Private Payer Update, June 2012

In case you missed these — here is a roundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists. If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help.  

Employees Retirement System of Texas Changing Carriers: On Sept. 1, 2012, United Healthcare Services will become the third-party administrator for HealthSelect of Texas, the state’s health care plan managed by the Employees Retirement System of Texas.

HealthSelect members can continue to receive medical care from Blue Cross and Blue Shield of Texas (BCBSTX) providers through Aug. 31, 2012. Medical office staff should be sure to ask for the patient’s current ID card to ensure you are filing claims with the correct carrier HealthSelect members switch carriers.


Clinical Payment, Coding and Policy Changes — Be sure to read pages 2-3 of the Aetna’s June 2012 Office Links Update for changes. Most will be effective Sept. 1; some took effect in March. For example:

Sept. 1, 2012
Modifier 59 will no longer override 29862 and 29863 when billed with 29914, 29915 or 29916.

Medicare Status Code T
Sept. 1, 2012
Codes designated with a status code T (injections) on the Medicare Physician Fee Schedule are not payable when billed by the same provider on the same date of service as any other service.

New Rules Will Make Electronic Transactions Easier — Aetna reports it already offers the HIPAA-compliant standard electronic transactions, and with limited exceptions, follows the published and anticipated operating rules laid out under the administrative simplification provision of the Patient Protection and Affordable Care Act.  The timeline for all health plans to use these standard transactions and operating rules is as follows:

Jan. 1, 2013      Eligibility and claim status transactions

Jan.1, 2014       Electronic funds transfer and advice

Oct. 1, 2014      Unique identifier for each health plan

Jan.1, 2016       Health claims/encounters, enrollment/disenrollment, referral certification and authorization

Once all health plans are using the same operating rules, it should be easier for practices to get the accurate information you need from health plans. Aetna reports it is making adjustments to be consistent with the new national rules.

BCBSTX  — Online Enhancements From RQI Administrator: BCBSTX requires physicians to obtain a Radiology Quality Initiative (RQI) number prior to ordering high-tech, outpatient, nonemergency imaging services (MRI/MRA, CT/CTA, nuclear cardiology, and PET scans) for most BCBSTX members (see note below). AIM Specialty Health, which administers the RQI program, has introduced enhancements to its online Optioned tool and its provider portal.

Optioned provides information to physicians and consumers regarding the price of advanced diagnostic imaging exams and the quality of the facilities where those exams are performed. First-time users must register prior to use the tool (call [800] 252-2021 for help). New in Optioned: 

  • Additional technologist and facility certification and accreditation options in the Staff section.
  • More details, including a new MRI/PET fusion modality, under the Equipment tab.
  • A Not Applicable response field for CT in the Equipment tab.

 The following enhancements were made to the AIM’s Provider Portal:

  • Disabled accounts may be reactivated by confirming the original email address or answering security questions on file.
  • A reset option has been added for quick online updates to expired passwords.

NOTE: Certain employer groups may require precertification for imaging services from other vendors. If you have any questions, call the number on the back of the member’s ID card.

Published June 28, 2012


Last Updated On

April 20, 2018