Private Payer Round-Up, November 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.


Last chance to change your Dec. 26 evaluation — If you are unhappy with your UnitedHealthcare (UHC) evaluation under its UnitedHealth Premium designation program, you have until Dec. 10, 2012, to request a reconsideration. UHC extended the deadline from Nov. 26 due to Hurricane Sandy. Your designation result will appear in UHC’s online provider directories on Dec. 26.

Note that you can ask UHC to reassess your evaluation after Dec. 10 or any time throughout the designation periods. UHC says it will “still review the request in an expeditious manner” and make resulting changes to your evaluation in the online provider directories “on a regular basis.” If you have any questions, email UHC or call (866) 270-5588.

Medical polity updates — UHC’s changes (PDF) include hyperbaric oxygen therapy, bariatric surgery, and blepharoplasty; most are effective Dec. 1, 2012. All specialties should review the changes in case one will impact them directly.  

Report if your patient uses free samples or starter packs — As of Nov. 15, UHC has modified its coverage review criteria for Notification and Step Therapy programs. The prescribing physician now must validate if a patient began a medication using a manufacturer-supplied free sample or starter pack. For coverage approval, UHC will not allow use of these free samples or starter packs as evidence that a member has begun therapy. 

Step Therapy is a clinical program that requires patients to use a lower cost medication before accessing a higher cost medication that treats the same condition in substantially the same way. Under the Notification program, you may need to provide UHC additional information to determine if the patient’s pharmacy benefit covers certain medications.   

Manufacturer coupon cards disallowed for some drugs — Beginning Jan. 1, pharmacies participating in UHC’s Designated Specialty Pharmacy network will no longer redeem manufacturer-sponsored coupon cards as payment of the patient’s cost share for these six tier 3 drugs on UHC’s Prescription Drug List: 

  • Extavia and Gilenya (for multiple sclerosis);
  • Cellcept (for patients receiving transplants);
  • Humira (for rheumatoid arthritis, Crohn’s disease, and psoriasis); and
  • Victrellis and Peg-Intron (for hepatitis C).

UHC estimates that 45 percent of patients use a tier 3 medication despite less costly alternatives. Manufacturer coupons encourage use of higher-tier medications, resulting in “significant cost to payers for little or no incremental clinical benefit to members,”  UNC says. 

Medicare, Medicaid, and other federal health care programs do not accept these coupons. UNC urges physicians to prescribe tier 1 and 2 options for patients newly diagnosed with a specialty condition, and step up to the tier 3 alternative only if medically necessary.

If a UHC Designated Specialty Pharmacy contacts your office on behalf of a patient interested in switching to a lower cost option and you agree to change the patient’s prescription to a tier 2 medication, you should authorize this change by speaking to a pharmacist directly or by faxing a new prescription or e-prescription to the specialty pharmacy.

Preventive Care Services Coverage Determination Guideline (CDG) updated — UHC has updated its CDG to reflect changes brought about by health system reform. Significant updates include addition of the diagnosis code V70.0 for certain screening services and also affect women’s preventive care services and behavioral counseling to prevent skin cancer — U.S. Preventive Services Task Force rating “B.”

In addition to the full 34-page CDG, UnitedHealthcare developed a seven-page coding summary as a handy reference guide. The guide and coding summary (PDF) are available on the UHC website.

Medicare Advantage patients must have notice of noncoverage — To be allowed to bill a UHC Medicare Advantage patient for noncovered services, practices have to get the patient’s agreement, in writing before providing the service, that the patient will be responsible for the charges. UHC provides a sample form for this purpose. To bill the patient, you must submit a claim with a GA modifier to demonstrate to UHC that you have informed the patient of the noncovered service and obtained the written acknowledgement. If you have questions, call UHC at (877) 837-1882.

Source: UnitedHealthcare network bulletin (PDF), November 2012


Policy, coding, and drug updates — Aetna policy and coding updates, including bundling lab codes, are summarized in this chart (PDF) (see page 2). As of Jan. 1, 2013, Aetna will update it Preferred Drug list regarding opiates and stimulants. Stimulant medications and short-acting opiate/opiate combination medications won’t require precertification, but quantity limits still apply.

Aetna updates its Medicare and commercial preferred drug lists at least annually and from time to time throughout the year. You can find the formularies here:

For a paper copy of these guides, call (800) AETNA RX ([800] 238-6279).

Surgical pathology testing payment policy postponed — In March 2012, Aetna informed impacted specialties that Clinical Laboratory Improvement Amendments and College of American Pathology certification would be required for payment of in-office surgical pathology testing beginning Jan. 1, 2013. However, Aetna has delayed the start date of this policy change to April 1, 2013.

Aetna Performance Network available for three Texas cities — Aetna Performance Network is a tiered network that aligns 20 specialties to top-performing hospitals. Aetna patients pay a lower percentage of their medical costs when they use these Aetna Performance Network doctors and hospitals. 

Aetna Performance Network will be available Jan. 1, 2013, for Austin, Houston, and San Antonio. To create the network, Aetna says it evaluated its participating hospitals based on certain cost and quality criteria. In some cases, it applied other business considerations as well. Aetna then looked at specialists in 20 categories that frequently use those hospitals. In some markets, 12 of the 20 specialties were also reviewed on additional measures for clinical quality and cost. 

By Jan. 1, you can look in Aetna’s DocFind to see if you are in an Aetna Performance Network or to check the status of doctors and hospitals you work with. Select an Aetna Performance Network plan from the dropdown menu and look for the checkmark symbol.

Some Medicare patients’ costs will change — Effective Jan. 1, 2013, Aetna Medicare Advantage (MA) HMO plan members’ cost-sharing responsibilities for certain benefits will change.  

  • Instead of a making a copayment, these patients will pay coinsurance for Part B drugs and durable medical equipment benefits. The amount they pay will be the applicable coinsurance percentage multiplied by Aetna’s reimbursement rate. This means your office must determine the applicable coinsurance amount Aetna MA HMO plan members will owe when they receive these benefits.
  • Starting Jan. 1, Aetna asks that you verify your Aetna MA HMO patient’s eligibility and cost share amount. You can access this information on Aetna’s provider website (once logged in, select Benefits and Eligibility from the Aetna Plan Central home page) or by calling (800) 624-0756. “To accurately track an Aetna MA HMO plan member’s out-of-pocket costs, it is vital that our members are charged accurate cost-share amounts,” Aetna says.

Aetna Medicare Advantage network adds Baylor, contracts with TRS — Baylor Health Care System joined Aetna’s Medicare Advantage network on Nov. 1, 2012. In addition, Aetna was recently awarded a two-year Medicare Advantage contract by the Teacher Retirement System of Texas. It takes effect on Jan. 1, 2013. Aetna anticipates that more than100,000 TRS plan members will join its MA networks in Texas.

Source: Aetna OfficeLink Updates (PDF), December 2012

Blue Cross and Blue Shield of Texas  

Blue Cross and Blue Shield of Texas (BCBSTX) adds plans — BCBSTX has been approved to offer a Medicare Advantage preferred provider plan. In addition, the company has announced the development of a new cost-effective network, Blue Advantage HMO.

General tips for using modifier 24 — BCBSTX reminded practices to use this modifier with evaluation and management (E&M) procedure codes only. The CPT definition of modifier 24 says: “The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.”

When the patient presents during the postoperative period with an unrelated problem, it is appropriate to report the E&M service with modifier 24. For postoperative E&M services, the postoperative periods are defined as 10 days for a minor surgery and 90 days for a major surgery.

Talking with medical management staff — 

  • To discuss, ask questions about or make requests regarding care management, call BCBSTX Medical Management staff at (800) 441-9188. Lines are open 6 am to 6 pm CT Monday through Friday and on nonlegal holidays, and 9 am to noon CT Saturday through Sunday and on legal holidays.
  • For preauthorization, call the Medical Preauthorization Helpline toll-free number listed on the back of your patient’s identification card. After business hours, you may leave a message in a confidential voice mailbox. When returning your call, staff will members identify themselves as BCBSTX employees and give their name and title.
  • Your BCBSTX patients with special communication needs and whose first language is not English may ask to speak to a bilingual (English-Spanish) representative when they call the Customer Service number on the back of their member ID card. BCBSTX staff also has access to a telephone-based translation service to help with other languages. For deaf, hard-of-hearing and speech-disabled members, BCBSTX can communicate using the Texas Relay Network. By dialing 711, the caller is connected to the state transfer relay service for TTY and voice carryover calls.

Source: Blue Review (PDF),  Nov. 5, 2012

AIM to roll out new imaging management program — AIM Specialty Health (AIM) on Jan. 1, 2013, will launch the Integrated Imaging Management Program, a national program for more than 65 employer groups with these primary components: 

  • Prospective case review and education: clinical review of outpatient CT, MRI, nuclear cardiology, PET, and echocardiography exams. Call the Customer Service number on the back of your patient’s BCBSTX ID card  to find out if the Radiology Quality Initiative program applies.
  • Provider/patient transparency, based on the Blue Cross Blue Shield Association’s National Consumer Cost Transparency data set (updated twice annually). Patients (excluding pediatric and cancer patients) may receive phone calls informing them about their imaging facility options. However, BCBSTX will not deny anyone access to services if he or she does not choose the lower-cost option.

 Source (includes information about how facilities’ cost of care is calculated): “AIM National Program Launch Jan. 1, 2013.”


Humana will update its physician (nonfacility) claim policies and/or code-editing on Jan. 26, 2013. Check these general reminders. Highlights are as follows (these apply to commercial fully insured, select self-funded, and all Medicare Advantage plans):

  • Modifier JW policy — Humana policy follows recommendations from the uniform billing (UB) auditor and the American Medical Association when modifier JW (drug wastage) is billed with drug codes. Humana will not pay for multiple vials submitted with modifier JW. If you submit modifier JW for discarded drugs, Humana will not pay for any units over and above the appropriate billable units(s) for the drug. For example:
    • If a billing unit for a drug is 20 mg (one unit) and the smallest single-dose vial available is 60 mg (three units), but you need to administer 40 mg (two units), bill the 40 mg as two units on one line and 20 mg as one unit on a second line with the JW modifier appended to show you did not use one out of three units.
    • If a billing unit for a drug is 20 mg and the single-use vial you use is 20 mg (one unit), but you need to administer 15 mg, bill the 15 mg as one unit to represent the entire vial of 20 mg on a single line. Do not bill the 15 mg as one unit and bill the 5 mg remaining as one unit with the JW appended. This would result in an overpayment of one unit.
  • Maximum per day for obstetric services — Certain obstetrical diagnostic services are allowed once per date of service for each gestation. They are:
    • 59000 (Amniocentesis);
    • 59020 (Fetal contraction stress test);
    • 59025 (Fetal nonstress test);
    • 76802 (Ultrasound, pregnant uterus, less than 14 weeks; each additional gestation);
    • 76810 (Ultrasound, pregnant uterus, greater than 14 weeks; each additional gestation);
    • 76812 (Ultrasound, pregnant uterus; each additional gestation);
    • 76814 (Ultrasound, pregnant uterus; each additional gestation);
    • 76816 (Ultrasound, pregnant uterus, follow-up, per fetus);
    • 76818-76819 (Fetal biophysical profile);
    • 76825-76826 (Echocardiography, fetal); and
    • 76828 (Doppler echo, fetal).

 Humana will not pay for obstetrical ultrasound codes for multiple gestations (CPT 76802, 76810, 76812, or 76814) when submitted without an appropriate multiple gestation diagnosis code. These obstetrical ultrasound codes describe “each additional gestation” and require a diagnosis that reflects multiple gestations.

Published Nov. 29, 2012