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BlueCross BlueShield of Tennessee | February 2017

This information applies to all lines of business unless stated otherwise.

2017 Medical Record Requests to Begin

BlueCross BlueShield of Tennessee and BlueCare Tennessee are required to report Healthcare Effectiveness Data and Information Set (HEDIS®) measures to maintain National Committee for Quality Assurance (NCQA) accreditation. Data is collected for Medicaid, Medicare Advantage, Commercial and CHIP/CoverKidsSM products.

Medical record requests are sent to providers who show they treated the member or were assigned as the member’s primary care provider. We will be contacting you soon for medical records related to prevention and screening, diabetes care, cardiovascular conditions, prenatal/postpartum care, medication management and well child visits.

You may be asked to provide records related to a certain condition. Even if you did not specifically treat the member for that condition, you may be able to provide valuable information on the member’s health – such as blood pressure or medications. Please provide as much of the requested information as possible.

We will work with you to arrange the most appropriate method for obtaining medical record information, which may include scheduling onsite collection in your office or arranging delivery of records. Oversight audits of our medical record abstraction methodology require that we scan pertinent elements of member charts. If you use a copy service, please ask them to respond promptly to record requests.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows Covered Entities (such as practitioners and their practices) to disclose protected health information (PHI) to another Covered Entity (such as BlueCross and BlueCare Tennessee) without patient authorization as long as both parties have a relationship with the patient and the PHI pertains to that relationship for the purposes of treatment, payment, and health care operations. Additionally, all nurses reviewing charts on behalf of BlueCross and BlueCare Tennessee have signed a HIPAA-compliant confidentiality agreement.

Emergency Preparedness Requirements Set by CMS

The Centers for Medicare & Medicaid Services (CMS) established regulations requiring national emergency preparedness for Medicare and Medicaid participating providers and suppliers to adequately plan for both natural and man-made disasters, and coordinate with federal, state, tribal, regional and local emergency preparedness systems. These requirements were mandated Nov. 15, 2016, and must be implemented by Nov. 15, 2017. Click here to view the Federal Register Rules and Regulations related to this requirement.

The regulation addresses three key essentials that are necessary for maintaining access to health care services during emergencies, safeguarding human resources, maintaining business continuity, and protecting physical resources. The three key elements are:

  1. Risk Assessment and Emergency Planning – See the Federal Emergency Management Agency (FEMA) National Preparedness System website for more information.
  2. Policies and Procedures – Develop and implement documents that support the successful execution of the emergency plan and risks identified during the risk assessment process.
  3. Communication Plan – Develop and implement a system to contact appropriate staff, patients’ treating physicians, and other necessary persons in a timely manner to help ensure continuation of patient care functions throughout the facilities and to ensure that these functions are carried out in a safe and effective manner.

Additionally, facilities must:

  • Develop and maintain an emergency preparedness training program.
  • Offer annual training to their staff.
  • Conduct drills and exercises to test the emergency plan.

Reminder: Verify Member Benefits and Eligibility Online

Member benefits often change at the turn of the new year, just like the calendar. The new year may bring new ID numbers for our subscribers and their families. Be sure to log into BlueAccessSM to obtain current eligibility and benefit details for your patients. These benefit details include information about copays, deductibles, coinsurance and benefit limitations. Most member ID cards are listed in the subscriber’s name. Looking up the member ID number in BlueAccess will list all members covered by the subscriber. Please contact your eBusiness Marketing Consultant for more information.

Reminder: New Opioid Prescription Policy Began January 1

BlueCross continues to address the growing national effort toward more appropriate use of opioids. Beginning Jan. 1, 2017, all members covered by BlueCross plans must have prior authorization (PA) for long-acting opioid drugs. Additionally, new quantity limits for all opioids are now in place.

Opioid Prescription Policy Changes Effective Jan. 1, 2017
Applies to your patients with BlueCross Commercial, BlueAdvantage (PPO), BlueChoice (HMO) and BlueCare Plus (HMO SNP) 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, visit our website at!SSL!/WebHelp/mpmprov.htm and select Administrative Services.

To Obtain Prior Authorization

  • For your patients with BlueCross Commercial plans, call 1-877-916-2271 or fax your request to 1-877-328-9799.
  • For your patients who are covered by BlueAdvantageSM, BlueChoiceSM or BlueCare PlusSM plans, call 1-844-648-9628 or fax your request to 1-877-328-9799.

Please remember, ALL patients must have a PA for their long-acting opioids.

Reminder: Understanding Member Rights and Responsibilities

We periodically remind members of the rights and responsibilities they have when they carry a BlueCross BlueShield of Tennessee or BlueCare Tennessee member ID card. These reminders are intended to make it easier for members to access quality medical care and to attain services. They also help members understand what they should expect from you, and what you expect of them.

Member rights and responsibilities are outlined in both the BlueCross BlueShield of Tennessee and BlueCare Tennessee provider administration manuals, which are available online at

Reminder: Credentialing Required for Nurse Practitioners and Physician Assistants

BlueCross requires all nurse practitioners and physician assistants to complete the credentialing and contracting process before providing services to our members. Beginning Jan. 1, 2017, nurse practitioners and physician assistants must be credentialed and contracted, either individually or as part of an existing physician group providing services to BlueCross members. Begin the credentialing process by completing the online Provider Enrollment Form.

Reminder: Obstetric Anesthesia Must Be Billed on Single Claim Form

Obstetric anesthesia for a planned vaginal delivery (01967) that ends in a C-Section delivery (01968) is to be billed on a single claim form using the date of delivery as the date of service. Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code on a separate claim. Add-on codes submitted with no primary code or a different date of service result in rejection and non-payment of the add-on code. In those cases with obstetrical anesthesia for the planned vaginal delivery beginning on one day and the actual caesarean delivery on the following day, dates of service for both codes should have the same “from and through” date, i.e. from beginning of anesthesia through to the completion.

Obstetric anesthesia services involving more than one provider (e.g. two physicians or two CRNA’s) for the same episode are to be submitted on a single claim, under one NPI, with the date of delivery as the date of service. Separate claims for multiple providers will result in denial for the add-on code.

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