Private Payer Round-Up, October 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 for help, or call TMA Knowledge Center at (800) 880-7955.


Triessent becomes Prime Specialty Pharmacy — As of Nov. 1, 2012, Triessent, the preferred specialty pharmacy for most Blue Cross and Blue Shield of Texas (BCBSTX) members, will become Prime Therapeutics Specialty Pharmacy, LLC (Prime Specialty Pharmacy). Benefit coverage for patients formerly served by Triessent will not unaffected by this transition. Here contact numbers for Prime Specialty Pharmacy:

  • Phone: (877) 627-MEDS (877-627-6337)
  • Fax: (877) 828-3939

For more information including updated forms, visit the Pharmacy Program section of the BCBSTX provider website.

Regence HealthWise clarification —Blue health insurance coverage for members with Regence HealthWise ID cards will not terminate effective Sept. 9, 2012, as previously announced. Coverage for members carrying Regence HealthWise ID cards will continue until further notice. 

Real-time processing for out-of-area electronic claims — BCBSTX now processes and transmits all BlueCard claims in real time between BCBS plans. BlueCard is the national program that enables members of one BCBS plan to obtain health care services while traveling or living in another BCBS plan’s service area. This will speed up payment of these claims.

Check out Electronic Refund Management (eRM) — This free online tool can help simplify your overpayment reconciliation and related processes. You can view a live demonstration of the system at an eRM webinar sessions, where you’ll also learn how to gain access and complete the online “onboarding” process. Note: Prior to accessing eRM, you must be registered with either

  • Availity, (800) AVAILITY (282-4548), or
  • RealMed, (877) REALMED (732-5633).

Submitting electronic Blue Cross replacement claims (professional) — The Blue Cross and Blue Shield of Texas (BCBSTX) claim system recognizes claim frequency codes on professional electronic claims (ANSI 837P transactions). Using the appropriate code will indicate that the claim is an adjustment of a previously adjudicated (approved or denied) claim. The claim frequency codes are as follows: 

1     Indicates the claim is an original claim
7     Indicates the new claim is a replacement or corrected claim — the information present on this bill represents a complete replacement of the previously issued bill.
8     Indicates the claim is a voided/canceled claim

Replacement claims (sometimes referred to as corrected claims) submitted electronically will reduce the potential for a claim to deny as a duplicate. If you need to send a replacement claim, submit the correction electronically with frequency code 7.

The replacement claim will replace the entire previously processed claim. Therefore, send the claim with all changes exactly how the claim should be processed (see examples).

 Note: If a charge was left off the original claim, please submit the additional charge with all of the previous charges as a replacement claim using frequency code 7. All charges for the same date of service should be filed on a single claim.

 If you sent a claim to BCBSTX in error and need to void it, submit the claim exactly as you submitted it previously along with the appropriate frequency code 8. If you have questions, contact the BCBSTX Electronic Commerce Center at (800) 746-4614.

 Source: BCBSTX News and Updates; Blue Review 


Coverage policy updates — Effective Oct. 22, 2012, Cigna updated the following coverage policies. Remember that Cigna payment and modifier policies apply to all claims, including those for patients with GWH-Cigna ID cards. However, practices should continue to follow separate claims submission procedures for these patients.

  • Acupuncture
  • Cardiac Events
  • Cardiac Rehabilitation
  • Cranial Orthotic Devices
  • Gait Analysis
  • Nutritional Support
  • Photodynamic Therapy (PDT) for Dermatologic and Ocular Conditions
  • Plasma Brain Natriuretic Peptide

Information about these updates is on the Cigna for Health Care Professionals website (go to Resources > Clinical Reimbursement Policies > Coverage Policy Updates).

MedSolutions, Inc. and Medicare primary claims — In June 2012, Cigna changed the claim submission process for Medicare primary claims for radiology services. Physicians contracted with MedSolutions, Inc. (MSI) should send all Medicare primary claims directly to Cigna. Cigna will process the claims and send the explanations of payment. If you send a Medicare primary claim to MSI, the claim will not be accepted, and you will be instructed to bill Cigna. Continue to submit all other radiology services claims directly to MSI.

Single payer ID for GWH-Cigna and Payer Solutions networks — Cigna moved to a single payer ID for GWH-Cigna and Payer Solutions network claims as of July 1, 2012. Submit these claims using payer ID 62308. 

Be sure to update your system to submit claims to the appropriate payer IDs.

Payer ID         Claim Type 

62308              Medical (including GWH-Cigna and Payer Solutions networks), behavioral PPO, and dental  

SX071             Employee Assistance Program and behavioral HMO

59225              Starbridge Beech Street

Wellness screening program available soon — Starting in December 2012, Cigna patients in select markets can be in new wellness screening program. As part of this incentive program, these patients are asked to track and maintain their biometric screening results (e.g., blood pressure and cholesterol levels), using a special wellness screening results form.  

They may ask you to complete and sign this form when you take their biometrics. If they don’t bring the form to their appointment, you can download and print it on the Cigna for Health Care Professionals website (go to Resources > Forms Center > Medical Forms > Wellness Screening Form). You or your patient can return the completed form to Cigna by fax or mail. This information is clearly identified on the form.

Your patients may be eligible to receive a monetary incentive through their Cigna medical plan. They can learn about the incentives and locate the wellness screening form by logging in to > Forms Center or call the toll-free number on their Cigna ID card. adds features — The Cigna for Health Care Professionals website ( has new features, including: 

  • A dashboard to help you access your tools,
  • The ability to “flag” patient and claim information to save and retrieve from your dashboard,
  • A patient-focused layout to help you manage tasks,
  • Multiple tabs that stay open during your visit so you can quickly switch to a previous view, and
  • An auto-save feature.

 Source: Cigna’s Network News (PDF), October 2012

Published Oct. 29, 2012 

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