Maryland Medical Group Management Association CareFirst Updates & Reminders

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1 Maryland Medical Group Management Association CareFirst Updates & Reminders May 11, 2018

2 Agenda Enhance Security for Provider Portal National Drug Code Requirement Medication Management and Electronic Prior Authorization FEP Electronic Prior Authorization for Drugs Behavioral Health & Substance Use Services Submitting Claims for Habilitative & Rehabilitative Services State of MD Wellness Rewards New G Codes New Medicare Cards Provider Portal User Guides Available Keeping your Provider Information Up-to-Date 5/11/18 CareFirst Updates & Reminders 2

3 Enhanced On-line Security Enhanced security for your online CareFirst Provider Portal account was implemented in March This additional layer is called multi-factor authentication (MFA) and it validates a user s identity by requiring more than one method of authentication (multi-factor) to verify the user. For providers who attempt to log in for the first time or log in using a new device (like a mobile phone, etc.) once this has been implemented, you can expect to: Receive a unique, one-time code via or text message at the number CareFirst has on file. Then, be required to enter that code in addition to their username and password to complete the login process. An communication was sent from CareFirst on March 8, 2018 regarding this enhancement and includes additional information along with detailed instructions. > Provider > Stay Connected > News Archives. 5/11/18 CareFirst Updates & Reminders 3

4 National Drug Code (NDC) Requirement Professional provider claims submitted with a date of service on or after January 1, 2018 that include drugs covered under the patient s medical benefit must also include the National Drug Code (NDC) number, quantity and unit of measure. NDC, is a universal number that identifies a drug and is the industry standard identifier for drugs. This change will allow us to more accurately track medications that are being administered. No other part of the claims submission process will change. You should continue to include the HCPCS and CPT code on your claim. This requirement will apply to claims submitted both electronically (submit in LIN03) or on paper claim forms CMS-1500 (submit in Box 24D). 5/11/18 CareFirst Updates & Reminders 4

5 National Drug Code (NDC) Requirement If the required NDC information is not included or is invalid for the HCPCS code submitted, your claim will be rejected at the Gateway by CareFirst and you will need to correct and resubmit the claim. See the chart below for details on entering the NDC information. You can also refer to the eblast sent on November 6, 2017 for information on the change be accessing the website at > Provider > Stay Connected > News Archives. 5/11/18 CareFirst Updates & Reminders 5

6 Medication Management and Electronic Submission for Drug Prior Authorizations CareFirst requires prior authorization (PA) for certain specialty medications administered in outpatient facilities, home and office settings. Effective May 2, 2018, new medications requiring PA have been added (see list included in your folder as well as access the full list at These PAs are to be submitted online by logging in to provider.carefirst.com and navigating to the Prior-Auth/Notifications tab to complete the request. CareFirst has delegated the processing of these prior authorizations to CVS Caremark. Failure to obtain a PA for these medications may result in the denial of the claim payment. Questions related to prior authorization approvals, denials or pends should be directed to CVS Caremark at (888) If you need information on how to submit a PA online refer please view the video on the website which is located under >Learn More>Office Staff Learning Library>Pharmacy>How to Request Prior Authorization Online. You can also access the User Manual online at >Provider>Program/Services>Pharmacy>Pharmacy Prior Authorization. Here you can find the links to both the video and user guide (training video or download the user guide). 5/11/18 CareFirst Updates & Reminders 6

7 FEP Electronic Prior Authorization for Drugs Effective Dec. 4, 2017, prior authorization requests for your FEP patients for the drugs below (at this time) that are covered under the member s medical benefit, must be submitted online via CareFirst Direct, following the same process you currently use to submit any epa request. This process applies even if you buy and bill for the drug. Actemra Bivigam Botox Carimune NF Cuvitru Dysport Flebogamma Flebogamma DIF GamaSTAN S/D Gammagard Gammagard S/D Gammagard S/D Less IgA Gammaked Gammaplex Gamunex-C Hizentra Hyqvia Inflectra Lucentis Myobloc Octagam Orencia Privigen Remicade Renflexis Simponi Aria Tysabri Xeomin Prior authorization requests for your FEP patients for any other drug should continue to be requested via the current FEP prior authorization process. Remember, you should always confirm how a drug should be submitted by checking online at and click on the hyperlink titled FEP specific services requiring authorization (This link will take you to the FEPBlue website where you can get information on all prior authorization requirements). Please continue to submit all drug prior authorization requests online for other CareFirst patients, just as you do today. 5/11/18 CareFirst Updates & Reminders 7

8 Behavioral Health & Substance Use Services CareFirst has brought in-house the behavioral health and substance use disorder services previously provided by Magellan HealthCare Inc. (Magellan). Effective April 1, 2018, authorization requests for behavioral health services must be submitted through the CareFirst Direct Provider Portal at All medical policy references to Magellan have been replaced with CareFirst effective April 1, For other behavioral health and substance use disorder inquiries, please call This action to bring in-house behavioral health and substance use disorder services does not in any way change CareFirst benefit plan coverage for these services or medical policy relating to these services. You can refer to the January 31, 2018 Provider Communication that was sent announcing the change. > Provider > Stay Connected > News Archives. Register to attend a Behavioral Health and Substance Use Prior Authorization webinar at > Webinars and Seminars > Professional Providers. 5/11/18 CareFirst Updates & Reminders 8

9 . Submitting Claims for Habilitative & Rehabilitative Services As a reminder, for dates of service on and after January 1, 2018 providers should now bill the following modifiers along with the CPT procedure code when submitting claims for habilitative and rehabilitative services. Modifier Code Description 96 Habilitative services 97 Rehabilitative services These new CPT modifiers were created by the American Medical Association (AMA) to identify habilitative and rehabilitative services and should be submitted with CPT procedure codes on professional claims. The 'SZ' modifier should only be added to claims for Habilitative services through December 31, Revised medical policies associated with these services are online in the Medical Policy Reference Manual at Pervasive Developmental Disorders Oral Facial Pathology/Trauma Physical Therapy Occupational Therapy Speech Therapy A Habilitative Services Prior authorization requests should continue to be submitting online through the CareFirst Provider Portal. 5/11/18 CareFirst Updates & Reminders 9

10 State of MD Wellness Rewards For State of MD accounts that participate in the Wellness Rewards Program, members are eligible for a waived copay for PCP visits and a reduced copay for Specialists visits when they meet program criteria. This information has been available to providers on the Eligibility Summary screen. Continued on next slide 5/11/18 CareFirst Updates & Reminders 10

11 State of MD Wellness Rewards A new field has been added on the Benefit Search results (when applicable) that details the copay reduction for a Specialist if the Wellness Rewards Program has been met. 5/11/18 CareFirst Updates & Reminders 11

12 New G Codes Beginning January 1, 2018, these G codes should be used for well exams when a member has Medicare as their primary or secondary carrier: G0438 G0439 It is particularly important on claims when CareFirst is primary to ensure you can send these to Medicare as the member s secondary carrier. 5/11/18 CareFirst Updates & Reminders 12

13 New Medicare Cards Beginning in April, 2018 Medicare started to send out new Medicare cards with new numbers. These new numbers will not impact crossover claims as CareFirst has been working with CMS and will be able to accept the new numbers when sent by Medicare on crossover claims. For more information about this change, go to the CMS website for details. 5/11/18 CareFirst Updates & Reminders 13

14 Provider Portal User Guides To help you navigate, we have developed four step-by-step Provider Portal User Guides for walking you through the new look and feel of the CareFirst Direct tab/section: - Checking Eligibility and Benefits - Reviewing Claims Details and Status - Reviewing a Remittance or Notice of Payment - Looking Up a Fee Schedule You can find these User Guides on the CareFirst Direct home page under the Quick Links heading. 5/11/18 CareFirst Updates & Reminders 14

15 Keep your Provider Information Upto-Date As you know, keeping your provider information up-to-date is important. It results in more accurate delivery of mail and notifications, reduced errors in reimbursement, members can locate your practice more easily, and your claims are processed more quickly and accurately. What Has Changed? CareFirst s systems are now fully integrated with CAQH ProView, which means that when you update your information with CAQH, it will automatically be updated in CareFirst s systems and provider directories. What Do You Need to Do? If you are already registered with CAQH ProView continue to make regular updates any time your provider information changes (or at least once each quarter). If you are not yet registered for CAQH ProView, learn more and register today at Why CAQH ProView? When you register with CAQH ProView, you will be contacted each quarter with a reminder to review, update and attest to your provider information. This will save your practice time, as you will only be required to keep your information up-to-date with CAQH ProView. When you make a change to your information in CAQH ProView, it will automatically be updated within CareFirst s systems and provider directories, as well as any other CAQH ProView participating health plans that you contract with, eliminating the need to update your information in more than one location. Additional reference and training materials can be located at 5/11/18 CareFirst Updates & Reminders 15

16 Thank you! Questions 5/11/18 CareFirst Updates & Reminders 16