May 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 BCBSNM Website
It’s important for you to stay informed about news that could affect your practice. Blue Cross and Blue Shield of New Mexico (BCBSNM) offers many ways to stay informed. When you visit our website, bcbsnm.com/provider, and sign up to receive email updates and our provider newsletter, Blue Review, you get better access to timely information on topics. Read more 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
ClaimsXtenTM Announces Software Version Upgrade
Beginning on or after July 17, 2017, Blue Cross and Blue Shield of New Mexico (BCBSNM) will perform a system software upgrade for ClaimsXten ™ from version 4.4 to version 6.0. See the Key enhancements.
Read more 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.
Insurers Required by CMS to Conduct ACA Risk Adjustment Program Audit In 2017, the Centers for Medicare & Medicaid Services (CMS) will conduct another Initial Validation Audit (IVA) to validate the data used when assessing the payment transfers for the Affordable Care Act's (ACA) Risk Adjustment (RA) program. The provider’s role is essential to the success of the IVA. Therefore, if any of your patients are selected to be included in the IVA, Blue Cross and Blue Shield of New Mexico (BCBSNM) is asking for your cooperation and commitment to fulfilling the requirements of the IVA.
The IVA is expected to begin in June of 2017 and BCBSNM will be working with Tactical Management Incorporated (TMI) to retrieve the requested medical records that we have to submit to our IVA auditor. Our IVA auditor requires medical records to validate the sampled member’s risk score calculation, which is based on the diagnosis codes submitted on a member’s claims, as well as through supplemental diagnosis submissions based on medical record review. As BCBSNM providers, you may be asked to provide medical records directly to TMI to validate all the diagnosis codes used in the ACA RA risk score calculation. It is of utmost importance that you respond to these requests in a timely manner.
The IVA will be performed on a sample of members enrolled in ACA-compliant individual and small group plans, both on- and off-exchange. Our IVA auditor will validate medical claims of the sampled members from the previous calendar year. For example, this IVA will be conducted in 2017 but will review claims with dates of service in 2016. Please be aware some of these claims may have been paid in 2017 and are likely to be included in the IVA sample.
We understand that this is a very busy time; however, to comply with CMS’ requirements, we appreciate your full support and cooperation as you receive requests from TMI and deliver the requested medical record(s) in a timely manner.
If you have any questions, please contact your Provider Relations Representative at 800-567-8540. 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 Receipt of Credentialing Application Notification
Providers interested in becoming a contracted provider with Blue Cross and Blue Shield of New Mexico (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. Benefit Information Accessible in the IVR Phone System
Starting on Dec. 12, 2016, Customer Advocate assistance was removed for several common benefit categories within the Interactive Voice Response (IVR) phone system. The IVR quotes the same level of patient eligibility and benefits information as a Customer Advocate provides. Remain assured; our Advocates will continue to be available for more complex benefit quotes. Read more Online Enrollment Options in Availity™
Blue Cross and Blue Shield of New Mexico (BCBSNM) offers you multiple enrollment opportunities for electronic options through the Availity Web portal, in addition to supporting utilization of standard administrative transactions through Availity or your preferred vendor portal. Read more 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. 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 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 a 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.
Blue Cross and Blue Shield of New Mexico Managed Care Program Blue Cross Community Centennial Changes, Effective May 20, 2017
To help improve efficiencies in routing, handling and post-adjudication processes for the Blue Cross and Blue Shield of New Mexico (BCBSNM) Blue Cross Community Centennial program, changes impacting electronic transactions and claim submissions will be implemented on May 20, 2017. Blue Cross Community Centennial members are identified by alpha-prefix YIF listed on their BCBSNM identification card. Read more 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
New Preauthorization Requirements through eviCore
In a previous update, Blue Cross and Blue Shield of New Mexico (BCBSNM) communicated the upcoming new preauthorization requirements for Blue Cross Medicare AdvantageSM members. Read more
Blue Cross Medicare Advantage and Blue Cross Medicare Advantage Dual Care plans are HMO, HMO-POS, PPO, and HMO Special Needs 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 and a contract with the New Mexico Medicaid program. Enrollment in HCSC’s plans depends on contract renewal. 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 .
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