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OO X F O R D P R O V I D E R | P R O G R A M A N D P O L I C Y U P D A T E

• Oxford Policies • General Information

• Oxford Programs • eBusiness

• Oxford Medicare AdvantageSM Program

• Pharmacy Program • Radiology Program

2ndQUARTERY o u r Q u a r t e r l y U p d a t e

t o t h e O x f o r d P r o v i d e r

R e f e r e n c e M a n u a l

In our ongoing effortsto provide the mostprompt, correctinformation, we askthat you be preparedwith your Oxfordprovider ID numberwhen calling ourProvider ServicesDepartment. We will be able to access your account morequickly and provideyou with a moresatisfactory experience.

Oxford Policies

Recently Approved Policies ..................................3

Revised Policies ........................................................4

Clarification of the Provider Appeals Process ......7Clarification of the Provider AdministrativeDisciplinary Appeals Process..................................7Laboratory Network Reminder..............................8

General Information

Summary of Revisions for the 2004 ClinicalPractice Recommendations for Diabetes ..............8

Credentialing Physician Extenders ........................8

Address Reminder for New Jersey Providers........9

New Fax Number for Clinical Appeals Department ..............................................9

Updating Your Practice Information ....................9

New York State Department of Health(NYSDOH) Pesticide Poisoning Registry..............9

Leapfrog Group and Patient Safety ....................10

Oxford Programs

Beta-Blocker Maintenance Therapy for Myocardial Infarction Patients ..............................11

eBusiness Updates

Oxford Medicare AdvantageSM PatientInformation Now Available Online ....................12

Updates to the Check Benefits Function on www.oxfordhealth.com ......................................12Submitting Your Claims with 2004 ICD-9-CM, CPT and HCPCS Codes ....................12Guidelines for Checking the Status of Your Claims ......................................................12

Oxford Medicare Advantage S M

Program Updates

Oxford Medicare Advantage BenefitEnhancements and Service Area Expansion ......13

Pharmacy Program Updates

2004 Drug Formulary Update ..............................19

Quantity Limit Updates ........................................20

Important Prescription Drug Information Regarding Ultram® ..........................21

Radiology Program Updates

Chest X-ray Update ................................................21

Nuclear Cardiology Certification Deadline Extension ................................................21

Nuclear Cardiology Accreditation Deadline Extension ................................................22

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OO X F O R D P R O V I D E R | P R O G R A M A N D P O L I C Y U P D A T E

2N D Q U A RT E R 2 0 0 4

Y o u r Q u a r t e r l y U p d a t e

t o t h e O x f o r d P r o v i d e r R e f e r e n c e M a n u a l

President and CEO Charles G. Berg

Chief Medical Officer and EVP Alan M. Muney,MD, MHA

Vice President, Marketing Chuck Green

Director, Provider Marketing Rebecca Madsen

Manager, Provider Marketing Maria Sommer

Copy Editor Starlet Coleman

Editor Val Martin

The Provider Program and Policy Updateis published exclusively for Oxford HealthPlans by: Onward Publishing, Inc.10 Lewis Road, Northport, NY 11768

Publisher Jeffrey Barasch

Creative Director Melissa Barasch

Editorial Director Wendy Murphy

Art Director Bruce McGowin

Designer Lisanne Schnell

Project Director Tamyra Zieran

Project Manager Bret Barasch

Business Manager Liz Lynch

Oxford Health Plans, Inc. and Onward Publishing,Inc. are not responsible for typographical errors.

© 2004 Onward Publishing, Inc. All rights reserved.

2 www.oxfordhealth.com

The Oxford Provider Program and Policy Update(PPU), a quarterly update to your ProviderReference Manual, is designed to provide regularupdates on Oxford policies and programs.

Did you know that the PPU is available on our website? Simply log in to your personalized accountpage at www.oxfordhealth.com and click onPolicies and Guidelines under the Business Center.Once in the Policies and Guidelines section, selectProgram and Policy Updates to read the onlineversion. As always, we encourage you to e-mail yourcomments to us at [email protected],or write to: Oxford Health Plans, c/o Val Martin,55 Corporate Drive, Trumbull, CT 06611.

Clinical Practice

Guidelines Availability

As of January 1, 2003, the Clinical PracticeGuidelines are no longer printed in the Program and Policy Update. If your office requires copies of the Clinical Practice Guidelines, simply log in toyour personalized account at www.oxfordhealth.com.Click on Policies and Guidelines under the BusinessCenter section and download a printable PDF.

Recently updated guidelines available online include:

• Cholesterol Management

• Congestive Heart Failure

• Diabetes

Why Go Online?

We know how important your time can be to you.And we know you want convenience and options, so we designed our web site to give you just that. By logging in to www.oxfordhealth.com, you canconduct many transactions, when you want, where you want, seven days a week, 24 hours a day(excluding periodic downtimes for maintenance).

Simply sign up for a user name and password, andlog in to Your Account, which will allow you to

access the following self-service transactions that can help streamline your administrative processes:

• Check patient eligibility, benefits, claims, referrals, and precertification status

• Submit claims, referrals and precertification requests

• Submit notification of admissions (facilities only)

• View Oxford’s Preferred Drug List

• Search for primary care physicians, specialists,hospitals, health facilities, and complementary and alternative medicine providers

• View radiology, physical therapy and laboratoryprogram information

• Change your address, e-mail address, password, and user name

• Request self-help materials and rosters, download forms

• E-mail our Provider Services Department

If you have questions or need assistance with web-related inquiries, please call Oxford’sTeam.com at 1-800-811-0881.

Contact Information

at a Glance

Provider Services Department............1-800-666-1353

Oxford Express® ......................................1-800-666-1353

Oxford’s Fraud Hotline ......................1-800-915-1909

Pharmacy Customer Service ..............1-800-905-0201

Provider eSolutions Support Team....1-800-599-4334

www.oxfordhealth.com 3

Oxford Policies

Issue Explanation

Medical Policy Medical policies can be requested by writing to:Policy Requests and InformationOxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

M & R and MCAP criteria Please remember that these are proprietary services to which Oxfordsubscribes. Information on specific criteria can be requested by writing to:

Policy Requests and InformationOxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

Payment Policies Generally, our payment policies are proprietary and cannot be distributed. If you have questions regarding claims payment, please call our ProviderServices Department at 1-800-666-1353.

Requests for Fees To request information regarding fees, please call our Provider ServicesDepartment at 1-800-666-1353.

New Medical Technology Requests for review of new medical technology can be made by writing to:New Medical TechnologyOxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

Recently Approved PoliciesThe appearance of an item or procedure on this list indicates only that Oxford has recently adopted a policy; it does not imply that Oxford providescoverage for the item or procedure listed.

Clinical Policies

• Unicondylar Interpositional Spacer (UniSpacer®) —Non-coverage policy

• Endovenous Laser Ablation for the Treatment of Varicose Veins — Non-coverage policy

• Biologics in the Treatment of Psoriasis for Oxford Medicare AdvantageSM Plans — Criteria for coverage outlined

• External Infusion Pumps (excluding InsulinPumps) for Commercial Plans — Criteria for coverage outlined

• Intra-operative Electro-Diagnostic Testing: Intra-operative Monitoring, Somatosensory EvokedPotentials, Nerve Conduction Studies (NCS), Late Responses, and Needle Electromyography(EMG) — Criteria for coverage outlined

• Fluency Enhancing Devices for Stuttering — Non-coverage policy

Administrative Policy

• Filing Deadlines for Claims Submissions — Outlinesappropriate time frame for claims submissions andrequests for additional documentation includingsubsequent denial for not meeting the time frames


The following policies are designed to inform providers regarding certain payment and processes:

Name of Policy Summary

Telephone Calls, E-mails and Other • Oxford does not cover telephone, e-mail or other typesNon-personal Communications between of non-personal communications since they are not a a Provider and Member covered benefit under the Member’s contract or

Certificate of Coverage

• The following communication vehicles apply to this policy: telephone, electronic mail, video conferencing, or other non face-to-face communications between aphysician and a patient for any purpose including, but not limited to, consultation, medical management or forcoordinating medical management with other healthcareprofessionals (e.g., nurses, therapists, social workers,nutritionists, physicians, pharmacists); this also applies to communications through various media by providersregarding a covered Member

Cost Shares for Commercial Plans • There is one copayment allowed per provider, per date of service, per like service (e.g., speech, occupational andphysical therapies are considered like services) from aMember; if Oxford receives bills from multiple providerswithin the same group for services performed during thesame visit, then a copayment will be applied for eachprovider visit

• If the full amount of a copayment is not applied in full for a service, the remainder of the copayment can betaken from another like service; if an Evaluation andManagement (E&M) CPT code is not billed, theMember’s copayment obligation will be taken fromeligible services provided during the service

Revised Policies The following policies were revised during their scheduled review:

Clinical Policy Updates

Name of Policy Update/Changes

Naturopathic Services Updated to reflect additional coverage rider

Hearing Aids for Commercial Plans Updated to reflect additional coverage rider

Prescription Drug Coverage for Oxford Updated to address benefit and cost share changes Medicare AdvantageSM Plans (2004) made in connection with changes to Medicare law

Minimally Invasive Treatments of Updated criteria for coverage Gastroesophageal Reflux Disease (GERD)

Treatment of Lysosomal Storage Disorders Updated conditions and criteria for coverage for Commercial Plans


Clinical Policy Updates (continued)


Surgical Treatment of Gynecomastia Updated criteria for coverage

Transurethral Microwave Thermotherapy (TUMT), Updated criteria for coverage Transurethral Needle Ablation (TUNA) and Laser Prostate Surgery for Benign Prostatic Hyperplasia (BPH)

Depo-Provera® (medroxyprogesterone) Updated criteria for coverage

Cialis® (tadalafil), Levitra® (vardenafil HCl) Updated criteria for coverage and Viagra® (sildenafil citrate)

Abortions (Therapeutic and Elective) for Updated criteria for coverage Commercial Plans

Abortions for Oxford Medicare AdvantageSM Plans Updated criteria for coverage

Nutritional Therapy — Intradialytic Peritoneal Non-coverage policyAmino Acids

Biologics in the Treatment of Psoriasis Updated criteria for coverage

Treatment of Obstructive Sleep Apnea for Updated criteria for coverageCommercial Plans

Treatment of Obstructive Sleep Apnea for Updated criteria for coverage Oxford Medicare Advantage Plans

Wheelchairs, Power Operated Vehicles and iBOT Mobility not coveredSpecialized Strollers, iBOT Mobility System®

Outpatient Pain Management Interventions Updated criteria for coverage

Hyaluronate Polymers (Hyalgan/Synvisc/Supartz) Updated criteria for coverage

Human Skin Equivalents and Skin Substitutes Updated criteria for coverage

Surgical Correction of Optical Errors Unresponsive Updated criteria for coverageto Spectacle or Contact Lens Correction (Refractive Eye Surgery)

Ophthalmoscopy: Extended Updated criteria for coverage

Gonioscopy Updated criteria for coverage

Computerized Axial Tomography (CAT) for Updated criteria for coverageOxford Medicare Advantage Plans

Magnetic Resonance Angiography (MRA) for • Updated criteria for coverageOxford Medicare Advantage Plans • Deleted CPT code 70541

Bone Marrow/Stem Cell Transplant for Restricted payment for CPT codes 38205 and 38207Commercial Plans to specialists in hematology/oncology only




Bone Marrow/Stem Cell Transplant for Restricted payment for CPT codes 38205 and 38207Oxford Medicare AdvantageSM Plans to specialists in hematology/oncology only

Transthoracic Echocardiography • Delineated between parent CPT codes and add-onCPT codes; if the parent CPT code is denied, the add-on CPT code will also be denied

• Added CPT codes 93303 and 93304

• Deleted CPT code 93350

Administrative Policy Updates


Member Administrative Grievance and Appeal Removed in-person grievance hearing option for (Non Utilization Management) Process and Connecticut and New Jersey plansTime Frames for All Commercial Plans

Utilization Management Appeal Process and Removed Grievance Review Board (GRB) hearingsTime Frames for New York Plans

Utilization Management Appeal Process and Removed GRB hearingsTime Frames for Delaware Plans

Utilization Management Appeal Process and Removed GRB hearingsTime Frames for New Jersey Plans

Referrals • Oxford Health Plans will not pay for claims of servicesarising out of prohibited physician referrals

• Providers are not allowed to balance bill Members for services provided under a prohibited referral that are not paid by Oxford

• Prohibited referrals are defined by applicable law and include, but are not limited to, instances where a provider or the provider’s relative have a financialinterest in the referral

Please note: When making a referral to a specialist, make surethat the specialist is participating in the network available to the Member. In addition, referrals should only be provided to an Oxford participating provider, when one is available. If aparticipating provider is not available, please call our ProviderServices Department at 1-800-666-1353 for further information.

Cost Shares for Oxford Medicare Advantage Updated to address benefit and cost share changes Plans (2004) made in connection with changes to Medicare law

In-network Deductible for Oxford Medicare Updated to address benefit and cost share changes Advantage Balance Individual Plans (2004) made in connection with changes to Medicare law




Emergency Room Outpatient Services for If an Oxford Medicare Advantage Member expires Oxford Medicare AdvantageSM Plans while in the emergency room, the emergency room

copayment is waived

Prompt Pay/Interest Payment for Oxford Updated time frame for payment of New Jersey Medicare Advantage Plans participating Oxford Medicare Advantage providers

to 30 days from receipt

Out-of-network Option (POS) for Oxford Updated to address benefit and cost share changes Medicare Advantage Plus Plans made in connection with changes to Medicare law

Payment Policy Updates


Distinct Procedural Service (Modifier –59) Oncologists, gynecological oncologists, hematologist/oncologists, pediatric hematologist/oncologist, cancertreatment centers, and hematology oncology groups must use Modifier –59 for CPT codes 90780, 90781 or 96530 whenbilled in conjunction with any of the following CPT codes:96410, 96412 or 96414

Modifier –25 • Removed starred procedures per the American MedicalAssociation (AMA) CPT 2004 book

• Added the following language: Established visits (99211-99215) are payable with those procedures/services that werepreviously starred, in 2003, when billed with Modifier –25

Please note: If a provider bills two or more procedures/services, one of which is a procedure/service that was not formerly starred, the E&M service will not be paid, as it is included in the servicerepresented by the procedure/service.

Clarification of the Provider Appeals ProcessThe 2003 4th Quarter issue of the Provider Programand Policy Update contained 2003 appealsinformation in the Clarification of the ProviderAppeals Process article on pages 19-23. You shouldrefer to the 2004 Provider Reference Manual, Section9 titled Payment Appeals and Grievances for themost current 2004 appeals process and information.

Clarification of the Provider AdministrativeDisciplinary Appeals ProcessSection 7 of the 2004 Provider Reference Manual,under Provider Disciplinary Policies andProcedures, describes the disciplinary process

for Oxford participating providers who breachOxford’s administrative policies and procedures.Information about the procedure for filing anadministrative appeal of decisions made by theAdministrative Management Committee (AMC) was inadvertently omitted from this section. Thisinformation is provided below.

Please note: The following procedure does not apply tothose instances when an appeal by hearing is allowed (e.g.termination as a result of repeated billing abuse, etc.).

Oxford’s policy states that the committee thatinitiates the disciplinary action also reviews theadministrative appeal. The provider is not entitledto attend this meeting.


The applicable policies and procedures for suchappeals are as follows:

• The provider must request an appeal in writingwithin 10 days of Oxford’s mailing the notice ofadministrative disciplinary action; failure to submitan appeal within 10 days will be deemed a waiverof any appeal rights; the provider is encouraged tosubmit any additional information about his/hercase along with the appeal

• Upon receipt of the appeal, the committeegathers all documentation (previous and current)about the case in preparation for the nextcommittee meeting

• The committee reviews the information at themeeting and makes a determination whether the administrative disciplinary action will berescinded, amended or upheld

• Discussions and outcomes related to the review aredocumented in the committee meeting minutes

• The provider is notified in writing of thecommittee’s decision

If you have further questions about Oxford’sdisciplinary policies and procedures, please call ourProvider Services Department at 1-800-666-1353.

Laboratory Network ReminderOxford’s outpatient laboratory network is managedby Quest Diagnostics,® Inc. and is comprised of a wideselection of specialty, hospital-based and full-servicelaboratories. As an Oxford participating provider,your contract requires you to refer Members toparticipating providers and facilities. When Membersobtain services from a non-participating laboratory,coverage may be denied or covered subject todeductible and coinsurance, which can be very costly for our Members. You can help control theseout-of-pockets costs by ordering laboratory work tobe performed at an Oxford participating laboratory.

For a complete listing of participating laboratories,log on to www.oxfordhealth.com and visit theBusiness Center on your account page. Next, select Lab, Pharmacy and Radiology Information.You may also request a listing by calling ourProvider Services Department at 1-800-666-1353.

General Information

Summary of Revisions for the 2004 ClinicalPractice Recommendations for Diabetes

Below is a summary of the revisions for the 2004Clinical Practice Recommendations for Diabetes.For a complete version of the recommendations,log on to the American Diabetes Association website at www.diabetes.org.

Updated recommendations include:

• Glycemic control — More stringent goals (i.e., a normal A1c <6%) can be considered in individual patients

• BP control — Updated recommendations basedon recent studies

• Lipid management — In people over the age of 40 with diabetes and a total cholesterol >135mg/dl, statin therapy may be appropriate toachieve an LDL reduction of approximately 30 percent regardless of baseline LDL levels

• Anti-platelet agents — Clarified recommendationregarding aspirin use as primary prevention intype 1 and type 2 diabetes

• Retinopathy — Consideration of less frequentexams in low-risk patients on the advice of an eye care professional

• Foot care — Screening for peripheral arterialdisease (PAD)

• Care of older adults — Incorporated language fromrecent guidelines by American Geriatric Society

• Smoking and diabetes — Extensively revised

Credentialing Physician ExtendersRecently, we opened our participating providernetwork to additional physician extender specialtiesincluding nurse practitioners, behavioral healthclinical nurse specialists, advanced practice nurses,and physician assistants. We are offering physicianextenders working in the same practice as aphysician (PCP or specialist), the opportunity tobecome a participating provider in our robustnetwork of healthcare providers.


To request an application for participation or for more information, please call our Provider Services Department at 1-800-666-1353.

Address Reminder for New Jersey ProvidersWe would like to remind you that hand-deliveredclaims and claims delivered by certified orregistered mail must be sent to:

Oxford Health PlansAttn: Intake Imaging7120 Main StreetTrumbull, CT 06611

New Fax Number for Clinical Appeals DepartmentThe fax number for the Clinical AppealsDepartment has been changed from 203-459-3229to 203-459-5423. Please refer to this new numberinstead of the number listed on page 175 of the2004 Provider Reference Manual.

Updating Your Practice InformationDid you know that Members usually contactCustomer Service or use Oxford’s web site whenthey’re looking for a new primary care physician or a specialist in their area? In order for Membersto obtain an accurate listing of providers, it isimportant for you to update your practiceinformation with us if it changes. Practiceinformation includes phone numbers, addresses,specialty, network affiliation, and board status. It is also essential to notify us in a timely manner ofthe following situations: retirement, relocation,closure of a secondary office, or change of practice.

When submitting updated information, pleaseinclude the following:

• A completed Oxford Address Change Form or a letter on your office letterhead

• A signed W-9 Form (needed for tax ID changes only)

When submitting changes on your office letterhead,you must include the following:

• A description of the change (new or additional address, telephone number or tax ID number change)

• Your old and new billing address (if applicable)

• Your old and new practice address (if applicable)

• Your old and new phone number (if applicable)

• Your Federal Tax ID Number and your providerID number

• The effective date of any change

All changes should be mailed/faxed to thefollowing address/telephone number:

Oxford Health PlansAttn:Vendor Audit7120 Main Street Trumbull, CT 06611

Fax: 203-601-6671

Did you know that you can also change yourpractice address, e-mail address and referral faxnumber electronically by logging on to YourAccount on www.oxfordhealth.com? Once logged in you can also download W-9 and Address ChangeForms from the Business Center. Certain updates can also be made by calling our Provider ServicesDepartment at 1-800-666-1353. We encourage you to provide us with your updated practiceinformation within 30 days of the change.

New York State Department of Health(NYSDOH) Pesticide Poisoning RegistryPesticide poisonings were added to the list ofreportable medical conditions in New York State in late 1990 as part of an effort to reduce the risk of pesticide poisoning in New York. Under theseregulations, physicians and health facilities arerequired to report suspected or confirmed cases of pesticide poisoning. Clinical laboratories are alsorequired to report depressed blood cholinesterase

OOXF O R D | I M PO RTA NT A D D R ES S

OOXF O R D | I M PO RTA NT A D D R ES S


levels or abnormally high levels of pesticides in human tissue samples. Physicians should call the NYSDOH Pesticide Poisoning Registry at 1-800-322-6850 within 48 hours of seeing anypatients they suspect of pesticide poisoning.

A definitive diagnosis is not needed prior to calling, and there is no paperwork for physicians to complete. The NYSDOH staff will investigate the reported case to collect information to monitorthe health effects of pesticides. They may intervenein situations where a continued risk of pesticidepoisoning exists. The work of the PesticidePoisoning Registry complements the work of theregional poison control centers. The poison controlcenters supply information on immediate treatmentand other emergency responses. Poisonings mayresult from structural applications, yard applications,manufacturing or formulation settings, farmsettings, or any other location where pesticides are used or stored. Because of their toxicity and easy availability, accidental or intentional ingestionof pesticides is also an ever-present threat.

The Pesticide Poisoning Registry strives to increaseawareness in the medical community of thepossibility of pesticide-related health effect and to develop interventions to reduce the risk ofpesticide poisoning.

Additional information on the Pesticide Poisoning Registry, industrial hygiene assistance and cholinesterase testing may be obtained by calling 1-800-322-6850.

An important public health issue in New York State this year is West Nile Virus (WNV). Somecounties may apply pesticides to control mosquitopopulations. The New York State Department ofHealth will be conducting surveillance of reportedhealth effects possibly resulting from exposure to the application of WNV-related pesticides.

Any physician who suspects or confirms that his/her patient is experiencing health effects due to exposure to WNV-related pesticides shouldreport that case to the Pesticide Poisoning Registryat 1-800-322-6850.

Leapfrog Group and Patient Safety A 1999 study by the Institute of Medicine (IOM)found that up to 98,000 Americans die every year

from preventable medical errors experiencedduring hospitalizations. Medical errors wereidentified as the eighth leading cause of death in the United States.

In response to this serious problem, The LeapfrogGroup — a coalition of more than 150 public and private organizations that provide healthcarebenefits — was created to help save lives and reduce preventable medical mistakes. It is avoluntary program aimed at mobilizing majorhealthcare purchasers to alert the healthcareindustry that big leaps in patient safety andcustomer value will be recognized and rewarded.

Hospital Safety Measures

The Leapfrog Group recently identified threehospital safety measures that are a focus forprovider performance comparison:

Computer Physician Order Entry (CPOE): TheCPOE system allows physicians to enter medicationorders through a computer linked to prescribingerror prevention software. CPOE has been shown toreduce prescribing errors in hospitals by 50 percent.

Evidenced-based Hospital Referral: Researchindicates that a hospital’s risk of patient deathscould be reduced by more than 30 percent byreferring patients needing complex medicalprocedure to hospitals offering the best clinicaloutcomes based on valid criteria.

Intensive Care Unit (ICU) Physician Staffing:Staffing ICUs with physicians who have credentialsin critical care medicine has been shown to reducerisk of patient deaths in the ICU by 10 percent.

The Leapfrog Group collects data on thesemeasures through a voluntary survey of hospitals in 22 regions throughout the United States. We encourage all of our network hospitals toparticipate in the Leapfrog survey. A copy of the survey may be obtained by logging on towww.leapfroggroup.org.

In addition, Oxford supports patient safetyinitiatives through:

• Promoting evidenced-based hospital referralsthrough Subimo™ Healthcare Advisor onwww.oxfordhealth.com to provide Members withcustomized information on hospitals, treatment


options, complication rates, and questions to asktheir doctors; Members enter their criteria (basedon specific medical conditions and procedures),and a list of up to 20 hospitals is displayed;Members can then select up to three hospitals to compare ratings based on the selected criteria

• Offering Oxford’s formulary through ePocratesRx™, a clinical drug reference tool for PersonalDigital Assistants (PDAs), that includesinformation about dosing, contraindications, drug interactions, and adverse reactions

• Offering educational materials on patient safetyissues through articles on www.oxfordhealth.comand in the Member newsletter, Healthy MindHealthy Body®

• Enhanced Discharge Planning Program, DrugUtilization Review

• Monitoring of continuity and coordination ofcare, office safety practices, adverse events, andcompliance with clinical practice guidelines

If you would like additional information on patient safety issues, we encourage you to visit the following sites:

Agency for Healthcare Research and Quality(AHRQ): www.ahrq.gov

Quality Interagency Task Force (QuIC):www.quic.gov

National Council on Patient Information andEducation (NCPIE): www.talkaboutrx.org

The Leapfrog Group: www.leapfroggroup.org

Oxford Programs

Beta-blocker Maintenance Therapy for Myocardial Infarction Patients

Multiple studies show that lifelong adherence to beta-blocker therapy is critical for the preventionof successive coronary events after an acutemyocardial infarction (MI). Large-scale clinicaltrials have proven that beta-blockers, when takenindefinitely after an acute MI, reduce subsequentcoronary events, cardiovascular mortality and

all-cause mortality by 20 to 40 percent, regardless of a patient’s age, gender or infarct size.

ACC and AHA Guidelines

The overwhelming data supporting the benefits of beta-blockers compelled the revision of thecardiac treatment guidelines, developed jointly by the American College of Cardiology (ACC) and the American Heart Association (AHA).

Current guidelines advise that beta-blocker therapy begins early after an acute MI and continues indefinitely in patients without absolutecontraindication to beta-blockers. Absolutecontraindications include cardiogenic shock,hypotension, bradycardia with a heart rate less than50, second-or third-degree atrioventricular block,active asthma, severe COPD with bronchospasm, orsevere peripheral vascular disease. The guidelinesrecommend beta-blocker use in patients with relativecontraindications, including diabetes mellitus, mildasthma, COPD, or peripheral vascular disease.

A recent study of beta-blocker therapy side effectsreported no significant increase in symptoms ofdepression and a small increase in symptoms offatigue and sexual dysfunction. The authors advisethat these risks should be put in the context of thedocumented benefits of the medications. Similarside effects were observed in patients taking aplacebo. They may resolve with continued therapyor by switching to cardioselective beta-blockers.

Compliance is Critical

Nationwide, more than 90 percent of managed care patients are prescribed a beta-blocker withinseven days of discharge from an acute MI. However,studies indicate that despite strong evidencesupporting the use of beta-blockers in the post-MIperiod, less than half of MI patients are prescribedbeta-blockers in the chronic setting. In addition toprescribing a beta-blocker, it is important to assesswhether a patient is adhering to his/her therapy.Physicians should talk to eligible patients about theimportance of the continued beta-blocker treatment,its benefits and possible side effects. With carefuldosing and monitoring, the benefits of beta-blockersoutweigh the potential risks in most patients.

1 2 www.oxfordhealth.com

What Oxford Is Doing

Oxford is participating in heartBBEAT for life SM

(Beta-blocker Education and Treatment), a publiceducation program developed by the Council forAffordable Quality Healthcare (CAQH), incollaboration with AHA, ACC, the AmericanAcademy of Family Physicians, the American Collegeof Physicians, and the AHRQ-sponsored DukeUniversity Center for Education and Research on Therapeutics, to educate patients about theimportance of beta-blocker adherence after an acute MI. As part of this effort, Oxford is providingeducational materials developed by CAQH to allOxford Members who have experienced an acute MI.

To learn more about heartBBEAT for life or to viewthe patient brochure, visit www.caqh.org/heart.

eBusiness Updates

Oxford Medicare AdvantageSM PatientInformation Now Available Online

Providers and facilities now have the ability to check claims status and patient eligibility for Oxford Medicare Advantage (OMA) patients onwww.oxfordhealth.com. In the past, providers only hadthe ability to perform these online transactions forcommercial Members. This functionality was added togive our providers additional resources to electronicallyobtain information about their OMA patients.

We will be enhancing other online transactions to include the ability to submit information forOMA Members.

If you would like more information about usingwww.oxfordhealth.com or any of Oxford’s otherelectronic solutions, please call our ProviderServices Department at 1-800-666-1353.

Updates to the Check Benefits Functionon www.oxfordhealth.comThis past January, we enhanced our “Check Benefits”function on www.oxfordhealth.com, providing youwith more detailed benefit information about yourpatients. Enhancements include:

• Elimination of the Swiftview application thatreturned Summary of Benefits information

• Return of Member benefit information in anindex or glossary style format, allowing you toeasily search for a specific benefit and access a full description

If you would like more information on usingwww.oxfordhealth.com or any of Oxford’s otherelectronic solutions, please call our ProviderServices Department at 1-800-666-1353.

Submitting Your Claims with 2004 ICD-9-CM, CPT and HCPCS CodesAs of February 2004, Oxford has been prepared toprocess all claims with the new 2004 code sets. In aneffort to remain compliant with HIPAA regulations,Oxford will be replacing any previously billed codesthat are now outdated with the updated 2004 codes.Regardless of whether your claims are submittedelectronically or on paper, it is imperative that yousubmit your claims with the 2004 updated codes.Any claim with a date of service after April 1, 2004that contains an outdated 2003 code will berejected. If you have been using an outdated code,please refer to your 2004 ICD-9-CM, CPT or HCPCSbooks to identify the appropriate code to submit.

Guidelines for Checking the Status of Your ClaimsDid you know that Oxford’s “Check Claims”function on www.oxfordhealth.com can answermany of the questions you may have about yourclaims submissions? The next time you have aquestion related to any of the items listed in thefollowing section, try using the “Check Claims”function on our web site before calling our ProviderServices Department. You may be surprised at howmuch information you can get and how much timeyou can save by using our web site.

What information can I obtain using the “CheckClaims” function?

• Status of claim

• Claim number

• Date received

• Billed amount

• Paid amount

www.oxfordhealth.com 1 3

• All claim detail — Member ID, procedure codes,deductibles, dates of service, etc.

Did Oxford receive my claim?

Using the “Search for claim(s) status” option, you can perform a search by the claim status“Acknowledged” to verify that Oxford has receivedyour claim. If you submit your claims electronically,your claim should be in an “Acknowledged” statuswithin 48 to 72 hours as long as the claim was notrejected by the clearinghouse or Oxford. If yousubmit your claims on paper, your claim should be in an “Acknowledged” status seven to 10 days after submission.

Did Oxford process my claim?

Using the “Search for claim(s) status” option, youcan perform a search by the claim status “Finalized”to find out if Oxford has processed your claim. Onaverage, Oxford has been processing claims within20 to 30 days. In order to save time and reduce theadministrative work you have to do, please allow atleast 30 days to pass before checking on anacknowledged claim.

Can I get a copy of my Remittance Advice?

Using the “Search for claims(s) by Check Numberand Issue Date” option, you can obtain the sameinformation that is provided on our RemittanceAdvice, including check date, total amount billed,total amount paid/denied, etc. This information isavailable on a printer-friendly page that you canprint and use for your record keeping process.

Can I find out which claims were paid with aparticular check?

Using the “Search for Claim(s) by Check Numberand Issue Date” option, you can view all the claimsthat were paid with a particular check. In order toperform this search, you will need the check numberand issue date of the check. Once you have enteredthat information, you will receive all the claimnumbers and claim detail associated with that check.

Can you tell me what happened with my claimfrom four months ago?

Using Oxford’s “Check Claims” function, you cansearch for claims submitted in the past 12 months.

Can I look up claims for my entire group?

Oxford recently added functionality that enablesour providers to search for claims using a FederalTax ID Number (FTIN). This enhancement allowsproviders to search for claims for their entire groupusing one user name and password, eliminating the need to log in to the web site under differentprovider accounts for the group.

What if I need help setting up a user name andpassword to access Oxford’s web site or I needhelp with the “Check Claims” function?

If you would like more information on usingwww.oxfordhealth.com or any of Oxford’s otherelectronic solutions, please call our ProviderServices Department at 1-800-666-1353.

Oxford Medicare

Advantage SM (OMA)

Program Updates

Oxford Medicare Advantage BenefitEnhancements and Service Area Expansion

Effective March 1, 2004, Oxford has made benefitenhancements to the plans currently being offered inNew York, New Jersey and Connecticut. In addition,we are considering expanding our service area inNew York and New Jersey to include some of thecounties in which Oxford Medicare Advantage wasformerly offered. The following charts indicate thebenefit enhancements made effective March 1, 2004.

2004 New York Oxford Medicare Advantage Plans

The following chart compares the OMA benefitspreviously offered in Brooklyn, Manhattan, Queens,Richmond, and Bronx counties in New York to the benefit enhancements implemented effectiveMarch 1, 2004. Benefits that have not changed are noted, as well.

Please note: The Oxford Medicare Advantage Balance Plan is not available in Bronx County.


Oxford Medicare AdvantageSM Signature

The 2004 Oxford Medicare Advantage Signature plan is available in Bronx, Kings (Brooklyn), New York (Manhattan), Queens, and Richmond (Staten Island) counties in New York. The following chart compares the 2004 OMA Signature benefits effective March 1, 2004 to the plan benefits that were offered from January 1, 2004 through February 29, 2004.

Benefit Jan-Feb 2004 March 1, 2004

Monthly plan premium $0 No change

Specialists referral Required No change

Primary care physician copayment $15 No change

Specialist copayment $25 No change

Generic prescription drug annual limit Unlimited No change

Generic drug cost share The greater of (i) $15 or No change(ii) 50% of the total cost1

of the covered drug2

Combined preferred and non-preferred $250 $1,100brand prescription drug annual limit

Preferred brand drug cost share The greater of (i) $25 or No change(ii) 50% of the total cost1


Non-preferred brand drug cost share The greater of (i) $50 or No change(ii) 50% of the total cost1


Inpatient hospital facility copayment $600 per benefit period3 $80 per day; not to exceed $640 per hospital stay

Inpatient hospital surgery copayment $150 No change

Ambulatory surgery facility copayment $250 No change

Ambulatory surgery physician copayment $100 No change

Radiology services 20% coinsurance No change

Ambulance services 20% coinsurance No change

Skilled nursing facility services $0 for days 1-10 No change$75 for days 11-100

Limited to 100 days per benefit period3

1 The total cost of the covered drug will reflect Oxford’s discounted rates, plus a prescription dispensing fee, minus an average per-drug forecast of the pharmacy rebates Oxford expects to receive for formulary drugs.

2 If the total cost of the covered drug is less than $15 for generic drugs, $25 for preferred brand drugs or $50 for non-preferred brand drugs, the Member pays the total cost of the covered drug.

3 A benefit period begins the first day the Member is admitted to a hospital or skilled nursing facility. The benefit period ends when the Member has not received hospital or skilled nursing facility care for 60 consecutive days. If the Member is admitted to a hospital after one benefit period has ended, a new benefit period begins. The Member must pay the inpatient hospital deductible for each new benefit period. There is no limit on the number of benefit periods a Member can have.


Oxford Medicare AdvantageSM Essential

Oxford introduced this plan in August 2001 to meet the needs of those who do not want to pay a copaymentfor services such as inpatient and outpatient hospital care, and those who may not require brand nameprescription drug coverage or have brand name prescription drug coverage through other sources such asthe Elderly Pharmacy Insurance Program (EPIC). The 2004 OMA Essential plan is available in Bronx, Kings(Brooklyn), New York (Manhattan), Queens, and Richmond (Staten Island) counties in New York. Thefollowing chart compares the OMA Essential benefits effective March 1, 2004 to the plan benefits that wereoffered from January 1, 2004 through February 29, 2004.



Specialists referral Required No change




Generic drug cost share The greater of (i) $15 or $15 copayment1

(ii) 50% of the total costof the covered drug

Combined preferred and non-preferred None No changebrand prescription drug annual limit

Inpatient hospital facility copayment $0 No change




Radiology services $0 No change

Ambulance services $0 No change

Skilled nursing facility services $0 No change

1 If the total cost of the covered drug is less than $15 for generic drugs, the Member pays the total cost of the covered drug.

Oxford Medicare AdvantageSM Balance

Oxford introduced this plan in January 2003 to provide an option for those who want to have a general ideaof what their annual healthcare costs will be. This plan replaces the various copayments for inpatient andoutpatient hospitalization found in OMA Signature with one annual deductible of $1,5001 for these services.Effective March 1, 2004, Members will no longer require a PCP referral when seeing a specialist. The 2004Oxford Medicare Advantage Balance plan is available in Kings (Brooklyn), New York (Manhattan), Queens,and Richmond (Staten Island) counties in New York. (The OMA Balance plan is not offered in BronxCounty). The following chart compares the OMA Balance benefits effective March 1, 2004 to the planbenefits that were offered from January 1, 2004 through February 29, 2004.


Oxford Medicare AdvantageSM Balance (continued)



Annual deductible $1,750 $1,500 ($500 delayed)1

Specialists referral Required Not required






Combined preferred and non-preferred $500 $1,200brand prescription drug annual limit





Inpatient hospital facility copayment $01 No change




Radiology services $01 No change

Ambulance services $01 No change

Skilled nursing facility services $01 No change

1 Oxford will cover the first $500 of the costs associated with certain services such as inpatient and outpatient hospital care and then the Member is responsible for paying the next $1500. Copayments will apply toward the initial $500 of services provided as outlined above; however, there are no additional copayments for services applied toward the $1500 deductible. For those services, the Member will not be responsible for additional costs beyond the $1,500 deductible.



The $1,500 deductible does not apply to:

• Physician office visits

• Wellness visits (preventive care)

• Urgent care

• Emergency room

• Immunizations

• Allergy testing and treatment

• Occupational therapy

• Speech therapy

• Physical therapy

• Chiropractic services

• Radiology services


• In-office surgery

• Additional Oxford benefits and services (hearing, vision, podiatry visits, nutrition visits, exercise and fitness classes, worldwide

emergency care, non-Medicare covered drugs, and dental services)

Please note: Copayments may apply to some of the benefits listed above.

Oxford Medicare AdvantageSM Plus

The Oxford Medicare Advantage Plus plan provides Members with the freedom to see providers outside theOxford network and still receive coverage. The 2004 OMA Plus plan is available in Bronx, Kings (Brooklyn),New York (Manhattan), Queens, and Richmond (Staten Island) counties in New York. The following chartcompares the OMA Plus benefits effective March 1, 2004 to the plan benefits that were offered from January1, 2004 through February 29, 2004.


Monthly plan premium $180 $170

Specialists referral In-network only No change






Combined preferred and non-preferred $500 No changebrand prescription drug annual limit





Inpatient hospital facility copayment $600 per benefit period3 $80 per day; not to exceed$640 per hospital stay






Skilled nursing facility services $0 for days 1-10 No change$75 for days 11-100Limited to 100 days per benefit period3



3 A benefit period begins the first day the Member is admitted to a hospital or skilled nursing facility. The benefit period ends when the Member has not received hospital or skilled nursing facility care for 60 consecutive days. If the Member is admitted to a hospital after one benefit period has ended, a new benefit period begins. The Member must pay the inpatient hospital deductible for each new benefit period. There is no limit on the number of benefit periods a Member can have.


2004 New Jersey Oxford Medicare Advantage Plan

The chart below compares the OMA benefits that were offered in Hudson County, New Jersey from January1, 2004 through February 29, 2004 to the benefit enhancements implemented effective March 1, 2004.



Primary care physician copayment $25 $10

Specialist copayment $35 $25

Generic drug annual limit None Unlimited

Generic drug cost share None The greater of (i) $15 or (ii) 50% of the total cost1 of the covered drug2

Combined preferred and non-preferred None $500brand drug annual limit

Preferred brand drug cost share None The greater of (i) $25 or (ii) 50% of the total cost1 of the covered drug

Non-preferred brand drug cost share None The greater of (i) $50 or (ii) 50% of the total cost1 of the covered drug


Inpatient physician surgery copayment $250 $150


Ambulatory surgery physician copayment $150 $100



Skilled nursing facility services $0 for days 1-10 No change

$75 for days 11-100Limited to 100 days per benefit period



3 A benefit period begins the first day the Member is admitted to a hospital or skilled nursing facility. The benefit period ends when the Member has not received hospital or skilled nursing facility care for 60 consecutive days. If the Member is admitted to a hospital after one benefit period has ended, a new benefit period begins. The Member must pay the inpatient hospital cost share for each new benefit period. There is no limit on the number of benefit periods a Member can have.


2004 Connecticut OMA Plan

The chart below compares the OMA benefits that were offered in New Haven County, Connecticut fromJanuary 1, 2004 through February 29, 2004 to the benefit enhancements implemented March 1, 2004.



Primary care physician copayment $25 $10

Specialist copayment $35 $25

Prescription drug benefit None No change


Inpatient physician surgery copayment $250 $150


Ambulatory surgery physician copayment $150 $100



Skilled nursing facility services $0 for days 1-10 No change$75 for days 11-100Limited to 100 days per benefit period

1 A benefit period begins the first day the Member is admitted to a hospital or skilled nursing facility. The benefit period ends when the Member has not received hospital or skilled nursing facility care for 60 consecutive days. If the Member is admitted to a hospital after one benefit period has ended, a new benefit period begins. The Member must pay the inpatient hospital cost share for each new benefit period. There is no limit on the number of benefit periods a Member can have.

Pharmacy Program

Updates

2004 Drug Formulary Update

The following is an update to the preferred drug list (PDL) for Oxford’s three-tier prescription drugbenefit. Oxford reviews new drug products approvedby the Food and Drug Administration (FDA) andreviews current products when new informationbecomes available. The following medications were reviewed by the Pharmacy and TherapeuticsCommittee in January 2004. Coverage for the listed items may be limited or excluded based on a Member’s eligibility or plan design.

Additions

The following drugs have been added to Oxford’spreferred drug list. This means that Members with a three-tier prescription drug plan may pay a lowercopayment as a result of the change to preferred (2nd tier) status.

Drug Therapeutic Use

Emtriva HIV/AIDS therapy

Reyataz HIV/AIDS therapy


Deletions

The following drugs have been removed from Oxford’s preferred drug list. This means that Members with a three-tier prescription drug plan may pay a higher copayment as a result of the change to non-preferredbrand (3rd tier) status. A listing of generic and preferred brand alternatives is provided. Unless otherwisenoted, all changes went into effect April 1, 2004.

Drug Therapeutic Use Generic and Preferred Brand Alternatives

Alphagan Glaucoma brimonidine (generic)

Azmacort Asthma Flovent

Bactroban ointment Topical antibacterial mupirocin ointment (generic)

Glucophage XR Diabetes therapy metformin, extended release (generic)

Glucotrol XL Diabetes therapy glipizide, extended release (generic)

Zaroxolyn Diuretic metolazone (generic)

No Change

There has been no change in the formulary status of the following drugs. This means that Members with athree-tier prescription drug plan will continue to pay a higher copayment as a result of the non-preferred(3rd tier) brand status. A listing of generic and preferred brand alternatives is provided.

Drug Therapeutic Use Generic and Preferred Brand Alternatives

Acular LS Non-steroidal anti-inflammatory diclofenac (generic), flurbiprofen (generic) agent/ophthalmic

Ciprodex Otic steroid/antibiotic neomycin sulfate/polymyxin Bsulfate/hydrocortisone (generic)

Clobex Topical corticosteroid clobetasol propionate (generic)

Femring Estrogen estradiol (generic), Climara, Estring,Premarin, Vivelle

Striant Androgen testosterone (generic), Androgel, Androderm

Uroxatral Benign prostatic hyperplasia doxazosin (generic), terazosin (generic)

Quantity Limit UpdatesFor certain medications, there may be a limit on the quantity covered at one time. This limit often reflectsthe maximum FDA-recommended dosage for a drug or use of the most efficient dosage strength for thefully prescribed daily dose. The following quantity limits were approved by the Pharmacy and TherapeuticsCommittee in January 2004.

Drug Name Retail (one-month supply) Mail Order (three-month supply)*

Cialis 7 tablets per 30 days Drug not covered through mail order

Emend 125 mg 1 capsule per 21 days Drug not covered through mail order

Emend 80 mg 4 capsules per 21 days Drug not covered through mail order

*Applicable for those Members with mail-order coverage through their prescription drug benefit.


Important Prescription Drug InformationRegarding Ultram®

Ultram® (tramadol) is a weak opioid agonist andessentially equal in analgesic effectiveness to 30 mgcodeine/300 mg acetaminophen. It is suggestedthat doses not exceed 400 mg per day. Side effectsof Ultram can include increased incidence ofseizures, especially if serotonin-selective reuptakeinhibitors (SSRIs), tricyclic antidepressants (TCAs)or other seizure inducing medications are usedconcurrently. Patients placed on this medication can develop opiate dependence and will run therisk of opiate withdrawal if the medication isabruptly stopped.

Ultram should not be confused with Toradol®

(ketorolac) which is a non-steroidal anti-inflammatory drug. Toradol is indicated for theshort-term relief of acute pain (five days) and canbe given orally (40 mg max), or by intramuscular(IM) or intravenous (IV) injection (120 mg max).

Radiology Program

Updates

Chest X-ray Update

Several medical professional associations, including The American College of ChestPhysicians, The US Preventive Services Task Force,The National Cancer Institute, and The AmericanCancer Society, have concluded that screening x-rays should not be a part of a routine periodicphysical examination. Our Medical Advisory Board has adopted that recommendation.

Effective July 1, 2004, CPT codes 71010 and 71020 performed routinely for screeningpurposes, as part of a periodic health maintenanceexamination in the absence of symptoms, signs or disease states, will not be covered. Oxford willcontinue to provide coverage for chest x-rays at the time of a routine periodic physical examinationwhen they that are medically necessary based onsigns, symptoms, illness, injuries, or diseases asindicated by ICD-9 code.

Nuclear Cardiology Certification Deadline ExtensionWe previously notified you that Oxford’s nuclearcardiology certification requirement would beeffective on February 2, 2004. Please take note thatthis deadline has been extended to February 1, 2005for providers who submit an exam application tothe ABR, ABNM or the CBNC by July 1, 2004 forthe October/November 2004 exam. EffectiveFebruary 1, 2005, all nuclear cardiology providersinterpreting nuclear cardiology examinations will be required to meet one of the following standardsin order to receive reimbursement for nuclearcardiology claims:

• Certification by the Certification Board forNuclear Cardiology (CBNC)

• Board certification in nuclear medicine by theAmerican Board of Nuclear Medicine (ABNM)

• Board certification in radiology by the AmericanBoard of Radiology (ABR)

This extension will be granted only for providerswho submit an exam application to the ABR, ABNM or the CBNC by July 1, 2004 for theOctober/November 2004 exam. Any provider who fails to notify Oxford that their application has been submitted by this date will not be eligiblefor the February 1, 2005 extension and will not have their nuclear cardiology claims reimburseduntil certification is obtained.

By July 1, 2004, providers need to submit proof to Oxford that they have submitted an applicationto sit for one of the three aforementioned examsoffered in 2004.

By February 1, 2005, providers will need to submitproof to Oxford that they passed the ABR, ABNMor CBNC exam in order to continue to bereimbursed for nuclear cardiology procedures.

Please fax your CBNC, ABNM or ABR certificationor a copy of the letter confirming your attendancein one of these exams to the attention ofAccreditation Credentialing Department at 914-467-4605.


Nuclear Cardiology AccreditationDeadline ExtensionWe previously notified you that Oxford’s nuclearcardiology lab accreditation requirement would be effective on February 2, 2004. Please note thatthis deadline has been extended to October 31,2004 only for providers who submitted a completeaccreditation application to American College ofRadiology (ACR) or Intersocietal Commission forthe Accreditation of Nuclear Laboratories (ICANL)by April 1, 2004. Effective October 31, 2004, allnuclear cardiology facilities must be accredited byeither the ICANL or the ACR in order to receivereimbursement for nuclear cardiology claims.

This extension is granted only for providers whosubmitted a complete accreditation application toACR or ICANL by April 1, 2004. Any provider whodid not submit an application to ACR or ICANL by April 1, 2004 will not be reimbursed for nuclearcardiology procedures until accreditation is obtained.

By October 31, 2004, providers will need to submitproof to Oxford that their nuclear cardiologylaboratory has obtained ACR or ICANL certificationin order to continue to be reimbursed for nuclearcardiology procedures.

Please fax your ACR or ICANL accreditation or a copy of the letter confirming you arein the accreditation process to the attention

of Accreditation Credentialing Department at 914-467-4605.


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