-mail address is maintained in a secure environment and held in thestrictest confidence.

2008 Provider Satisfaction Survey resultsThis summer, BCBSNM conducted its annual providersatisfaction survey, which was administered by TheMyers Group, an independent consultant. The MyersGroup collected responses from a random sampling ofparticipating BCBSNM providers on such areas as cus-tomer service, provider relations, utilization and qualitymanagement, finance, pharmacy and drug benefits, con-tinuity and coordination of care, and overall providersatisfaction.

Results are still being compiled, but we already havesome overall percentages. In overall satisfaction and loy-

alty, 81 percent of providers were either “very satisfied”or “satisfied” with BCBSNM. We are particularlypleased that 93.2 percent of physicians would recom-mend BCBSNM to other physicians and 92.9 percentwould recommend our plan to other patients.

Look for detailed information on the survey results inthe January 2009 issue of Blue Review. We value yourcontinued feedback.

Angela Sanchez-Caldwell joined BCBSNM as the Medicaidcontractor in August. She brings more than 15 years of healthcare administration experience to Network Services.Contracting allows her to continue working with the providercommunity, where she has developed many friendships over theyears. “Developing long-term relationships in the provider com-munity is important,” says Angela. “These partnerships havemade it a pleasure to come to work every day.”

Angela says of BCBSNM, “I have never encountered a morewelcoming group of people, and their commitment to work as ateam to accomplish a common goal is to be commended. Thething that really stands out with BCBSNM is the desire to pro-vide outstanding service to customers.”

Angela offers this advice to participating BlueSalud providers:“Build strong relationships with your BCBSNM contacts.Together we can provide better care for our BlueSalud members.”

BLUE Review Issue 6 - 20082 www.bcbsnm.com/provider

BCBSNM welcomes Medicaid program staffOn October 1, BCBSNM launched BlueSaludSM to provide comprehensive health care benefits for the Medicaid-eligible population in New Mexico. Mary Winters Morse oversees BlueSalud as Director of Medicaid Programs.

Mary’s background in health care management spans 35 years and includes the administration of the largest freestand-ing Medicare-certified home health care agency in New Mexico. “Because of my experience as a health care adminis-trator,” Mary says, “I understand the provider per-spective and the challenges they face. Some of thosechallenges with BlueSalud will be developing cultur-al awareness and overcoming language barriers.”

Mary says her two biggest challenges in serving theBlueSalud membership will be ensuring adequateaccess to primary care and specialist providers andsteady membership growth. BCBSNM is committedto wellness and serving the community, and Maryintends to further that commitment through theBlueSalud program.

Mary is a registered nurse and worked at BCBSNMfrom 1977 to 1991. Before returning to BCBSNM,she served as Director of Quality Management andMedicaid Compliance Officer at Presbyterian HealthPlan. Mary holds a B.S. in health care administra-tion from University of Albuquerque and an M.B.A.from the University of Phoenix.

BLUE Reviewwww.bcbsnm.com/provider Issue 6 - 2008 3

The Early Periodic Screening, Diagnosis, and Treatment program (EPSDT) is federally mandated to ensure compre-hensive health care to Medicaid recipients from birth to 21 years of age. To help this population of BlueSalud mem-bers receive health care, BCBSNM covers medically necessary prevention, treatment, and ameliorative health servicesunder EPSDT.

Services provided under EPSDT can be accessed only after an initial health screening service, called the “tot-to-teenhealthcheck” or “healthcheck referral.” EPSDT services include:

• Comprehensive health and development history*• Comprehensive unclothed physical exam*• Appropriate immunizations*• Laboratory tests, including an appropriate lead blood level assessment at 12 and 24 months of age*• Health education*• Dental screening• Vision and hearing testing

*These services must be documented to fulfill EPSDT exam requirements and to allow us to measure clinical processesusing the Healthcare Effectiveness Data and Information Set (HEDIS®). Accurate HEDIS reporting is importantbecause it will be used as part of a BlueSalud performance recognition strategy currently in development.

HEDIS® is a registered trademark of the National Committee for Quality Assurance.

CPT codes for EPSDT visitsThe Centers for Medicare and Medicaid Services (CMS) has mandated that the following CPT-4 codes be used tocapture all EPSDT visits:

• 99381 New patient (under 1 year)• 99382 New patient (1-4 years)• 99383 New patient (5-11 years)• 99384 New patient (12-17 years)• 99385 New patient (18-39 years)• 99391 Established patients (under 1 year)• 99392 Established patients (1-4 years)• 99393 Established patients (5-11 years)• 99394 Established patients (12-17 years)• 99395 Established patients (18-39 years)• 99431 Newborn care (history and examination)• 99432 Normal newborn care

In addition, the above CPT-4 codes must be used in conjunction with V codes V20 through V20.2 and/or V70.0 andV70.3 through V70.9:

• V20 Health supervision of infant or child• V20.0 Foundling• V20.1 Other healthy infant or child receiving care• V20.2 Routine infant or child health check• V70.0 Routine medical examination at a health care facility• V70.3 Other medical examination for administrative purposes• V70.4 Examination for medicalogical reasons• V70.5 Health examination of defined populations• V70.6 Health examination in population surveys• V70.7 Examination for normal comparison or control in clinical research• V70.8 Other specified general medical examinations• V70.9 Unspecified general medical examination

EPSDT program for BlueSalud members


Approved new or revised Medical Policies and their effective dates are posted on our website the first day of eachmonth. These policies may impact your reimbursement and your patients’ benefits. To View All Active Policies or View AllPending Policies, visit the Provider Library at bcbsnm.com under Medical Policies. Select Draft Medical Policies to viewpolicies that are under development or are being revised and e-mail your comments.

Some information about new or revised Medical Policies is also published in this newsletter for your convenience.However, please rely on our website for access to the most complete and up-to-date Medical Policy information. If youhave questions about BCBSNM’s Medical Policies, please contact Health Services at (505) 816-2093.

Medical Policy updates

Drug List updatesThe BCBSNM and Prime Therapeutics Pharmacy and Therapeutics Committee met on August 25, 2008, and recom-mended the following changes to the BCBSNM Drug List. To search the Drug List and learn more about BCBSNMdrug benefits, including pharmaceutical management procedures such as prior authorization, step therapy, and dispens-ing limits, go to bcbsnm.com and select Providers, then scroll down to Pharmacy.

Eff. date Policy # Policy name

12/1/08 MED202.055Intravascular Brachytherapy for Prevention and Management of RestenosisafterPrecutaneous Transluminal Angioplasty

12/1/08 RAD605.015 Endobronchial Brachytherapy12/1/08 RAD605.017 Accelerated Partial Breast Irradiation (APBI)12/15/08 OTH903.020 Neovascular Wet Age-Related Macular Degeneration (ARMD or AMD)1/1/09 RAD601.049 Epiretinal Radiation Therapy for Age-Related Macular Degeneration (ARMD)1/1/09 DME104.001 Prosthetics, Except Lower Limb Prosthetics1/1/09 DME104.012 Lower Limb Prosthetics, Including Microprocessor Prosthetics1/1/09 MED205.032 Percutaneous and Implanted Nerve Stimulation and Neuromodulation1/1/09 MED207.116 Collagen Cross Links as Markers of Bone Turnover1/1/09 SUR706.013bu Electromagnetic Navigation Bronchoscopy (ENB)1/1/09 SUR716.019 Breast Ductal Lavage, Endoscopy, or Ductoscopy1/1/09 THE801.030 Non-Pharmacologic Treatment of Rosacea1/15/09 RAD604.011 CT (Computed tomography) Perfusion Imaging1/15/09 SUR707.003 Automatic Implantable Cardioverter Defibrillator1/15/09 SUR712.032bu Minimally Invasive Percutaneous Facet Joint Fusion (TruFUSE)

Brand-name medications added to third-tier copayEffective October 1, 2008Third-tier brand Second-tier alternatives First-tier generic alternatives

Fosamax® Actonel®, Evista® alendronate (Fosamax)Vivelle® Estraderm®, Vivelle-Dot® estradiol patches (Climara®)Altace® ramipril, lisinopril, enalapriPrecose® acarboseRequip® ropiniroleRisperdal® Seroquel®, Geodon® risperidone

Brand-name medications added to second-tier copay Effective October 1, 2008

New second-tier medicationAlbenza®

Effective October 1, 2008

Quantity limitsPristiq® (30 tablets/30 days)omeprazole 40 mg (30 caplets/30 days)

Effective January 1, 2009Preferred medicationomeprazole 20 mg

BLUE Reviewwww.bcbsnm.com/provider

OFFICE StaffIssue 6 – 2008 • November/December

Here are four tips to help your paper claims process morequickly:1. Use the proper version of the claim form.BCBSNM is no longer accepting the old version of theCMS-1500 (version 12/90 and/or HCFA form) or theUB-92 claim form. Claims received on these outdatedforms will be returned to you. Please recycle any oldforms in your inventory and replace them with the cur-rent version. The current versions of these forms areCMS-1500 (version 08/05) and UB-04.

2. Include all required identification information.In addition to including the appropriate member identifi-cation, such as the group policy number and alpha-prefixidentification number, it is important to include yourType 1 and/or Type 2 NPI in all appropriate fields. (Note:Your billing NPI must be included in field 33a on theCMS-1500 and in Form Locator 56 of the UB-04.) Yourtaxpayer identification number (SSN, EIN, or TIN) willcontinue to be required on all claims for tax reportingpurposes. Claims that are missing any required informa-tion will be returned to you with a cover letter explain-ing the reason for return.

3. Provide readable originals.Use only the original, standard red-ink claim form. Thisform is printed with a special red ink to ensure properscanning. If the form is not scanned properly, errors orprocessing delays could occur. Claims that are partiallylegible, too light, or too dark will be returned to you.

4. Check out our helpful reference guides.For a printable CMS-1500 or UB-04 User Guide, and anonline CMS-1500 tutorial, visit the Provider Library onour website at bcbsnm.com. Additional information onthe CMS-1500 claim form can be found on the NationalUniform Claim Committee (NUCC) website atnucc.org. For complete detailed information on theUB-04 claim form, visit the National Uniform BillingCommittee (NUBC) website at nubc.org.

Expediting paper claims processing

Use the Forms section of our online Provider Library toobtain the most updated version of the document youneed. We see many instances where providers are using oldversions of forms. When you use an outdated form, we maynot receive the information we need to expedite yourrequest.

In our ongoing effort to improve our processes and service,the forms and other information on our website are updat-ed frequently. Rather than printing multiple copies of aform, or saving the PDF to your hard drive, please go tobcbsnm.com each time to obtain the form you need, there-by ensuring you have the most current version.

Find the forms you need at bcbsnm.com

5

BLUE Review Issue 6 - 2008

Our PSU handles all provider inquiries regarding claims status, eligibility, benefits, and claims processing issues forBCBSNM members. For out-of-area claims inquiries, please call the BlueCard® Provider Service Unit at 800-222-7992.

Claims inquiries? Call the Provider Service Unit (PSU) at 888-349-3706

www.bcbsnm.com/provider

Network Management contacts and related service areasPROVIDER SERVICE REPRESENTATIVES

Handle general questions on contractingand provider education

PROFESSIONAL CONTRACTINGIncluding allied health practitioners

Network Contract Rep: Rick BogleTelephone: (505) 816-2145

E-mail: [email protected] Provider Rep: Jan MontoyaTelephone: (505) 816-2303

E-mail: [email protected]

Our Provider Service Representatives are available toassist you Monday through Friday, 8 a.m. to 5 p.m.

General department telephone numbers:(505) 837-8800 or toll-free: 800-567-8540

Direct fax numbers:(505) 816-2688 or toll-free: 866-290-7718

NORTHERN REGIONNorthwest Region Network Contract Rep: JoAnn Ireland

Telephone: (505) 816-2159E-mail: [email protected]

Northeast Region Network Contract Rep: Joyce HambletTelephone: (505) 816-2146


Lead Provider Rep: Gina GutierrezTelephone: (505) 816-2156


Network Contract Rep: Mike NelsonTelephone: (505) 816-2139

E-mail: [email protected] Provider Rep: Gina Gutierrez


HOSPITAL CONTRACTINGIncluding acute care, behavioral health,

and speciality hospitals

GOVERNMENT CONTRACTINGMedicaid and Medicare Advantage

Blue Medicare PPO Network Contract Rep:Cathie Rowland-Robert


BlueSalud Network Contract Rep:Angela Sanchez-Caldwell


ANCILLARY CONTRACTING

6

OFFICE Staff, continued

✂

SOUTHERN REGIONSouthwest Region Network Contract Rep: Karen Burgess


Southeast Region (includes Harding and Union Counties)Network Contract Rep: Jill Billingsley


Lead Provider Rep: Jan MontoyaTelephone: (505) 816-2303


CENTRAL REGIONNetwork Contract Rep: Michelle Quintero


Lead Provider Rep: Liz MartinezTelephone: (505) 816-2161


OFFICE Staff continued on p. 8

Issue 6 – 2008 • November/December

BLUE Reviewwww.bcbsnm.com/provider

Blue Medicare PPOSM

Corner

Don’t forget your CLIA number when billing for lab work

7

Blue Medicare PPO follows the same billing and coverage guidelines as original Medicare. This includes the require-ment to report the Clinical Laboratory Improvement Amendments (CLIA) number on claims submitted by all laborato-ries, including physician office laboratories.

Your CLIA number is required on the CMS-1500 (08/05) claim form for lab services by any lab performing tests cov-ered by CLIA. Be sure to:

• Place the CLIA number in field 23 of the paper CMS-1500 (08/05)• Ensure that the CLIA number is included with all electronic filings• Include modifier QW on claims for CLIA-waived lab tests

Your CLIA number is not required for the CMS-1450 (UB04) claim form.

New! Blue Medicare PPO provider portalBlue Medicare PPO will have a separate, standalone provider portal before the end of 2008. Blue Medicare PPOproviders will have the ability to verify Blue Medicare PPO member benefits and eligibility online, as well as checkclaims status and payment.

To use the portal, providers must have a high-speed Internet connection and an Internet browser that supports 128-bitencryption (Microsoft Internet Explorer 6.0 or greater is required). The portal will be best experienced with a 800x600or greater pixel screen resolution and when Frames, Graphics, and Java browser settings are enabled.

Providers may call Blue Medicare PPO provider Customer Service for registration instructions at 866-706-7745.

Not yet contracted forBlue Medicare PPO?Providers who are participating in commercialBCBSNM products are not automatically consid-ered participating providers in Blue Medicare PPO.They must sign a Medicare Advantage amendmentto their Medical Services Entity Agreement(MSEA) to become a Blue Medicare PPO provider.Please call Cathie Rowland-Robert at (505) 816-2132 if you are interested in becoming a BlueMedicare PPO provider.

BLUE Review Issue 6 - 2008www.bcbsnm.com/provider

High Desert Nephrology Associates, PLLC1801 Red Rock DriveGallup, NM 87301(505) 863-7993

Bloomfield Chiropractic Center, Inc.308 North First StreetBloomfield, NM 87413(505) 632-1111

Additions to our provider network

Look for new sections in the Blues Provider ReferenceManual (PRM) for 2009. We are adding sections on e-business and network management and are giving cre-dentialing its own section. We’ve also added hyperlinksfor the online version and more attachments to makethe PRM more user-friendly.

The PRM is updated throughout the year, but we willadd the new sections and updated attachments byJanuary 2009. You can find those changes summarized inProvider Reference Manual Changes in the Providerssection of our website, bcbsnm.com. Keep this sectionbookmarked for the latest updates.

To access a copy of the PRM, go to bcbsnm.com andselect Providers, then Provider Reference Manual underthe Provider Library heading. Providers without accessto the website may order a hard copy from NetworkServices by calling (505) 837-8800 or 800-567-8540.

2009 Blues Provider Reference Manual

8

Continued from OFFICE Staff, p. 6

A provider who specifically states that he or she is submitting an appeal on behalf of the member as an authorized rep-resentative must submit the information listed below before BCBSNM will accept the appeal request.

Written authorization must be included with each appeal filed by an authorized representative. Use the “ProviderRequest for Appeal on Behalf of the Member” form, available from bcbsnm.com/providers – select Forms underProvider Library. The authorization must include:

1. Member signature2. Member’s acknowledgment authorizing the representative to appeal on his or her behalf3. Pertinent claim information, including:

• Cardholder name, address, and phone• Copies of explanation of benefits (EOB),

remittance advice, and/or denial letter• Date(s) of service• BCBSNM identification number• BCBSNM group/enrollment number• Patient name• Provider name• Provider NPI number

Checklist for requesting appeals on a member’s behalf

Send appeals requests to:Blue Cross and Blue Shield of New MexicoAttn: Appeals DepartmentP.O. Box 27630Albuquerque, NM 87125-7630

BLUE Reviewwww.bcbsnm.com/provider Issue 6 - 2008 9

BCBSNM has recently chosen TriessentTM, a new program offered by Prime Therapeutics®, as the exclusive provider ofspecialty medications for its members. Members currently on specialty medications will be transitioned from McKessonto Triessent effective November 1, 2008.

Triessent is a full-service Specialty Pharmacy and will provide physician offices with the following services:• Custom fax forms for simplified enrollment• Alerts for patient nonadherence issues• Assistance with paperwork and coverage options• Verification of patient eligibility• Toll-free helpline available 24/7• Batched delivery directly to your office, usually within 24 to 48 hours• Full inventory of specialty medications in stock• Easy access to disease-focused teams• Assistance with prior authorizations• Coordinating medication refills• Links to patient assistance organizations• Insurance specialists to save your staff time and resources

Triessent offers complete specialty pharmacy management, which includes safe and efficient delivery of specialty med-ications, guidance and education from experienced professionals, and integrated medical and pharmacy benefits man-agement.

Triessent is new Specialty Pharmacy vendor

We value your participation in the Blue Cross and Blue Shield Service Benefit Plan for federal employees. FEP offerstwo plans, Standard Option and Basic Option, through BCBSNM and other participating Blue Cross and Blue ShieldPlans nationwide.

The Standard Option offers benefits for covered services performed by both preferred and nonpreferred providers.PPO benefits apply when the member uses a PPO preferred provider. If no PPO preferred provider is available, or themember does not use a PPO preferred provider, non-PPO benefits apply. Out-of-pocket expenses, such as coinsuranceand copayments, are lower when members use preferred providers.

The Basic Option is a network-only benefit program that requires the member to use preferred providers in order toreceive benefits, except in emergency situations. This option offers a lower premium than the Standard Option andcomprehensive coverage with no deductibles or referrals. There is no coverage when a Basic Option member uses anon-PPO provider. The Basic Option plan has different copays for PPO primary care providers and specialists.

The following benefits are available for FEP:• Hearing aids, including bone-anchored hearing aids, for children up to age 22, and bone-anchored hearing aids

for adults when medically necessary due to traumatic injury or malformation of the external or middle ear.Benefits for these hearing aids are limited to $1,000 per ear per calendar year.

• Office visits and diagnostic tests related to the treatment of morbid obesity. (Previously, benefits were notavailable for these services.)

• Inpatient and outpatient hospital care related to the treatment of children up to age 22 with severedental caries.

• Home hospice pre-enrollment visits when provided by a physician employed by the hospice agency.(Previously, benefits were not available for these services.)

• Ambulance transportation paid in full after a $50 per day copayment.• Medically necessary emergency care provided at the scene when ambulance transport is not required.

For additional information on both options, visit the FEP website at fepblue.org.

Federal Employee Program (FEP) highlights


We are here to help youIn each issue we profile employees of Provider NetworkManagement, the Provider Service Unit (PSU), or theProvider Access and Servicing Strategy (PASS) group,briefly describing what they do for you, the provider.

This issue features three of our Contract Representatives:Michelle Quintero, Jill Billingsley, and Joann Ireland.Network Services assigns contractors by contract typeand region. We have ancillary, hospital, and governmentcontractors in addition to each regional contractor.

The contractors coordinate contracts and contract mat-ters. They are supported by lead provider representativeswho coordinate contracts with standard pricing andassist with provider site visits, orientations, etc. Call thegeneral department phone number at (505) 837-8800or 800-567-8540, or go to bcbsnm.com/contact to con-tact a specific contractor or representative.

Michelle Quintero has been in Network Services for the10 years that she hasworked for BCBSNM.Michelle is the CentralRegion contractor, serv-ing Bernalillo andSandoval counties. Shesays that in her depart-ment, “We have differentjobs, but we all strive forthe success of the depart-ment and the providercommunity we serve.What I like best about

our providers is their passion for providing quality careto our members.”

Michelle recommended that providers checkbcbsnm.com first for forms and information. “There is somuch information available such as the Blues ProviderReference Manual, pharmacy information, MedicalPolicies, and downloadable forms. This, along with linksto Availity® and other programs, will help answer yourquestions. If you don’t find what you’re looking for, weare always happy to help.”

Jill Billingsley is the Southwest Region contractor. Jillhas been with BCBSNM for almost eight years. Sheenjoys working for BCBSNM because “it’s an incrediblecompany. I’m so appreciative of the opportunities I’vebeen given. I love working in Network Services because

there is truly a sense of family. Everyone works togetherso well and really supports each other.”

“Working withproviders is alwaysinteresting. It can bedifficult at times, butthat challenge makesit all worthwhile.Once I achieve a res-olution to their issuesor complete a negoti-ation, I really get asense of accomplish-ment. Keeping it awin-win situation forboth the provider and BCBSNM is my main goal.”

Joann Ireland, the Northwest Region contractor, hasworked for BCBSNM for 12 years. Before coming toNetwork Services four years ago, she worked in theProvider Service Unit. She brought her experience and

expertise fromBlue Shield ofPennsylvaniawhere she workedas a customerservice represen-tative for sevenyears prior tocoming to NewMexico.

“Even though we are part of a larger corporation, HealthCare Service Corporation (HCSC), and benefit frombeing a part of a larger, economically sound entity,”Joann says, “we have a smaller workforce in NewMexico. Using the resources available to us throughHCSC, we are able to improve how we work with allour customers, internal and external, while retaining afamily atmosphere.”

“It is important for our providers to know thatBCBSNM is committed to them and the community,”she continued. “Our mission is to promote the healthand wellness of our members and communities throughaccessible, cost-effective, quality health care. We cannotdo this without our network of providers.”

www.bcbsnm.com/provider BLUE Review Issue 6 - 2008 11

New wellness resources for your officeBCBSNM encourages our members to take an active role in managing their health. Our library of online tools andworkplace resources are available to help educate members on healthy lifestyle choices and setting goals to makeimprovements.

Recent additions to boost interest in wellness include posters and pads of information about weight control and smok-ing cessation. Designed to be displayed in your office, the posters offer quick, memorable tips, and the pads includetake-away pointers. Both items are available in English and Spanish.

Your Network Management Representative has a supply of these new wellness resources and may be stopping by toleave some with you. You may also call 800-567-8540 to request copies for your office. Thank you for your participa-tion in this initiative on behalf of your patients and our members.

Electronic funds transfer holiday scheduleProviders may receive electronic funds transfer (EFT), transmit electronic media claims (EMC), and retrieve paymentreports at almost any time during the year. However, Health Care Service Corporation (HCSC) and legal bankingholidays can delay EFT and claims processing. Following is the schedule for EFT, system, and payment report avail-ability for the remaining 2008 holidays through January 2009.

HCSC will be closed on Holiday Observed days. Claims received during the holidays will be processed the followingbusiness day. Payment reports, such as electronic admittance advice (ERA) and electronic payment summary (EPS),for claims processed on a business day following the holiday will be available for retrieval the next business day.

Regular hours:rEDI-link Blue System: Available 24/7.

Note: Customers will receive EMC real-time reports on the day of transmission. For Availity’s holiday schedule, pleasevisit availity.com or call 800-AVAILITY (282-4548).

Holiday HCSC holiday Legal banking holidayChristmas Eve Dec. 24, 2008 Not observedChristmas Day Dec. 25, 2008 Dec. 25, 2008New Year's Day Jan. 1, 2009 Jan. 1, 2009Martin Luther King, Jr. Day Jan. 19, 2009 Jan. 19, 2009

EFT payment schedule:Claims processed File sent to bank EFT payment availableDec. 23, 2008 Dec. 26, 2008 Dec. 30, 2008Dec. 24, 2008 ClosedDec. 25, 2008 ClosedDec. 31, 2008 Jan. 2, 2009 Jan. 6, 2009Jan. 1, 2009 ClosedJan. 19, 2009 Closed

Electronic data interchange (EDI) system and report availability schedule:Claims Received Holiday rEDI-link Processed PaymentDate Observed Blue Date ReportsDec. 1, 2008 Business day Regular hours Dec. 1, 2008 Dec. 2, 2008Dec. 23, 2008 Business day Regular hours Dec. 23, 2008 Dec. 24, 2008Dec. 24, 2008 Christmas Eve Regular hours ClosedDec. 25, 2008 Christmas Day Regular hours ClosedDec. 26, 2008 Business day Regular hours Dec. 26, 2008 Dec. 29, 2008Jan. 1, 2009 New Year's Day Regular hours ClosedJan. 2, 2009 Business day Regular hours Jan. 2, 2009 Jan. 3, 2009Jan. 19, 2009 MLK, Jr. Day Regular hours ClosedJan. 20, 2009 Business day Regular hours Jan. 20, 2009 Jan. 21, 2009

INSIDE1Blue Reviewgoing paperless in 20092BCBSNM welcomes Medicaid program staff3EPSDTprogram for BludSalud members4Medical Policy updates

Drug List updates5OFFICE Staff:

Expediting paper claims processingFind the forms you need at bcbsnm.com

6OFFICE Staff, continued:Claims inquiries? Call the PSUNetwork Management contacts, related service areas

7Blue Medicare PPO Corner:Don’t forget your CLIA number when billing for lab workBlue Medicare PPO provider portalNot yet contracted for Blue Medicare PPO?

8Provider network additions2009 Blues Provider Reference ManualRequesting appeals on a member’s behalf

9Triessent is new Specialty Pharmacy vendorFederal Employee Program highlights

10We are here to help you11New wellness resources for your office

Electronic funds transfer holiday schedule

P.O. Box 27630Albuquerque, NM 87125-7630

A Division of Health Care Service Corporation, a Mutual Legal ReserveCompany, an Independent Licensee of the Blue Cross and Blue Shield Association

Have an idea?

Blue Reviewis your newsletter, provided toserve you as valued members of our providercommunity.Your views are important to us.If you have ideas for articles or suggestionson how we can improve this newsletter,please e-mail us at [email protected] visit the provider area on our website andclick on Contact Us.

PRSRT STDU.S. POSTAGE

PAIDPERMIT NO. 581

CHICAGO, IL

Blue Reviewreader survey

inside

www.bcbsnm.com/providerBLUE ReviewIssue 6 - 2008

The Issue:�Diabetic retinopathy remains the leading cause of

blindness in adults. People with diabetes are 255 timesmore likely to become blind.

�Diabetic eye disease is preventable. Up to 90 percentof diabetes-related blindness could be prevented byappropriate screening and treatment.1

�Two physician-driven interventions can substantiallyreduce the risk or progression of retinopathy: treatinghigh blood pressure to goal (<130/80) and reducingA1C to goal (<7.0%).

�Standard prophylactic aspirin therapy that is nowrecommended for most people with diabetes does notincrease the risk of retinal hemorrhage.

The Current Clinical Recommendation:The Neww Mexicoo Healthh Caree Takess Onn Diabetess Practicee Guideline 2008 recommends that all peoplewith diabetes have a dilated retinal examination by an ophthalmologist or qualified optometristannually.

New Mexico's Numbers:Blue Cross and Blue Shield of New Mexico/HMO New Mexico, Molina Healthcare of NewMexico, Lovelace Health Plan, and Presbyterian Health Plan agreed to pool their data to get asnapshot of how New Mexico is doing. Together, these plans provide health care for nearly 791,000New Mexicans.

Percentagee off Peoplee withh Diabetess Whoo Receivedd aa Dilatedd Retinall Examm inn 20011 andd 20072-5

Retinal Exams a Must

Did you know?

“Thee dilatedd speciall eyee examm forpeoplee withh diabetess iss aa criticall partoff takingg caree off yourr diiabetes.Everyonee withh diabetess shouldd havethiss speciall eyee examm everyy year.”

— Alfredo Vigil, MDSecretary, New MexicoDepartment of Health

A quarterly publication for clinicians caring for people with diabetes - VA quarterly publication for clinicians caring for people with diabetes - Vol 9 No. 16, 2008ol 9 No. 16, 2008

Diabetes ResourcesPractical Information for New MexicoHealth Care Professionals

1 Diabetes: A Serious Public Health Problem At a Glance 2003. Department of Health and Human Services, Centers for Disease Controland Prevention. http://www.cdc.gov/diabetes/pubs/glance.htm.

2 Data reported using nationally validated HEDIS® methodology. Rates derived from meeting continuous enrollment requirements.HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

3 HEDIS 2007 data for CY 2006 provided by BCBSNM, Molina Healthcare of New Mexico, Lovelace Sandia Health Systems andPresbyterian Health Plan.

4 Indian Health Service data were provided for the Albuquerque Area and based on Government Performance and Results Act (GPRA)indicators from 2006 fiscal year.

5 National average data provided by Centers for Medicare & Medicaid Services (CMS) for CY 2006, Quality Compass for CY 2006 andIndian Health Services for FY 2005.

20012007National Average

33.8%33.8%

Commercial Medicaid Medicare

100%

0%

45.8%45.8% 54.7%54.7% 51.3%51.3% 57.0%57.0% 51.4%51.4% 59.7%59.7% 69.1%69.1% 62.3%62.3%47.4%47.4% 49.0%49.0%

Indian Health Service(Albuquerque Area)

In each issue of DiabetesResources we provideinformation aboutmanagement of diabetes forhealth care providers.

Our publications support theNew Mexico Diabetes PracticeGuideline by providingspecific tools and resourcesfor providers to help reducethe complications associatedwith diabetes. The ABCs ofdiabetes is a reminder to testpatients 2 to 4 times per yearfor A1C, check Blood pressureat each visit and testCholesterol levels annually.The Diabetes Resourcesaddress other clinicalrecommendations. Dilatedeye exam, foot exam andkidney disease screening aswell as nutrition and physicalactivities are additionalcovered topics.

In support of the New MexicoDiabetes Practice Guideline2008, please see the reverseside of Diabetes Resourcesfor tools and resources thatcan help in your efforts toprovide education andsupport to your patients withdiabetes.

Check www.nmtod.com fororganizations that have graciouslyprovided funding for DiabetesResources.

New Mexico Health Care Takes OnDiabetes, a New Mexico non-profitcorporation, is a broad coalition ofNew Mexico's diabetes care profes-sionals, New Mexico Health Plans,the New Mexico Department ofHealth, and the New Mexico MedicalReview Association, with technicaland administrative support from theAmerican Diabetes Association.

P.O. Box 3548Albuquerque, NM 87190

(866) 796-9121(505) 796-9121

1. We mail six issues of Blue Review per year. How many issues per year do you at least scan to see if there is content of interest to you?

❑ 6 ❑ 5 ❑ 4 ❑ 3 ❑ 2 ❑ 1 ❑ 0

2. How much of each issue of Blue Review do you read?

❑ All ❑ Most ❑ Some ❑ Very Little ❑ None

3. Please rate the design and layout of Blue Review –how easy it is to get the information you need?

❑ Excellent ❑ Very Good ❑ Average ❑ Fair ❑ Poor

If “Fair” or “Poor,” how could it be improved?

4. Please rate Blue Review overall.

❑ Excellent ❑ Very Good ❑ Average ❑ Fair ❑ Poor

5. Do you receive provider-oriented newsletters fromother health plans?

❑ Yes ❑ No

If “Yes,” how does Blue Review compare to them?

❑ Better ❑ About the same ❑ Worse

Please explain:

6. The following topics have appeared in Blue Review.Please rate how useful and interesting the informationprovided in each topic is to you. If you do not recallseeing the topic, please leave the item blank.

Topic Interesting Useful

Clinical practice guidelines for Y N Y Ndiabetes, asthma, hypertension, and hyperlipidemia

Annual preventive health guide- Y N Y Nlines for children and adults

Practical resource publications Y N Y N from New Mexico Health Care Takes on Diabetes

Information on Disease Manage- Y N Y Nment Programs (Blue Care Connection®)

Topic Interesting Useful

Health status of BCBSNM members Y N Y Nas reported by HEDIS® rates

Office Staff section (filing and coding Y N Y Nclaims, Network Services contact information)

Blue Medicare PPOSM Y N Y N

Prior authorization Y N Y N

Our website, bcbsnm.com Y N Y N

Any comments on the above topics?

7. What topics would be most useful for you in futureissues of Blue Review?

8. Which best describes your practice or facility?❑ Primary care ❑ Radiology center❑ OB/GYN ❑ Laboratory❑ Specialist: ❑ Pharmacy❑ Hospital ❑ Other:❑ Outpatient surgery center

9. Who completed this survey?❑ Physician ❑ Office manager❑ Nurse ❑ Other: ❑ Physician assistant/

Nurse practitioner

If you have additional comments, please add them to your fax cover sheet.

2008 Blue Review reader survey Help us make Blue Review more valuable to you. Please complete this survey and fax it to: Blue Review Editor,505-816-5556. You may submit your survey anonymously, but if you provide your name and phone number, we’llenter you in a drawing for a $50 American Express

®

gift card! You may also complete the survey atbcbsnm.com: select Providers, then look for the electronic version of the survey under News and Updates. Thank you for your time and interest.

Name: Phone Number:

Deadline: Friday, December 19, 2008

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