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Regular BusinessRegister online at www.triwest.com/provider andreceive: E-mail confirmation of your registration Reminder e-mail notice prior to the scheduled seminar Eligibility to participate in a drawing for a small prizeat the seminarFor additional information, please visit the ProviderConnection area of www.triwest.com. If you havequestions, email your Provider Network ServiceRepresentatives at HCS-X3600@bcbsmt.com or call1-800-447-7828, Extension 3600.PTSD Resources for Primary Care ManagersMilitary members returning from overseas deploymentmay experience post-traumatic stress disorder (PTSD)and will often seek care from his or her primary caremanager (PCM). It is important for PCMs to recognizeand understand the effects of PTSD. Studies fromthe National Center for Post Traumatic Stress Disordershow that PTSD affects mental and physical health,increases utilization of services, and is under-recognizedby practitioners. PTSD is treatable and with earlyintervention, the severity can be reduced.Practitioners often cite time constraints as the majorbarrier to in-depth discussions about feelings of anxiety,depression, and stress. PCMs should routinely askwhen active duty service members or members of theNational Guard and Reserve have recently returned fromdeployment to a combat zone.However, it is important to remember that pressingsomeone into discussing a traumatic event soon aftermay have a detrimental effect on the individual. Expertson traumatic stress emphasize that people have theirown pace for processing trauma, and it is important forPCMs to let survivors know that they should listen to andhonor their own pace of recovery.TRICARE PCMs have resources available to help theirpatients deal with PTSD and its symptoms. The TriWestProvider Connection published at www.triwest.com (clickon Provider) includes practice guidelines, assessmenttools, and a number of other resources to assist patientsexperiencing depression, stress, PTSD, and substanceabuse disorders.PCMs can also contact a PTSD consultant by calling1-888-TRIWEST (1-888-874-9378) and asking for theBehavioral Health Department or by contacting theirlocal Veterans’ Center. Veterans’ Centers providereadjustment counseling and outreach services to allveterans who served in any combat zone. The 232community-based Vet Centers are located in all 50 states,the District of Columbia, Guam, Puerto Rico and the U.S.Virgin Islands.Establishing PTSD referral procedures ahead of time canmotivate patients to accept the course of treatment, andpatients can be treated by highly trained PTSD clinicianspecialists. Once the referral is made, it is important tomaintain contact with the PTSD consultant to coordinateany care your patient may need. This communicationand coordination often results in improved patientcompliance with the treatment program.Beware of Referral Directory SolicitationIt has come to our attention that an organization callingitself Military Media is contacting providers by mail andrequesting them to purchase a listing in their directory.The letter is in the form of an invoice for a listing in the“Armed Forces Medical Directory, published for selectiveCHAMPUS providers.”The letter also says the listing will bring providersadditional exposure and an additional “influx ofCHAMPUS patients, retired and active duty, to yourpractice.” The letter received by some providers had aPalm Springs, CA address on the letterhead, while thereturn address had a different Palm Springs address.This is similar to another solicitation that occurredrecently in Alaska, in which some providers were toldthat they would not receive TRICARE referrals unlessthey purchased a listing in the directory.There is a company called Military Media Inc., based outof Poughkeepsie, NY, that offers advertising, marketing,and consumer promotions to reach the militaryaudience. When contacted by telephone, a companyofficial said it has no other offices, was not affiliated withthis organization and does not print any type of providerdirectory.Providers throughout the TRICARE West Region shouldbe alert to any other similar solicitations. TRICAREreferrals are not based on listings purchased in anydirectory. Network providers are listed in the providerdirectory located at www.triwest.com/provider and donot have to pay to be listed.If you are contacted by this organization or anorganization making similar claims, please contact yournetwork representative.If you have questions about TRICARE benefits, resources,or need more information, log onto www.triwest.com orcontact the TriWest Healthcare Alliance at 1-888-TRIWEST(1-888-874-9378).[ Third Quarter 2008 ] CapsuleNews7

Regular BusinessTo submit a claim for deluxe medical equipment, list the HCPCS code on line 1with the charge for the standard equipment. List the same HCPCS code withModifier GA on line 2 with the charge for the upgrade or deluxe feature.Other BusinessAdvanced Member Notification Coding UpdateAdvanced Member Notification (AMN) allows a providerto inform a member that a service, supply, device, ordrug (SSDD) is not likely to be compensated by BCBSMTprior to delivery of the SSDD (refer to the AdvancedMember Notification – Professional Services medicalpolicy). The AMN lets the member know the financialimplications of receiving the SSDD, and the provider isable to assign the financial liability to the member foran SSDD that would be denied. The AMN only appliesto professional services and does not apply to hospitalbased services, skilled nursing facilities, or home healthagencies.BCBSMT changed the coding guidelines to only allowModifier GA to be submitted instead of the threeprevious options. The coding section from the AMNMedical Policy has been updated and now states:CodingClaims billed with Modifier GA indicate a signed AMN is on fileat the provider’s office. When the claim is processed, BCBSMTassigns financial liability to the member.To submit a claim for an SSDD considered not medicallynecessary, experimental/investigational, cosmetic, or aconvenience item, list the CPT code with the Modifier GA foreach nce,or DeductibleResponsibilityLine 1E0730-NU 400.00 370.56 222.34 144.22The differencebetweenthe allowedamount andcharge is theprovider’sresponsibility,except forcopayment,coinsurance, ordeductible.Line 2E0730-GA 200.00 200.00 0.00NAThe chargeis memberresponsibility.BCBSMT considers submission of Modifier GA with a valid CPT or HCPCScode proof that the member has signed an AMN according to this policy andthat the provider has the AMN on file. Unless BCBSMT requests a copy of theAMN, do not send an AMN with the claim.If you have questions about this policy update, callJacque Jakovac, Medical Policy Coordinator, at 1-800-4477828, Extension 8877 or email jjakovac@bcbsmt.com.Mental Health Release AuthorizationBCBSMT has developed a form to help providers obtainpatient consent to send information pertaining to mentalhealth treatment to BCBSMT. Members have the optionto provide all medical records, except psychotherapynotes, a brief summary, or assign specific records. Theauthorization is valid for two years and can be revokedat any time.ChargeAllowancePaidCopayment,Coinsurance,or DeductibleResponsibilityCopies can be downloaded at www.bcbsmt.com (clickProviders). An example is on the next page. 820.00 753.87 0.00NAThe chargeis memberresponsibility.If you have questions, call your Provider NetworkRepresentatives at 1-800-447-7828, Extension 3600, oremail HCS-X3600@bcbsmt.com.[Continued on page 10][ Third Quarter 2008 ] CapsuleNews8

Regular BusinessAUTHORIZATION FOR RELEASE OFMENTAL HEALTH INFORMATIONTO BLUE CROSS AND BLUE SHIELD OF MONTANAI authorize the following health care provider to disclose my health information pertaining to mental healthtreatment to Blue Cross and Blue Shield of Montana (BCBSMT) including the following (applicable only ifmarked): A copy of all my medical records, except psychotherapy notes including, but not limited to, the following:inpatient chart notes, outpatient therapy notes, billing statements, laboratory reports, and medicationrecords. A brief summary of my mental health treatment including the date(s) I was treated or evaluated, diagnosesassigned, and the name(s) of any other providers who treated me in the past for a mental health problem.This does not include release of actual chart notes or other medical records. A copy of the following records:Provider Name:Address:City, State, Zip:Phone:Fax:Provider NPI:The purpose of the mental health records requested is to (applicable only if marked):Make determinations concerning insurance coverage and/or benefitsInvestigate a preexisting conditionInvestigate a possible investigational/experimental service, supply, drug, or deviceInvestigate a possible not medically necessary service, supply, drug, or deviceI may cancel this authorization at any time by sending written notice to:Blue Cross and Blue Shield of MontanaP.O. Box 4309Helena, Montana 59604This authorization is valid for two years from the date of my signature, but may be less and can be revoked by me at any time.Revocation of the authorization does not affect records already sent to BCBSMT. I have the right to a copy of thisauthorization once I have signed it. My treatment may not be conditioned upon completing this authorization. Refusal mayaffect BCBSMT processing of my claims for benefits. The information disclosed pursuant to this authorization may be subjectto Federal confidentiality rules published at 42 C.F.R. Part 2. Unless otherwise permitted by 45 C.F.R. Part 2, these rulesprohibit the recipient of substance abuse information from further disclosing it without express consent. I acknowledge certainlaws permit disclosure and if permissible disclosures occur, federal law may no longer protect the privacy of this information. Iunderstand the recipient of this information may only use or disclose this information as allowed by law.Last NameFirst NameHealth Plan IDM.I.Date of BirthAddressCitySignedStateZipDateSignature required of Person whose information is to be disclosed to BCBSMT or the Parent or Guardian of the Person.Please complete the following if you are signing as a Personal Representative in a capacity other than as theparent of a minor child. Please attach a copy of the document establishing your legal authority as a PersonalRepresentative.Name of Personal RepresentativeSignature of Personal RepresentativeAUTHMNTLHLTHINFO\MRDateCreated 08/12/2008[ Third Quarter 2008 ] CapsuleNews9

Regular Business[Other Business continued from page 9]CHIP Providers May Be Contacted for Medical RecordsThe Montana Children’s Health Insurance Plan(CHIP) is required to participate in the federal Officeof Management and Budget’s Payment Error RateMeasurement program. The objective of this nationalprogram is to determine if the program authorized anyimproper payments for health care services.The Centers for Medicare and Medicaid Services will usenational contractors to measure the accuracy of MontanaCHIP payments. The documentation and databasecontractor Livanta may contact Montana CHIP providers.Livanta will collect medical policies from CHIP as well asmedical records from providers.Medical records are needed to determine if claims werecorrectly paid. If a provider’s ID number is identified ona claim as receiving payment, and the claim is selectedfor review, Livanta will contact the provider for a copy ofthe required medical records.Livanta will verify the CHIP provider’s correct name andaddress and determine whether the provider wants toreceive the request by fax or mail. Once the requestis received, the provider must submit the informationelectronically or in hard copy within 60 days. Theprovider who is identified on the claim as receivingpayment will be responsible for ensuring that anyand all supporting medical records, from any and allproviders who rendered a service for which the claimpayment under review was requested, are submittedin a timely manner. During this 60-day timeframe,Livanta will follow up to ensure the provider submitsthe documentation before the deadline. Providing therequested medical records is required by the SocialSecurity Act and is permissible by HIPAA.It is very important that CHIP providers submit completemedical records to Livanta in a timely manner to supportthe evaluation of claims payments. No response orinsufficient documentation will count against MontanaCHIP as an error, and may result in recovery of apayment from the provider. The Program ComplianceBureau at the Montana Department of Public Health andHuman Services is available to help providers identifythe required documentation for submission. If you havequestions, please contact Karen Wood at 406-444-9355.Home Health and Hospice Type of Bill ReminderWhen submitting claims for home health and hospiceservices, it is important to code the Type of Bill fieldappropriately to make sure claims process according tothe member benefits. The UB-04 Handbook for HospitalBilling has more information.A home health agency should report Type of Bill 32X,33X, or 34X. A hospice agency should report Type of Bill81X when the provider is not hospital-based, and 82Xwhen the provider is hospital-based.If you have questions, contact Customer Service at1-800-447-7828.New Integrated Healthcare Management ServicesEffective containment of health care costs occurswhen our members receive the right care at the righttime from the right provider. With that in mind, webegan the implementation of our Integrated HealthcareManagement (IHM) program.IHM provides individual case management, chronicdisease management, and utilization managementadministered by a team of registered nurses andlicensed clinical social workers. This team of exceptionalprofessionals assists our members in working theirway through the complexity of health care services andbenefit management.Members are identified for these services using criteriasuch as high claim costs, recent inpatient admissions,or certain high-risk diagnoses like diabetes, congestiveheart failure, chronic obstructive pulmonary disease,and hypertension. A wellness program, including healtheducation and coaching, will also be blended with theIHM services to support and empower members to livesmarter, healthier lives and control their future healthcare needs.More information will be sent to hospitals and otherproviders in September and be presented at the fallprovider workshops.If you have questions, call your Provider NetworkRepresentatives at 1-800-447-7828, Extension 3600, oremail HCS-X3600@bcbsmt.com.MedicareBlue PPOClinical Practice Guidelines Available OnlineOn May 16, 2006, the Regional Quality ImprovementCommittee approved the implementation of the Institutefor Clinical Systems Improvement Clinical PracticeGuidelines for the MedicareBlue PPO plan administeredby the BCBS Northern Plains Alliance. The guidelineswere developed using an evidence-based approach,which emphasizes the critical evaluation of scientificevidence, rather than expert opinion or consensus.[ Third Quarter 2008 ] CapsuleNews10

Regular BusinessThe guidelines are published online at www.yourmedicaresolutions.com (click For Providers). If youdo not have Internet access and require a printed copy,contact Kris Thompson at 406-444-8905.BCBSMT Provider Manual UpdatedThe BCBSMT Provider Manual has been updatedand published at www.bcbsmt.com. The manual iscontinually reviewed for clarity and style with the goalof providing simple and direct instructions. A summaryof material changes made in the third quarter of 2008includes:1. Updated the products excluded from the BlueCardProgram (6-1).2. Updated BlueCard international member informationwith instructions for BCBS Canada members (6-4).If you have suggestions for improvement or content,contact your Provider Network Service Representativesat hcs-x3600@bcbsmt.com or at 1-800-447-7828,Extension 3600.New VOIP Phone SystemInternal Phone Extensions to ChangeBCBSMT has begun the conversion of its currenttelecommunications system to a new Voice over InternetProtocol (VoIP) system that will allow faster and moreefficient information exchange, easier routing of calls,and single-cable networking. The main BCBSMT 800number will remain the same, but all internal extensionswill change in October.Prior to implementation, employees will leave outgoingvoicemail messages informing callers of their newtelephone numbers and when callers should begin usingthe new telephone numbers. After implementation, arecorded message will notify callers of the employees’new telephone numbers.If you have questions, call your Provider NetworkRepresentatives at 1-800-447-7828, Extension 3600, oremail HCS-X3600@bcbsmt.com.[ Third Quarter 2008 ] CapsuleNews11

FraudNational Anti-Fraud Efforts for 2007Number One Concern IdentifiedThe Blue Cross Blue Shield Association (BCBSA) recentlyreleased the results of the Blue Cross and Blue Shieldcompanies’ 2007 anti-fraud investigations, finding morethan 249 million in overall savings and recoveries. Theoverall return on investment for all BCBS anti-fraudunits was 5 for every 1 spent on anti-fraud efforts.Nationally, BCBS companies’ anti-fraud investigatorsreceived more than

All BCBSMT compensation policies are available for review at www.bcbsmt.com (Click on Providers and then Provider Policies). If you have questions, call your Provider Network Representatives at 1-800-447-7828, Extension 3600 or email HCS-X3600@bcbsmt.com Cover Story [Continued from page 1] Health-e-Web is the preferred data network that