June 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

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

Member Rights and Responsibilities

BCBSNM members have the right to:

• Available and accessible services when medically necessary, as determined by the primary care or treating physician in consultation with BCBSNM, 24 hours per day, 7 days a week, or urgent or emergency care services, and for other health services as defined by the member’s benefit booklet.
• Be treated with courtesy and consideration, and with respect for their dignity and need for privacy.
• Have their privacy respected, including the privacy of medical and financial records maintained by BCBSNM and its health care providers as required by law.
• Be provided with information concerning BCBSNM’s policies and procedures regarding products, services, providers, appeals procedures and other information about the company and the benefits provided.
• All the rights afforded by law, rule, or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language they understand.
• Receive from their physicians or providers, in terms that they understand, an explanation of their complete medical condition, recommended treatment, risks of the treatment, expected results and reasonable medical alternatives, irrespective of BCBSNM’s position on treatment options. If they are not capable of understanding the information, the explanation shall be provided to their next of kin, guardian, agent or surrogate, if able, and documented in their medical record.
• Prompt notification of termination or changes in benefits, services or provider network.
• File a complaint or appeal with BCBSNM or with the New Mexico Superintendent of Insurance and to receive an answer to those complaints within a reasonable time.
• Request information about any financial arrangements or provisions between BCBSNM and its network providers that may restrict referral or treatment options or limit the services offered to members.
• Adequate access to qualified health professionals near their work or home within New Mexico.
• Affordable health care, with limits on out-of-pocket expenses, including the right to seek care from an out-of-network provider, and an explanation of their financial responsibility when services are provided by an out-of-network provider, or provided without required preauthorization.
• Detailed information about coverage, maximum benefits, and exclusions of specific conditions, ailments or disorders, including restricted prescription benefits, and all requirements that they must follow for preauthorization and utilization review.
• Make recommendations regarding BCBSNM’s member rights and responsibilities policies.
• A complete explanation of why care is denied, an opportunity to appeal the decision to BCBSNM’s internal review, the right to a secondary appeal, and the right to request the assistance of the Superintendent of Insurance. BCBSNM members have the responsibilities to:
• Supply information (to the extent possible) that BCBSNM and its network practitioners and health care providers need in order to provide care.
• Follow plans and instructions for care that have been agreed on with their treating provider or practitioners.

ClaimsXten^TM 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. Read more

Appointment Availability and Access Guidelines

As a contracted Blue Cross and Blue Shield of New Mexico (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.

• 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. Instead of faxing or mailing paper enrollment forms, you may complete the online enrollment options listed below through Availity, at no cost. Read more

Medicaid only

Blue Cross Community Centennial^SM (Medicaid)

Not yet contracted?

Blue Cross and Blue Shield of New Mexico’s (BCBSNM) 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.

Member Rights and Responsibilities

Blue Cross and Blue Shield of New Mexico (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

Appointment Availability and Access Guidelines for Blue Cross Community Centennial Members

As a contracted Blue Cross and Blue Shield of New Mexico (BCBSNM) provider for Blue Cross Community Centennial, the following appointment availability and access guidelines should be used to ensure timely access to medical and behavioral health care for our Blue Cross Community Centennial membership. 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

Blue Cross Medicare Advantage^SM

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 Advantage members.

The Specialty Prior Authorization Program requirement for Blue Cross Medicare Advantage members initially planned to be effective on April 3, 2017, has been delayed. The new target effective date is June 1, 2017.

Please note that the list for services requiring preauthorization beginning June 1, 2017, has been updated to exclude Cardiac Rhythm Implantable Devices (Crid) and Post-Acute Care (PAC).
Both BCBSNM and eviCore will be providing additional information and training opportunities in the coming months on the Provider website at bcbsnm.com/provider and in Blue Review.

You will continue to use iExchange^® for all other services that require a referral and/or preauthorization. Services performed without preauthorization may be denied for payment, and the rendering provider may not seek reimbursement from members.

* eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSNM. Physicians, professional providers, facility and ancillary providers who are contracted/affiliated with an IPA/PHO must contact the IPA/PHO for questions and information regarding the preauthorization requirements.

Please note that the fact that a service has been preauthorized 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 coverage applicable on the date services were rendered. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

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 Advantage members.
Read more

Member Rights and Responsibilities

Blue Cross Medicare Advantage members have the right to timely, high quality care and treatment with dignity and respect. Participating providers must respect the rights of all members. Blue Cross Medicare Advantage members have been informed that they have the following rights and responsibilities. Read more

Federal Employee Program^®

Federal Employee Program Self-Measured Blood Pressure Monitoring

The Blue Cross and Blue Shield Federal Employee Program^® (FEP) and the American Medical Association (AMA) are working together to provide physicians with resources designed to help improve health outcomes for patients with hypertension or suspected hypertension. This effort supports the goals of the Million Hearts^® initiative. Read more

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^®, Blue Shield^® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.