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 Feb. 12, 2017
Note: These effective dates also apply to BlueCare Tennessee pending state approval.
Based on input we have received from you, we are pleased to announce that extended timelines for claims appeals and arbitration are in effect as of Jan. 1, 2017. After receiving a response on a claim reconsideration, providers now have up to 60 days to request an appeal to a claim. Additionally, after receiving a final decision on a claim appeal, providers now have up to 60 days to request arbitration.
Important Note: When making claim reconsideration and appeals requests, please be sure to use the new forms found on the Reconsideration and Appeals webpage. As of Jan. 1, 2017, reconsideration and appeals requests submitted on the old provider dispute forms may be returned, directing you to resubmit on the appropriate new forms. Please use the new Provider Reconsideration Form and Providers Appeal Form to prevent delays in processing these requests.
Please check the Reconsideration and Appeals webpage for updated resources throughout the year.
The Centers for Medicare & Medicaid Services (CMS) requires Affordable Care Act (ACA) individual and small group health plans to confirm diagnosis codes submitted on claims are supported in medical records. BlueCross BlueShield of Tennessee has partnered with ArroHealth, formerly MedSave USA, to obtain medical records on our behalf to meet this requirement.
ArroHealth will begin formal medical records requests over the next two months. We ask that you please follow the return instructions provided with the list of requested records. Medical records can be returned to ArroHealth via:
The Commercial Efficiency Practice Pattern Analysis (PPA) reports, which help provide you with important information about your utilization and quality of care as it compares to your peer group within BlueCross, are updated bi-annually and are available through BlueAccessSM. The next bi-annual PPAs will be available soon.
Please note that the 2016 first quarter bi-annual PPAs were recently updated on BlueAccess to correct an indicator error. Although the indicator error only affected less than one percent of the first quarter PPAs, the first quarter PPAs were recently updated and now available on BlueAccess.
Patients diagnosed with mental illness are more likely than their peers to develop obesity and have an increased risk for being diagnosed with Type 2 Diabetes, heart disease, hypertension, stroke, and premature death. Antipsychotic medications have been associated with an increase in appetite and weight gain. Assessing your patient’s psychological state and social situation should be taken into consideration when managing obesity. Their affect and mood, stressors, social support, and cognitive skills will also influence the treatment plan.
Collaboration between medical and behavioral treatment providers may be especially helpful when developing a treatment plan. Once a plan is in place, both providers can address aspects related to maintaining a healthy diet and exercise with their patient. Patients should be encouraged to believe that in the midst of mental illness, good health is possible. http://www.nhlbi.nih.gov/files/docs/guidelines/prctgd_c.pdf
BlueCross continues to address the growing national effort toward more appropriate use of opioids. Earlier this year, BlueCross made a policy change requiring your patients who are new to long-acting opioid pain medication therapy and covered by BlueCross commercial plans to have prior authorization (PA) for these drugs. To further promote prescription safety, BlueCross is making other significant changes that will go into effect in January.
|Opioid Prescription Policy Changes Effective Jan. 1, 2017|
|(Applies to your patients with BlueCross commercial, BlueAdvantage (PPO)SM, BlueChoice (HMO)SM and BlueCare Plus (HMO SNP)SM plans)|
|Prior authorization required for all long-acting opioid prescriptions|
|Quantity limits for both short-acting and long-acting opioids prescriptions|
|The combined morphine equivalent dose (MEqD) of all prescriptions cannot exceed 200mg/day|
|Note – Opioid treatment for members in hospice care or undergoing cancer treatment will receive approval, but still require a prior authorization request.|
To view the entire policy on the Use of Opioids in Control of Chronic Pain, please visit our website: http://www.bcbst.com/mpmanual/!SSL!/WebHelp/mpmprov.htm
Now Accepting Prior Authorization Requests for Jan. 1 Effective Dates For your patients taking long-acting opioids, and for whom you expect to need the medicines in January, you may request the prior authorization for a Jan. 1 effective date now. The maximum length of a prior authorization for long-acting opioid is six months. When you make your request, please inform the PA Desk that the request is for prescriptions obtained on or after Jan. 1, 2017.
How to Obtain Prior Authorization for Your Patients
All provider-administered drugs for medical claims filed on a CMS-1500 Health Insurance Claim form or submitted electronically in the ANSI-837 version 5010 format 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.
Please note, submitting claims without the appropriate NDC could delay your reimbursement payments
As a BlueCross network provider, you should know what our members are being told to expect from you and what you have the right to expect from those members. To comply with regulatory and accrediting requirements, we periodically remind members of their rights and responsibilities. These reminders are intended to make it easier for members to access quality medical care and to attain services.
Member rights and responsibilities are outlined in both the BlueCross BlueShield of Tennessee and BlueCare Tennessee provider administration manuals, which are available online at http://www.bcbst.com and http://bluecare.bcbst.com/.
BlueCross requires all nurse practitioners and physician assistants to complete the credentialing process before providing services to our members. As of Jan. 1, 2017, nurse practitioners and physician assistants must be credentialed, even if they are employed by a physician or group that is contracted to provide services to BlueCross members. Begin the credentialing process by completing the online Provider Enrollment Form.
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.
The State of Tennessee is continuing its growth of the Tennessee Healthcare Innovation Initiative (THCII) through the development of the Tennessee Health Link (THL), which launched Dec. 1, 2016, and the expansion of the Patient-Centered Medical Home (PCMH) model for the TennCare population, which will launch Jan. 1, 2017.
The PCMH expansion begins with 29 primary care provider groups selected to be in the first wave of implementation. Approximately 100,000 members are assigned to these providers. Preview reports that feature quality and utilization details were issued in December 2016 and the first payments will be made in January 2017. Large practices with 5,000 or more attributed members are eligible for shared savings based on total cost of care. Smaller practices with fewer than 5,000 members are eligible for payments based on improved efficiency metrics. These shared savings require practices to meet quality metric thresholds.
Both programs represent new opportunities to partner with providers to improve the health and wellbeing of members.
More information can be found on the State’s website:
It is sometimes necessary for BlueCare Tennessee employees to contact providers with questions about a patient’s clinical or demographic information. On occasion, provider offices will cite HIPAA as the reason for not releasing the requested information. Please make sure your staff is aware that we are authorized to handle the Protected Health Information (PHI) of your patients and they should provide the information when BlueCare Tennessee makes a request.
This information is critical, especially for our Population Health Case Management staff when they work with your patients who have complicated care needs, chronic illness and catastrophic illnesses or injuries.
For more information about the provider requirements for the release of personal health information (PHI), please see the BlueCare Tennessee Provider Administration Manual.
The Centers for Medicare & Medicaid Services (CMS) has extended the EHR Incentive Program enrollment deadline beyond the original Dec. 31, 2016, date. Providers now have until March 31, 2017, (11:59 PM CT) to enroll and submit their Program Year 2016 attestation to TennCare. Click here for more information about the Medicaid Electronic Health Record (EHR) Incentive Program.
Benefits of program participation include:
Get Started To register and get started with the program attestation, please visit https://ehrincentives.cms.gov/hitech/login.action.
Give the Program Another Try
Some providers stopped attesting because they felt meeting Meaningful Use (MU) was too difficult. CMS heard you and MU requirements have changed. Whatever reason caused you to stop attesting, the State would like to help you get back on track. Send an email to TennCare.EHRIncentive@tn.gov.
Please ensure each field in the TennCare published Hysterectomy Form is completed accurately. The form was revised for clarity to ensure providers complete only one section of the form. All Abortion, Sterilization, and Hysterectomy (ASH) forms, along with instructions for completion, are accessible online in the ASH section of the BlueCare Tennessee Provider Administration Manual.
In accordance with their periodicity guidelines, the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care requires evidence of a comprehensive unclothed/suitably draped physical examination in a TennCare-eligible child’s medical record.
All required components of the physical exam should be performed and documented in the medical record with the date of the exam. If the child is uncooperative or the examination was deferred/refused, be sure to include this information in the medical record.
Please refer to the American Academy of Pediatrics at http://tnaap.org/coding for the required components of the TennCare Kids exam as well as required medical record documentation criteria.
An annual wellness exam (AWE) is an important first step to a healthy 2017. 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. These members may also be eligible to earn a reward for completing the exam. You can help your BlueCross Medicare Advantage patients earn additional rewards for their healthy living by scheduling a check-up early in the year.
In 2017, members will need to take two steps to be eligible for rewards:
The Member Wellness Incentive FAQs document is being revised to reflect the changes to the 2017 program and is available on the Quality Care Rewards website.
Note: The AWE is a calendar year benefit, which means each member is entitled to one AWE in 2016, one in 2017, etc. regardless of the number of days between each exam. It is not necessary to wait 365 days between exams.
Effective Jan. 1, 2017, initial dialysis clinic claims filed with Type of Bill 072X will also 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-U03form is not on file with BlueCross. Initial and subsequent claims will be denied, and you will be asked to submit the completed form.
You may fax the applicable CMS-2728-U03 form to (423) 535-5498, or mail it to:
BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Revenue Reconciliation
1 Cameron Hill Cr, Ste 0002
Chattanooga, TN 37402-0002
The Right of Reimbursement and Recovery (Subrogation) is a provision in the member’s health care benefits plan that permits Medicare Advantage to conditionally pay the health care provider when a third party causes the member’s condition. Medicare Advantage follows Medicare policy whereby law, 42 U.S.C. §1395y(b)(2) and § 1862(b)(2)(A)/Section and § 1862(b)(2)(A)(ii) of the Social Security Act, 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 workers’ compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.”
The federal law found at 42 U.S.C. 1395y(b)(2(B)(ii) and 1862(b)(2)(B)(ii) and federal regulations found at 42 C.F.R. 411.24(e) & (g), state that the Centers for Medicare and Medicaid Services (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. A Medicare Advantage plan sponsor may recover in the same manner as CMS.
Similar to Medicare, if responsibility for the medical expense incurred is in dispute and other insurance will not pay promptly, the provider may bill the Medicare Advantage plan as the primary payer. If the item or service is reimbursable under Medicare Advantage and Medicare rules, Medicare Advantage may pay conditionally on a case-by-case basis, 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 recover damages.
In 2017, you will again be eligible to receive payments for completing and submitting a Provider Assessment Form for your attributed BlueAdvantageSM and BlueChoiceSM members.
Note: The CPT® code that should be used to file a PAF claim changed Jan.1, 2017, to 96160. The 2016 CPT® code, 99420, is invalid in 2017.
BlueAdvantage will continue to reimburse the service as E/M Code 96160, with a maximum allowable charge of:
To receive reimbursement, you must complete the form and submit electronically via BlueAccess or complete the writable Provider Assessment Form and submit via fax to 1-877-922-2963. The form should also be included in your patient’s chart as part of his or her permanent record.
It is not necessary to wait 365 days between PAF submissions. For additional information about the Provider Assessment Form, please visit: http://www.bcbst.com/providers/quality-initiatives.page
Effective Jan. 1, 2017, there are eight new CPT® codes for occupational therapy and physical therapy services. These new codes replace four codes currently being used. See below for changes:
The Tennessee Healthcare Innovation Initiative (THCII) Episodes of Care program is delaying the first performance period for the ADHD episode. The performance period will begin Jan. 1, 2018. Additional time allows changes to be made to the episode design, such as adding additional quality measures and excluding episodes where the member experienced homelessness. Primary care and behavioral health providers who are accountable for this episode will continue to receive quarterly preview reports throughout 2017 and will have additional time to prepare for the performance period.
These changes are a result of additional feedback received from stakeholders in Tennessee. The original design was based on input from a Technical Advisory Group (TAG) of expert Tennessee clinicians. The THCII met again with the same TAG members in November 2016 and asked for additional design recommendations. Preview reports released in May 2017 and after will reflect the updated design and new recommendations.
According to the Centers for Disease Control and Prevention (CDC), cervical cancer is the easiest gynecologic cancer to prevent, with regular screening tests and follow-up. Two screening tests, the Pap test/smear and HPV test, can help prevent cervical cancer or find it early.
Starting at age 21 your female patients should begin receiving cervical cancer screenings at least every three years. Once women turn age 30, they have options for cervical cancer screening: to get cervical cytology tests at least every three years, or get a co-testing of cervical cytology and HPV testing every five years. However, you, as their health care provider, can make the best decision for your patient.
This recommendation from the U.S. Preventive Services Task Force applies to women who have a cervix, regardless of sexual history. It does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised – such as those who are HIV positive.
A pap test may be performed annually for women ages 21 to 65. Please note that annual screenings are a covered benefit for BlueCare Tennessee and CoverKids members. Commercial member coverage is subject to verification of benefits.
As a BlueCross BlueShield of Tennessee provider, you have the opportunity to encourage our members to improve their health by quitting smoking. You can provide vital support by discussing tobacco cessation with members and directing members to support resources.
Follow these tips to help patients kick the nicotine habit:
One out of three older adults falls each year, and many older adults don’t know they have balance problems because symptoms are often mild or seem unrelated. Because even a minor fall can be serious, please take a moment to talk to your patients about fall prevention and what they can do to make sure their homes are safe environments.
Fall Prevention Tips
BlueCross BlueShield of Tennessee complies with the applicable federal and state laws, rules and regulations and does not to 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.
*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.
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