As a reminder, Independence began to make changes to its office-based pathology network as of January 1, 2018. These changes affect the credentialing of pathologists who perform services in the office setting and the HMO and PPO policies related to reimbursement referenced below.

Closure of the office-based pathology network to new pathologists

We previously communicated to you on December 1, 2017, that the Independence pathology provider network is closed to new office-based pathology providers effective January 1, 2018. This change applies to pathologists in the Independence five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) and contiguous counties (i.e., counties that border the Independence five-county service area) except when the pathologist meets the following condition:

A pathology provider is joining an existing participating hospital-based pathology group in a participating hospital in our five-county service area or a contiguous county (as identified above).

Note: Pathologists cannot be added to participating non-pathology practices as of January 1, 2018.

Affected policies for existing in-network pathologists

HMO policies

Effective April 1, 2018, Independence will not reimburse for pathology services according to the following existing policies:

• Commercial: #00.03.07u: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
• Medicare Advantage: #MA00.030l: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products

Claims submitted for pathology services that are billed by an office-based pathologist on or after April 1, 2018, will be denied consistent with these policies.

To view these existing HMO policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, select the Commercial or Medicare Advantage tab, and type the policy name or number in the Search field.

PPO policies Effective April 1, 2018, Independence will update the following policies to prohibit billing and reimbursement for pathology services provided by office-based pathologists for PPO members: Commercial: #00.01.25aq: PPO Network Rules for Provision of Specialty Service for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services Medicare Advantage: #MA00.010s: PPO Network Rules for Provision of Specialty Service for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services To view the updated PPO policies and the Limited Circumstances Procedure Code List, which were posted as Notifications on January 3, 2018, and will go into effect April 1, 2018, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial or Medicare Advantage under Active Notifications.

Clarification for non-pathology specialists This change does not apply to providers in specialties other than pathology. Non-pathology specialties can continue to bill for certain pathology codes in the office setting as outlined in our PPO Network Rules for Provision of Specialty Service for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services policies. For a list of CPT® codes for which non-pathology specialists may be eligible for reimbursement, refer to the Limited Circumstances Procedure Code List in Attachment B3 of the applicable PPO Network Rules policy.

Why we are making these changes

Independence has decided to make these changes after an in-depth analysis of our HMO and PPO laboratory network and a review of our policies. Our current participating Independence HMO and PPO laboratory network provides sufficient coverage to our members and your patients. These policy changes will help to:

• reduce out-of-pocket expenses for our members;
• ensure consistency with industry standards and practices.

If you have any questions about these changes, please email us at officebasedpathology@ibx.com. Be sure to include your name, contact number, and provider ID number in your email.

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