Private Payer Round-Up, November 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 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.

Aetna on the ACA health insurance marketplace To find out what qualified health plans (QHPs) Aetna is selling on the Affordable Care Act (ACA) marketplace for Texas, go to its Health Insurance Exchange/Marketplace website. ID cards for members in these plans will have "QHP" on them; the product name is on the right  side of the card, and the plan name is on the left  side.

To identify network participants in Aetna QHPs, visit Aetna's online directory for health care professionals in its health care reform plans. You should make all referrals to in-network QHP providers. When treating patients enrolled in a QHP, follow the same processes you use today to check eligibility and benefits, and to submit claims. Use the pharmacy search tool on the Health Insurance Exchange/Marketplace website to check formulary information.

For more information, visit Aetna's Exchanges page on its Health Reform Connection website. To learn more about the health care marketplace and how it might affect you, read this preview from the December 2013 Texas Medicine.

Correction  The September 2013 issue of Aetna OfficeLink Updates inadvertently used the term "mid-level physician" in an item about the multiple surgical reductions that will apply to midlevel provider claims effective Dec. 1, 2013. The item appeared correctly in TMA Practice E-Tips.

New no-cost, direct-connect way to submit claims  Post-n-Track is cloud-based, desktop application for exchanging administrative, financial, and clinical information. It delivers your transactions directly to Aetna and other payers who subscribe to Post-n-Track, and back to you. You'll get an immediate receipt for every claim you send, showing receipt and delivery. You'll also have access to online reports for claims sent, financial totals, errors, and payer responses for all your transactions. In addition to claims, you can submit eligibility/claim status transactions, precertification/referrals, clinical lab results, and encounters, and you can download your 835 electronic remittance advices.

Installing Post-n-Track on your desktop doesn't require any interfaces to your existing practice management system. To sign up (it's free), enroll directly in Post-n-Track. Type "Aetna" in the Initial Interest field. If you have questions, call Post-n-Track at (860) 257-2030 or email

Use new fax number for Medicare expedited precert requests  Aetna has a new dedicated fax number for Medicare physicians. Use this number to submit expedited (or urgent) requests for precertification, also known as expedited organization determinations (EODs). The new dedicated fax number for EODs is (860) 754-5468.

Do not use this number for:

  • Requests for Part B medical injectables, or
  • Standard precertification requests. You should continue to submit standard precert requests electronically through Aetna's secure provider website or your own electronic vendor.

Submit expedited or urgent requests when you or your patient believes that waiting for a decision under the standard time frame could place the patient's life, health, or ability to regain maximum function in serious jeopardy. If your request does not meet this criterion, submit a standard request.

Source: Aetna OfficeLink Updates (PDF), December 2013


New radiology precerts coming  Effective Feb. 21, 2014, Cigna will add two new radiology service categories to the list of services that require precertification  diagnostic heart catheterizations and stress echocardiograms. You will be able to obtain precertification for the codes associated with these categories by calling (888) 693.3297 or at

Coverage for IUDs — Cigna covers intrauterine devices (IUDs) including ParaGard, Mirena, and Skyla brands, as well as the professional services related to IUDs, as part of the ACA's expanded women's preventive health services.

When you provide IUD devices on your patients' behalf, they obtain the full benefit of their medical plan. If a patient obtains an IUD on her own through a pharmacy or directly from the manufacturer, the preventive care services benefit will not cover the device, and the patient will have to pay the applicable nonpreventive or out-of-network copay or coinsurance.

To submit a claim for providing an IUD and the related professional services, use these codes:

  • IUD devices: ParaGard (J7300), Mirena (J7302), Skyla (Q0090)
  • Professional services: insertion of IUD (58300), removal of IUD (58301)

Code preventive services correctly — To receive accurate payment as well as ensure your patients receive the full benefit of their health plan, note the following:

  • Submit ICD-9 codes that describe preventive care services and not treatment of illness or injury.
  • Identify preventive care services as the primary (first) diagnosis codes on the claim form. If you submit the claim with primary diagnosis codes that represent the treatment of an illness or injury, the service will not be identified as preventive care, and your patient's claims will be paid as normal medical benefits instead of enhanced preventive care benefits.
  • The preventive care coverage offered under Cigna-administered plans complies with the ACA, i.e., with no patient cost-sharing (no copays or coinsurance) unless the plan qualifies under the grandfather provision or under an applicable exemption. The majority of Cigna-administered plans fall under the ACA. A grandfathered plan is a group health plan that was in effect when the ACA became law on March 23, 2010. Plans remain grandfathered indefinitely unless companies significantly reduce benefits, increase costs to their employees, or reduce how much the employer pays toward benefits.

GWH-Cigna network health and wellness programs — Starting in January 2014, all Cigna customers will have access to the same health and wellness programs; Cigna will no longer offer those programs currently available to your patients with GWH-Cigna ID cards.

Not all customers have access to every program, and some programs are offered at an added cost to the Cigna client. Be sure to check your patients' coverage to determine the programs their plan covers. Details about the Cigna health and wellness programs is available at > Resources > Medical Resources > Clinical Health and Wellness Programs, or call Cigna Customer Service at (866) 494-2111.

LocalPlus expands in Texas  LocalPlus, a managed care product encompassing a smaller network of Cigna-contracted health care professionals and hospitals, will expand to Austin and Dallas on Jan. 1, 2014, after having launched this year in Tennessee and Houston.

In July, Cigna sent letters to Austin and Dallas physicians informing them if they were selected to participate in the LocalPlus network. Some of their patients may present the new LocalPlus ID card beginning in January.

All Cigna administrative guidelines, claim submission processes, policies, and procedures apply to the LocalPlus, LocalPlus IN, Choice Fund LocalPlus, and Choice Fund LocalPlus IN plans. Physicians who participate in the LocalPlus network will continue to have access to the same Cigna resources available today. For more information, call Cigna Customer Service at (800) 88Cigna (882-4462).

 Source: Cigna Network News (PDF), October 2013


Humana HMOx enters the marketplace  Humana's products sold on the ACA health insurance marketplace will include primarily HMO offerings, called HMOx. If you participate in these plans, pay close attention to members' ID cards.

Humana Image

These illustrations from Humana show where the plan name and the primary care physician's (PCP's) name will appear on the ID cards. Humana will advise HMOx members that their PCP is responsible for their care and will refer them for specialty care as needed. Physicians can make referrals two ways:

  • Online: Initiate a referral request by logging in to Humana's provider website and choosing Referral & Authorization Submission. Or, if your practice uses, log in and choose Auths and Referrals>Referrals. You can learn more about submitting online referrals in this Humana webinar Tuesday, Dec. 3, at 10 am CT.
  • By phone: Call (800) 523-0023 and follow the prompts to submit your referral request 

Humana recently launched Healthcare For You, a website where consumers can get more information about health care reform and the health insurance marketplace. TMA's "Hey, Doc" campaign also answers frequently asked questions about the marketplace.

If you have questions or need more information about Humana's HMOx plans, call Humana at (800) 626-2741, M-F, 8 am to 5 pm CT.

New billing requirements for home health — Effective with dates of service of Dec. 1, 2013, you must code all home health claims submitted to Humana for Humana Medicare Advantage members according to the following Medicare guidelines (not all-inclusive), or Medicare will reject the claim.

  • Submit the claim with an appropriate home health prospective payment system bill type and include:
    • The appropriate health insurance prospective payment system (HIPPS) code (submitted with Rev 023),
    • A treatment authorization code obtained through Medicare's Outcome and Assessment Information Set (OASIS) system, and
    • The core-based statistical area where services were rendered (submitted with value code 61). 
  • Bill each visit on a separate claim line with the appropriate Medicare-designated revenue and HCPCS codes.

Units billed must be appropriate for the description of the HCPCS code; Medicare visit G-codes represent 15-minute increments of service.

Changes to 2014 formularies  Beginning Jan. 1, 2014, certain drugs will have new limitations or will require utilization management under the Humana commercial and Medicare formularies for the 2014 plan year. These changes could mean higher costs or new requirements for Humana members who use these drugs.

You can view lists of some commonly used medications affected by: 

You can find prescription drug information for Humana patients on the Humana website. When searching by drug name, choose "commercial" or "Medicare" to see the drug's tier placement in the appropriate formulary and any restriction that may apply.

If you have questions regarding these changes, call Humana at (800) 457-4708, 8 am-8 pm local time.

Flu vaccinations coverage and coding  The Centers for Disease Control and Prevention (CDC) urges everyone 6 months and older to get an annual flu vaccine. This year's trivalent seasonal flu vaccine covers the three most common flu strains in the northern hemisphere:

  • A/California/7/2009 (H1N1) pdm09-like virus (same as last year's vaccine)
  • New: A/Texas/50/20121-(H3N2)-like virus (antigenically like the cell-propagated A/Victoria/361/2011)
  • New: B/Massachusetts/2/2012-like virus (B/Yamagata lineage) 

A quadrivalent vaccine is available that includes the B/Brisbane/60/2008-like (B/Victoria lineage) virus.

Remember, you need to submit two codes for each influenza vaccination claim, one administrative code and one vaccine code. Select one code from each of the following groups:

  • Administration codes: G0008, 90471, 90472, 90473, 90474
  • Vaccine codes:
  • 90654, 90655, 90656, 90657, 90658, 90661, 90662, 90672, 90673, 90685, 90686
  • Medicare: Q2033, Q2035, Q2036, Q2037, Q2038

Consider the following guidelines when determining coverage for your Humana-covered patients:

  • Commercial fully insured  The flu vaccine may be covered 100 percent for members, depending on their group plan.
  • HumanaOne  The flu vaccine may be covered for members depending on their individual HumanaOne plan.
  • Administrative services only  Individual self-insured groups provide Humana direction about coverage.
  • Medicare  Most Medicare Advantage members have access to the flu vaccine under their Part B benefit. Humana members with Medicare Part-D-only coverage will not have coverage for the flu vaccine with their Humana benefit. Part-D-only members may be referred back to original Medicare or to their medical carrier to determine how the vaccine is covered. Additionally, Limited Income Newly Eligible Transition Program members are not eligible for the vaccine.

If you have questions about Humana's policies for flu vaccination coding or coverage, call the phone number on the back of the member's Humana ID card.

More information about flu season is available from and the TMA website. CDC has print, audio, and video materials you can download.

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

Notes from the Humana Military network:

  • Compound medications, non-FDA approved — On Feb. 1, 2014, the TRICARE Pharmacy Program will no longer cover compound medications containing ingredients the U.S. Food and Drug Administration (FDA) has not approved. 

Express Scripts, the TRICARE Pharmacy administrator, now can identify compound medications containing non-FDA approved ingredients. Many are made with non-FDA approved bulk powders with no established patient safety profile. By TRICARE regulation, and in alignment with Medicare Part D policy, TRICARE will no longer reimburse such ingredients. TRICARE will continue to reimburse claims for compound medications containing FDA-approved ingredients. 

Letters went out in June 2013 from Express Scripts to approximately 44,000 beneficiaries who filled prescriptions for a compound medication that contained a non-FDA approved ingredient. A second, more detailed letter will follow.

For additional information about this change please go to

  • Referring to TRICARE network providers  If you submit a request for a TRICARE patient to a non-Humana Military network provider, but the requested service can be delivered in-network, you may receive a call from a patient care coordinator asking if you can redirect the beneficiary to a network provider. When entering a referral or authorization request on the web, you will be shown a pre-selected provider and four alternate providers who can deliver the service the beneficiary needs. Also, if the beneficiary has seen a specialist for the type of service requested, that specialist will be the pre-selected provider.

Make sure your office staff knows which physicians and health care providers are members of the Humana Military network. You can find them on the Provider Locator page at

  • Billing tips for injectables  If you are billing for injectables, be aware that electronic billing does accommodate two digits behind the decimal point for a more refined calculation of the dosage. (See example below.)


Injectables Image


If you bill on paper using the CMS-1500 form, use the shaded area of Fields 24A-24G to report the National Drug Code (NDC) information in the following order: qualifier, NDC code, one space, unit/basis of measurement qualifier, quantity. The number of digits for the quantity is limited to eight digits before the decimal point and two digits after the decimal. If entering a whole number, there is no need for the decimal. And do not use commas.

Administration fees process the same way as the injections for the same date of service and the same provider. For example, if you billed J3246 (random code) and it paid, then the administration fee pays as well. If the J3246 rejected, then the administration fee would reject too.

 Source: Tricare Provider News (PDF)


New electronic prior authorization (ePA) process  Now you can submit PA requests for drugs electronically to Blue Cross and Blue Shield of Texas (BCBSTX). Look for the Electronic Prior Authorization link in the Pharmacy Program/Prior Authorization and Step Therapy section of The link takes you to the log-in page for CoverMyMeds, where you can create a free account. This online tool has BCBSTX pharmacy request forms you can complete and submit electronically. 

When you initiate a PA request, CoverMyMeds will check the patient's eligibility as a BCBSTX member who has Prime Therapeutics as pharmacy benefit manager. Upon approval, you'll receive an electronic notification from CoverMyMeds. The member's pharmacy will also receive an alert that the previous request can be resubmitted, if applicable. Watch for enhancements to the ePA process in the coming months.

Billing with National Drug Codes  Effective Dec. 15, 2013, BCBSTX will begin reimbursing claims submitted with a National Drug Code (NDC) in accordance with the NDC Fee Schedule posted on the BCBSTX provider website, under "Drugs" (log-in required). The NDC Fee Schedule will be updated monthly on the first of the month, starting Jan. 1, 2014. 

For more information and to find out about a free NDC calculator tool, take advantage of the NDC Billing Tutorial in the BCBSTX website's General Reimbursement Information section (see link under Related Resources).

Also refer to the following from BCBSTX: 


Multiple surgery pricing per session update  Effective Feb.1, 2014, is a change to BCBSTX's "per-operative session" methodology for multiple surgery pricing. The change is specific to modifier 51 exempt codes and codes related to skin lesion removal and fracture care.

Currently these codes are in the same category as "add-on procedures." After the change, BCBSTX will consider the codes in the multiple-surgery pricing for the purposes of determining the primary procedure. The codes will remain exempt from the multiple-surgery fee reduction if they are identified as a secondary procedure. However, if a modifier 51 exempt code or a code related to skin lesion removal and fracture care is determined to be the primary surgical procedure, it will be adjudicated at 100 percent of the allowed amount and each subsequent surgical procedure performed will be adjudicated at 50 percent of the allowed amount. Note:  Add-on codes will continue to be exempt from multiple-surgery pricing logic and will not be considered when determining primary procedures.


Code auditing tool update, additions  Beginning on or after Feb. 10, 2014, BCBSTX will enhance the ClaimsXten code auditing tool by adding the fourth quarter 2013 and first quarter 2014 codes and bundling logic into its claim processing system.

Additionally, on or after Feb. 10, 2014, the following edits will be added, based on CPT and HCPCS code descriptions: procedure code S2900 (Surgical techniques requiring use of robotic surgical system) will bundle to 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed). And procedure code S9088 (Services provided in an urgent care center) will be considered inclusive to all evaluation and management services.


Risk adjustment and your documentation  Risk adjustment, a provision of the Affordable Care Act, is a mechanism to convey the illness burden a physicians is managing within his or her patient population, thus allowing for fair comparison of quality outcomes and cost performance.

Risk adjustment a two-step process:

  1. Risk assessment, which evaluates the health risk status of an individual to create a clinical profile, and
  2. Rate adjustment, which determines the level of resource needed to provide medical care to an individual.

Comprehensive documentation and accurate diagnosis coding are critical for accurate risk assessment by conveying a complete picture of a patient's conditions. For example, accurate coding enables identification of patients who may benefit from disease and medical management programs. For background information related to risk adjustment and the potential impact to physician practices, refer to the September 2012 Blue Review (PDF) See page 5.

ICD-10 and your documentation  Many larger practices and hospitals have already started clinical documentation improvement (CDI) programs as a result of quality initiatives, risk adjustment, and ICD-10. Even without a formal CDI program, smaller practices should assess their documentation processes to ensure they are prepared for ICD-10.

Transitioning from ICD-9 to ICD-10 requires everyone involved along the continuum of patient care to understand the greater specificity of ICD-10, and to be able to capture the relevant new information that needs to be recorded with ICD-10. One of the major changes in ICD-10 is the ability to record laterality in many applicable diagnoses. Many codes also require identifying the encounter, whether it is initial, subsequent or sequela.

Over the next several months, Blue Review will feature documentation and coding information for behavioral/mental health disorders, chronic kidney disease, diabetes mellitus and pulmonary disorders. The goal of the series is to provide a review of accurate and compliant documentation to support best coding practices. Be sure to bookmark TMA' ICD-10 page for news, tools, and education, as well.

ICD-10 example: A patient was treated for a compound fracture of the right tibia and fibula after being struck by a car. The ICD-9 code would likely be 823.92, fracture of tibia and fibula unspecified part, open. For ICD-10 coding, the coder must know. 

  • Which leg and which specific bone(s) the patient injured (in this example, the right tibia and fibula);
  • Whether the fracture is open or closed;
  • Whether the fracture is displaced;
  • For open fractures - need to know type of trauma to choose the appropriate character from Gustilo-Anderson classification system);
  • The severity of the soft-tissue damage; and
  • Whether the encounter sequence is initial, subsequent or sequel. 

This will give the coder the necessary information to determine the ICD-10 codes of S82.201A, unspecified fracture of shaft of right tibia, initial for closed fracture; and S82.401A, unspecified fracture of shaft of right fibula, initial for closed fracture.

Support services for physicians - The BCBSTX Provider Relations representatives are available to provide information, answer questions, address concerns and help resolve your problems regarding benefits, eligibility, claims, verification, and general network concerns, including complaints and appeals. You may contact them by telephone or in writing. Contact information is on the BCBSTX provider website - scroll down to find your geographical area. If you have a question about claims processing, call (800) 451-0287.

Claim review process - Follow these tips regarding the BCBSTX claim review process:

Submit claim review requests in writing on the Claim Review form. Mail the form, along with any attachments, to the appropriate address indicated on the form. Attach any additional information you wish to be considered in the claim review process such as:

  • Reason for claim review request,
  • Progress notes,
  • Operative report,
  • Diagnostic test results,
  • History and physical exam,
  • Discharge summary, and
  • Proof of timely filing.

For claims being reviewed for timely filing, BCBSTX will accept the following documentation as acceptable proof of timely filing:

  • TDI mail log,
  • Certified mail receipt (only if accompanied by TDI mail log),
  • Availity Electronic Batch Report response report,
  • Documentation indicating the claim was timely filed with the wrong BCBS plan and evidencing the plan's date of rejection,
  • Documentation from BCBSTX indicating the claim was incomplete,
  • Documentation from BCBSTX requesting additional information, and
  • Primary carrier's explanation of benefits indicating the claim was filed with primary carrier within the timely filing deadline.

There are two levels of claim reviews available to you. For the following dispute types, the first claim review must be requested within these timeframes:

  • Audited payment - Within 30 days following the receipt of written notice of request for refund due to an audited payment,
  • Overpayment - Within 45 days following the receipt of written notice of request for refund due to overpayment, and
  • Claim dispute - Within 180 days following the date of the BCBSTX Physician or other Professional Provider Claims Summary for the claim in dispute

BCBSTX will complete the first claim review within 45 days following the receipt of your request for a first claim review. You will receive written notice of the claim review determination. If it is not satisfactory to you, you may request a second claim review within 15 days following your receipt of the first claim review determination.

BCBSTX will complete the second claim review within 30 days following the receipt of your request for a second claim review. Again, you will receive written notice of the claim review determination. At that time, the process is considered complete.

Source: Blue Review (PDF), November 2013


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