This information applies to all lines of business unless stated otherwise
We’re updating the BlueCross BlueShield of Tennessee Medical Policy Manual with these new and/or revised policies. To read the complete policy information, please click here.
Effective Dec. 20, 2017
Each year, BlueCross formularies are reviewed to determine changes based on a drug’s effectiveness, safety and affordability. While many changes to the BlueCross formularies are made at the beginning of the year, changes may occur at any time because of market changes such as:
Please visit the following links to view the “What’s Changing on the Formulary for 2018”:
Last month, we sent letters to our members whose medications are changing to non-formulary status beginning Jan. 1, 2018. Please remind your patients that they can check for formulary changes at bcbst.com
Effective Nov. 17, 2017, Besponsa and Rituxan Hycela were added to the Provider-Administered Specialty Drug Lists. All lines of business require prior authorization for these drugs. You can find information on all provider-administered specialty medications that require prior authorization on our websites.
Starting Dec. 10, 2017, all BlueCross providers will be able to switch from BlueAccessSM to the Availity Provider Portal for essential administrative tasks. With Availity, you’ll be able to interact securely with BlueCross and other participating health plans on one convenient system. You can review remittance advices, claims status, eligibility and benefits. You’ll also have access to important BlueCross-specific features, including a payer space that can connect you to other BlueCross applications.
To aid in your transition, BlueAccess will continue running for the next few months. However, it’s important to note the provider tool will no longer be available after March 2, 2018. If you haven’t already, please be sure to assign someone in your organization to manage your transition to Availity and register at Availity.com. Updates and links to the resources needed for the transition are posted on bcbst.com/providers. Please notify any third-party vendors who are using BlueAccess on your behalf.
The Availity organization administrator is responsible for setup, which includes registering your organization, establishing and assigning access to users, and other important tasks. BlueAccess currently uses a security model based on your BlueCross provider number. Availity manages access at the Organization Tax ID level. When choosing your administrator, it’s also important to evaluate how your organization(s) should be setup with Availity so you can effectively manage your staff’s access to their specific job functions. As we work with Availity to build further integrations such as Single Sign-On, we will follow the roles and permissions your administrator assigns to manage appropriate access to your data.
Although BlueAccess is going away, all of your claims and payment data, and many of your applications, will still be available. If you have an issue with a BlueCross-specific application on Availity, our eBusiness team is here to train and support you as needed. Of course, you can always call us with any questions you may have about the transition.
We continue to explore ways to make the provider enrollment process easier for you. Our online enrollment application has helped make the process more efficient for provider offices and we’re working on ways to continue that trend. For example, the application will soon include an update that displays which specific documents are needed based on the provider type along with the capability to upload the information when submitting the online application
A requirement of the application is to have a valid CAQH ID and permission for us to review that data. Our system will soon verify the information in real time and notify you if there are any issues to resolve. Look for these and other changes in the coming months.
It’s important that you help set 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.
Please make every effort to schedule your high-risk patients for a flu shot as early as possible this flu season. To avoid missed opportunities for vaccination, you might consider offering immunizations during routine health care visits and hospitalizations.
The following influenza immunization and reimbursement guidelines apply for BlueCross.
For more information, please call 1-800-404-3006, Monday through Friday, 8 a.m. to 4:30 p.m. (ET).
According to the current guidelines set by the American Dental Association (ADA), the following CDT® codes will be deleted as of Jan. 1, 2018: D5510, D5610 and D5620.
The following CDT® codes will be added as of the same date, and will also be covered under the standard DentalBlue contract: D5511, D5512, D5611, D5612, D5621, D5622, D6096, D7979, D9222 and D9239.
If you file a claim with a deleted code on or after Jan 1, 2018, that line item will not be processed and you will be advised to refile with the most current ADA code. For questions, please contact Dental Customer Service at 1-800-523-1478.
New billing requirements for Commercial plans are going into effect Jan. 1, 2018 for air ambulance providers (rotary or fixed-wing):
Member cost share can be significant for this type of service, so please try to work with in-network providers.
You can find updated billing guidelines for Commercial plans in your BlueCross BlueShield of Tennessee Provider Administration Manual.
Starting Jan. 1, 2018, prior authorization is required for non-emergent air ambulance transportation. Prior authorization won’t be required for emergency transport (e.g., from the scene of an accident when ground isn’t appropriate or would pose a threat).
To arrange non-emergent air ambulance transport for a patient with BlueCross Commercial benefits, please request prior authorization by calling BlueCross at 1-800-515-2121 (extension 6900) from 8 a.m. to 6 p.m. ET.
This prior authorization requirement may affect your patients if an out-of-network air ambulance is used for non-emergent transportation.
For all lines of business, diagnostic services provided within three days of an inpatient admission are included in the global surgery reimbursement (for the same patient and same provider tax ID), unless stipulated differently by the provider’s contract. In addition, for some Commercial contracts, diagnostic services within one day of an outpatient surgery are included in global surgery reimbursement. Please refer to your contract for specific guidelines.
Payment will be made under the physician fee schedule for technical component services provided in a free-standing ambulatory surgery center (ASC) (Place of Service 24). Commercial and BlueCare Tennessee DRG and outpatient case rates paid to all institutions and facilities, other than free-standing ASCs, will continue to include any technical component for professional services provided for institution and facility patients. Reimbursement for the technical component services is part of the all-inclusive global payment made to these institutions/facilities. Provider pathology claims with any (institutional or facility) place of service other than 24 will receive a T33 denial.
Please note that non-compliance denials aren’t subject to reconsideration. However, you have 60 days to submit an appeal related to a non-compliance denial. Please complete and submit the Provider Appeal Form located on our provider webpage under the forms section. If you send the Reconsideration Form, it will delay your appeal, so be sure to use the correct form. If you need help or have questions, please call the Provider Service Line.
Beginning Jan. 1, 2018, BlueCross BlueShield of Tennessee will recover overpayments through an offset to the provider’s remittance advice 30 days from the date of notification. Please do not send a check for the overpayment amount. If checks are sent to BlueCross, they will be returned to the payee.
When billing professional claims, the rendering provider NPI should be included only when it’s different than the billing provider. Your electronic claims need to include the rendering provider in Loop 2310B and billing provider in Loop 2010AA. We’ll only accept paper claims if you can verify technical difficulties or temporary extenuating circumstances exist. In this case, enter the rendering provider in Block 24J and the billing provider in Block 33. This requirement aligns with both Version 5, Release 1, ASC X12 Standards for Electronic Data Interchange Technical Report Type, Health Care Claim: Professional (837) and Version 4.0 7/16 of the NUCC 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12. We’ll reject and return claims if the rendering provider NPI is the same as the billing provider.
This information applies to all lines of business unless stated otherwise
Effective Jan. 1, 2018, regardless of date of service, BlueCross will follow CMS Policy for National Correct Coding Initiative (NCCI) edits of the National Physician Fee Schedule Relative Value file for Status T codes.
Under these guidelines, additional services payable under the physician fee schedule that are billed on the same date by the same provider will be bundled into the physician services for which payment is made. One example of a Status T code is CPT® 94760. For more details regarding these guidelines, please refer to the CMS website.
Many codes for high tech imaging procedures require prior authorization. The codes that require prior authorization are listed on the company website at bcbst.com.
Codes that require prior authorization for the Commercial lines of business can be found here: bcbst.com/docs/providers/hti/2016HTICodeList.pdf.
Codes that require prior authorization for Medicare Advantage can be found here: bcbst.com/docs/providers/hti/HTICodeList.pdf.
This information applies to BlueCareSM and TennCareSelect plans, excluding CoverKidsSM and dual-eligible BlueCare Plus (HMO SNP)SM unless stated otherwise.
Mental health outpatient facilities are required to include the rendering provider on all professional claims when the provider rendering the service to BlueCare Tennessee, BlueCare Plus or CoverKids members is different than the billing provider. If an agency bills for services that weren’t provided by a licensed clinician, the supervising professional shall be entered on the claim as the rendering provider. Claims submitted without the rendering provider will be rejected and returned unprocessed
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, CoverKids, and BlueCare Plus, your claims may be denied or the reimbursement reduced.
Thousands of kids from low-income homes in Tennessee miss their annual well-care checkups, and the number increases every year. Any time children (patients under age 21) with TennCare Kids or CoverKids benefit plans are in your office is a great time to make sure their 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 allow 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.
On Nov. 1, 2017, BlueCare Tennessee began using a 30-day readmission look-back period for members 21 or older. A readmission is a preventable, unplanned admission of a patient to the same facility for a condition or complication related to the original hospital stay. Claims for patients who are readmitted under these circumstances are not eligible for multiple payments at facilities that are paid on a DRG or per diem basis. These claims are also subject to retrospective claims review and recovery.
This policy applies to all readmissions except those specifically listed in the BlueCare Tennessee Provider Administration Manual as readmissions that may be approved for authorization and payment.
Federal regulations require providers ordering services for BlueCare, TennCareSelect or CoverKids members be registered with the Division of TennCare. These regulations not only apply to those providing care, they also apply to providers who request care for patients with TennCare coverage.
Providers must have a valid, active Medicaid ID from TennCare before submitting an application to participate in the BlueCare Tennessee networks. Professional and institutional claims that are filed by a provider without a Medicaid ID can’t be processed or paid.
Currently, all member deaths under the age of 21 and unexpected deaths over the age of 21 are required to be reported. Starting Jan. 1, 2018, BlueCare Tennessee and CoverKids providers will only need to report unexpected deaths. This change doesn’t affect the requirements to report the death of a member while receiving care from home health services nor how providers must report Behavioral Health Adverse Occurrences that may also involve a member's death.
This information applies to BlueAdvantage (PPO)SM and BlueChoice (HMO)SM plans. BlueCare Plus (HMO SNP)SM is excluded unless stated otherwise.
Each year, we review our prescription drug formularies to make sure the medications we cover for our members are safe, effective and affordable. While many changes to the BlueCross formularies are made at the beginning of the year, changes may occur at any time because of market changes such as:
Please visit the following links to view the 2018 Formularies:
Last month, we sent letters to our Medicare Advantage and BlueCare Plus members whose medications are changing to non-formulary status beginning Jan. 1, 2018. Please remind your patients they can call us at 1-800-831-2583 for a complete list of drugs their plan covers.
In 2018, you’ll again be eligible to receive payments for completing and submitting a Provider Assessment Form (PAF) for your attributed BlueAdvantage and BlueChoiceSM patients.
Please use CPT® code 96160 to file a PAF. BlueAdvantage will continue to reimburse the service as E/M Code 96160, with a maximum allowable charge of:
To receive reimbursement, you must submit the completed form through BlueAccess or fax a completed writable form to 1-877-922-2963. The form should also be included in your patient’s chart as part of their permanent record.
You don’t need to wait 365 days between PAF submissions. For additional information about the Provider Assessment Form, please visit bcbst.com/providers/quality-initiatives.page.
Starting Jan. 1, 2018, we’ll require prior authorization for non-routine supplies used for skilled nursing care provided in a patient’s home or a facility. Both the supplies and associated service will require authorization.
You can find the Home Health Agency Non-Routine Supply List in the billing section of your BlueCross BlueShield of Tennessee Provider Administration Manual. You won’t be reimbursed for charges related to non-routine supplies if they aren’t included and reviewed during the authorization. Also, please bill supplies using the appropriate revenue and HCPCS codes when filing claims.
Under Medicare guidelines, routine supplies are inclusive in the per diem reimbursement. They aren’t separately reimbursed, even if requested by another provider for the same dates of service.
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 BlueCross Medicare Advantage 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.
To ensure proper claim payment for requests for lung cancer screening with Low Dose Computed Tomography (LDCT), HCPCS codes G0296 and G0297, the claim must be billed with ICD-10 diagnosis code Z87.891. These codes are limited to reimbursement once per calendar year.
One out of three older adults fall each year, and many older adults don’t know they have balance problems because symptoms are often mild or seem unrelated. Even a minor fall can be serious, so take a moment to talk to your patients about fall prevention and what they can do to make sure their homes are safe.
Please share these fall prevention tips with your patients:
Beginning Jan. 1, 2018, BlueAdvantage members who have been identified as having gaps in care are able to receive in-home screenings by Matrix Medical Network, our newest in-home health care vendor.
Matrix will schedule in-home assessments, including bone mineral density screenings, diabetic retinal eye examinations, FIT testing for colorectal cancer and hemoglobin A1C measurements for diabetic patients. These are all screenings that link directly to the Medicare Advantage Stars program.
Matrix will send copies of all test results to each member’s primary care physician of record. Please email Jodi Bolen, Manager of Stars Member Experience, if you have questions about this program.
While BlueCross will continue to offer our BlueAdvantage plan in 95 counties across Tennessee in 2018, we will no longer offer our BlueChoice HMO. A majority of our Medicare Advantage members are enrolled in our PPO and will not be impacted by this change.
We sent our BlueChoice members a letter in early October announcing this change and gave them the option to enroll in BlueAdvantage for 2018. BlueAdvantage has similar benefits including prescription and limited dental coverage within a larger provider network. We also encouraged them to call the number on the back of their identification card to speak with our customer service team if they had any questions. If you have questions, please call our Provider Service line.
This information applies to all lines of business unless stated otherwise.
The Quality Care Quarterly newsletter includes informative articles on our quality programs. Each edition features success stories from your peers, helpful information on clinical measures, tips for using our Quality Care Rewards tool, and more.
The summer edition is still available online on the provider page of our website, under Your Guide to Quality Programs. You can also view it here. Previous editions can be found in the newsletter archives at the bottom of the page.
Each issue is formatted as a printable PDF. Please consider printing copies for your staff, and particularly for all the practitioners in your practice. We want to make sure everyone in our providers’ offices has access to this information.
Watch for an email, with a link to the fall/winter edition, from your BlueCross contact in early December.
Tennessee Health Care Innovation Initiative (THCII) Episodes of Care risk/gain share payments and/or recoupments for the 2016 performance period were released the week of Nov. 19 for Medicaid providers.
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
Be sure your CAQH ProViewTM profile is kept up to date at all times. We depend on this vital information.