Private Payer Round-Up, September 2013

In case you missed these —  here is a roundup of coding, payment, and policy changes and tips from commercial payers, compiled by TMAs reimbursement specialists. If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call TMA Knowledge Center at (800) 880-7955. And remember, TMA members can turn to the TMA Hassle Factor Log for help resolve insurance-related problems.


DSM-5 diagnostic descriptions required for authorizations — Beginning Jan.1, 2014, Cigna will require diagnostic descriptions for authorizations in accordance with the fifth edition of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Health care professionals and researchers use DSM-5 to diagnose and classify mental disorders.

Released in May 2013, DSM-5 contains changes to some diagnostic criteria while eliminating some diagnoses and adding others. Note that DSM-5 contains ICD-9 codes for immediate use along with ICD-10 codes in parentheses to use beginning Oct. 1, 2014, when ICD-10 becomes mandatory. Cigna will provide additional ICD-10 billing information closer to that date.

Source: Cigna eBrief, August 2013


2013 AIM clinical guideline changes  The effective date of Oct. 21, 2013, for the AIM Specialty Health Clinical Appropriateness Guidelines has changed and will be Nov. 4, 2013.

You can review complete details and updates of the new guidelines on AIM's website.

Medicare Part D formulary updates  Prime Therapeutics, the Blue Cross and Blue Shield of Texas (BCBSTX) pharmacy provider, updates the Blue MedicareRx (Medicare Part D) formulary monthly. For a complete formulary listing, go to the Prime Therapeutics Medicare Part D member website and click on Find Drugs & Estimates. From the drop-down menus, choose BCBS Texas, Medicare Part D Member (YES), and Blue MedicareRx.  This takes you to a page where you can determine the formulary status and applicable utilization management programs for individual drugs, or access information about prior authorizations, step therapy, coverage determinations/RE-determinations, transition plan benefits, and appointment of representative for your BCBSTX members.

2013-14 synagis predetermination process  Its respiratory syncytial virus (RSV) season; follow these steps in the predetermination process for the BSBSTX RSV Prophylaxis program.

  1. Complete the Synagis request form (online or hard-copy) posted on the BCBSTX forms page.
  2. Submit online form or fax the hard-copy form to Allan J. Chernov, MD, (medical director, Health Care Quality & Policy) at (972) 766-5559.
  3. Fax the Synagis request form, along with written authorization from BCBSTX, to Prime Specialty Pharmacy (877) 828-3939. If the request form is incomplete, Prime Specialty Pharmacy will return it to the prescribing physician to supply the missing information

An approved predetermination will cover a maximum of five monthly injections for that patient for the 2013-14 RSV season, Oct. 1, 2013, to March 15, 2014. No additional reviews will be needed. For out-of-state members, contact the member's home plan (use the phone number on the back of the patients ID card) for eligibility and benefit information.

Billing with National Drug Codes  BCBSTX currently accepts National Drug Code (NDC) for billing of all physician- or ancillary provider- administered and supplied drugs. Effective Dec. 15, 2013, BCBSTX will begin paying claims submitted with an NDC in accordance with the NDC Fee Schedule posted on the BCBSTX provider website.

Go to Standards & Requirements>General Reimbursement Information (log-in required) scroll to Reimbursement Schedules and Related Information> Professional>BlueChoice and HMO Blue Texas Schedules>2013 Schedules effective Nov. 1, 2013> scroll to Drugs. The NDC Fee Schedule will be updated monthly on the first of the month, starting Jan. 1, 2014.


  • BCBSTX may pay lower-cost generic medications with a larger margin compared with higher-cost generic and brand medications.
  • Effective June 1, 2014, BCBSTX will revise the methodology it uses to determine the allowables for HCPCS CPT 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.
  • When billing drugs under the medical benefit, be sure to include NDCs and related data.
  • BCBSTX requires inclusion of the NDC along with the applicable HCPCS or CPT code(s) on claim submissions for unlisted or "Not Otherwise Classified" drugs. Excluding these drugs, BCBSTX will continue to accept the HCPCS or CPT code elements without NDC information.

For more information, see the guidelines (PDF) and FAQs (PDF) on the BCBSTX provider website, as well as this interactive online tutorial (log-in required.)

Source: Blue Review (PDF), Issue 9, 2013


Claims payment policies go online  Humana has begun publishing its payment policies online, with information about claims payment methodologies and acceptable billing practices. Referring to this information may help reduce claim processing delays, and avoid rebilling and requests for additional information. Humana says it plans to publish new and updated policies online as they become effective. Recently published policies are:

Routine physical exams for Medicare Advantage (MA) patients - The Humana MA routine physical exam is not  the same as the Welcome to Medicare initial physical exam. The Welcome to Medicare exam is allowed once per lifetime within the first 12 months of Medicare Part B enrollment. Humana MA patients may receive a routine physical exam once in addition to the Welcome to Medicare exam during the first 12 months of Medicare Part B enrollment, and then once per 365 days at no cost in the years following the Welcome to Medicare physical.

Bill the routine physical for new patients using the CPT preventive medicine visit codes 99381-99387. Bill for established patients using the CPT preventive medicine visit codes 99391-99397.

The routine physical includes the following components: 

  • Review of medical history and a physical exam to identify risk status and manage any needed interventions;
  • Counseling on diet, exercise, substance abuse, and injury prevention;
  • Recording of height and weight at intervals according to the physician's clinical discretion;
  • Blood pressure check every two years after age 21; and
  • Vision and hearing screenings at the discretion.


Humana Organizes Support PODS  Humana has created a new Provider Organized Delivery Systems (PODS) program that aims to coordinate communication among a patient's caregivers and improve practice efficiency. The PODS program focuses on Humana's Medicare Advantage members in preferred provider organizations, private fee-for-service, and nonrisk HMO groups. Further, the sharpest care management focus is on complex-chronic and special needs plan patients.

The program groups physicians and health care providers in each region into PODS, with a team of Humana associates assigned to support them. Each POD team consists of a manager, a care coordinator who coordinates clinical program referrals, a Medicare risk adjustment representative who helps practices with coding accuracy, an analyst who provides data-driven recommendations, and a consultant. Each PODS team can provide a variety of monthly practice-level, physician-level, and patient-level reports, distributed during scheduled visits by a PODS team member. For more information about the PODS program, contact Ashley Warrick at awarrick[at]humana[dot]com.

Updated commercial preauthorization and notification list  Humana adopted an updated preauthorization and notification list, effective Sept. 14, 2013, for all commercial fully insured plans (e.g., HMOs, point of service plans, preferred provider organizations, and exclusive provider organizations). Note that precertification, preadmission, preauthorization and notification requirements all refer to the same process of preauthorization.

Be sure to refer to your provider agreement for additional information or requirements concerning preauthorization. You can call the phone number on the back of the patient's identification card to determine if a service requires preauthorization. Remember, an authorization does not guarantee payment; payment or coverage determination is based on the patient's benefit plan document.

Updates to the list include the addition of outpatient transthoracic echocardiogram and outpatient coronary angioplasty/stent procedures. Also note:

  • The full list of commercial preauthorization requirements applies to Humana commercial HMO members.
  • Employer groups for which Humana provides administrative services only (self-insured, employer-sponsored programs) may customize their plans with different requirements. Humana recommends that an individual practitioner making a specific request for services or medications verify benefits and authorization requirements before providing services.

For more information about authorization, contact the Humana clinical intake team at (800) 523-0023.

Source: Humana's YourPractice (PDF), August 2013

Published Sept. 27, 2013  


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April 19, 2018

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