Blue Cross and Blue Shield of New Mexico

August 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

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.
  • Understand their health problems and participate in developing mutually agreed upon treatment goals with their treating provider or practitioner to the degree possible.

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

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

Code-Auditing Enhancement

Effective Nov. 12, 2017, Blue Cross and Blue Shield of New Mexico (BCBSNM) will be implementing a code-auditing enhancement.* This software will help improve auditing of professional and outpatient facility claims that are submitted to BCBSNM by clinically validating modifiers submitted on such claims. Upon implementation of the code-auditing enhancement, providers may use the Claim Research Tool, available on the AvailityTM Web Portal, to research specific claim edits. For additional information, check the Blue Review, as well as the News and Updates section of our Provider website. 

*The above notice does not apply to government programs claims.

Availity is a trademark of Availity, LLC, 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.

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.

Visit Our Website for New Claim Payment and Remittance Resources|

Blue Cross and Blue Shield of New Mexico (BCBSNM) recently updated the Claim Payment and Remittance page in the Claims and Eligibility section of our website at bcbsnm.com/provider. This section of our Provider website focuses on electronic transactions that may increase administrative efficiencies for your office while also helping to make it easier for you to conduct business with BCBSNM. Read more

EFT and ERA Update for Non-Contracted Government Programs Providers

Effective July 24, 2017, if you are an independently contracted commercial Blue Cross and Blue Shield of New Mexico (BCBSNM) provider who is enrolled to receive Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) files from BCBSNM. Read more

Integration of Prime Therapeutics® and Walgreens® Specialty Pharmacy and Mail-Order Services

The Blue Cross and Blue Shield of New Mexico (BCBSNM) pharmacy benefit manager (PBM), Prime Therapeutics LLC (Prime), and Walgreens announced a strategic alliance in August 2016 to create a first-of-a-kind model for pharmacy benefit management. Read more

Where Data Flows, Improvements are Bound to Follow

Payers and providers are increasingly collaborating to share clinical and claims data, with the shared goal of working to improve health outcomes and better manage the overall cost of care to consumers. Read more

Medicaid only

Blue Cross Community CentennialSM (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.

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

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

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 Community Centennial Changes, Effective July 21, 2017

To reduce the number of Blue Cross Community Centennial claim rejections and denials related to billing and rendering provider taxonomy codes, Blue Cross and Blue Shield of New Mexico (BCBSNM) relaxed the following edits on July 21, 2017. Read more

Submitting Electronic Claims for Blue Cross Community Centennial Members

Our May 2017 Blue Review edition announced the implementation of payer ID MC721, which took effect May 20, 2017, for Blue Cross Community Centennial claims submitted electronically. Blue Cross Community Centennial members are identified by alpha-prefix YIF listed on their Blue Cross and Blue Shield of New Mexico (BCBSNM) identification card.

Health care providers who utilize a clearinghouse or practice management system vendor for electronic claim submissions are encouraged to share this new payer ID with their vendors to ensure Blue Cross Community Centennial claims are processed efficiently. If these claims are submitted via direct data entry through the Availity Web portal, providers should utilize the dropdown payer option of “Blue Cross Community Centennial.”

Availity is a trademark of Availity, LLC, 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.

Pharmacy Change for Blue Cross Community Centennial Members Effective Sept. 1, 2017

As of Sept. 1, 2017, TRUEplus® and TechLITE® insulin pen needles will be the only covered insulin pen needles and TRUEplus insulin syringes  will be the only covered insulin syringes on the Blue Cross and Blue Shield of New Mexico (BCBSNM) Medicaid formulary. Prescriptions for other brands will require prior authorization from BCBSNM. Plan members who are affected will be sent a letter in the mail letting them know of this change.

TRUEplus is the trademark of Trividia Health, Inc. a separate company that is a manufacturer and marketer of advanced performance products for people with diabetes. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Trividia Health. If you have any questions about the products or services offered by such vendor, you should contact the vendor directly.

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.

Antidepressant Medication Management Initiative

Blue Cross and Blue Shield of New Mexico (BCBSNM) is committed to improving the rate at which Blue Cross Community Centennial members remain on antidepressant medications after newly diagnosed and treated depression. Read more

Blue Cross Medicare AdvantageSM

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

Prohibition on Billing Dually-Eligible Members Enrolled in the Qualified Medicare Beneficiary Program

Medicare providers may not bill, charge, collect a deposit, or seek reimbursement from any Medicare and Medicaid dually-eligible members enrolled in the Qualified Medicare Beneficiary (QMB) program. The QMB program is a State Medicaid benefit that exempts Medicare beneficiaries from Medicare cost-sharing liability and covers premiums, deductibles, coinsurance and copayments for Medicaid and Medicare dually-eligible QMB members. Read more

Federal Employee Program®

Federal Employee Program Member Rights and Responsibilities
BCBSNM Federal Employee Program members have the right to 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.


 

 

 


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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