March 2015 Please distribute this newsletter, which contains claims, billing, Medical Policy, reimbursement, and other important information, to all health care providers, administrative staff, and billing departments/entities that this email address represents.
You can find Blue Review online! Ideas for articles and letters to the editor are welcome; email NM_Blue_Review_Editor@bcbsnm.com
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Maintaining up-to-date contact and practice information helps to ensure that you are receiving critical communications and efficient reimbursement processes. Please complete our quick and easy online form if you have: - Moved to another location
- Left a group practice
- Changed your phone number
- Changed your email address
- Retired
- Any other changes to your practice information
Medical Policy Updates
Approved new or revised Medical Policies and their effective dates are usually posted on our website the first and fifteenth of each month. These policies may impact your reimbursement and your patients’ benefits. On our website, you may view active, pending and updated policies and/or view draft policies and provide comments. The policies are located under the Standards & Requirements tab at bcbsnm.com/provider Provider Reference Manual Updates
The Blues Provider Reference Manual on our website is updated throughout the year. Any updates that have occurred so far this year are located in the Table of Contents with Changes and Updates Preface page. Please note that these changes might not be current in the print and CD ROM versions; always refer to bcbsnm.com for the most current information. Diagnosis and Medical Management of Sleep-Related Breathing Disorders – Revised Medical Policy Reminder
Recently, we announced a change to the Blue Cross and Blue Shield of New Mexico (BCBSNM) Medical Policy for Diagnosis and Medical Management of Sleep Related Breathing Disorders (MED205.001) that will take effect for services rendered on or after May 1, 2015. This policy has been revised to establish new criteria and guidance for testing in the diagnosis of Obstructive Sleep Apnea (OSA). The revised policy is intended to align BCBSNM’s Medical Policy with nationally recognized clinical criteria and current industry standards.
View full story Tobacco Cessation: Coverage Expanded to Include Approved Medications
Tobacco cessation counseling and screening for adult members who use tobacco products are covered benefits under the Affordable Care Act (ACA). As of Sept. 1, 2014, BCBSNM expanded coverage for eligible members to include two 90-day treatments for tobacco cessation medications per benefit period with no cost-sharing. This coverage includes certain U.S. Food and Drug Administration (FDA) approved tobacco cessation drugs. In order for benefits to be considered for coverage, the patient must present a prescription from an in-network provider according to the member’s benefit plan. A prescription also is required for approved over-the-counter drugs. A new flyer is available to help educate our members about tobacco cessation preventive services under ACA. If you are interested in viewing or sharing this flyer with your patients who use tobacco products, visit the Standards and Requirements/Affordable Care Act/Patient Perspective section of our website. The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider. 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. Blue Cross and Blue Shield of New Mexico 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 505-816-2092. All medical policies are available for review online in the Standards & Requirements section of our website. Member Rights and Responsibilities
Our health plan members have rights and responsibilities that are listed in their Benefit Booklet or Member Handbook. Providers can locate member rights and responsibilities in the Section 7 of the Blues Provider Reference Manual. 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 Services contacts and related service areas Network Services regional map New and Established Patients – Understanding When to Use Patient E/M Codes
According to the Current Procedural Terminology (CPT®) codebook, there are two subcategories of office visits: new patient and established patient. Claims submitted to BCBSNM are sometimes inappropriately coded where new patient codes are billed repeatedly for the same patient.
View full story Identification Card Changes for Exchange Members
Identification cards for BCBSNM exchange members are being revised to indicate the member responsibility. Currently, the ID cards indicate the BCBSNM responsibility. New ID cards will be sent to members on or after February 23, 2015. Below is an example of the new ID card for your reference. 
ClaimsXtenTM Updates – 1st Quarter 2015
BCBSNM reviews new and revised Current Procedural Terminology (CPT®) and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson and are not considered changes to the software version. BCBSNM will normally load this additional data to the BCBSNM claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSNM Provider website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will continue to be posted on the BCBSNM Provider website.
View full story Providers who have Joined or Left the BCBSNM Network, January 2015
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care.
View full story Blue Cross Community CentennialSM (Medicaid) Not yet contracted?
Blue Cross and Blue Shield of New Mexico’s (BCBSNM’s) Medicaid plan is Blue Cross Community Centennial. Providers who are participating in commercial BCBSNM products are not automatically participating providers in Blue Cross Community Centennial. To become a Blue Cross Community Centennial provider, you must sign a Medicaid amendment to your Medical Services Entity Agreement (MSEA). If you have any questions please call 505-837-8800 or 1-800-567-8540 if you are interested in becoming a Blue Cross Community Centennial provider.
Reminder: Update Your Enrollment Information
Due to Centennial Care requirements, all enrollment information (changes to demographics, licensure or certification, provider status, etc.) must be updated on the NM Medicaid Provider Web Portal. Medicaid Drug List Updates Pharmacy Preauthorization Fax Number Change
To better streamline our pharmacy preauthorization process, a new fax number has been implemented. The new fax number is 505-816-3867. The current number of 505-816-3853 will still be in service for a short period of time but will eventually be turned off. Please begin using the new number for pharmacy preauthorization requests for Medicaid members.
Free Continuing Education!
Diabetes continuing education is available for you and your staff; links to free professional development opportunities are now on the BCBSNM provider website under Clinical Resources/Diabetes Guidelines.
View full story Importance of Advance Directives
Advance directives (AD) allow competent individuals to direct and document their preferences about future health care treatments and interventions. The Patient Self-Determination Act of 1991 requires that individuals be advised of their right to participate in health care decisions as well as their right to execute advance directives. Ideally, the discussion about AD should occur when an individual is healthy, which makes the primary care office an ideal setting for AD discussion. While studies have shown that primary care providers (PCPs) think that discussing AD will make their patients uncomfortable, studies have also shown that PCP initiation of advance care planning discussions has a positive effect on patients completing AD.
View full story Morphine Equivalent Dose (MED): New Pharmacy Safety Program for Blue Cross Community Centennial Members
Effective Jan. 1, 2015, new edits have been added to the BCBSNM pharmacy claims system to ensure safe use of opioids. This new edit will allow a maximum of 240 mg Morphine-Equivalents per day. Pharmacies will receive the following message when they fill a prescription that exceeds 240mg MED: ➢ High Risk Opiate Use. Morphine Equivalent Dose >240mg. Prior Auth Required. Pharmacists may discuss the situation with the member directly OR call the BCBSNM Pharmacy Department about the edit. If a member requires a dose that exceeds 240mg MED, please submit a Drug Prior Authorization Request Form to BSBSNM for review.
Reminder: Medicaid Preauthorization Requirements
Blue Cross and Blue Shield of New Mexico would like to remind our contracted providers of the preauthorization requirements to be considered prior to scheduling care for Blue Cross Community Centennial members. Refer to Health Care Management in the Blue Cross Community Centennial section of the Blues Provider Reference Manual for services requiring preauthorization. Such services are funded in part with the State of New Mexico. Blue Cross and Blue Shield 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 Blue Cross Medicare AdvantageSM Participation Requirements
To participate in Blue Cross Medicare Advantage, the provider or facility:
View full story Blue Cross Medicare Advantage and Blue Cross Medicare Advantage Dual Care plans are HMO, HMO-POS, PPO, and HMO Special Needs Plans provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract and a contract with the New Mexico Medicaid program. Enrollment in HCSC’s plans depends on contract renewal. | 