Private Payer Round-Up, January 2014

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. Or, ask your county medical society to set up a 30-Minute Billing Cure session in your area.


 Humana Medicare Advantage PPO patients need primary physician — Beginning in plan year 2014, Medicare Advantage (MA) HumanaChoice (PPO) plans will require that members designate a primary care physician to coordinate their care as needed. However, these patients do not need to get referrals to receive services or to see other physicians. They still can see the physician of their choice, regardless of specialty.

What does this mean for physicians? You will continue to work as you do today regarding clinical management of Humana MA PPO members. But, to ensure continuity of care, specialists' offices should forward results of office visits and tests to patients' primary physicians. If needed, primary physicians' offices should follow up with the specialist to obtain results for the patient's medical record. Humana has developed a Primary Treating Physician Change Request Form that physicians can use to ensure the MA members they serve are correctly attributed to their practice.

Members' primary care physician will be listed on the back of their Humana ID card.

Review process available online  If you are the subject of a Humana concurrent or retrospective review to assess member care, you may end up requesting a hearing, depending on the course of the review. Humana's Provider Quality Review Process, is now posted in detail on the Humana website.

A review begins when a Humana medical director, with help from the quality operations compliance department, identifies a potential problem, for example through a member complaint, referral from a clinical program, or data analysis leading to chart review.

Source: Humana's YourPractice, December 2013 


 Networks offered on the Texas health insurance marketplace  Blue Cross and Blue Shield of Texas (BCBSTX) is offering two networks on the Texas health insurance marketplace (under the Affordable Care Act [ACA]): Blue Advantage HMO and Blue Choice PPO. Both are available in all 254 Texas counties and are offered on and off the marketplace. The products offered on the marketplace are as follows: 

Blue Choice Gold PPO 001 Blue Advantage Gold HMO 001
Blue Choice Gold PPO 002 Blue Advantage Gold HMO 00
Blue Choice Silver PPO 003 Blue Advantage Silver HMO 003
Blue Choice Silver PPO 004 Blue Advantage Silver HMO 004
Blue Choice Bronze PPO 005 Blue Advantage Bronze HMO 005
Blue Choice Bronze PPO 006 Blue Advantage Bronze HMO 006
Blue Security Choice PPO 010  
Blue Cross Blue Shield Premier 1, a multistate plan  
Blue Cross Blue Shield Premier 2, a multistate plan  
Blue Cross Blue Shield Solution 3, a multistate plan  
Blue Cross Blue Shield Solution 4, a multistate plan  
Blue Cross Blue Shield Basic 5, a multistate plan  

BCBSTX is serving many new members as a result of the ACA.  When verifying patients' eligibility in these plans, keep in mind:

  • Member ID information: Some of your patients may not have received their member ID card at the time of their appointment. If they have their member ID number and group number from another source, such as their new member welcome letter or phone confirmation, BCBSTX can verify eligibility and benefits. For patients who do not have this information, direct them to contact BCBSTX member customer service at (888) 697-0683 to obtain their information, or reschedule their appointment to a later date. See sample ID cards. BCBSTX is serving many new members as a result of the ACA.  When verifying patients' eligibility in these plans, keep in mind:
  • Confirming coverage: As usual, members cannot use their coverage until their first month's premium payment has been applied to their policy. Also, benefits may vary depending on the coverage the member purchased. It is important to check for eligibility and benefits each time you see a patient. 
    • BCBSTX reports experiencing high call volumes and increased hold times due to 2014 updates. The payer requests that you wait until patients have scheduled appointments before making eligibility and benefit inquires.
    • When possible, verify eligibility and benefits through BCBSTX's automated phone line at (800) 451-0287 (see instructions [PDF]), or online through Availity and Availity's CareCost Estimator.  
  • Network terms: Be sure to confirm your network status for the member's plan before providing services. Also, remember that the terms of your network contract prevent you from refusing to provide services to a BCBSTX member, irrespective of where he or she purchased coverage. Care provided for emergency conditions will follow BCBSTX's standard authorization process.

 The BCBSTX call center has extended hours from 7 am to 8 pm M-F and Saturday from 7 am to 5 pm.

 Sources: Blue Review (PDF) January 2014;

New and improved for 2014:

  • iEXCHANGE  BCBSTX's web-based preauthorization tool now supports requests for additional behavioral health, pharmacy and medical/surgical treatment services. You can find out more about changes to iEXCHANGE in a 90-minute BCBSTX webinar Jan. 29. To register, to go the iEXCHANGE page on the BCBSTX website.
  • Claim letters  BCBSTX has updated the format, tone, and readability of many of its standard claim letters. Here is a sample (PDF). Your patients can view their letters securely at Blue Access for Members.

 Quick tips:

  • Look for medication-recommendation letters  You may receive letters from BCBSTX referencing GuidedHealth that give you medication-related recommendations for specific patients. The GuidedHealth program targets overutilization, safety, and cost in drug therapy. To see what BCBSTX focused in the fourth quarter of 2013, see Blue Review (PDF) January 2014, page 5.
  • Review your CAQH profile periodically  BCBSTX uses the Council for Affordable Quality Healthcare (CAQH) Universal Provider DataSource (UPD) for gathering data for physicians. It's wise to review and update your demographic data every four months, within your CAQH profile at or by calling the CAQH Help Desk at (888) 599-1771. You can make changes to your record anytime by phone or online. When updating your UPD application, be sure BCBSTX is authorized to access your data.
  • Check your records for outdated drug codes  When billing with National Drug Codes (NDCs), be sure the NDC is valid for the date of service; NDCs can expire or change. The NDC on your claim should match the active NDC on the medication's current label or packaging.

A drug's market availability in nationally recognized drug information databases determines its inactive status. In addition, an NDC is considered obsolete two years after its inactive date. It is a good idea to periodically check the record of NDCs you use in your office for billing.

BCBSTX will continue to pay claims for inactive products until they become obsolete.

See the NDC billing guidelines and NDC FAQs on the BCBSTX website.

Source: Blue Review (PDF) January 2014

Published Jan. 21, 2014

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