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Medicare Advantage | February 2017

This information applies to BlueAdvantage (PPO)SM and BlueChoice (HMO)SM plans. BlueCare Plus (HMO SNP)SM is excluded unless stated otherwise

Code Changes for Drugs Requiring Prior Authorization

As of Jan. 1, 2017, code changes are effective for specialty drugs requiring prior authorization for Medicare Advantage patients. The 2017 Medicare Advantage Specialty Pharmacy List is available online.

BlueCross has partnered with Magellan Rx ManagementSM to facilitate the prior authorization process for provider-administered specialty medications.

Because more detailed information is being requested through the prior authorization process, and because we want to help ensure you get the fastest response possible, authorization requests must be submitted online through BlueAccess or by calling 1-800-841-7434. Prior authorization requests for specialty medications are no longer being accepted by fax.

New CPT® Code for Submitting a Provider Assessment Form in 2017

In 2017, physicians are again eligible to receive payments for completing and submitting a Provider Assessment Form (PAF) for their attributed BlueAdvantageSM and BlueChoiceSM members.
Note: The CPT® code that should be used to file a PAF claim is changing. The new code, as of Jan. 1, 2017, is 96160. CPT® code 99420 is no longer valid.

BlueAdvantage will continue to reimburse the service as E/M Code 96160 with a maximum allowable charge of:

  • $250 for dates of service between Jan. 1 and March 31, 2017
  • $200 for dates of service between April 1 and June 30, 2017
  • $175 for dates of service between July 1 and Sept. 30, 2017
  • $150 for dates of service between Oct. 1 and Dec. 31, 2017

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.

Annual Wellness Exam Must Be Documented for Members to Earn Incentives

An annual wellness exam 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. They are also 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 2017, members will need to take the following steps to be eligible for rewards:

  • “Opt in” to the rewards program with OnLife Health, our new rewards partner. Each member received a welcome kit in January detailing opt-in instructions.
  • Get an annual wellness exam. Claims must be on file for members to receive additional rewards in 2017 for other needed screenings. Annual wellness exams should be filed with 96160, 99385, 99386, 99387, 99395, 99396, 99397, GO402, GO438, GO439, plus appropriate E/M codes.

Members earn 15 wellness points for completing their exam in 2017; however, they can also earn 10 bonus points if completed prior to Oct. 1, 2017.

Additional information about specific screenings eligible for rewards will be available soon. This program aligns with the annual STAR rating and quality bonus for providers.

High-Tech Imaging Authorization Vendor Changes Effective Jan. 1, 2017

BlueCross BlueShield of Tennessee has partnered with Magellan Healthcare National Imaging Associates (NIA) radiology benefit management program to perform authorization review for non-emergent outpatient advanced imaging and cardiac imaging services for BlueCross’ Medicare Advantage and BlueCare PlusSM members. Emergency room, observation and inpatient imaging procedures do not require prior authorization. If an urgent/emergent clinical situation exists outside of a hospital emergency room, please call 1-888-258-3864.

Procedures requiring prior authorization:

  • CT/CTA
  • CCTA
  • PET Scan
  • Myocardial Perfusion Imaging
  • Muga Scan
  • Stress Echocardiogram

You may request prior authorization from Magellan by logging in to BlueAccess at or by calling 1-888-258-3864. Magellan does not accept authorization requests via fax.

Medicare Part D Prescriber Enrollment Requirement

The Centers for Medicare & Medicaid Services (CMS) will implement a multifaceted/phased approach to help ensure enforcement of the Part D Prescriber Enrollment requirement on Jan. 1, 2019, unless the health care provider formally “opts out”. This requirement impacts most providers (e.g., dentists, physicians, psychiatrists, residents, nurse practitioners and physician assistants), including Medicare Advantage providers, who prescribe medications for patients with Part D plans.

Prescribers must be enrolled in an active status for their written prescriptions to be covered under the Medicare Part D benefit plan. CMS previously announced that enforcement of the prescriber enrollment requirement would begin Feb. 1, 2017, but has delayed the implementation requirement to minimize the impact on the beneficiary population and to help ensure beneficiaries have access to the care they need.

Note: CMS must also be notified by Jan. 1, 2019, if you choose to opt out of the program. By opting out you cannot receive reimbursement from traditional Medicare or a Medicare Advantage plan, either directly or indirectly (except for emergency and urgent care services).

To help your Medicare patients, please enroll in Medicare to bill and prescribe Part D benefits. There are no fees to complete the process. Enroll online or by mail.

For more information see the CMS How to Enroll page.

Coding Information for Compounded Bevacizumab (Avastin)

In November 2016, the Medicare Administrative Contractor (MAC) for the State of Tennessee retired its Local Coverage Determination (LCD) for intravitreal Avastin.

Beginning Feb. 1, 2017, compounded bevacizumab (Avastin) for the treatment of retinal diseases of the eye should be coded in the following manner: CPT® 67028, and HCPCS J7999, with a primary diagnosis supporting the retinal eye condition. Claims for compounded bevacizumab (Avastin) for intrivitreal administration coded with J9035 will be denied.

The National Drug Code (NDC) for Avastin, when billed as compounded bevacizumab, does not require prior authorization. Avastin for other clinical conditions does require authorization through Magellan Rx.

Other intravitreal medications for the treatment of retinal diseases also require prior authorization.

Reminder: Right of Reimbursement and Recovery (Subrogation)

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 where by 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.”

According to 42 U.S.C. 1395y(b)(2(B)(ii)/Section 1862(b)(2)(B)(ii) of the Act and 42 C.F.R. 411.24(e) & (g), the Centers for Medicare & 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. Likewise, the MA plan sponsor may recover in the same manner as CMS.

Similar to 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.

Reminder: Annual CAHPS Survey Includes Questions About Member Experiences with Physicians

The Centers for Medicare & Medicaid Services (CMS) conducts the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey every year which contains several questions directly related to the member’s experience with their doctor. The specific questions include:

  • In the last six months, when you needed care right away, how often did you get care as soon as you thought you needed?
  • In the last six months, how often did your personal doctor explain things in a way that was easy to understand?
  • In the last six months, how often was it easy to get an appointment with specialist?

The responses CMS receives from our Medicare Advantage members become part of BlueCross’ network contracted physician’s annual STAR quality rating score.

For more information about the CAHPS survey, please see the Quality Care Rewards page on our website.

Reminder: Peer-to-Peer and Re-Evaluation Process Changes

New guidance from the Centers for Medicare & Medicaid Services (CMS) will change some BlueCross provider peer-to-peer and re-evaluation processes. The following are changes that became effective Jan. 1, 2017:

  • When insufficient clinical documentation exists to support an organizational determination, and after BlueCross has made three separate attempts to obtain clinical information from the requesting provider, a BlueCross medical director will contact the provider for the documentation. If the provider cannot be reached, we will follow up with a specific “intent to deny” fax. If the needed clinical information is not received within one business day, an adverse determination will be issued for insufficient clinical documentation. No additional peer-to-peer options will be available to the requesting provider. Documents submitted after the organizational determination will be treated as a member appeal (reconsideration) according to CMS regulations.
  • When an adverse determination was rendered and there was sufficient clinical information, the requesting provider can ask for a peer-to-peer conversation or submit additional clinical documentation. Either will be treated as a member appeal if services have not yet been rendered. There will not be a re-evaluation process per CMS guidance.
  • When requests are treated as member appeals, only the member and rendering provider have appeal rights. Everyone else needs to have an Appointment of Representative (AOR) form on file before the appeal can be processed. This includes third-party companies acting on behalf of a facility for adverse determinations appealed while the member is still in the hospital.
  • Services rendered with no additional member financial responsibility will be processed as provider appeals. One peer-to-peer conversation and one level of provider appeal are permitted during this process, followed by binding arbitration. This process includes inpatient services with adverse determinations and the member was discharged from the hospital.

Reminder: CMS-2728-U03 Required Annually for Dialysis Clinic Claim Reimbursement

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 the provider 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

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