December 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.
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 Avoiding Administrative Claim Denials
Blue Cross Medicare AdvantageSM (BCMA) Health Plan wants to help you avoid administrative claim denials. To prevent denials from occurring, a list of administrative claim denials that providers may receive has been created, along with tips on how to avoid them. The table below has been created as a tool to help you avoid administrative claim denials. Read more Coordination of Care Between Medical and Behavioral Health Providers Blue Cross and Blue Shield of New Mexico (BCBSNM) 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. Read more CMS Compliance Program Training Requirements
Per the CMS Memo 4642 released in January 1, 2016, all Managed Care Organizations (MCOs) and their vendors identified as First Tier, Downstream and Related Entities (FDRs) are required to complete CMS’s compliance trainings. Read more CVP Implementation Notice
Blue Cross and Blue Shield of New Mexico (BCBSNM) will be implementing a secondary code auditing software starting March 2017. This software will audit professional and outpatient facility claims for correct coding as outlined by AMA CPT coding guidelines and CMS. Auditing will be done on professional claims within the following categories. Read more Provider Payment and Provider Credentialing Requirements
The New Mexico Office of Superintendent of Insurance finalized a new rule effective Jan. 1, 2017, pertaining to provider payment and provider credentialing requirements which is codified in Part 28, Chapter 10, Title 13 of the New Mexico Administrative Code. The stated objectives of this new rule are to establish a uniform and efficient provider credentialing, ensure that providers receive prompt payment from health carriers for clean claims and interest on unpaid claims, and establish a process for resolving payment-related credentialing disputes between health carriers and providers.
Please refer to the following link for a copy of the Final Order adopting the new rule: http://www.osi.state.nm.us/MiscPages/docs/finalorders/15-00026-RULE-LH.pdf Enroll Now Through AvailityTM for Electronic Payment and Remittance Options Did you know providers can enroll and make necessary changes to the Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) set up through the Availity Web portal? Read more Annual Medical Record Data Collection for Quality Reporting begins Feb. 1, 2017
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. Read more Reminder: Phone System Update for Eligibility and Benefits Several benefit categories have been evaluated in the Blue Cross and Blue Shield of New Mexico (BCBSNM) Interactive Voice Response (IVR) phone system. This evaluation confirmed that the IVR adequately quotes the same level of information a Customer Advocate would provide. As a result, beginning Dec. 12, 2016, the option for Customer Advocate assistance will be removed from the call flow for common benefit categories.
BCBSNM strongly encourages providers to check patient eligibility and benefit information prior to every scheduled appointment, and having quick access to this data is imperative. The fastest and most efficient way to obtain eligibility and benefits information is electronically through Availity, or your preferred Web vendor. Taking advantage of electronic options allows retrieval of needed information at your convenience. If eligibility and benefits are unable to be verified online, the same information is often readily accessible through our IVR phone system. In addition, a confirmation number will be provided for your records, after the phone system has completed the quote. To learn more about obtaining eligibility and benefits electronically, join us for a complimentary Back to Basics: “Availity 101” Webinar. Visit the Training page in our online Education and Reference Center for additional information, or select a session date and time below to register now: Dec. 1, 2016 – 11 a.m. to noon, CT
Dec. 8, 2016 – 11 a.m. to noon, CT
Dec. 15, 2016 – 11 a.m. to noon, CT
Dec. 22, 2016 – 11 a.m. to noon, CT For more advanced training on online tools and resources, email our Provider Education Consultant team at PECS@bcbsnm.com. Checking eligibility and/or benefit information 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. If you have questions, please call the number on the member’s ID card. Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly. Opiates
It has been shown that people who use opiates at daily doses greater than 100 to 120 morphine equivalents have a substantially higher risk of accidental overdose when compared with patients receiving less than a 100 to 120 morphine equivalents per day.1-5 Therefore, as of Jan. 1, 2017, BCBSNM Centennial Care members will be subject to a Morphine Equivalent Dose (MED) quantity limit of 120 mg per day over a rolling 90-day period. Patients who require quantities of opiates at doses exceeding 120 MED per day, over a 90-day period, will need to obtain prior authorization. Read more Enrollment Needed for Providers Prescribing to Medicare Patients If you are a provider who currently prescribes drugs for Medicare patients, but who is not enrolled in (or validly opted out of) Medicare, because of a new Medicare requirement, it is crucial for your patients’ health that you enroll in Medicare (or validly opt out, if appropriate). As soon as possible, please follow the below steps. A delay on your part could result in your Medicare patients not being able to obtain drugs you prescribe for them. Read more
Changes to the Claim Review Form The paper Claim Review Form for Blue Cross and Blue Shield of New Mexico (BCBSNM) has been updated to simplify the process for providers when submitting written claim inquiries. Read more 2016 Medical Record Review
Blue Cross and Blue Shield of New Mexico’s (BCBSNM’s) Quality Improvement Department performs an annual medical record review to assess whether practitioners and practice groups meet the minimum New Mexico Administrative Code (NMAC) and Human Services Department (HSD) medical record documentation standards for our Blue Cross Community CentennialSM members. Medical records are also evaluated according to BCBSNM standards. Read more Obtaining Provider Claim Summaries Online Starting Dec. 12, 2016, independently contracted Blue Cross and Blue Shield of New Mexico (BCBSNM) providers will have access to a new report viewer application in the Availity Payer Spaces section of the Availity Web Portal. This report viewer will give Availity users the ability to view, download, save and/or print the Provider Claim Summary (PCS). Read more Obtaining Patient Eligibility and Benefits: Phone System Update
Several benefit categories have been authenticated in the Blue Cross and Blue Shield of New Mexico (BCBSNM) Interactive Voice Response (IVR) phone system. This validation supports a complete IVR quote of eligibility and benefits, with the same level of information a Customer Advocate would provide. For this reason, the option for Customer Advocate assistance has been removed from the call flow for these common benefit categories.
Verification of patient information is strongly encouraged prior to every scheduled appointment and we know that for your practice, having quick access to this data is imperative. The fastest way to obtain patients’ eligibility and benefit information is electronically through Availity™, or your preferred Web vendor. Taking advantage of electronic options allows retrieval of needed information in real-time in most instances.
If eligibility and benefits are unable to be verified online, the same information is often readily accessible through our IVR. A confirmation number will be provided for your records, after the phone system has completed the quote.
For more information, refer to the Claims and Eligibility/Eligibility and Benefits section. For assistance with verification via phone, refer to the Eligibility and Benefits IVR Caller Guide  , found in the same section.
Checking eligibility and/or benefit information 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. If you have any questions, please call the number on the member’s ID card.
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly. Provider Claim Summary Paper Conversion Coming March 1, 2017 Blue Cross and Blue Shield of New Mexico (BCBSNM) recognizes immediate access to the Provider Claim Summary (PCS) is vital for posting patient accounts and reconciling financials. Often times providers who receive this information via post office mail are waiting on delivery, which delays administrative processes. Read more Appointment Availability and Access Guidelines As a contracted BCBSNM provider, the following appointment availability and access guidelines should be used to ensure timely access to medical and behavioral health care for our BCBSNM membership. Read more BCBSNM Vision Plan Transitions to EyeMed - Revisions
Effective Jan. 1, 2017, Blue Cross and Blue Shield of New Mexico (BCBSNM) members will transition from Davis Vision to EyeMed Vision Care. This impacts BCBSNM members with the voluntary plan (premier or preferred), pediatric members (in individual, small group and student health markets) and Blue Cross Medicare AdvantageSM members. In November, we sent letters to affected members notifying them of the new vision vendor. With EyeMed Vision Care, the member also receives discounts on eyewear materials in addition to the funded benefit. Should you have any questions regarding this transition, please contact your BCBSNM Provider Network Representative for assistance. For all other BCBSNM members, providers for vision care could vary. Contact the customer service number on the back of the member’s ID card to verify the member’s vision benefits.
Medicaid only
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.
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 | 