This information applies to all lines of business unless stated otherwise
We’re updating the BlueCross BlueShield of Tennessee Medical Policy Manual with these revised policies. To read the complete policy information, please click here.
Effective Feb. 21, 2018
Effective March 1, 2018
Effective April 1, 2018, urine/serum drug testing will be limited to 20 episodes per annual individual benefit period. An episode is defined as either a presumptive or confirmatory test, or both, for the same date of service per provider billed on the same claim. A presumptive test is also known as a qualitative point-of-care test (POCT) or a drug screen. A confirmatory test is a definitive or combined qualitative/quantitative test. This policy does not apply to BlueCare Tennessee, CoverKidsSM, FEP or our Medicare Advantage members.
Effective Jan. 1, 2018, the following provider-administered specialty medications require prior authorization for all lines of business:
Effective Jan. 18, 2018, the following provider-administered specialty medications require prior authorization for all lines of business:
You can find information on all provider-administered specialty medications requiring prior authorization on our website.
Save the date for our annual All Blue Workshops. We’re mailing invitations soon, so be on the lookout for yours. You’ll also be able to find more details on our registration page.
The Availity Provider Portal opened in December for BlueCross BlueShield of Tennessee providers. Now, you can use a single system to transact with BlueCross and other health plans. Register today, and begin reviewing remittance advices, claims status, eligibility and benefits right online. Availity also features a BlueCross-specific payer space, which lets you see updates from BlueCross and use our other applications. For example, to access our Quality Care Rewards tool, go to Payer Spaces in the Availity Provider Portal, select BlueCross BlueShield of Tennessee, and then click on Quality Care Rewards.
Exclusive features for BlueCross providers include:
If you haven’t registered for Availity, it’s time to register and get started at Availity.com. If you’re already an Availity user, you can access BlueCross by selecting “BCBS TENNESSEE” as the payer in the Tennessee region. Be sure to review available role assignments specific to BlueCross functionality within the “Maintain Organization” section of the My Account Dashboard.
Here’s how to get started:
To aid in your transition, BlueAccess for providers will continue running through March 2. It will not be available after that date. Please be sure to notify any third-party vendors who are using BlueAccess on your behalf. If you have questions or need help transitioning to the Availity portal, please contact your eBusiness Regional Marketing Consultant.
Starting Feb. 17, 2018, the following applications will only be available through the Payer Spaces in the Availity Provider Portal:
Please make sure your practice is using Availity by Feb. 17, 2018 to avoid possible disruption.
We’re committed to improving our enrollment experience so it’s easy and efficient for you. We appreciate your patience as we continue to refine our enrollment process. In the meantime, here are some important pointers and updates:
Please use a Provider Enrollment Form (PEF) if you’re:
Please use a Change Form if you’re:
This will help speed the process for providers who are already in a BlueCross network.
Issues we are working to resolve:
If you have any questions, please email us at ProviderSupport@bcbst.com or call our Provider Service line at 1-800-924-7141. We’ll continue to post updates in future BlueAlerts.
All dental network providers are required to be credentialed as specified in the amended and restated contract, with re-credentialing occurring every three years. If you’ve been in our dental network longer than the last three years, you’ll need to be re-credentialed.
To prepare for re-credentialing, please confirm your information – including the attestation and all applicable required documentation (DEA licensure, state licensure and current liability information) – is still accurate with the Council for Affordable Quality HealthCare, Inc. (CAQH). We collect all provider data and credentialing information from CAQH, a universal credentialing application and central repository used by all health plans for credentialing.
If you have any questions, please call us at 1-800-357-0395.
Each year, we are required to report Healthcare Effectiveness Data and Information Set (HEDIS®) measures to maintain National Committee for Quality Assurance (NCQA) accreditation. These measures determine whether members received the care and screenings they needed and if the care improved their health.
Soon, we’ll be requesting medical records related to prevention and screenings, diabetes care, cardiovascular conditions, prenatal/postpartum care, medication management and well-child visits.
For your convenience, we can help coordinate your record submission using any of these methods:
Thank you for your cooperation and support of this requirement.
We appreciate your help in taking preventive care measures to protect your patients during this time of year. Please educate all patients and parents who have children older than 6 months of age on the importance of getting a yearly flu vaccine.
To avoid missed opportunities for vaccination, you might consider offering immunizations during routine health care visits and hospitalizations – especially for your high-risk patients.
The following influenza immunization and reimbursement guidelines apply for BlueCross.
Code 90756 became effective Jan. 1, 2018, for Flucelvax Quadrivalent – antibiotic-free vials (2017-2018 NDCs 70461-0301-10 and 70461-0301-12). Prior to the implementation/effective date, codes 90749 or Q2039 submitted with NDC may be billed for this product.
Code 90674 became effective Sept. 1, 2016, for BlueCare, and Jan. 1, 2017, for all other lines of business for Flucelvax Quadrivalent – preservative and antibiotic-free syringes (2017-2018 NDCs 70461-0201-01 and 70461-0201-11).
FDA labeling, including “approved for use” information, should be consulted when selecting the appropriate agent for specific beneficiaries.
This information applies to all lines of business unless stated otherwise.
Changes to High-Tech Imaging Program Prior Authorization for Commercial Plans
The following list of CPT® codes now require prior authorization through the High Tech Imaging Program administered by eviCore. This change became effective Jan. 1, 2018.
Before submitting prior authorization requests, please verify member benefits/eligibility through Availity® at Availity.com. For more information about registering with Availity, visit our provider page at bcbst.com/providers/availity.page. You may also call our Provider Service Line to verify benefits/eligibility.
Prior authorization requests can be submitted through Availity via Payer Spaces, through BlueAccess via eHealth Services, by phone at 1-888-693-3211 or by fax at 1-888-693-3210.
This information applies to BlueCareSM and TennCareSelect plans, excluding CoverKidsSM and dual-eligible BlueCare Plus (HMO SNP)SM unless stated otherwise.
Beginning Feb. 1, 2018, BlueCare will be using a revised medical necessity guideline for Psychosocial Rehabilitation (PSR). BlueCare, the Division of TennCare, other Managed Care Organizations (MCOs) and providers worked in collaboration to develop a consistent approach across all MCOs. Please refer to the following link for more information. https://www.bcbst.com/providers/UM_Guidelines/default.htm
When your patients covered by BlueCare Tennessee receive their well-child checkup, please document all seven required components of the exam, which include:
It should also indicate assessments of your patients’ nutrition and physical activity.
If the child is uncooperative or the examination was deferred/refused, be sure to include this information in the medical record.
Helpful services are available from the Tennessee Chapter of the American Academy of Pediatrics for the required components of the TennCare Kids exam as well as required medical record documentation criteria.
As a reminder, professional claims need a taxonomy code to be submitted for the billing and rendering NPIs. It’s extremely important that both the billing and rendering provider taxonomy codes match the taxonomy codes on file for BlueCross. If you don’t submit the appropriate taxonomy codes for BlueCare Tennessee, CoverKidsSM, and BlueCare PlusSM, your claims may be denied or the reimbursement reduced.
This information applies to BlueAdvantage (PPO)SM. BlueCare Plus (HMO SNP)SM is excluded unless stated otherwise.
In 2018, you’ll again be eligible to receive payments for completing and submitting a Provider Assessment Form (PAF) for your attributed BlueAdvantage patients.
Please use CPT® code 96160 to file a PAF, which will be reimbursed with a maximum allowable charge of:
To receive reimbursement, please submit your claim and the completed PAF within 30 days of the face-to-face visit with your patient. You’ll be able to submit this information through BlueAccess until Feb. 17, 2018. After this date, you’ll need to submit forms through Availity® at availity.com. For more information about registering with Availity, visit our provider page at bcbst.com/providers/availity.page. You may also fax a completed Provider Assessment Form to 1-877-922-2963.
The form should also be included in your patient’s chart as part of their permanent record.
An annual wellness exam is an important first step to a healthy 2018. Patients who complete a wellness exam at the beginning of the year are more likely to continue with important tests and screenings throughout the year. You can help your BlueCross Medicare Advantage patients earn additional rewards for their healthy living by scheduling a checkup early.
In 2018, BlueCross Medicare Advantage members will need to “opt in” to the rewards program with OnLife Health, our rewards partner. Each member received a welcome kit in January detailing opt-in instructions, which can be done online or by phone.
Note: The annual wellness exam is a calendar year benefit, which means each member is entitled to one wellness exam annually, regardless of the number of days between each exam. It’s not necessary to wait 365 days between exams.
Starting April 1, 2018, we’re rolling out a new required benefit for our pre-diabetic Medicare Advantage members. In partnership with Solera Health, we’re offering the Medicare Diabetes Prevention Program (MDPP).
The program teaches members who are at risk for developing diabetes how to make lasting changes by eating healthier, increasing physical activity and managing the challenges that come with lifestyle change.
The program is free to qualifying members and includes:
You’ll also be able to refer your patients to the program through the BlueCross Population Health program. Please look for more information, including details on physician referrals, in a future edition of BlueAlert.
With flu season in full swing, remind your patients to get their annual flu shot. It’s quick, easy and included in the benefits for BlueAdvantage and BlueCare PlusSM members. Most important, it can help keep them healthy.
Patients 65 and older are at greater risk for serious complications from flu. Because our immune system weakens as we age, almost 90 percent of flu-related deaths happen in patients older than 65, along with nearly 60 percent of hospitalizations for this same age group. The flu shot is a calendar-year benefit, so it’s covered once a year regardless of the number of days between vaccinations.
Your senior patients may receive the regular or newer higher dose vaccine. The higher dose vaccine is 24 percent more effective in those who are 65 and older according to The New England Journal of Medicine.
This time of year is also a good time to review your patient’s pneumococcal vaccine status.
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
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