April 2010
Clinical Practice Guidelines: A shared baseline
We have completed our annual update of the BCBSNM Clinical Practice Guidelines. Recognizing that practitioners are very busy, we have designed these Guidelines to be quick summaries. Each Guideline refers to a more in-depth version, which can be accessed by clicking on the appropriate links.
The Guidelines summarize national, evidence-based guidelines that improve health for most patients with the condition. Individual patients, however, may have unique needs, indications, and contraindications, and the practitioner must apply clinical judgment to an individual patient. That’s why we consider the Guidelines a starting point or “shared baseline.”
While individual patients have unique needs, the care outlined in these Guidelines provides a baseline and is appropriate for most in the affected population. BCBSNM annually measures our network providers’ delivery of the recommended care. Those elements that are measured are called “core elements” and are listed as such in the Guidelines.
We encourage you to review the Clinical Practice Guidelines to understand the basis upon which BCBSNM measures the extent to which our members receive care consistent with national recommendations. Results of how well the Guidelines are applied will be published in a later issue, when we publish our HEDIS® results.
HEDIS® is a registered trademark of the National Committee for Quality Assurance.
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 patients’ benefits. You may view all active and pending Policies or view draft Medical Policies and comment.
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 Medical Policy 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 |
5/15/10 | OB402.023 | Assisted Reproductive Technologies (ART) and Related Services |
6/1/10 | SUR713.001 | Refractive and Therapeutic Keratoplasty |
How to change the information you have on file with BCBSNM
Click the UPDATE Your Contact Information >Update Now button at bcbsnm.com/provider to electronically submit a change to your name, office or payee address, e-mail address, telephone number, tax ID, or other information. Please submit all changes at least 30 days in advance of the effective date of the change.
Talking with Health Services staff
BCBSNM Health Services staff members are available to receive incoming calls, make outbound calls, and discuss care management issues with members and providers Monday through Friday, 8 a.m. to 5 p.m. MT, toll-free, at 800-325-8334. The medical director is available to address care management request issues at (505) 816-2093, or you may leave a message at the toll-free number above. When returning your call or otherwise calling your office or home, Health Services staff members identify themselves as BCBSNM employees and give their names and titles.
New hours for our UM Authorization Unit
Beginning April 1, 2010, our Utilization Management (UM) Authorization Unit will be closed from 12 to 1 p.m. Our new office hours will be Monday through Friday, 8 a.m. to 12 p.m., and 1 p.m. to 5 p.m.
You may leave a message at (505) 291-3585 or 800-325-8334, or fax your request to (505) 816-3608 between 12 and 1 p.m. A UM Intake Specialist will return messages the same business day. An on-call nurse will also be available for urgent medical needs.
Medicare Part D formulary updates – first quarter 2010
Following is a summary of recent BCBSNM Medicare Part D formulary changes. This list is updated regularly (usually monthly) by our pharmacy benefits provider, Prime Therapeutics®.
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Free brochure on medical identity theft available
The Federal Trade Commission (FTC), the nation’s consumer protection agency, recently published the free consumer brochure, Medical Identity Theft. The six-page publication explains how medical identity theft occurs, how it differs from traditional identity theft, how to minimize the risk, and how to recover should you experience a theft.
This free brochure is available in hard copy, and providers can order them in bulk quantities for their patients. To order bulk copies, please visit bulkorder.ftc.gov. Here are the links to HTML and PDF versions of the brochure.
“Got Shots? Protect Tots!” event planned for April 26 to May 1
The New Mexico Immunization Coalition (NMIC) will host a “Got Shots?” event during National Infant Immunization Week. For this event, NMIC is asking providers to open their doors on one or more days between April 26 and May 1, preferably during evening or weekend hours, and to see any child who presents for immunizations without an appointment, regardless of whether he or she is a patient or have insurance. Providers should bill insurance for administration fee reimbursement if the child is insured, but during this event, NMIC requests providers to immunize all children at no cost to the parent (including copayments). NMIC also encourages every provider’s office to provide Medicaid eligibility services during the event. The New Mexico Primary Care Association can help arrange for on-site Medicaid applications if providers do not have eligibility workers.
For more information on this event, visit the NMIC website.
Office Staff
Providers who have joined or left the BCBSNM network, February 2010
Coding allergy immunotherapy claims
There has been some confusion among providers about the proper use of allergy immunotherapy CPT codes. The following description of the codes can help you use these codes correctly. Please refer to your CPT book for more detailed information on the correct use of each code.
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Easier access to pre-authorization information for out-of-area Blue members
We are pleased to announce enhancements to the BlueCard® Eligibility Line. These changes will improve your experience in verifying eligibility and obtaining pre-authorization information for your out-of-area Blue patients. Please note the changes as follows:
If calling 800-676-BLUE (2583) to obtain pre-authorization only:
Effective April 1, 2010, when pre-authorizations for a specific member are handled separately from eligibility verifications, BlueCard will route your call directly to the area that handles pre-authorizations. You will choose from four options regarding the type of service for which you are calling:
• Medical/surgical
• Behavioral health
• Diagnostic imaging/radiology
• Durable medical equipment (DME)
Upon making your selection, BlueCard will transfer you to the appropriate area of the member’s Plan to service your specific request.
If calling 800-676-BLUE (2583) to obtain eligibility only or if you need both eligibility and pre-authorization:
Your call will be handled as it is today. You will select the option to obtain eligibility and pre-authorization information. BlueCard will handle your eligibility inquiry first, then transfer you to the appropriate pre-authorization area.
Request for a duplicate 1099
Do you believe you should have received a 1099 from Blue Cross and Blue Shield of New Mexico (BCBSNM) and have not received one?
You may request a duplicate 1099 by sending your request to the BCBSNM Finance Department in our Texas-based office via the following:
• E-mail address: 1099Inquiries@bcbstx.com
• Fax #: 972-766-4360
Your request should include the following information:
• Physician/group name
• Tax identification number
• Correct mailing address
• Contact name and contact number
Questions regarding your 1099 should be directed to our Finance Department at 972-766-6623.
Note: If you have less than $600.00 in claims payments, the IRS does not require that we supply you with a 1099.
BlueSaludSM
BlueSalud Preferred Drug List
BlueSalud providers must use the BlueSalud Drug List when prescribing medications for their BlueSalud patients. BlueSalud will usually only cover drugs that are on the list. We will send a copy of the Drug List to you at your request, or you can view it on our website.
Reviewing this list before writing a prescription for BlueSalud members will prevent problems when BlueSalud members have their prescriptions filled. The pharmacy will not be able to fill the member’s prescription if it is for a drug that is not on the list. Providers must request approval from BCBSNM for any drugs not on the Drug List. This request will be approved only if medicines on the Drug List have been used without success or cannot be used for the member’s condition.
