January 2012

Please distribute this newsletter, which contains claims, billing, Medical Policy, and other important information, to all health care providers and administrative staff that this e-mail address represents. Thank you.

Blue Review: Share the wealth!
Each issue of Blue Review is packed with valuable information. It is very important that you share Blue Review with your billing departments/entities. Many issues contain articles relevant to department employees, such as system and coding updates, billing and reimbursement, new account groups, federal mandates, and electronic commerce solutions. You can find Blue Review online.

Do we have your correct information?
If you have moved or made other changes to your practice contact information, please complete our quick and easy online form to share your updates with us. Thank you!

Medical Policy updates
Approved new or revised Medical Policies and their effective dates are posted on our website the first day of each month. These policies may impact your reimbursement and your patient's benefits. You may view all active and pending Policies or view draft Medical Policies and provide comments.

While information on new or revised Medical Policies is also published in this newsletter for your convenience, please visit our website for access to the most complete and up-to-date information. If you have any questions about BCBSNM's Medical Policies, please call Health Services at (505) 816-2093.

Effective Date

Policy Number

Policy Name



Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer



Non-BRCA (Breast Cancer) Risk Assessment



Acoustic Cardiography



Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis



Extracorporeal Photopheresis (ECP)

Utilization management determinations
Utilization management (UM) determinations are made by licensed clinical personnel based on the benefit policy (coverage) of a member's health plan, evidence-based medical policies, and the medical necessity of care and service. BCBSNM does not provide any reward or incentive to employees, providers, or other individuals for decisions that result in determinations that services are not covered; nor do we reward providers for underutilization of services.

If you have questions about criteria for UM decisions and official medical policy, or if you wish to discuss a UM coverage determination, you may contact a medical director at (505) 816-2093. In addition, all medical policies are available for review online in the Providers section of bcbsnm.com.

Preauthorization and predetermination process
All inpatient admissions and air ambulance requests require preauthorization except for emergency admissions.
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BCBSNM is ANSI Version 5010 (V5010) ready
As planned and previously announced, BCBSNM is prepared to accept and transmit ANSI V5010 electronic transactions beginning January 1, 2012.

The Centers for Medicare & Medicaid Services (CMS) recently announced a 90-day period of enforcement discretion for this mandate. To assist those providers who have not completed their conversion, BCBSNM will continue to process both V4010 and V5010 transactions during the enforcement discretion period.

We urge all providers to continue working with their trading partners to ensure they have a plan in place to process V5010 transactions within the enforcement discretion period. If you have any questions about this, please e-mail us.

Why switch to Electronic Refund Management (eRM)?
As a participating BCBSNM provider, you have the option to use our eRM system for electronic notification/resolution of overpayment requests.
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Provider education webinars available
BCBSNM offers complimentary educational webinar sessions for our provider community and their staff. Some of the current training modules are:

  • ANSI 5010 and ICD-10
  • Availity
  • BlueCard®
  • Clear Claim Connection
  • Electronic commerce
  • Interactive Voice Response (IVR)
  • Refund and recoupment
  • Provider website tour

Visit our Provider Training page for more information and to register. If you have questions, please e-mail us.

Blue MedicareRxSM Medicare Part D formulary changes from 2011 to 2012

Updates to the BCBSNM Drug List

Pharmacy program update: Utilization management transition
Effective January 1, 2012, Prime Therapeutics® will conduct all prior authorization (PA) and step therapy (ST) requests from physicians for BCBSNM commercial members with prescription drug coverage administered by Prime.
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Use the Claim Research Tool for expanded claim status information
Do you, your staff, or your billing agent (billing service or clearinghouse) need an easy-to-use administrative solution that provides more information in less time, at no charge, and with printable results?
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Alineo®: Integrating a comprehensive view of members' health
BCBSNM is capitalizing on an enterprise technology infrastructure that supports simpler, more affordable, and more accessible health care management programs for our clients. Since January 1, 2011, the BCBSNM behavioral health program has been supported by Alineo, a new state-of-the-art health care management platform with 360-degree views of member health information based on claims and clinical information. A phased transition of our medical care management programs to the new platform will begin third quarter 2012.

After implementation, system integration will be achieved between BCBSNM Behavioral Health and medical care management programs, providing a new and innovative solution to help deliver improved outcomes, maximize efficiencies, and streamline performance across the health care continuum.

Office Staff
Claims inquiries? Call the Provider Service Unit (PSU) at 888-349-3706
Our PSU handles all provider inquiries about claims status, eligibility, benefits, and claims processing for BCBSNM members. For out-of-area claims inquiries, please call the BCBSNM BlueCard PSU at 800-222-7992.

Network Management contacts and related service areas

Network Management regional map

Filing BlueCard® ancillary claims
Generally, claims should be filed to the local Blue Cross and Blue Shield Plan. However, there are unique circumstances when claims filing directions will differ based on the type of provider and service.
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Providers who have joined or left the BCBSNM network, November 2011

New BlueSalud provider requirements for billing supplies
Effective January 1, 2012, professional providers, outpatient hospital providers, and medical supply companies will be required to include the National Drug Code (NDC) when billing certain supply items.
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Not yet contracted for BlueSalud?
Providers who are participating in commercial BCBSNM products are not automatically participating providers in BlueSalud. To become a BlueSalud provider, you must sign a Medicaid amendment to your Medical Services Entity Agreement (MSEA). Please contact the Network Services Department at (505) 837-8800 or 1-800-567-8540 if you are interested in becoming a BlueSalud provider.

Ideas for articles and letters to the editor are welcome; e-mail NM_Blue_Review_Editor@bcbsnm.com.

BCBSNM makes no endorsements, representations, or warranties about any products or services offered by independent third-party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions about the products or services mentioned in this newsletter, contact the vendor directly.

BlueSalud services are funded in part under contract with the State of New Mexico.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.



P.O.Box 27630, Albuquerque, NM 87125-7630

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