BlueCross BlueShield of Tennessee, Inc.

1 January 2016. SM. Management Guidelines. These Provider-administered via pharmacy BlueCross BlueShield upcoming changes to the UM benefits: of tennessee , Inc. Guidelines can be viewed on the Empliciti (PA). Applies to all lines of business unless Utilization Management Web page. Onivyde (PA). stated otherwise Imlygic (PA). Effective Feb. 20, 2016 Mircera (PA). Medical Policy BlueCross BlueShield of tennessee Nucala (PA). will begin using MCG Care Portrazza (PA). Updates/Changes Guidelines 19th edition for the The BlueCross BlueShield of Yondelis (PA).

2 Following guidelines. tennessee Medical Policy Manual has Self-administered via pharmacy been updated to reflect the following The following Utilization Management benefit: policies. The full text of the policies Guidelines related to Rehabilitative Daklinza (PA). listed below can be accessed at Care will be archived: Daraprim (PA). Inpatient Rehabilitation Keveyis (PA). html under the Upcoming Medical Policies link. Admissions UM Guidelines Lonsurf (PA). Skilled Nursing (SNF) Admission Mircera (PA).

3 Effective Feb. 14, 2016 UM Guidelines Ninlaro (PA). Ecallantide (New) Odomzo (PA). Filgrastim/Pegfilgrastim The following Utilization Management Praulent (PA). (Revised) Guideline related to Inpatient Surgical Repatha (PA). Magnetic Resonance Imaging Care will be archived: Tagrisso (PA). (MRI) of the Breast (Revised) Sacral Colpopexy, Abdominal Xenazine(PA). Approach Effective Feb. 20, 2016 Providers can obtain prior authorization Carfilzomib (Revised) Note: These effective dates also apply for: Elosulfase Alfa (Revised) to BlueCare/TennCareSelect pending Provider-administered drugs that Golimumab for Intravenous State approval.

4 Have a valid HCPCS code by Infusion (Revised) logging onto BlueAccessSM, the Ramucirumab (Revised) secure area of , selecting Service Center from the Note: These effective dates also apply to BlueCare /TennCareSelect pending State New Drugs Added to Main menu, followed by approval. Commercial Specialty Authorization/Advance Determination Submission. If you Pharmacy Listing are not registered with BlueAccess or need assistance, call eBusiness Effective Jan. 1, 2016, the following Technical Support.

5 Utilization Management drugs have been added to our Specialty Guideline Updates/Changes Pharmacy drug list. Drugs requiring Provider-administered specialty prior authorization are identified by drugs that do not have a valid BlueCross BlueShield of tennessee 's (PA). HCPCS code by calling website has been updated to reflect 1-800-924-7141. upcoming changes to select Utilization BlueCross BlueShield of tennessee , Inc. is an Independent Licensee of the BlueCross BlueShield Association January 2016. Self-administered specialty drugs BlueCross is working with CAQH to use Update: BlueCross by calling Express Scripts at that same self-reported professional 1-877-916-2271.

6 Information to also simplify the process Behavioral Health Network of updating provider directories. NOTE: BlueCross updates web The BlueCross BlueShield of CAQH will email reminders, on at least authorization forms on a quarterly tennessee Behavioral Health network a quarterly basis, to select providers to basis. If the HCPCS code is not is effective Jan. 1, 2016. review their directory information. available now, it may be in the near Providers who do not respond will be future. BlueCross Medicare Advantage and contacted by phone.

7 We ask that all Commercial members are impacted by providers in our networks respond this change with the exception of two promptly to CAQH email requests to accounts, Nissan and State of update the information required for CMS Changes for Toxicology tennessee , which will still use the provider directories. Magellan behavioral health network. Testing With BlueCross ' participation in this Providers who elected not to participate initiative, we hope to reduce the in the BlueCross network have been All BlueCross lines of business will notified about the 120-day member administrative burden on health care follow the Centers for Medicare & transition period.

8 Providers, increase the accuracy of our Medicaid Services (CMS) 2016 coding directories and enable patients to make changes for drug presumptive and More information on the BlueCross more informed choices about their care. definitive testing, which include Behavioral Health network, including a . appropriate coding for the four tiers of recorded webinar, is available at definitive testing. Code G0478 has also replaced code G0434 on the Quest If you have BlueCare Exclusion List. Gender Reassignment any questions about this transition, Surgery please contact your behavioral health network manager.

9 Effective Jan. 1, 2016, gender . New Regulations to Improve reassignment surgery is now a covered benefit for certain commercial, fully- Provider Directory Data insured groups and requires prior Quality authorization. Reminder: ICD-10. Compliance Beginning Jan. 1, 2016, a new regulation from the Centers for The transition from ICD-9 to ICD-10. Medicare & Medicaid Services (CMS) Provider Service Hours diagnostic codes is now complete. In will require Medicare Advantage and Medicare-Medicaid health plans to Extended order to help ensure prior authorization requests and claims are processed maintain more current, accurate Beginning in January, Provider Service correctly, please keep these key points provider directories.

10 Health plans are Phone Lines for our Commercial lines in mind: required to contact participating health of business, as well as eBusiness ICD-9 and ICD-10 codes cannot be care providers on a quarterly basis to Technical Support and BlueCard, will submitted on the same claim. review, update and confirm their be available to you until 6 (ET), information in provider directories. Monday through Friday. This change Claims for individuals who were The Council for Affordable Quality has been made to provide better service inpatient as of the Oct.