July 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. Ideas for articles and letters to the editor are welcome; email NM_Blue_Review_Editor@bcbsnm.com Do we have your correct information?
Medical Policy Updates BCBSNM Website Member Rights and Responsibilities ClaimsXtenTM Announces Software Version Upgrade 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. 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. Read more Benefit Information Accessible in the IVR Phone System 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 Additional Benefit Categories Contained in IVR Phone System Our May 2017 Blue Review included a list of the common benefit categories contained within the Blue Cross and Blue Shield of New Mexico (BCBSNM) Interactive Voice Response (IVR) phone system. Beginning June 19, 2017, the list expanded to include additional common benefit categories. Read more Careful Documentation Paves the Way for Accurate Coding Capture It all begins with you and your patient. This fact did not change with the transition to ICD-10. However, with ICD-10, a higher level of specificity in your documentation is necessary in many instances – such as documenting laterality – to support proper assignment of ICD-10-CM/PCS codes. Read moreMedicaid only 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 Screening for Hepatitis C 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: Medical Assistance Division (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 Medical Assistance Program (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 Children's Health Insurance Program (CHIP) or Working Disabled Individuals (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 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 Member Rights and Responsibilities 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. |