Private Payer Round-Up, April 2013

In case you missed these — below is a roundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists. Also:


 High-tech and nuclear cardiac services precertification reminder — Referring physicians must contact MedSolutions, Inc. (MSI) to precertify all high-technology radiology services, including CT, MR, and PET scans, as well as nuclear cardiac and other outpatient services.

To view a list of the CPT codes for which Cigna requires precertification, visit the dedicated MedSolutions Cigna website and click on “CPT Codes Requiring Precertification.” For a printed list, call Cigna at (800) 575-4517.

 Electronic claim submission tips — Use these Cigna payer IDs when submitting electronic claims:

  • 62308 Medical (including GWH-Cigna), behavioral, and dental
  • SX071 Employee Assistance Program
  • 59225 Starbridge Beech Street

Both primary and secondary coordination of benefits claims can be submitted to Cigna electronically. You don’t have to submit Medicare coordination of benefits (COB) agreement claims to Cigna. The Medicare explanation of benefits or electronic remittance advice will show those claims are forwarded to Cigna as the secondary payer.

New childhood immunization program — Cigna has developed a program to help promote the pneumococcal vaccine, where appropriate. Its goals are to increase the number of recommended immunizations infants 8-17 months old receive, encourage parents to partner with their health care professionals, and ensure parents are aware of the recommended vaccinations.

How it works: Cigna sends a postcard to the parents, informing them their child may have missed the recommended pneumococcal immunization and encouraging them to follow up with their child’s physician. Cigna also places a follow-up call to parents to help ensure they receive this information.  

Cigna will measure the effectiveness of its outreach program by reviewing how often the billing codes for this service are used. Be sure to use the appropriate codes for the pneumococcal vaccine (use these codes even when the pneumococcal vaccine is administered at the same time as other immunizations): 90669, 90670, or G0009.

Medical injectable coverage “carve-out” to pharmacy benefit managers — Some of Cigna’s health plan clients have “carved out” injectable medications covered under their Cigna medical benefit to a stand-alone pharmacy benefit manager (PBM). In these cases, some or all medical injectable medications are excluded from the Cigna medical plan and covered separately by the PBM. The injectable medication then must be obtained through a PBM specialty pharmacy.

In addition, when a PBM covers an injectable, the PBM is responsible for finding a health care professional to administer the medication. According to Cigna, this arrangement “often leads to confusion, disruptions in care, and delays in treating patients” because the PBMs can have difficulty finding physicians willing to support the administration of a medication they do not dispense and over which they do not have quality control.

When a Cigna medical plan covers injectables, in most cases, the physician who orders them will also manage their proper handling, which includes appropriate temperature storing.

How can you tell if Cigna or a PBM covers a patient’s injectable medication? Most Cigna plans require precertification for outpatient services, including the administration of injectable medications. When you call to precertify a medical injectable, Cigna will inform you if a PBM handles the coverage for that medication. If so, the PBM must precertify the medication as required and coordinate care. Some Cigna plans do not require precertification of medical injectable medications. It is important to discuss coverage for these medications with the patient and to check benefits eligibility at (800) 88Cigna (882-4462).

Source: Cigna’s Network News (PDF), April 2013


Medicare Part D formulary updates —The Blue Cross and Blue Shield of Texas (BCBSTX) pharmacy provider, Prime Therapeutics, updates the Blue MedicareRx formulary monthly. For a complete formulary listing and inquiries regarding prior authorizations, step therapy, coverage determinations/RE-determinations, transition plan benefits, and appointment of a representative for your BCBSTX members, go to Prime Therapeutics’ Medicare Part D member website:

  1. Click on “Find Drugs & Estimates.”
  2. Follow directions to …
  • ‘Select your Health Plan” — click on “BCBS Texas;”
  • “Medicare Part D Member?”  — click “YES;
  •  “Select Your Health plan type” — click “Blue MedicareRx.”

 From this page you will be able to determine the formulary status and applicable utilization management programs for individual drugs or access any of the important databases mentioned above.

Source: BCBSTX News and Updates  

Self-administered specialty drug reminder — BCBSTX members must use their pharmacy benefit for U.S. Federal Drug Administration-approved self-administered drugs (oral, topical, and injectable) and obtain these medications through a pharmacy provider.

Effective July 1, 2013, BCBSTX will return the following message on the electronic payment summary or provider claim summary to practices billing for self-administered drugs for hemophilia, hepatitis C, and multiple sclerosis: “Self-administered drugs submitted by a medical professional provider are not within the member’s medical benefits. These charges must be billed and submitted by a pharmacy provider.”

Refer to the Specialty Pharmacy Program Drug List in the Pharmacy Program/Specialty Drug Programs section of the BCBSTX provider website to help you determine the correct path for medication fulfillment and ensure the correct benefit is applied.

Note: In accordance with their benefits, members may be required to use a preferred specialty pharmacy. Call the number on the member’s ID card to verify coverage. For members whose benefits require them to use Prime Therapeutics Specialty Pharmacy, you may fax the prescription to (877) 828-3939 or call 877-627-MEDS (877-627-6337) for more information. Medication(s) can be delivered to any requested location (e.g., member’s home or physician’s office).

Avoid delay in claims pending COB information — BCBSTX receives thousands of claims each month that require unnecessary review for coordination of benefits. What that means to you is a possible delay, or even denial of services, pending receipt of the required information from the member. Here are some tips to help prevent claims processing delays when there is only one insurance carrier: 

  • CMS-1500, box 11-d — if there is no secondary insurance carrier, mark the “No” box.
  • Do not place anything in box 9, a through d — this area is reserved for member information for a secondary insurance payer.

It is critical that no information appears in box 11-d or in box 9 a-d if there is only one insurance payer.

Source: BlueReview (PDF), April 2013

Published April 23, 2013

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Last Updated On

April 19, 2018

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