Private Payer Round-Up, October 2013

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 paymentadvocacy[at]texmed[dot]org for help, or call TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems.

Are your patients asking you questions about the Affordable Care Act's (ACA's) new health insurance marketplace? TMA's "Hey, Doc" campaign provides answers to help you understand and explain what the marketplace does, and what steps individuals need to take.


 Revised provider manual available now  A revised version of Humana's provider manual is now available and in effect. It was last updated in 2010. Be sure to review the new manual, as your participation agreement with Humana or ChoiceCare Network contains a compliance obligation with its provisions.

Overall, the provider manual has been reorganized and streamlined; similar subjects are grouped together to help you locate the information. For example, the Claims Procedures section now includes information on both utilization management and referrals.

Additional notable revisions in this edition include the following:

  • Restructuring of the Grievance and Appeal section to detail the characteristics of member grievances/appeals, provider claims reconsiderations, and provider termination appeals.
  • New language outlining obligations for physicians and health care providers who submit a claim or encounter to Humana that generates a lab test result to submit the result electronically to Humana within 30 days of the patient's date of service. This information is relevant to Humana's quality management and improvement programs, and provider rewards initiatives. Keep in mind, payments will not be affected immediately on the effective date of the revised provider manual (Oct. 21, 2013); Humana will contact you before there is financial impact. Until contacted, you don't need to change what you are doing.
  • Additional language to describe physicians' contractual obligations to report demographic changes (e.g., name, number, address, new physicians) quickly to Humana. This information confirms that Humana's network filings are accurate and ensure you receive communications from Humana.
  • Addition of a new Compliance/Ethics section that covers liability insurance; fraud, waste, and abuse-related requirements; notification requirements; conflicts of interest; and Medicare obligations.

 You can request a printed versions of the manual at chcpr[at]humana[dot]com or by fax to (800) 626-1686. You must include your practice name, name of person to receive the manual, and complete address.

Preauthorization and notification lists updated for 2014  Humana has updated its preauthorization and notification lists for all commercial fully insured plans and Medicare Advantage (MA) plans. (Note that prior authorization, precertification, preadmission and preauthorization are all used to refer to the preauthorization process.) However, for MA private fee-for-service plans, notification is requested, not required. In addition, certain services outlined in the lists may not be applicable for physicians affiliated with an independent practice association via a capitated or delegated arrangement. Refer to your provider agreement for clarification or contact Humana for details at (800) 448-6262.

Humana updates its lists as preauthorization or notification requirements are added and when new drugs or technology enter the market.



Learn about the Blue Advantage HMO network  If you signed a contract with the new Blue Advantage HMO network, you might want to attend a provider orientation session (PDF).

Blue Cross and Blue Shield of Texas (BCBSTX) will offer the Blue Advantage HMO through the federal health care insurance marketplace under the ACA.

In anticipation of the "go live" date, Jan. 1, 2014, BCBSTX is hosting the orientation sessions across the state, now through Feb. 6, 2014. To register for a session, print out and complete a registration form (PDF), and fax it to your BCBSTX provider relations office. Not sure if you are participating in this network? Contact your BCBSTX provider relations representative to find out. The registration form contains a list provider relations office fax and phone numbers.  

More on the marketplace: Remember, open enrollment for the new public health care marketplace began Oct. 1, 2013, for individuals and small employers. Individuals will need to have completed the enrollment process by Dec. 15, 2013, to begin receiving benefits on Jan. 1, 2014. Individuals can continue to enroll for coverage in 2014 until March 31, 2014.

If you are a participating provider in the Blue Choice PPO or new Blue Advantage HMO network, you may see members who purchase coverage through the health insurance marketplace or the Small Business Health Options Program.

Essential health benefits: All ACA marketplace plans will be divided into four levels - bronze, silver, gold and platinum. The key difference among these plans is the percentage of covered medical expenses shared between the health plan and the patient. Some types of plans must cover certain preventive services with no out-of-pocket costs to patients.

The ACA requires all health plans in the marketplace to cover 10 categories of essential health benefits:

  1. Ambulatory patient services,
  2. Emergency services,
  3. Hospitalization,
  4. Maternity and newborn care,
  5. Mental health and substance use disorder services, including behavioral health treatment,
  6. Prescription drugs,
  7. Rehabilitative and habilitative services and devices,
  8. Laboratory services,
  9. Preventive and wellness services and chronic disease management, and
  10. Pediatric services.

In addition, insurers cannot refuse coverage to anyone based on health status, including preexisting conditions. Young adults may stay on a parent's policy until they turn age 26

Countdown to ICD-10: Less than a year to go  If your transition plan is under way, and you're either already in the testing phase or interested in starting testing with BCBSTX next year, first complete the readiness survey online on the ICD-10 section of the BCBSTX website. If you've already completed the survey this year, consider updating your answers  before going into testing.

Claim number format change on electronic payer responses  BCBSTX assigns a document control number (DCN) to each claim it receives. For electronic claims, the alpha-numeric DCN appears on the electronic payer response report. As of Oct. 13, 2014, DCNs were expanded with the addition of a zero in the second-to-last character in the sequence. Example:

Before Oct. 13: 123456A7891X
Now: 123456A78910X

When you are conduct research on a particular claim, reference the new DCN for faster results. If you have questions, contact the BCBSTX Electronic Commerce Center at (800) 746-4614.

New voucher numbering  The BCBSTX numbering system is changing for vouchers used for payments to providers. The current process generates zeros as placeholders in the voucher number field when no payment is being issued. Now the system will create an eight-character voucher number beginning with the letter "N" and subsequent unique seven-digit number.

Additionally, the format for voucher numbers provided in the electronic remittance advice data is changing to include a new date prefix and suffix built around the voucher number. Example:

C13nnnN12345670, the new format, reads:
C (claims) 13 (year) nnn (Julian calendar date) N1234567 (voucher no.) 0 (sequence no.)

 Source: www.

Infertility and oral oncology drugs now under pharmacy benefit - Effective Jan. 1, 2014, BCBSTX patients taking infertility and oral oncology medications will be required to use their pharmacy benefit. (If you prescribe infertility or oral oncology drugs for your patients, you may have received a letter from BCBSTX with related information. Affected patients also received letters.)

The following message will be returned on the electronic payment summary or provider claim summary to physicians billing for self-administered drugs: "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."

Drug prior authorization going electronic - BCBSTX is transitioning to electronic submission of prior authorization (PA) requests for drugs that are part of its PA program. Pharmacy benefit manager Prime Therapeutics is converting the current inventory of paper PA forms to a library of electronic forms that practices can complete and submit online. Watch for more details in the Blue Review and News and Updates sections of the BCBSTX website.

Single edit, medical policy online request forms going away - Effective Jan. 1, 2014, BCBSTX will no longer use the single edit request form or the medical policy and coding procedure disclosure request form for bundling, medical policy, or similar requests.

Use the phone system's fax back options - If you have limited Internet access - or at times prefer using the phone rather than an online vendor portal such as Availity to obtain eligibility, benefit and claim status information - take advantage of BCBSTX's fax back option through its Interactive Voice Response (IVR) phone system. You won't have to wait on the phone to speak to a customer advocate or obtain a person's name to validate your call. Instead, you will receive faxed documentation within one hour after a completed call. In addition to the benefit or claim information that was relayed in the call, the fax will include the confirmation number assigned to the inquiry by the IVR for your records.

Silent PPO bill - In accordance with Senate Bill 822, TMA's "silent PPO" bill passed this year by the Texas Legislature, BCBSTX plans to file an exemption from registration with the Texas Department of Insurance (TDI) identifying its affiliate companies that may access the BCBSTX networks in Texas.

SB 822 requires "contracting entities" to register with TDI or to file an exemption from registration if licensed as an insurer or HMO.  The bill also requires contracting entities to get permission from physicians for contract participation by line of business and to disclose applicable fee schedules for each line of business.

Calling itself a "strong supporter" of SB 822, BCBSTX said:

BCBSTX is committed to transparency in contracting with participating providers. BCBSTX provider agreements are specific to lines of business - we use separate agreements for HMO Blue Texas, Blue Advantage HMO, PPO and our Medicaid/CHIP networks. Blue Medicare Advantage is addressed by a separate amendment to the PPO agreement that is signed by the participating provider. Providers also know who has permission to access the BCBSTX networks in Texas. All members have ID cards that clearly show the BCBS logo and/or name, including members covered by our Blue Card program.

 Source: Blue Review (PDF) October 2013

Published Oct. 24, 2013

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April 19, 2018

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