Blue Cross and Blue Shield of New Mexico

March 2017

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

ClaimsXtenTM Quarterly Updates

New and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes are periodically added to or deleted from the ClaimsXten code auditing tool software by the software vendor on a quarterly basis and are not considered changes to the software version. Read more

How are You Diagnosing Hypertension?

“High blood pressure is a prevalent condition, affecting approximately 30% of the adult population. It is the most commonly diagnosed condition at outpatient office visits. High blood pressure is a major contributing risk factor to heart failure, heart attack, stroke, and chronic kidney disease. In 2010, it was the primary or contributing cause of death for more than 362,000 Americans.” Read more

AvailityTM Claim Research Tool Offers Enhanced Status Results

Using an electronic route, such as the Availity Claim Research Tool (CRT), is the most convenient, efficient and secure method of requesting detailed claim status. The Availity CRT now returns more detailed information than ever before! Read more

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 these 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.

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. BCBSNM 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.

Kicking the Habit: Helping to Overcome Opioid Addiction in America

More Americans are getting caught in a growing web of addiction to opioids – powerful narcotics that relieve pain – than ever before. Read about one member’s journey to learn what we are doing to help members avoid becoming victims. 

America is seemingly beset by an epidemic of people becoming addicted to opioids – powerful narcotics that were designed to ease pain. In 2014, more than 28,600 died from such overdoses. In fact, six out of 10 overdoses involve prescription opioids.

In our Connect community, we are running a three-part series on how BCBSNM is helping members who may be struggling with opioid abuse. The first article chronicles the journey of a member who slipped into addiction and is fighting to recover. The second article is a Q&A about our unique program to identify addiction and help members. It’s followed by a third article that discusses the differences between acute and chronic pain and how to talk to your doctor when asking for relief.

Receipt of Credentialing Application Notification
Providers interested in becoming a contracted provider with BCBSNM must complete the applicable BCBSNM Participating Provider Interest Form and CAQH Credentialing Application. Upon submission, BCBSNM will notify applicants by certified mail within 10 days of receipt that the credentialing request has been received and that:

  • If the application is found to be complete, the credentialing process will begin according to the 45-day time period set forth in Subsection C of 13.10.28.11 NMAC.
  • If the application is found to be incomplete, the 45-day credentialing process DOES NOT commence until all requested information has been provided and application deemed complete by BCBSNM.

Additionally, providers can obtain the current status of their credentialing application by contacting the Provider Relations Representative assigned to the region.
A full list of Provider Relations Representatives is available in the Network Contact List under the Contact Us section of the BCBSNM provider website, bcbsnm.com/provider.


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.

Billing Medicaid Members

Appointment, interest and carrying charges:  MAD does not cover penalties on payments for broken or missed appointments, costs of waiting time, or interest or carrying charges on accounts.
A provider may not bill an MAP-eligible recipient or his or her authorized representative for these charges or the penalties associated with missed or broken appointments or failure to produce eligibility cards, with the exception of MAP recipient eligibility categories of CHIP or WDI who may be charged up to $5 for a missed appointment.

Member Rights and Responsibilities
BCBSNM is committed to ensuring that enrolled members are treated in a manner that respects their rights as individuals entitled to receive health care services. BCBSNM is committed to cultural, linguistic and ethnic needs of our members. BCBSNM policies help address the issues of members participating in decision-making regarding their treatment; confidentiality of information; treatment of members with dignity, courtesy and a respect for privacy; and members’ responsibilities in the practitioner-patient relationship and the health care delivery process. Read more

Blue Cross Medicare AdvantageSM

New Medicare Preauthorization Requirements through eviCore
BCBSNM has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide Utilization Management services for new preauthorization requirements outlined below. Read more

Such services are funded in part with the State of New Mexico.

 




 

 


Blue Cross and Blue Shield of New Mexico is committed to the highest standards of business ethics and integrity as well as strict observance and compliance with the laws and regulations governing its business operations.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.

P.O.Box 27630, Albuquerque, NM 87125-7630

© Copyright 2017. Health Care Service Corporation. All rights reserved.
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