This information applies to all lines of business unless stated otherwise
The BlueCross BlueShield of Tennessee Medical Policy Manual will be updated to reflect the following new and revised policies. The full text of the policies listed below can be accessed at http://www.bcbst.com/providers/mpm.shtml under the “Upcoming Medical Policies” link.
Effective May 13, 2017
Effective June 21, 2017
Note: These effective dates also apply to BlueCare Tennessee pending state approval.
Intracavitary Balloon Catheter Brachytherapy for Malignant Gliomas or Metastases to the Brain – This medical policy is no longer used by BlueCross Utilization Management. It will be archived and no longer active 30 days after this notification.
Please join us at one of our free annual All Blue provider workshops. Our knowledgeable representatives and subject matter experts will be available to answer questions and address your concerns. Register online today!
Chattanooga – April 5, 2017
Johnson City – April 18, 2017
Knoxville – April 19, 2017
Nashville – May 4, 2017
Memphis – June 6, 2017
Jackson – June 7, 2017
Lartruvo will be added to the Provider-Administered Specialty Drug Lists requiring prior authorization, for all lines of business, effective April 1, 2017. Periodically, new specialty drugs are added to the lists which vary by lines of business. You can find information on all provider-administered specialty medications requiring prior authorization on the web pages below.
|BlueCare Plus(HMO SNP)SM||Medicare Advantage|
The Centers for Disease Control & Prevention (CDC) has released its 2017 immunization schedules. As is the case each year, there are a number of changes to the vaccine recommendations. Among them were three vaccines that showed low member compliance in 2016: Human papillomavirus (HPV), influenza and meningococcal.
For the new recommendations regarding HPV, flu and meningococcal, as well as the complete 2017 schedule of immunizations for kids 18 years and younger, see the CDC website.
The Centers for Medicare & Medicaid Services (CMS) maintains and publishes codes used by providers when filing claims and by payers when issuing payments. These codes are updated frequently and can be found on the BlueCross website.
Several times a year, BlueCross reviews and updates code mapping in order to remain compliant with CAQH CORE EFT & ERA Operating Rules. These updates may impact your internal processes. Please remember to check our website regularly to remain informed of these code changes. The changes will be highlighted and can be found here.
As of March 1, 2017, BlueCross requires all dental providers to be credentialed. This will apply to dental providers who have not been credentialed and/or recredentialed in the past three years. You should receive a letter soon providing additional information about the credentialing process.
Beginning in April BlueCross has a new process that will help reduce the administrative burden put on providers when we recover overpayments on your patients’ claims. Our claims payment process for all lines of business, including BlueCare Tennessee and BlueAdvantage (PPO)SM, will more carefully analyze claims with the goal of delivering payments to providers with more accuracy, reducing the need for recovering payments that exceed claims liability.
This process will not reduce provider reimbursement rates, your patients’ benefits or the speed at which we pay your claims. In fact, this addition to our system will increase efficiency and compliance with standards set by CMS and other governing organizations.
While this system will not completely eliminate overpayments or the need for recovery, our efforts in 2017 help ensure a more accurate and efficient payment process to our providers.
Medical claims for all provider-administered drugs must include the National Drug Code (NDC) of the drug(s) administered, along with the quantity and unit.
Providers are encouraged to share NDC billing requirement guidelines with their electronic software vendor to assist in the submission of electronic claims and to help ensure accurate placement of data. http://www.bcbst.com/docs/providers/Supplemental-EDI-Information.pdf
Please note: Claims submitted for provider-administered drugs without the appropriate NDC may be rejected.
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 your office’s transition or any barriers that may prevent you from filing electronic claims.
In keeping with current coding standards, BlueCross made changes to payment rates for codes related to Moderate Conscious Sedation. Please review this important information for each line of business.
BlueCross’ changes are in response to CMS modification of procedure codes and corresponding payment rates for the Medicare Physician Fee Schedule, based on the AMA’s CPT® coding changes for Moderate Conscious Sedation services.
For more information, see our website at http://www.bcbst.com/sedationcode.
CT and MRI testing for Commercial members associated with joint arthrogram procedure codes 23350, 27093, 27095, 27370, G0259, and G0260 can be authorized through the Musculoskeletal Program administered by OrthoNet.
Prior authorization requests can be submitted via BlueAccessSM at http://www.bcbst.com/blueaccess, by phone at 1-866-747-0586 or by fax to 1-866-747-0587. (When submitted online, the musculoskeletal code must be the primary code.)
BlueCross requires all nurse practitioners and physician assistants to be credentialed and contracted before providing services to our members. This requirement went into effect Jan. 1, 2017, and applies even if nurse practitioners and physician assistants are employed by a physician or group already contracted with BlueCross.
Please contact your local Provider Relations Consultant (PRC) with any questions. If you don’t know who your PRC is, visit http://www.bcbst.com/providers/mycontact/ to locate your BlueCross contact.
This information applies to BlueCareSM and TennCareSelect plans, excluding CoverKidsSM and dual-eligible BlueCare Plus (HMO SNP)SM unless stated otherwise.
The Bureau of TennCare has identified a large number of prescriptions written for members with TennCare coverage that don’t correspond with provider claims. If your office sees patients with BlueCare Tennessee benefits, the only payments you can accept from them are copayments for authorized services. Providers who violate this part of their contract can be removed from participating in TennCare provider networks.
The American Academy of Pediatrics (AAP) recommends a schedule of comprehensive, age-specific, preventive health care screenings, assessments, physical examinations and procedures used as the standard of care for your young patients. These recommendations have recently been updated in the Bright Futures/AAP Periodicity Schedule.
In addition to covering scheduled periodic checkups, BlueCare Tennessee also covers other inter-periodic screens for kids. Children should have 12 TennCare Kids checkups between birth and age 30 months and a checkup every year from age 3 to age 20.
Ideally, BlueCare Tennessee members who are assigned to you as their primary care provider (PCP) would visit you for all of their care. Seeing you for check-ups, as well as when they’re sick, would allow you to best coordinate their care. Since that doesn’t always happen, our claims data is a great resource when you need to know more about your patients’ complete health histories.
BlueCare Member Information Available to Assigned PCPs is available to you and includes:
To request the health history of a BlueCare Tennessee member, please call Provider Service.
If you need to request information regarding a SelectKids member, please e-mail your request including the member name, member ID number and date of birth to SelectKids_GM@bcbst.com.
Due to privacy concerns, any claims related to Behavioral Health Services will not be released.
Please ensure each field in the TennCare published ASH forms are completed accurately. The Hysterectomy form has been revised for clarity to help ensure providers complete only one section of the form. All ASH forms, along with instructions for completion, are accessible online in the ASH section of the BlueCare Tennessee Provider Administration Manual.
Note: This information is applicable to your patients with BlueCare Tennessee and CoverKids health plans.
As a part of the Tennessee Health Care Innovation Initiative, Level 2 Mental Health Case Management is no longer a reimbursable service. Instead, members can be referred for Care Coordination Services that are delivered by Bureau-approved Tennessee Health Link providers. For more information, please visit https://www.tn.gov/hcfa/article/tennessee-health-link.
This information applies to BlueAdvantage (PPO)SM and BlueChoice (HMO)SM plans. BlueCare Plus (HMO SNP)SM is excluded unless stated otherwise.
Approximately one in five seniors is likely to struggle with behavioral health issues, and this can worsen other chronic health problems. Additionally, the senior population typically manages multiple medical conditions on a daily basis, which puts them at greater risk for behavioral health issues such as depression and anxiety. This can negatively impact medication compliance and other efforts to follow your prescribed treatment plan.
Starting June 1, BlueCross will partner with AbleTo to provide a telephonic counseling and outreach program to a small group of Medicare Advantage members with adjustment and mood disorders. AbleTo will provide 16 telephonic sessions with a licensed therapist and a behavioral health coach over the course of eight weeks. Once enrolled in the program, members can access these services 24 hours a day, seven days a week at no additional cost.
Initially, this service will be limited to 250 Medicare Advantage members with adjustment and mood disorders and other chronic health conditions. Members may be asked to participate via letter, or you can refer a BlueCross Medicare Advantage patient by calling 1-866-287-1802. This program does not limit any other behavioral health services through the patient’s Medicare Advantage plan.
CMS revised the Notice of Denial of Medical Coverage (Integrated Denial Notice [IDN]) template that all Medicare Advantage plans must use by April 10, 2017. CMS issues the IDN to inform enrollees of their appeal rights as applicable for payment or service denials and for discontinuation or reduction of a previously authorized course of treatment.
Please note the following changes to the IDN:
Beginning June 1, 2017, Medicare Advantage will require HCPCS codes for all outpatient physical, occupational and speech therapy services. Skilled nursing, medical social services and home health aide services also require the appropriate HCPCS codes that correspond with the Revenue Code being billed.
Please be sure the billing units for home health services are filed as 1 unit for each 15-minute increment. Refer to the BlueCross BlueShield of Tennessee Provider Administration Manual for additional home health billing information.
|Description||Revenue Code||Procedure Code||Billing Unit|
|Home Health Agency Physical Therapy||421||G0151||1 unit per 15 minutes|
|G0157||1 unit per 15 minutes|
|G0159||1 unit per 15 minutes|
|Home Health Occupational Therapy||431||G0152||1 unit per 15 minutes|
|G0158||1 unit per 15 minutes|
|G0160||1 unit per 15 minutes|
|Home Health Speech Therapy||441||G0153||1 unit per 15 minutes|
|G0161||1 unit per 15 minutes.|
|Home Health Agency Skilled Nursing (RN or LPN)||551||G0493||1 unit per 15 minutes|
|G0494||1 unit per 15 minutes|
|G0495||1 unit per 15 minutes|
|G0496||1 unit per 15 minutes|
|Home Health Agency Medical Social Services||561||G0155||1 unit per 15 minutes|
|Home Health Agency Home Health Aide||571||G0156||1 unit per 15 minutes|
*This change will be included in the second quarter provider administration manual update.
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.
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 requesting you 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
Home-based polysomnography sleep studies do not require a prior authorization. Facility-based sleep studies (polysomnogram or PSG), CPAP titration and split-night sleep studies all require prior authorization.
CMS requires Medicare Advantage health plans to confirm diagnosis codes submitted on claims are supported in medical records. BlueCross has partnered with ArroHealth to obtain medical records on our behalf to meet this requirement.
ArroHealth will formally request medical records beginning in late April and early May. You will soon receive a letter along with a list of requested member records and instructions on how to send medical records. Please follow the instructions provided with your letter how to return the requested medical records to ArroHealth.
You have three convenient ways to submit medical records to ArroHealth:
You also may request on-site assistance by calling ArroHealth at 1-855-651-1885, or by contacting your Provider Relations Consultant.
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.
Access benefit and eligibility details, submit electronic claim transactions and much more – all to help reduce your administrative costs.Learn More