This information applies to all lines of business unless stated otherwise
The BlueCross BlueShield of Tennessee Medical Policy Manual is being updated to reflect the following revised policies. The full text of these policies can be found online by clicking Upcoming Medical Policies.
Note: These effective dates also apply to BlueCare Tennessee pending state approval.
BlueCross is making enhancements to our online tools to keep pace with advancements in technology and to provide you with the resources you need. We have partnered with Availity, a leading provider of electronic health care transactions, to offer you a wider range of web-based products and services. Availity offers a multi-payer portal solution allowing you to use a single sign-on to work with BlueCross and other participating health care plans online.
Initially, the new portal will be used for reviewing remittance advices, claims status, eligibility and benefits. More features will be phased in throughout the year. As changes emerge, you will see eBusiness and other BlueCross resources leading efforts on education, provider engagement and training. We will continue to keep you updated about our transition to Availity through BlueAlert, online messages and updates through BlueAccessSM. Availity will eventually replace BlueAccess for providers.
BlueCross has enhanced its online authorization tool. The upgraded tool improves the MCG guideline selection and documentation process for your web authorization requests.
Please remember to always load the primary diagnosis first.
When did the changes go into effect?
The changes were implemented on May 1, 2017. If you’re not currently using online authorization submission or are using the tool but would like additional training and support, please contact the eBusiness Technical Support or the eBusiness Marketing team.
You can find more information and other resources by visiting the National Center for Biotechnology Information (NCBI) website.
We recommend that behavioral health providers notify their patient’s PCP when antipsychotic medications are being considered. The American Psychiatric Association (APA) recommends an assessment of the patient’s health due to the increased risk for weight gain and type 2 diabetes associated with the use of antipsychotics. Targeted assessments should include: Weight, waist circumference and/or BMI, blood pressure, heart rate, blood glucose level and lipid profile. Continued assessment of these factors should occur throughout the course of treatment, and collaboration is encouraged between treating providers. The efficacy and safety of antipsychotics should be monitored proactively.
See APA Practice Guidelines for more information.
As of April 28, 2017, Bavencio and Ocrevus were added to the Provider-Administered Specialty Pharmacy Lists and require prior authorization for all lines of business.
You can find information on all provider-administered specialty medications requiring prior authorization on our website(s).
|BlueCare Plus (HMO SNP)SM||Medicare Advantage|
The Tennessee Health Care Innovation Initiative (THCII) preview and performance reports are now available on Blue AccessSM for your review. You can use them to identify specific opportunities to further improve quality and reduce the cost of care.
Applies only to BlueCare Tennessee, CoverKidsSM, State Employee Health Plan and Fully Insured.
Beginning immediately, CPT® code 27279 requires prior authorization through the Musculoskeletal Program administered by OrthoNet.
Prior authorization requests can be submitted through BlueAccess or by fax to 1-800-747-0587. When submitting requests online, the musculoskeletal code must be the primary procedure code.
Effective July 8, 2017, a prior authorization is required for CPT® Code 81545 (Molecular Markers in Fine Needle Aspirates of the Thyroid) for Commercial lines of business. For a list of services that require prior authorization, see the BlueCross website.
BlueCross requires all nurse practitioners and physician assistants to be credentialed and contracted before providing services to our members. This includes nurse practitioners and physician assistants who are employed by a physician group already contracted with BlueCross. This requirement went into effect on Jan. 1, 2017.
BlueCross had previously indicated that claims submitted by non-credentialed, non-contracted nurse practitioners and physician assistants would be considered out of network and would be denied beginning May 1, 2017. In order to allow more time to comply with this requirement, BlueCross will not process these claims as out of network or deny them for dates of service beginning May 1, 2017. A revised date will be published in an upcoming BlueAlert.
Providers can begin the credentialing, enrollment and contracting process by completing the online Provider Enrollment Form. Please contact your local Provider Relations Consultant (PRC) with any questions. If you don’t know who your PRC is, please visit our website to locate your BlueCross contact.
Network providers (including oral surgeons) are required to submit all claims to BlueCross electronically. This includes secondary and corrected claims.
Paper claims will only be an accepted method of submission when technical difficulties or temporary extenuating circumstances exist and can be demonstrated. Please call eBusiness Technical Support if you need to discuss any barriers that prevent you from filing electronic claims.
This information applies to BlueCareSM and TennCareSelect plans, excluding CoverKidsSM and dual-eligible BlueCare Plus (HMO SNP)SM unless stated otherwise.
Each parent/guardian or patient has the right to refuse recommended vaccines. Refusal to get recommended immunizations must be documented in the patient’s medical record. Resources for documenting the refusal are available on the American Academy of Pediatrics website.
Additionally, the Centers for Disease Control and Prevention has conversation tools to help talk with parents/guardians and patients about the importance of immunizations and the importance of preventive care.
Thousands of kids from low-income homes in Tennessee miss their annual well-care checkups, and the number who miss increases every year. Any time a child (patient under age 21) with TennCare Kids coverage is in your office is a great time to make sure your patient’s checkups are up to date.
While your patient’s visit might be for an illness, shots or a prescription refill, statistics show it could be years before you get another chance to conduct a checkup, especially if your patient is a teenager. TennCare Kids Screening Guidelines permit reimbursement for both a “sick” and “well” visit on the same day, so you don’t have to schedule another appointment.
For the correct coding and modifier usage for billing both types of care on the same day, please see the TennCare Kids Screening Guidelines section of the BlueCare Tennessee Provider Administration Manual.
Diabetes medications DPP-4 and SGLT-2 inhibitors and their combinations require prior authorization (PA). For questions or prior authorization requests for BlueCare Tennessee members, please contact Magellan Health Services Clinic Call Center at 1-866-434-5524 or fax your request to 1-866-434-5523.
Drugs requiring prior authorization for BlueCare Tennessee members are identified by (PA) on the TennCare Preferred Drug List (PDL).
Beginning with claims on or after June 1, 2017, the following secondary providers submitting professional and/or institutional claims for BlueCare Tennessee and CoverKids members must be registered with the Bureau of TennCare as well as with BlueCare Tennessee for all dates of service on the claim.
Claims submitted on or after June 1, 2017, with an unregistered secondary provider will be returned to the provider unprocessed.
To learn more about registering with TennCare please visit the TennCare website.
To register with BlueCare Tennessee, please call the Provider Service lines.
This information applies to BlueAdvantage (PPO)SM and BlueChoice (HMO)SM plans. BlueCare Plus (HMO SNP)SM is excluded unless stated otherwise.
As of Jan. 1, 2017, initial dialysis clinic claims filed with Type of Bill 072X require annual submission of a completed CMS-2728-U03 form for each patient. Reimbursement will not be considered for dialysis clinic claims in a given calendar year if a completed CMS-2728-U03 form is not on file with BlueCross. The initial and subsequent claims will be denied, and you will be asked to submit the completed form.
You may fax the form to (423) 535-5498 or mail to:
BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Revenue Reconciliation
1 Cameron Hill Circle, Suite 0002
Chattanooga, TN 37402-0002
As you know, the key to living with diabetes is properly managing the disease over the long term. That’s why BlueCross offers your Medicare Advantage patients tools and rewards to encourage them to follow your plan of care and maintain a healthy lifestyle.
For details about the rewards your patients can receive for completing recommended diabetes screenings, see the comprehensive list of wellness incentives on our Quality Care Rewards webpage.
If you have diabetic patients who have trouble making it to your office, we can help schedule in-home visits so your patients can complete the tests they need. Just call us at 1-800-841-7434 and we can schedule in-home visits with our health partners to help your patients complete each of the following screenings annually:
You will receive all copies of test results. And if you participate in our provider quality program, you will receive credit for these gaps in care getting completed.
The Right of Reimbursement and Recovery (Subrogation) is a provision in the member’s health care benefit plan that permits the Medicare Advantage Part C (MA) plan to conditionally pay you when a third party causes the member’s condition. The MA plan follows Medicare policy. According to 42 U.S.C. § 1395y(b)(2), Medicare may not pay for a beneficiary's medical expenses when payment "has been made or can reasonably be expected to be made under a workmen's compensation law or plan of the United States or a State or under an automobile or liability insurance policy or plan (including a self-insured plan) or under no fault insurance.”
According to 42 U.S.C. § 1395y(b)(2)(B)(ii) and 42 C.F.R. § 411.24(e) and (g), CMS may recover from a primary plan or any entity, including a beneficiary, provider, supplier, physician, attorney, state agency or private insurer that has received a primary payment. Likewise, the MA plan sponsor may recover in the same manner as CMS.
As with Medicare, if responsibility for the medical expenses incurred is in dispute and other insurance will not pay promptly; the provider may bill the MA plan as the primary payer. If the item or service is reimbursable under MA and Medicare rules, the MA plan may pay conditionally on a case-by-case basis, and will be subject to later recovery if there is a subsequent settlement, judgment, award or other payment. In situations such as this, the member may choose to hire an attorney to help them recover damages.
Physical activity is an important part of living a healthy and fulfilling life as a person ages.
SilverSneakers® is a value-added benefit that offers all BlueCross Medicare Advantage members access to hundreds of fitness facilities and fitness classes throughout Tennessee. To find out more about this benefit and what it can do for your patient’s activity levels, sign up for a free 30-minute webinar.
Find out how SilverSneakers can help your patients improve or maintain a healthy lifestyle.
This information applies to all lines of business unless stated otherwise.
The Breast Cancer Medical Oncology and Mastectomy episodes in Wave 5 will not be included in the Tennessee Health Care Innovation Initiative (THCII) May 2017 preview reports, because the Cancer Registry data has not yet been incorporated. The performance period for these two episodes will begin with calendar year 2019, instead of calendar year 2018.
The Breast Biopsy episode will not be delayed, and will be included in the May 2017 reports. The first performance period for this episode will be in calendar year 2018.
An encounter claim may be filed for patients who have a retinal or dilated eye exam by an eye care provider in 2017. For patients who had a negative dilated retinal eye exam in 2016, you can file an encounter claim and refer them to an eye care professional for a comprehensive eye exam in 2017.
The CPT® Category II code for a negative retinal screen in the prior year is 3072F. You can find sample codes for diabetic retinal exams and more information on our website.
BlueCross BlueShield of Tennessee complies with the applicable federal and state laws, rules and regulations and does not discriminate against members or participants in the provision of services on the basis of race, color, national origin, religion, sex, age or disability. If a member or participant needs language, communication or disability assistance, or to report a discrimination complaint, please, call 1-800-468-9698 for BlueCare, 1-888-325-8386 for CoverKids or 1-800-263-5479 for TennCareSelect. For TTY help call 771 and ask for 888-418-0008.
This information is educational in nature and is not a coverage or payment determination, reconsideration or redetermination, medical advice, plan pre-authorization or a contract of any kind made by BlueCross BlueShield of Tennessee. Inclusion of a specific code or procedure is not a guarantee of claim payment and is not instructive as to billing and coding requirements. Coverage of a service or procedure is determined based upon the applicable member plan or benefit policy. For information about BlueCross BlueShield of Tennessee member benefits or claims, please call the number on the back of the member’s ID card.
*Changes will be included in the next provider administration manual update as applicable. Until then, please use this communication to update your provider administration manual.
Archived editions of BlueAlert are available online at http://www.bcbst.com/providers/newsletters/index.page
BlueCross BlueShield of Tennessee, Inc., BlueCare Tennessee and BlueCare are Independent Licensees of the BlueCross BlueShield Association
CPT® is a registered trademark of the American Medical Association
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