July 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.
Keep up-to-date with the latest news and updates!
Along with all the valuable information included in our Blue Review newsletter, the News and Updates section of our website gives the latest updates in webinar schedules, current programs, and policies. The eCommerce Alerts section provides notification of system enhancements, upgrades, new functionality, and any Electronic Data Interchange (EDI) transaction issues that may affect claims processing, payment, or remittance delivery. We periodically update the forms on our provider website, so it’s important to check often to help ensure you are using the most current version. Forms are organized by category in our Education and Reference section. Be sure to visit us online at bcbsnm.com/provider to access the most updated information. Pharmacy Program Updates: Upcoming Pharmacy Changes Effective July 1, 2015
STANDARD DRUG LIST (FORMULARY) CHANGES
Based on the availability of new prescription medications and the Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions will be made to the Blue Cross and Blue Shield of New Mexico (BCBSNM) standard drug list effective July 1, 2015.
Read more Tips to Help Your Patients Improve Medication Adherence
Using the GuidedHealth® clinical rules platform to review BCBSNM claims data, patients with BCBSNM pharmacy benefits are identified as potentially non-adherent to an antiviral, cholesterol, diabetes, depression, hypertension and/or respiratory prescription drug. Informational letters are sent on a quarterly basis to prescribing providers of these identified members to help increase awareness and promote patient safety.
Read more 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 Claim Status Option to Exit Automated Phone System, Effective July 13, 2015
As announced previously, effective July 13, 2015, claim status will no longer be available through the BCBSNM interactive voice response (IVR) phone system.
Read more Join Us for a Webinar: Using ICD-10 in Online Benefit Preauthorization Requests
Blue Cross and Blue Shield of New Mexico (BCBSNM) will be offering educational webinars through September 2015 to demonstrate the differences you may encounter when using ICD-10 codes in iExchange®, our online benefit preauthorization tool. Select a date from the list below to register now for an iExchange ICD-10 Enhancements webinar. July 22, 2015 – 1 to 2 p.m., MT
Aug. 12, 2015 –10 to 11 a.m., MT
Sept. 16, 2015 – 1 to 2 p.m. MT Please note that the fact that a guideline is available for any given treatment, or that a service has been preauthorized/pre-certified 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 applicable on the date services were rendered. ICD-10: It’s Really Happening
The transition to ICD-10 is federally mandated. The compliance deadline is Oct. 1, 2015. As of the compliance deadline, claims without valid ICD-10 codes, as required, will not be accepted by BCBSNM. Use of ICD-10 also affects eligibility and benefits requests, preauthorization, electronic health records, referrals and other processes. Are you ready? Are you sure? Take action now. Visit the Standards and Requirements/ICD-10 section of our website at bcbsnm.com/provider for readiness tips and educational resources. It’s Not Too Late to Enroll for ICD-10 Testing with BCBSNM
If you submit electronic claims, confirming ICD-10 readiness with your software vendor, billing service and/or clearinghouse is just the first step. End-to end or “round-trip” testing with payers is necessary to help ensure your claims will make a successful journey from start to finish. The best place to encounter issues is within the test environment while there is still time to resolve them. The testing process also offers you and your staff the opportunity to practice coding with ICD-10.
Read more ICD-10: Quick Facts and Resource Reminders
The U.S. Department of Health and Human Services (HHS) published a final ruling in early August 2014, confirming an Oct. 1, 2015, mandated transition to ICD-10. As of this compliance deadline, all Health Insurance Portability and Accountability Act (HIPAA) covered entities must use ICD-10 on claims and other health care transactions.
Read more Important Notice Regarding Billing for Point of Use Convenience Kits
BCBSNM periodically reviews claims submitted by providers to help ensure that benefits provided are for services that are included in our member’s benefit plan and meet BCBSNM’s guidelines. Some providers are submitting claims for point of use convenience kits that are used in the administration of injectable medicines. These prepackaged kits contain not only the injectable medicine, but also non-drug components including, but not limited to, alcohol prep pads, cotton balls, band aids, disposable sterile medical gloves, povidone-iodine swabs, adhesive bandages and gauze. Typically, the cost of convenience kits exceeds the cost of its components when purchased individually. Non-drug components included in the kits are inclusive of the practice expense for the procedure performed for which no additional compensation is warranted. Effective Oct. 1, 2015, reimbursement for these point of use convenience kits will be reduced. Services should be provided in the most cost effective manner and in the least costly setting required for the appropriate treatment of the member. Modifier 25 Reminders
The Current Procedural Terminology (CPT®) codebook defines Modifier 25 as a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”
Read more Providers Who Have Joined or Left the BCBSNM Network, May 2015
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care.
Read more 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.
Pharmacy Preauthorization Criteria Updates
There are updates to the pharmacy preauthorization criteria for Blue Cross Community Centennial. Visit the Pharmacy Program section of our website to view the updates.
Health Risk Assessment
As many of you know, a healthy lifestyle is about more than being reactionary. If we are to be as healthy as possible, we need to be proactive. This means looking at an overall picture of our health. For our members and patients, taking a look at themselves by answering some basic questions is a way to be involved. These questions come in the form of the Health Risk Assessment, also known as an “HRA”. The HRA helps Blue Cross Community Centennial determine just where a member has the most need of services. These services include assistance with food, utilities, transportation, housing… even environmental modifications in some cases. Blue Cross Community Centennial Care Coordinators may even assist in managing a member’s medical visits. The HRA also helps Blue Cross Community Centennial ensure that our members are receiving the medical care they need. 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 | 