Health Plan News

TMA reimbursement specialists know how difficult it is to keep up with health plans’ constant changes. We are here to help you stay informed about the latest news from the major payers: Medicare, Medicaid, Aetna, Blue Cross and Blue Shield of Texas, Cigna, Humana, and UnitedHealthcare. Check back frequently for billing, coding, and health plan policy updates.

Aetna  |  BCBS |  Medicare  |  Medicare Advantage  |  United Healthcare


  • Aetna Imaging Study Coding Tip
    Aetna requires an exact Current Procedure Terminology (CPT) code match between submitted claims and eviCore Healthcare’s authorizations for computerized tomography (CT) and magnetic resonance (MR) studies. Aetna will deny claims billed with nonmatching codes.
    Effective as of Jan. 1, 2021, this applies to Aetna commercial plan patients for whom Aetna requires preauthorization of certain radiation services. In addition to the specific type of imaging study, eviCore Healthcare, the authorization vendor, will make medical necessity determinations about the correct use of contrast for MR and CT procedures – and also will offer recommendations “for requests that are not appropriate based on the contrast component of the imaging procedure,” Aetna says. Note that the specific Healthcare Common Procedural Coding System codes for these contrast agents are not included in the eviCore Healthcare prior authorizations. You can find more information about coverage of specific contrast material in Aetna clinical policy bulletins.
    CPT copyright American Medical Association. All rights reserved.     
  • ER Surgical Procedures and Modifier 54
    Effective March 1, 2021, Aetna will pay for surgical procedures at 75% of the contracted surgery rate when performed by an emergency physician in the emergency department, whether or not the procedure is billed with modifier 54 (surgical care only). See details about modifier 54, a “split-care” modifier.
  • New Aetna Third-Party Claim Edit Coming
    Aetna will introduce new claim edits on March 1, 2021, as part of its third-party claim review. Aetna may ask you for medical records for certain claims, such as high-dollar claims, claims for implants, and bundled services claims. To access a prospective claims editing disclosure tool and find out if the new edits will apply to your claim, log in to the Availity provider portal. Then, then go to Aetna Payer Space > Applications > Code Edit Lookup Tools.

Blue Cross Blue Shield 

  • New List Helps ID When to Verify Coverage
    Blue Cross and Blue Shield of Texas (BCBSTX) has created a predetermination code list of procedures for which predetermination of benefits may be available and is recommended. Predetermination is a voluntary request for written verification of benefits before providing a service that may be considered experimental, investigational, or unproven, as specified in BCBSTX Medical Policy. Visit the BCBSTX’s Predetermination of Benefits Request page to view the list, find instructions for submitting a request electronically, or download a request form. 

  • BCBSTX Will Recoup Overpayment of Multiple Surgical Procedures
    Blue Cross and Blue Shield of Texas (BCBSTX) will begin post-payment reviews of claims on June 1, 2021, to make sure they adhere to its payment policy for multiple surgical procedures. According to BCBSTX, “you may have been paid 100%” for multiple procedures erroneously. For claims with dates of service of June 1 or later, BCBSTX will recoup any overpayments it finds against future claims.

    Under the multiple surgical procedure policy, when the same physician or physician group performs multiple procedures on the same patient in the same operative session, only the primary procedure will pay 100% of the allowed amount. Secondary or subsequent procedures will pay at 50%.

    • The surgical procedure with the highest allowed amount is primary. If two procedures have the same allowed amount, only one will be considered primary.
    • For bilateral procedures, if the surgical procedure for either side is the highest allowed amount, one procedure will pay at 100% and the second one, as well as all other secondary procedures, at pay will at 50%. If at least one other surgical procedure is the highest allowed amount, the bilateral procedure (both sides combined) will be paid at 75% and all other secondary procedures at 50%.

    Some procedures may be exempt from this policy and pay 100% of the allowed amount (see the policy for details). Also, Medicare, Medicare supplement, and BCBSTX as secondary payer policies are exempt.
  • Blue Cross May Have Assigned Primary Care Physicians in Error
    On Jan. 1, 2021, Blue Cross and Blue Shield of Texas (BCBSTX) became aware of a system error that may result in an erroneous primary care physician number assignment to Blue Cross Medicare Advantage HMO members, according to the payer.
    If you receive an error message when accessing Availity, continue to treat the assigned members and, if applicable, refer them to in-network providers. If you receive any inappropriate claim denials, BCBSTX says it will automatically reprocess them after the system is corrected. Call BCBSTX at (800) 676-2583 with any questions.
  • BCBSTX May Terminate Unused Provider Record IDs
    Blue Cross and Blue Shield of Texas may automatically cancel a provider record ID that has no claim dates of service within a 12-month period. This also will result in termination of associated networks. Provider record IDs are specific to billing/rendering National Provider Identifiers and tax identification numbers.


  • Fact Sheet Summarizes Medicare Payment for E&M Visits
    Medicare has generally adopted the new American Medical Association coding, language, and interpretive guidance framework for office and outpatient evaluation and management (E&M) visits (CPT codes 99201 through 99215), effective Jan.1, 2021. See this fact sheet for more information, including:

    • Payment of Medicare’s add-on codes for prolonged office and outpatient visits (G2212) and visit complexity (G2211), and
    • Medical review when time is used to select visit level. 
    CPT copyright American Medical Association. All rights reserved.        
  • Medicare Updates Codes Accepted With Cost-Sharing Modifier
    The Centers for Medicare & Medicaid Services has updated the list of codes (ZIP) physicians can use with the cost-sharing (CS) modifier to identify a service as subject to the cost-sharing waiver for COVID-19 testing-related services. For dates of service on or after Jan. 1, 2021, through the end of the public health emergency, Medicare will accept these codes with the CS modifier:

    • HCPCS codes G2250, G2251, and G2252, and
    • CPT codes 98970, 98971, and 98972 (these replace HCPCS codes G2061-G2063, which are accepted for services provided in 2020).   
    • CPT codes 98966, 98967, and 98968 are accepted for services with the CS modifier provided on or after March 18, 2020. 
    CPT copyright American Medical Association. All rights reserved.       
  • Novitasphere Login to Change Jan. 15
    The log-in screen for Novitasphere, the physician portal for Medicare payer Novitas Solutions, will change slightly on Jan. 15 when the Centers for Medicare & Medicaid Services (CMS) adopts a new identity management system for CMS applications. Your existing Novitas user ID and password will migrate to the new system. When you log in, you’ll be prompted to select your multifactor authentication (MFA) device and enter the code. If you no longer have access to the email address associated to your user ID, you need to update the address before midnight on Jan. 14, on the CMS Enterprise portal. Note that the Novitasphere helpdesk will no longer provide a one-time MFA passcode after the transition; you must rely on your MFA device to receive it. Remember, you must log into every month to keep your access active.

Medicare Advantage

  • Collect Medicare Info to Bill for Medicare Advantage COVID-19 Vaccine Administration
    Physicians contracted with Medicare Advantage plans should submit to original Medicare – not to the plan carriers – claims for administering a COVID-19 vaccine to their Medicare Advantage patients. To submit the claim to Medicare through Novitas Solutions, the Medicare payer for Texas, your practice will need to have on file your Medicare Advantage patient’s original Medicare card or Medicare ID number. Be sure to have your staff collect this when Medicare Advantage patients make appointments to receive a COVID-19 vaccine.

    Bill only for the vaccine administration when you’ve received the COVID-19 vaccine doses from the  government for free; don’t include the vaccine codes on the claim. Any other services you provide the patient on the same date should be filed to the Medicare Advantage plan. 

United Healthcare

  • Peer Comparison Reports Now Available 
  • Notify Us - Changes in Medical Professional Staff 
  • Preferred Lab Network 
  • New, Streamlined Referral Experience Now Available 
  • Stay Connected With UnitedHeathcare Tools
    Some upgrades and other changes coming over the next few months will change how you interact with UnitedHeathcare (UHC) digital tools. Be aware of these dates in spring and summer 2021:

    As of March 3, referral information will no longer be available on the Link dashboard. Instead, you’ll access it using the UnitedHealthcare Provider Portal, as UHC continues to retire tools from Link and upgrade its digital services to the new system. You can use your current Link login credentials to access the UnitedHealthcare Provider Portal. Read more information.

    In May, the patient management tool UHCCareConnect will transition to a new application, Practice Assist. You won’t need to do anything differently, UHC says; you’ll still access it through the Link portal. UHC says Practice Assist will provide better access to population data, personal data, and more.

    Update your web browser by Aug. 17, as Microsoft will no longer support Internet Explorer 11 online services. To get the best user experience with UHC’s online tools and help stay protected against security threats, UHC recommends changing your default web browser to Microsoft Edge, Google Chrome, or Apple Safari. Here’s how.

  • Find UnitedHealthcare Patients’ Medicare IDs
    Need your UnitedHealthcare (UHC) Medicare patient’s original Medicare ID number so you can bill Novitas Solutions for COVID-10 vaccine administration? (See above: Collect Medicare Info to Bill for Medicare Advantage COIVID-10 Vaccine Administration.) UHC has added Medicare IDs under Eligibility & Benefits on the UnitedHealthcare Provider Portal.

  • CIOX Health May Ask You for UnitedHealthcare Medical Records 
    A chart retrieval vendor for UnitedHealthcare, CIOX Health, may contact you in February 2021 for patient information as part of the Centers for Medicare & Medicaid Services (CMS) Risk Adjustment Data Validation Audit for benefit year 2019 (which had been paused due to COVID-19). CMS performs this audit of patients it selects randomly to validate the accuracy of codes submitted by plans for payment. If your patient has been selected, CIOX Health will request medical records to support the auditor. You can find a video tutorial to learn about electronic submission of medical records at
  • UnitedHealthcare to Require Preferred Lab Network Integration 
    Staring April 1, 2021, for commercial UnitedHealthcare (UHC) plans, physicians with an electronic health record (EHR) will be required to allow at least one Preferred Lab Network (PLN) provider integration into the EHR. If you don’t have a Preferred Lab Network integrated into your EHR for lab testing, go to UHC’s Preferred Lab Network webpage and complete this integration request form to identify the PLN you’d like to use for integration.
  • Submit Social Determinants of Health Codes to UnitedHealthcare 
    A UnitedHealthcare (UHC) protocol encourages physicians to routinely screen all your UHC patients for social determinants of health (SDoH), document SDoHs in the patients’ medical record using these ICD-10 diagnostic code(s), and submit the codes to UHC. This code list may be updated, so keep an eye on it. 

Last Updated On

February 25, 2021