August 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. Additionally, the Centers for Medicare & Medicaid Services require Blue Cross and Blue Shield of New Mexico (BCBSNM) to make sure that our online Provider Finder® and provider directory are kept current with our provider demographic information. 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. Commercial Drug List Updates Join Us for an iExchange® Webinar
BCBSNM continues to enhance iExchange, our Web-based benefit preauthorization tool. iExchange supports online submission and electronic approval of benefits for inpatient admissions and select outpatient services such as pharmacy and behavioral health. This flexible tool enables you to send benefit preauthorization requests 24 hours a day, 7 days a week and provides real-time responses. View full story The Operator of BCBSNM Named One of America’s Most Community-Minded Companies
The Civic 50 has honored us for our work to improve health and wellness in our local communities. View full story The Critical Importance of Care Coordination
Blue Cross and Blue Shield of New Mexico (BCBSNM) performs an annual Provider Satisfaction Survey. The survey includes items about continuity and coordination of care in order to help ensure members are attaining the highest quality of care possible, which depends largely upon communication between specialists, hospitals, and PCPs. Our goal is to see statistically significant increases in provider satisfaction with coordination of care.
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. View full story Preventive Care and Medical and Behavioral Health Clinical Practice Guidelines
BCBSNM Preventive Care Guidelines and medical and behavioral health Clinical Practice Guidelines are available in the Clinical Resources section of our website at bcbsnm.com/provider
View full story
BCBSA Report Highlights Dramatic Increase in Specialty Drug Spending
Spending on medications used to treat chronic health conditions such as cancer and hepatitis C rose 26 percent across most Blue Cross and Blue Shield (BCBS) companies* from 2013 to 2014 – similar to a national spending rate that is expected to quadruple within four years, according to a new Blue Cross and Blue Shield Association (BCBSA) Health of America report
View full story New CDC Guidelines for Prescribing Opioids for Chronic Pain, Part 1
Part 1 of a 3-part series describing the CDC guidelines for prescribing opioids
In March 2016, the Centers for Disease Control and Prevention (CDC) issued new recommendations for prescribing opioid medications for chronic pain, excluding reasons for cancer, palliative and end of life care. These recommendations were in response to an increased need for provider education due to a nationwide epidemic of opioid overdose and opioid use disorder. View full story CDC Guidelines for Prescribing Opioids for Chronic Pain, Part 2
Part 2 of a 3-part series describing the new CDC guidelines for prescribing opioids
In March of 2016, the Centers for Disease Control and Prevention (CDC) issued new recommendations for prescribing opioid medications for chronic pain, excluding reasons for cancer, palliative and end of life care.1 These recommendations were in response to an increased need for provider education due to a nationwide epidemic of opioid overdose and opioid use disorder. View full story New Mexico Statewide Pharmacy Standing Order for Naloxone
New Mexico had the second highest overdose death rate in the nation in 2014. The majority of overdose deaths involved heroin or a prescription opioid. The New Mexico Department of Health (NMDOH) recognizes the complex and difficult nature of opioid dependence and addiction. Overdose prevention strategies must be wide-reaching and multifaceted. Expanding access to naloxone is one of several overdose prevention strategies aimed at combating this major public health issue. View full story 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 provider inquiries about many areas, including eligibility, benefits, and claim adjustments 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 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. Remittance Viewer Introduction – New Training Sessions Available!
The remittance viewer offers providers and billing services a convenient way to view and help reconcile claim data provided by Blue Cross and Blue Shield of New Mexico in the 835 Electronic Remittance Advice (ERA)
Register for an upcoming Introducing Remittance Viewer online training session.
Upcoming dates and times are available here. iExchange® Now Accepts Electronic Medical Record Attachments
We are pleased to announce that enhancements have been made to iExchange, our online tool that supports online benefit preauthorization requests for inpatient admissions, medical, behavioral health and clinical pharmacy services. Effective July 1, 2016, iExchange now accepts electronic medical record attachments when necessary in support of benefit preauthorization requests. Electronic medical record documentation also may be submitted via iExchange for predetermination of benefit requests. With these enhancements, iExchange offers providers and facilities a secure, online alternative to faxing their patients’ protected health information.
View full story Corrected Claim Request Alert: Changes Effective July 11, 2016
Effective July 11, 2016, corrected claim requests for previously submitted electronic and paper claims can no longer be initiated by calling Provider Customer Service. View full story Electronic Option to Replace Duplicate Provider Claim Summary Requests
Effective July 11, 2016, duplicate copies of paper Provider Claim Summaries (PCSs) may no longer be requested by calling Provider Customer Service, and duplicate PCSs will no longer be provided by our Customer Advocates. View full story Providers Who Have Joined or Left the BCBSNM Network, August 2016
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care. View full list 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 Medicaid Reminders
Federal requirements for Medicaid health plans specify that certain benefits and services be available to Medicaid members. These include: - Women are allowed direct access to in-network women's health specialists for covered routine and preventive health services.
- Medicaid members are allowed a second opinion from an in-network provider. If an appropriate in-network provider is not available, members are allowed to obtain a second opinion outside of the network.
- If a health plan is unable to provide a necessary and covered service to a Medicaid member in-network, it must adequately and timely cover these services out-of-network, for as long as the health plan is unable to provide the service. In addition, the health plan will coordinate payment with the out-of-network practitioner and ensure that the cost to the member is no greater than it would be if the service was provided in-network. Pre-authorization is needed for a member to see an out-of-network practitioner.
- The hours of operation provided by practitioners to Medicaid members is no less than those offered to commercial members.
For more information about Medicaid requirements and policies, please visit the provider portal on the New Mexico Human Services Division website. Free Diabetes Continuing Education!
Diabetes continuing education is available for you and your staff. Visit BCBSNM's Diabetes Guidelines and Resources page for updated information and links to continuing education opportunities offered by the American Diabetes Association. View full story New Blue Cross Community Centennial Pharmacy Contact Information
Effective July 15, 2016, the current Blue Cross Community Centennial Pharmacy phone number, (855) 699‑0040, and fax number, (505) 816-3867, will be discontinued. Please use the contact information below going forward. View full story Enteral Nutrition Covered Benefit Changes
BCBSNM requires preauthorization for enteral nutrition benefits. Effective August 1, 2016, preauthorization requests must be submitted to the fax or phone numbers listed below. Once benefits are approved, enteral nutrition must be billed as a medical claim following HCPCS billing procedures and are to be billed as billable units, which is unique to each HCPCS code. View full story Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program
EPSDT is a federally mandated program ensuring comprehensive health care to Medicaid recipients from birth to 21 years of age. View full story Blue Cross Medicare AdvantageSM
Medicare Resources
The Blue Cross Medicare AdvantageSM Plans offer all of the coverage of Original Medicare — plus benefits not covered by Medicare or most Medicare Supplement insurance plans, including built-in prescription drug coverage. View full story | 