April 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
Do we have your correct information?
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 High-tech Radiology Management Program Change, Effective April 1, 2015
Effective April 1, 2015, Blue Cross and Blue Shield of New Mexico (BCBSNM) no longer requires providers to obtain Radiology Quality Initiative (RQI) numbers through AIM Specialty Health® (AIM) prior to ordering outpatient, non-emergency high-tech diagnostic radiology services for BCBSNM members. While obtaining RQI numbers through AIM is no longer required prior to ordering high-tech radiology services for these members, providers should continue to follow BCBSNM Medical Policy criteria when applicable. There may be members residing in New Mexico that carry membership cards from Blue Cross and Blue Shield plans that are out of state. These plans may require an RQI from AIM for these services. As always, checking eligibility and benefits is an important first step to verify any additional requirements. AIM Specialty Health (AIM) is an operating subsidiary of Anthem. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors, such as AIM. If you have any questions about the products or services they offer, you should contact the vendor(s) directly. Please note that the fact that a guideline is available for any given treatment, or that a service has been pre-certified or an RQI number has been issued is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Certain employer groups may require pre-certification for imaging services from other vendors. If you have any questions, please call the number on the back of the member's ID card. Now Available Online: Behavioral Health Coordination of Care Form
The Blue Cross and Blue Shield of New Mexico (BCBSNM) Behavioral Health Care Management team continually strives to promote coordination of member care between medical and behavioral health providers. We understand that communication between providers regarding the treatment and coordination of a patient’s care can pose difficult challenges. To provide assistance when coordinating care, BCBSNM has created a Coordination of Care form that is now available on our Provider website.
View full story Medical Policy Update Reminder: Diagnosis and Medical Management of Sleep-Related Breathing Disorders
An important change to the BCBSNM Medical Policy for Diagnosis and Medical Management of Sleep Related Breathing Disorders (MED205.001) will take effect for dates of service 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).
View full story Provider Education Webinars Available
BCBSNM offers complimentary educational webinar sessions for our provider community and their staff. Some of the current training modules are:
View full story Preventive Care Guidelines for Clinicians
BCBSNM publishes and disseminates evidence-derived Preventive Care Guidelines based upon the recommendations of recognized sources such as professional medical associations, medical specialty societies, professional consensus panels, national task forces, and governmental entities. The guidelines are designed to improve physician/practitioner awareness of (and compliance with) effective clinical preventive care, to improve patient education, and to increase the percentage of members who receive recommended clinical preventive care services. The most recent guidelines are available on our website under the Clinical Resources tab.
View full story When our members speak, we listen!
BCBSNM conducts the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) combined HMO/PPO survey once a year. The survey is a random sample of PPO and HMO members. A total of 1541 members were requested to participate in the survey. Members could return their survey either electronically via the internet, standard mail or they were given the opportunity to conduct the survey over a phone call with a trained telephone interviewer. In 2014, our response rate (the percentage of members in the sample who returned a completed survey) was 31% which was on par with the previous year. Many of the measures results were similar to 2013. Here are the highlights for the 2014 Survey.
View full story Findings from the 2014 Annual HEDIS® Audit
Commercial members
Using the nationally standardized Healthcare Effectiveness Data and Information Set (HEDIS), we were able to assess how the quality of our members’ health care compared to the previous year and to the national averages. As shown in the table below, our commercial members are either meeting or exceeding last year’s rate. We have highlighted three measures where we have exceeded the national average:
View full story New Member Education Campaign Focuses on Level of Care Options
A BCBSNM analysis of claims activity has shown increased utilization of emergency room services for non-emergent diagnoses. This may indicate that some of our members are selecting the ER as their first choice for care even when other settings may be more clinically appropriate.
View full story 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 CMS Reports Preliminary ICD-10 Testing Results
ICD-10 Testing Begins this Month at BCBSNM
The Centers for Medicare & Medicaid Services (CMS) has announced successful completion of the first of three ICD-10 end-to-end testing weeks. In an MLN Connects® Provider eNews article posted on its website on Feb. 25, 2015, CMS reported that approximately 660 health care providers, billing services and other stakeholders participated in the first round of testing, which was conducted Jan. 26, 2015, through Feb. 3, 2015.
View full story 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). After hours callers can leave a message and receive a call back the next business day. - For Commercial members, call 800-325-8334
- For Medicaid members, call 877-232-5518
- For Medicare members, call 877-774-8592
A Medical Director is available to address care management requests with providers at 505-816-2957.
When calling your office, Health Services staff members identify themselves as BCBSNM employees and give their names and titles. TTY/TDD and language translation services are available for callers who may need assistance. Appropriate Use of Modifier 50
This article provides general guidelines to help assist you with proper use of modifier 50 when submitting professional claims to BCBSNM. Also included are reminders on appropriate use of HCPCS Level II RT and LT modifiers, which should not be used when modifier 50 applies.
View full story Providers Who Have Joined or Left the BCBSNM Network, February 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?
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 Now Available! Provider Toolkit: Putting Quality First
BCBSNM is pleased to introduce the Quality Provider Toolkit. The toolkit contains a collection of concise resource tools for the busy provider. Topics include: ✔ Quality health standards which promote best health practices
✔ Screening for clinical depression resource tool
✔ Key documentation points*
✔ Corresponding billing codes for easy and accurate billing
✔ Centennial Rewards program information about member incentives to promote healthy choices (pregnancy, diabetes, asthma, dental) Go to the Network Participation/Medicaid tab on the bcbsnm.com website, and then click on “Quality Toolkit” to download your Provider Toolkit. You may also call 1-855-699-0042 option 2 to request a toolkit in a folder with laminated pages. *Key documentation points comply with State and Federal auditing requirements. 2014 Medicaid Medical Record Review Report
Data Collection Process
The Medical Record Review is performed to assess provider compliance with the Blue Cross Community Centennial medical record documentation standards. The results are reported to internal key parties annually for analysis and recommendations for future action. During the period January 1, 2014 – February 9, 2015, 238 medical records were reviewed for 49 providers at 9 office sites of primary care providers, OB-GYN providers, and behavioral health providers who delivered services to Blue Cross Community Centennial members during 2014. Each provider had 1-5 member charts reviewed based on claims data. The results were impressive and are shown in the table below:
View full story 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 | 