Private Payer Round-Up, August 2013

In case you missed these — here is a roundup of coding, payment, and policy changes and tips from commercial payers, 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.

Don’t Ignore Your Cigna Ranking Letter: Cigna began sending 2014 Cigna Care designation letters to physicians at the end of July. Your letter will tell you if you met this physician quality and cost-efficiency rating from Cigna, and if not, why (see sample letter).

If you do not agree with your designation, you can request additional information or reconsideration from Cigna, according to instructions in the letter. Be sure to pay attention to the dates in the letter you receive regarding the reconsideration.

If you decide to appeal your ranking, follow TMA’s two-page guide in developing your appeal. It’s on the TMA Physician Ranking webpage. If you have questions, contact the TMA Knowledge Center at (800) 880-7955 or

Source: Aetna Officelink Updates, September 2013

 More From Aetna

Clinical payment, coding and policy changes — Among the changes announced in Aetna Officelink Updates , September 2013, are the following:

  • Lab national coverage determinations (NCDs): Effective for dates of service on or after Jan. 1, 2013, Aetna will apply the 23 Centers for Medicare & Medicaid Services lab NCDs to participating and nonparticipating Medicare Advantage claims.
  • Levonorgestrel-releasing intrauterine system, 13.5 mg (Skyla): Effective July 1, 2013, HCPCS code Q0090 replaced J3490 (when billed with a preventive diagnosis) as the appropriate code for Skyla. Aetna will continue processing claims incurred prior to July 1 for J3490 when billed with a preventive diagnosis as a preventive benefit for up to 120 days after July 1.
  • Therapy reevaluations: Effective Dec. 1, 2013, therapy reevaluations are subject to the following billable timeframes (refer to the Therapies — Evaluations/Reevaluations payment policy on the Aetna website):
    • Physical and occupational therapy reevaluations (97002 and 97004) are eligible for payment once every 30 days.
    • Speech therapy reevaluations (S9152) are eligible for payment once every 90 days.
    • Athletic training reevaluations (97006) are eligible for payment once every 30 days.

Oncology split fill program starts in January — Aetna is changing how it fills prescriptions and bill for copays for certain oral oncology drugs. Effective Jan. 1, 2014, Aetna will begin “split fill” dispensing: Patients will receive an initial 15-day supply of their drug, followed by a second 15-day supply within 30 days (one month) for the duration of their therapy. Partial copayment will coincide with each dispense. Aetna says split filling will allow monitoring of the patient’s response to therapy and any potential reactions or side effects.

The new program includes these drugs: Nexavar (sorafenib), Votrient (pazopanib), Afinitor (everolimus), Inlyta (axitinib), Jakafi (ruxolitinib), Sprycel (dasatinib), Tarceva (erlotinib), Zelboraf (vemurafinib), and Sutent (sunitinib).

Changes to National Precertification List (NPL) — The following changes to Aetna’s NPL will take effect on Jan. 1, 2014, unless otherwise noted. You can view the clinical policy bulletin applicable to any precertification service.

  • Additions: Kadcyla (ado-trastuzumab emtansine) and Herceptin (trastuzumab); also Perjeta (pertuzumab) —see Update below. To precertify these medications, call (866) 503-0857 or fax the related Medication Request Form to (888) 267-3277. Newly approved drugs administered orally, or by injection or infusion also may be subject to precertification review.
  • Modifications: Aetna will require precertification for elective cervical and lumbar spinal fusion.
  • Deletions: customized braces and canthopexy. Note: The removal of a service from the precertification list does not mean Aetna will cover it. Claims for the service are still subject to review and may be denied in accordance with the member’s plan terms.
  • Update —These oncology medications will not be added to the NPL on Sept. 1, 2013 (this means precertification will not be required): Perjeta (pertuzumab), Istodax (romidepsin), Dacogen (decitabine), Temodar (temozolomide), Ixempra (ixabepilone), and Torisel (temsirolimus)
  • Reminders: Effective July 1, 2013, Aetna requires precertification for Reclast for osteoporosis only (ICD-9 diagnosis codes 733.0-733.09). Also, precertification is now required for Tecfidera (dimethyl fumarate) and Gattex (teduglutide [rDNA origin] for injection). Effective April 30, 2013, percert is required for Bivigam (Immune GlobulinIntravenous [Human], 10 percent Liquid).

 Heads up on 2014 Medicare formulary changes — In 2014, Aetna will introduce Select Care generics to group and individual Aetna Medicare Advantage plans with Medicare prescription drug benefits and Aetna stand-alone prescription drug plans. According to Aetna, these generics are highly effective drugs that have lower cost-share options to treat high blood pressure, high cholesterol, and diabetes. In addition, some higher-cost generics, such as calcipotriene cream and famciclovir tablets, will go on nonpreferred, brand-name drug tiers for individual and some group plan formularies. Details about upcoming formulary changes will be available after Oct.1, 2013.

Access Aetna’s Medicare and non-Medicare preferred drug lists here:

 For a paper copy of these lists, call the Aetna Pharmacy Management Provider Help Line at (800) AETNA RX or (800) 238-6279.

Remember to submit patient referrals — When patients need a referral to another doctor or facility, be sure to submit referrals to Aetna. When doing so, use the consult-and-treat CPT code of 99499. It will cover any items on the automatic studies list.

Primary care physicians (PCPs) can complete referrals under taxonomy codes. This allows the patients to go to any participating specialist under that specialty taxonomy code. PCPs can enter the patient’s referral, and specialists can verify their patient’s referral within the Aetna website.

If you’re a specialist performing a procedure not on the automatic studies list, those procedures will need a new referral from the patient’s PCP. You can access the automatic studies list on the Aetna provider website under the referral section. Note: No paper referral confirmation will be sent out to anyone.

Source: Aetna Officelink Updates, September 2013


Attention high-tech imaging providers: action needed — If you bill Blue Cross and Blue Shield of Texas (BCBSTX) for the technical component of imaging services like CT or MRI, be sure to complete your OptiNet assessment. Not completing it means your facility may not appear in the online directory for ordering providers to select from during the Radiology Quality Initiative process.

AIM Specialty Health has recently upgraded the OptiNet enrollment and data entry process. If you have already registered, you do not need to reenter any information, unless you need to report changes.

Note also: AIM has completed its 2013 guideline review and will integrate the updates into its systems, effective Oct. 21, 2013. You can review complete details and updates of the new guidelines on AIM’s website.

Fee schedule update —BCBSTX will change the maximum allowable fee schedule used for BlueChoice, Blue Advantage HMO, HMO Blue Texas (Independent Provider Network and THE Limited Network only), and ParPlan.

The new schedule will take effect Nov. 1, 2013. For those services for which BCBSTX bases payment on Centers for Medicare & Medicaid Services (CMS) values, it uses the 2011 CMS values. Here are some highlights:

  • The payment percentage for modifier 78 will decrease from 100 percent to 75 percent.  
  • Geographic practice cost indices will not be applied to the relative values, so the relative values will not differ by Medicare locality.
  • HMO Blue Texas, BlueChoice, and ParPlan relative values and Blue Advantage HMO weights will consider the site of service where the service is performed (facility or nonfacility).
  • A multiple procedure payment reduction will be made on the professional component of certain diagnostic imaging procedures.

In addition, note the upcoming changes in drugs payments:

  • Dec. 1, 2013 — BCBSTX will begin paying claims submitted with a National Drug Code (NDC) in accordance with the NDC fee schedule that will be posted on the Blue Cross website and updated monthly. BCBSTX may pay lower-cost generic medications with a larger margin compared with higher-cost generic and brand medications.
  • June 1, 2014 — BCBSTX will revise the methodology it uses for determining the allowables for CPT and HCPCS codes associated with multiple NDCs. The HCPCS or CPT code allowable generally will be equivalent to the lowest NDC allowable associated with the HCPCS or CPT code.

 Electronic payments go daily — If you receive weeks electronically transferred funds from BCBSTX, you should start receiving your payments by the end of August. If you have questions or need help, call BCBSTX at (800) 746-4614.

Claim processing rule updates — BCBSTX will now load updates to its claim processing system, generated through the code auditing tool ClaimsXten, every 60 to 90 days rather than quarterly. BCBSTX will continue to post advance notices and confirm the effective date on its website. Be sure to monitor BCBS updates.

 Source: Blue Review (PDF), August 2013

 TMA Can Help

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Published Aug. 27, 2013

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