January 2016 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.
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 Annual Medical Record Data Collection for Quality Reporting begins Feb. 1, 2016
Blue Cross and Blue Shield of New Mexico (BCBSNM) collects performance data using specifications published by the National Committee for Quality Assurance (NCQA) for Healthcare Effectiveness Data and Information Set (HEDIS®) and by the U.S. Department of Health and Human Services (HHS) for the Quality Rating System (QRS). HEDIS is the most widely used and nationally accepted effectiveness of care measurement available and HHS requires reporting of QRS measures. These activities are considered health care operations under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule and patient authorization for release of information is not required.
View full story. Implementation Reminder: Three New Facility Rules for ClaimsXten™, Effective Feb. 22, 2016
Listed below are details regarding three new facility rules that were originally scheduled to be added to our claims processing system effective Oct. 12, 2015, as an enhancement to our ClaimsXten code auditing tool. Please note that the deployment of these rules has been postponed to on or after Feb. 22, 2016. A notice regarding this change in effective date was published in the News and Updates section of our Provider website on Oct. 2, 2015.
View full story. Pharmacy Program Benefit Changes – Effective January 1, 2016
Blue Cross and Blue Shield of New Mexico (BCBSNM) will be implementing pharmacy benefit changes as of Jan. 1, 2016, for some members with prescription drug benefits administered through Prime Therapeutics.*
View full story. Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2016
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 were made to the BCBSNM standard drug list and generics plus drug list effective January 1, 2016.
View full story. Providers Who Have Joined or Left the BCBSNM Network, December 2015
This list reflects contracted providers for all lines of BCBSNM business: Commercial, Medicaid managed care, and Medicare Advantage Prescription Drug (MAPD).
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. Reduction in Prior Authorization Requirements
Blue Cross and Blue Shield of New Mexico (BCBSNM) is pleased to announce that we have significantly reduced the prior authorization requirements for Blue Cross Community Centennial members effective January 1, 2016. This reduction in the prior authorization requirements is a reflection of our continuous efforts to ease the administrative burden on our contracted health care providers and addresses an area of opportunity for improvement from our most recent provider satisfaction survey results. The full list of Blue Cross Community Centennial services requiring prior authorization is available on our website at bcbsnm.com/provider. Updates to Drug List Limitations, Exclusions and Preauthorization Criteria
Blue Cross and Blue Shield of New Mexico (BCBSNM) has updated the Preauthorization Criteria Document that applies to Blue Cross Community Centennial members. Please pay special attention to the revised Hepatitis C Therapies/Provider Checklist section. 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 Provider Medicare Enrollment Information
An enrollment information message from the Centers for Medicare & Medicaid Services (CMS) may have been sent to you recently if you currently prescribe drugs to Medicare patients but are not enrolled in (or validly opted out of) Medicare. A new requirement that CMS will begin enforcing on June 1, 2016, requires that all providers who prescribe drugs for Part D patients must enroll in Medicare (or validly opt out, if appropriate). This is important to providers because unless you enroll (or validly opt out), Medicare Part D plans will be required to notify your Medicare patients that you are not able to prescribe covered Part D drugs. Please also note that if you opt out of Medicare, you cannot receive reimbursement from traditional Medicare or a Medicare Advantage plans, either directly or indirectly (except for emergency and urgent care services; see 42 CFR 405.440 for details.) Please refer to the CMS letter on bcbsnm.com/provider for more information on this requirement for enrollment (or to validly opt out). CMS contact information is also included in the letter if you have questions regarding this regulation.
2015 to 2016 Medicare Part D Formulary Changes
Blue Cross MedicareRx (PDP)SM / Blue Cross Medicare Advantage (HMO)SM /
Blue Cross Medicare Advantage (HMO-POS)SM / Blue Cross Medicare Advantage (PPO)SM /
Lovelace Medicare Plan (HMO) / Lovelace Medicare Plan Enhanced (HMO-POS)
Based on CMS mandates (i.e., safety concerns, drugs that no longer meet the CMS definition of a “Part D medication,” etc.) and a regular review of changes in the pharmaceutical marketplace, the Blue Cross MedicareRx/Blue Cross Medicare Advantage 2016 Part D plans will have formulary and utilization management changes for 2016.
View full story. Blue Cross Medicare Advantage plans are HMO and PPO 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. Enrollment in HCSC’s plans depends on contract renewal. | 