December 2015

Read our December 2015 issue of Provider News.

2016 HEDIS® Project Begins

Because BMC HealthNet Plan is NCQA-accredited, we are required to participate in an annual HEDIS project to measure the quality, access and use of services by our members during the previous year. As a result, we’re launching our annual project with a chart review component that will be ongoing through the end of March. This will ensure that we have adequate time to review the records.

Provider groups that are part of the project can expect to be contacted so we can obtain chart information about pertinent services delivered to our members who are among those chosen for the sample.

We’ll Work With You

Member samples are randomly selected for various NCQA HEDIS preventive and chronic disease measures. Depending on the volume of charts, we will ask providers to fax or postal mail the records to our Boston office, or we will offer an onsite visit by one of our reviewers. If providers wish, they may send chart information through encrypted, password protected electronic distribution methods. We also are willing to access your electronic medical record system either onsite or remotely.

Please be assured that we will do whatever we can to minimize disruption to provider practices during this process.

Get Valuable Provider Reports Easily Online

On a monthly basis, we post your site’s specific reports directly to our online provider portal; you can easily access them anytime with your secure login and password.

Membership Roster-RPT0095 details your newly added members, as well as those who have disenrolled. Our Well Child Report - RPT120874B and other clinical reports, including our Asthma Treatment Advisory and EPSDT reports are also readily available to you.

Visit us at and then immediately click on Provider Login where you will log in to retrieve your reports.

If you still need a login ID to access our secure provider portal, you can email us at

Please contact your dedicated Provider Relations Consultant if you have questions about accessing your reports or if you want to learn more about the schedule of clinical reports and when they are run and published to our online provider portal.

We Recommend These Important Preventive Care Screenings for Our Members

Here is a list of common health issues with the most updated screening guidelines. It’s important to note the significance of shared decision making with your patient in the screening process.

  • Colon cancer: Beginning at age 50 and continuing until age 74, screening options include colonoscopy every 10 years, sigmoidoscopy every five years, double contrast barium enema every five years or annual fecal occult blood testing.

    Colon cancer risk increases if there is a positive family history in a first-degree relative, specific genetic syndromes, or a history of inflammatory bowel disease or precancerous polyps.

  • Cervical cancer: Initial Pap smear should be performed at age 21 and repeated every three years until age 30. Pap smears may be continued every three years until age 65 or extended to five year intervals if HPV testing is added.

    Cervical cancer risk increases with HPV infection, high-grade cervical dysplasia, and a compromised immune system.

  • Breast cancer: Beginning at age 45 (for those at average risk), screening mammography should be performed every year until age 54. Women 55 and older should switch to mammography every two years or they can continue yearly screenings. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. Women over age 20 should be educated on breast self-awareness.

    Risk factors for breast cancer include age, first-degree relative with breast cancer, genetic predisposition, personal history of ovarian cancer or high risk breast biopsy result, or history of chest radiation therapy at a young age.

  • Sexually transmitted infections: Screen annually all sexually active women ages 25 years and younger. You should offer high intensity behavioral counseling to prevent STIs for those at increased risk.

    Risk factors include inconsistent condom use, new or multiple sex partners, a history of previous sexually transmitted infection, a current partner who has other sexual partner(s), and a history of exchanging sex for money or drugs.

    According to the Centers for Disease Control, each year nearly 17,000 women and 9,000 men are affected by HPV-related cancers. We support the Massachusetts Department of Public Health recommendation for administering HPV vaccinations for preteen girls and boys, ages 11 or 12, before they become sexually active. However, the vaccine series also may be given to girls and boys anytime between ages 9 and 26 if it is more convenient and effective. The HPV vaccine does not promote sexual promiscuity.

Dealing with Unsolicited Requests for Approvals

Providers have notified us that they’ve received unsolicited requests faxed from some ancillary service providers. The requests asked for approval of various procedures, supplies or drugs, such as recurring drug testing related to a substance abuse diagnosis, medical supplies, DME and/or compounded medications for any number of conditions. Typically these requests are pre-populated with the member’s name, address, date of birth, and/or demographic information. The requests also may include information such as the specific service requested and duration. In some cases the provider is not currently treating the member for a related condition.

Please be certain that you complete and return requests only for our members you are actively treating for a condition related to the request. If you question the legitimacy of a request, you should contact our Special Investigations Unit in one of the following ways:

  • Call our Fraud Hotline: 888-411-4959
  • Email the Special Investigations Unit:
  • FAX the Special Investigations Unit: 866-750-0947
  • Postal mail us:
    BMC HealthNet Plan
    Attn: Special Investigations Unit
    Two Copley Place, Suite 600
    Boston, MA 02116

Coverage Now Available for Applied Behavior Analysis Services

As of October 1, 2015, BMC HealthNet Plan – through our behavioral health partner, Beacon Health Options – began covering Applied Behavior Analysis (ABA) services through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit for children and youth under age 21 years who:

  • are diagnosed with an Autism Spectrum Disorder (ASD), and
  • are enrolled in MassHealth Standard or CommonHealth

Coverage also began for children under age 19 enrolled in MassHealth Family Assistance.

ABA is an evidence-based practice commonly used for individuals diagnosed with ASD. Based on the science of learning and behavior, ABA is considered a best practice treatment by the U.S. Surgeon General and by the American Psychological Association. Treatment is provided in a variety of settings, such as at home and in the community.

For more information about ABA services, including how to access them, please visit or call 866-444-5155.

Patients on Antidepressants May Require Additional Support

Antidepressant medications can transform lives, yet many individuals who are prescribed these drugs may need additional support and education from you and your office team. In order for your patients to get the maximum benefit from taking antidepressants, make sure you take the time to provide them with as much information as possible:

  • Explain the importance of taking the medication as prescribed. Try to dispel any cultural barriers or stigma with antidepressants.
  • Encourage your members to ask their pharmacy if they have an “auto reminder” program, and recommend that they enroll in it.
  • Reinforce the importance of taking medication at the same time, for example, when they’re brushing their teeth or watching the news.
  • Suggest to your patients that using a pill box is a great way to track medication use.

Since antidepressant medications often take time to work, urge your patients to continue taking the medication even if they feel better.

We also urge providers to develop a system for staying in contact with patients on antidepressants for follow-ups. This is one of the most successful ways to ensure compliance.

The information below is from our July issue of Provider News. Please take the time to re-read this valuable information.

Antidepressant Medication Management Outreach Program

Our members who recently have been prescribed antidepressants can participate in a program to improve medication adherence. The Antidepressant Medication Management Member Outreach Program is administered by Beacon Health Options, our behavioral health partner. Trained health coaches telephone participating members and provide therapy coaching services. Members may benefit by having a successful outcome associated with improved adherence for their newly prescribed antidepressants. As a provider, you have the opportunity to refer and enroll eligible members in this program. To qualify, the member must:

  • Be at least 18 years of age and currently eligible as a BMC HealthNet Plan member
  • Have been prescribed an antidepressant recently that was filled at a pharmacy
  • Have been diagnosed with major depression during the 60 days prior (inclusive) through 60 days after (inclusive) the date antidepressant in #2 was originally dispensed
  • Be starting a new course of prescription antidepressant treatment and thus have NOT filled a prescription for an antidepressant medication in the immediately preceding 105 days from when the new prescription was filled

Questions about this program or requests for enrollment forms may be directed to 781-994-7572 or by email at

A Provider's Role in the Lives of Patients with Asthma is Significant

Your patients who have asthma can successfully manage this condition with the right education and support, particularly when it comes from you. And since you’re a key resource, please make sure to discuss:

  • How to identify and avoid asthma triggers
  • The difference between rescue and controller medications
  • The importance of adhering to controller medications

Caregivers of children with asthma need particular training. You should make sure to cover topics that range from what symptoms the child may exhibit, to what to do for an acute asthma attack and how to ensure that the child avoids asthma triggers. Also be sure to prescribe spacers for children with asthma, and make sure that the children’s caregivers understand how to use these important tools.

Asthma Control Test

To help your patients monitor their asthma, BMC HealthNet Plan and the American Lung Association recommend the asthma control test (ACT), a 5 question survey your patients can download, print and complete. And make sure to review and discuss the results with your patients.

As always, you should refer to the Asthma Clinical Practice Guidelines that we have endorsed.

If you have BMC HealthNet Plan members with asthma whom you believe would benefit from care management, please contact us at 866-853-5241. Care managers will work with you and these patients to assess their health status, develop an individualized care plan, provide educational materials and provide continuing care management support.

Clinical Practice Guidelines Endorsed

HEDIS® 2016 Billing and Coding Tips are Available Online

The BMC HealthNet Plan Healthcare Effectiveness Data and Information Set (HEDIS) Billing & Coding Guide is now available. Or you may request a copy from your Provider Relations consultant. This resource is intended to help you easily locate and use appropriate codes for common health care services.

The guide includes all applicable codes to document office visits, preventive health services and other common health care services. In addition, the guide may help reduce the need for medical record chart reviews during the annual HEDIS data collection season.

Appropriate coding also helps with:

  • Maximizing provider reimbursement
  • Processing claims quickly and efficiently
  • Identifying and addressing care gaps for patients
  • Improving the accuracy of the care gap reports available on our provider portal

Using Billing Code Modifier 25 Correctly

Modifier 25 indicates a significant, separately identifiable Evaluation and Management service by the same physician or other qualified health care professional on the same day of the procedure or other service. This modifier can be misunderstood, and it is sometimes used when it is not necessary to append a modifier in order to obtain reimbursement.

Modifier 25 should only be appended to an Evaluation and Management service. It should not be appended to every Evaluation and Management Service you provide, only to those situations where there is a significant, separately identifiable Evaluation and Management service performed.

There are some questions you can ask yourself to assist you with determining whether a service is significant and separately identifiable:

  • Did you perform and document the key components of a problem-oriented Evaluation and Manaagment service for the complaint or problem?
  • Could the complaint or problem stand alone as a billable service?
  • Is there a different diagnosis for this portion of the visit?
  • If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or post-operative work associated with the procedure code?

For example, if a preventive examination (99381-99397) includes a patient being treated for a significant, separately identifiable (and documented) service, then modifier 25 should be appended only to the office or other outpatient service (99201-99215).

If you have any further questions about the appropriate use of modifiers, please reach out to your BMC HealthNet Plan Coding Consultant.

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