This information applies to BlueAdvantage (PPO)SM and BlueChoice (HMO)SM plans. BlueCare Plus (HMO SNP)SM is excluded unless stated otherwise
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.
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 CPT® code 99420 is no longer valid.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:
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.
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:
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.
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:
You may request prior authorization from Magellan by logging in to BlueAccess at http://www.bcbst.com or by calling 1-888-258-3864. Magellan does not accept authorization requests via fax.
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.
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.
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.
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:
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.
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:
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
8 a.m. to 6 p.m. (ET)
BlueAdvantage Group 1-800-818-0962More
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