Private Payer Round-Up, December 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.

Policy and Code Edit Updates

  • Cigna will update these payment policies (log-in required) effective February 2014:
    • Modifier TC technical component;
    • Laboratory services,
    • Assistant surgeon  modifiers 80, 81, 82; assistant-at-surgery  modifier AS; co-surgeon (two surgeons)  modifier 62; surgical team  modifier 66; and
    • Modifier 26 professional component.


ID cards have incorrect coverage date  Some Blue Cross and Blue Shield of Texas (BCBSTX) ID cards for members of group plans issued after Nov. 16, 2013, with a 2013 or earlier effective date, display an incorrect coverage date of Jan. 1, 2014. This is an error on the ID card and does not affect the member's coverage or claims processing. All other information on the ID card is accurate. However, you should follow your normal process of checking the members' eligibility before their appointment.


Not receiving your 835 era files from Availity?  As part of a Dec. 9, 2013, production change, the 835 Electronic Remittance Advice (ERA) files you receive from BCBSTX reflect a new receiver ID and file name. Since receipt of the 835 ERA is automated for many practices, be sure to contact your practice management system vendor to make any necessary adjustments. If you use a billing service or clearinghouse as your designated receiver, you will need to contact it to ensure it have accommodated the change.

Source: (PDF)

Electronic Refund Management webinars  BCBSTX's Electronic Refund Management (eRM) is an online tool that can help simplify your overpayment reconciliation and related processes. For example, you can receive electronic notification of overpayments, view overpayment requests, inquire/dispute/appeal a request, deduct from future payments, and pay by check. BCBSTX webinars offer a live demonstration of the eRM system and instructions for gaining access. Register for a webinar on Jan. 8, 2014, or Jan. 22, 2014.


Know your drug status  When billing with National Drug Codes (NDCs), it's important to know the status of the drug you are including on a medical claim. That's because BCBSTX will only pay for a drug for up to two years past its inactive date, or in the case of obsolete drugs, two years after the date the manufacturer stops making the drug. Inactivity is determined by a drug's market availability by nationally recognized drug information databases.

Quick tip: When you use the NDC Units Calculator Tool to covert HCPCS or CPT units into NDC units, you also can determine if a drug is valid for the date of service. The NDC Units Calculator Tool is available on the Availity provider portal. Keep in mind that codes for new drugs can take some time to update into the system. For a quick reference, access the NDC Billing Guidelines and Frequently Asked Questions in the Claims and Eligibility/Claim Filing Tips/Submitting Claims area of the BCBSTX provider website.

Radiology Quality Initiative updates

  • Expansion delayed  An expansion of the Radiology Quality Initiative (RQI) program administered by AIM Specialty Health (AIM), originally scheduled for Jan. 1, 2014, has been delayed until a time to be determined. Existing services currently included in the RQI program will remain in place. As announced previously, the expansion will include stress, resting transthoracic, and transesophageal echocardiography.
  • New cost information available  For Blue Choice PPO subscribers, AIM now includes cost information from the Blue Cross Blue Shield Association's National Consumer Cost Transparency (NCCT) data set during provider selection and clinical review. BCBSTX provides this information directly by using up-to-date, annualized claims information.
    • AIM's online registration tool, OptiNet, collects modality-specific data directly from imaging providers in areas such as facility qualifications, technician and physician qualifications, accreditation, equipment, and technical registration. Providers may update their information whenever necessary online. First-time users must register prior to gaining access to the OptiNet assessment tool. Visit the AIM website for more information, or contact AIM OptiNet Customer Service at (800) 252-2021. Providers who have already registered do not need to re-enter any information, unless they have changes to report.
    • For more information, including a direct link to the OptiNet Assessment Tool, visit the Education and Reference Center/Provider Tools section of the BCBSTX provider website.
  • RQI for Blue Advantage HMO network to launch Jan. 1, 2014  Before scheduling or performing CT/CTA scans, MRI/MRA scans, SPECT/nuclear cardiology studies, and pet scans in a physician's office, outpatient department of a hospital, or a freestanding imaging center, the ordering physician or other professional provider must contact AIM to obtain an order number. The AIM number to call for Blue Advantage HMO members is (800) 859-5299, or you can request one online from AIM.

Expect high traffic in the call center  BCBSTX will soon begin processing annual benefit changes for 2014. Beginning January 2014, if you are using an online vendor to obtain patient eligibility and benefits, you may be instructed to contact BCBSTX Provider Customer Service. BCBSTX expects a substantial increase of calls due to the large number of policy changes underway, and encourages you to limit your general eligibility and benefit calls to patients scheduled for an upcoming appointment. Call the appropriate provider customer service number listed on the patient's ID card.

Use correct address for paper claims  If you submit paper claims and claims correspondence to BCBSTX, be sure to use this mailing address, unless otherwise instructed: Blue Cross and Blue Shield of Texas, PO Box 660044, Dallas, TX 75266-0044. For information about getting started with electronic claim submission, visit the Claims and Eligibility/Submitting Claims section of the BCBSTX provider website.

Update your contact information online  To update your contact information, go to, click on the Network Participation tab and follow the directions under Update Your Contact Information. You can submit a change to your name, office or payee address, email address, telephone number, tax ID, or other information. You should submit all changes at least 30 days in advance of the effective date of the change. If your specialty, practice information/status or board certification is not correct on the BCBSTX Provider Finder, or if you would like to have a subspecialty added, you can enter the information in the "Other" field or contact your Provider Relations office.

Source: BlueReview (PDF), December 2013

Published Dec. 19, 2013


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