Private Payer Round-Up, February 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 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.


Bulk your EFT payments the way you want them  As a result of health care reform laws, you now have the option to bulk your electronic funds transfer (EFT), or direct deposit, payments the way you want them:

  • By taxpayer identification number (TIN) and payment address, or
  • By your billing provider National Provider Identifier (NPI).

If you are already enrolled for EFT with Cigna, you are receiving your payments for patients covered through its PPO, Open Access Plus, and HMO plans bulked by TIN. To receive your payments bulked by NPI,* update your payment preference by logging in to > Working with Cigna > Manage EFT Settings.

If you are not currently enrolled for EFT with Cigna, use one of these options to enroll and choose your payment bulking preference:

  • Enroll in EFT directly with Cigna by logging in to > Working with Cigna > Enroll in Electronic Funds Transfer (EFT) Options.
  • Or, enroll in EFT with multiple payers (including Cigna)  at the Council for Affordable Quality Health Care (CAQH) website.

Important tips when bulking by NPI: 

  • The electronic remittance advice (ERA) or direct deposit activity report will be bulked by TIN or NPI, depending on your payment bulking preference.
  • If you are enrolled in ERA, you should contact your electronic data interchange vendor to update it of your change in bulking preference.
  • You can elect a separate bank account for each "billing provider" NPI.
  • You must identify a primary or default bank account for any payments where the submitted claim does not include an NPI tied to a bank account.

*NPI bulking is expected to become available in early 2014 for payments for patients with GWH-Cigna ID cards.

Precertification changes  As of Feb. 17, 2014, Cigna updated its list of CPT and HCPCS codes that require precertification* to include 32 additional codes and remove 31 codes. The new list reflects new CPT and HCPCS codes released Jan. 1, 2014.

Codes added: 

32701 61797 93351 93456 93530 L2005         

32850 61798 93451 93457 93531 S2095

44132 61799 93452 93458 93532

44133 61800 93453 93459 93533

44135 81223 93454 93460 C9734

61796 93350 93455 93461 J2505 

Codes deleted: 

0030T 0252T 0277T 91013 C9730 Q2047

0048T 0256T 0279T C9287 C9731

0173T 0257T 0280T C9289 C9732

0242T 0258T 88384 C9366 J1680

0250T 0259T 88385 C9368 J9218

0251T 0276T 88386 C9369 Q2046

*The 17 codes in bold above are for outpatient stress echocardiogram and diagnostic heart catheterization procedures for patients whose benefit plan requires precertification for outpatient procedures.   

Coming medical policy updates  Effective April 1,  updated policies will be in effect for the following (information about the changes will be available at least 30 days in advance at

  • Genotyping for thiopurine tethyltransferase, and
  • Deficiency in individuals with inflammatory bowel disease.

New for behavioral health plans  You can verify eligibility and benefits, check claim status, and access Cigna behavioral health plan resources at Cigna's main physician website, You no longer have to use to perform these tasks. You can use the Cigna Cost of Care Estimator for your patients covered by Cigna Behavioral Health. The estimator can help patients understand what out-of-pocket expenses may be, provides itemized cost estimates, and explains the sources of payment (including, in some cases, anticipated payments from your patient's health account.) To use this tool, log in to> Patients > Search Patients > Select a Patient > Estimate Costs.

Pay attention to the ID card  Always enter your patient's demographic information on the claim exactly as it appears on his or her Cigna ID card to help prevent claim rejections. Below are some examples of messages you may receive on a rejected claim, and what you should do to help ensure correct claim processing.

  • Patient ID not correct: For the most accurate patient match, submit the complete patient ID, including the extension, as shown on the ID card.
  • Incorrect use of extension  (01, 02, 03, etc.): Cigna ID cards include a two-digit number (e.g., 01 or 02) at the end of the patient ID. This extension confirms whether the patient is the subscriber or a dependent. The 01 extension usually indicates the subscriber; any other extension indicates the patient is a dependent.
  • Newborn not on file: Confirm that the subscriber has added a newborn to his or her policy. 
  • Patient billed as subscriber: Confirm that the patient is the subscriber. 
  • Date of birth: Confirm the patient’s date of birth. 
  • Subscriber no longer eligible: Check the patient’s eligibility and verify coverage effective and termination dates. 
  • Address: Confirm that the patient’s address is correct. When submitting a dependent claim, confirm if the address is the same or different from the subscriber’s. 
  • Hyphenated names: If the patient’s name contains a hyphen, include it in the claim. 
  • Claim submitted for medical coverage when patient or subscriber only has dental coverage: Confirm the patient is eligible for the type of service being rendered. 
  • Spelling mistakes or incorrectly keyed information: Check for spelling mistakes. 
  • First and last name included in same field: First name should be in the “First Name” field, last name in the “Last Name” field. If a patient has a dual first name, verify if the name has a space or no space (e.g., Billy Joe versus BillyJoe; or BobbySue versus Bobby Sue). The patient’s name on the claim must be submitted exactly as shown on his or her ID card. 

Cigna sleep management program update  Cigna has expanded its Sleep Management Program to include SleepMed, which provides direct-to-patient home sleep testing (HST) devices and in-office home sleep testing services. A local board certified sleep physician who is part of the SleepMed sleep community network interprets the studies.

Authorizations for HST services are electronically routed to SleepMed, which then delivers a report to the ordering physician. Throughout the process, CareCentrix (the entity that determines if the patient meets the Cigna protocol for HST) is updated so the ordering physician can contact SleepMed or CareCentrix for an authorization status. To learn more, contact (877) 710-6999, ext. 3, or email bbelcher[at]sleepmedinc[dot]com. Boarded sleep doctors interested in joining the SleepMed community should contact SleepMed at sleepcommunity[at]sleepmedinc[dot]com.

If you are currently contracted with Cigna to do home sleep testing, continue to work with CareCentrix for precertification requests. 

Coordination of benefits for Medicare primary claims  When Medicare is the primary payer for a claim and Cigna is the secondary payer, applicable Medicare billing rules, including Medicare coordination of benefits (COB) rules, apply to payment.

Cigna's financial responsibility in such claims is limited to the patient's financial liability (i.e., the applicable Medicare copay, coinsurance, and/or deductible) after application of the Medicare-approved amount. The Medicare payment plus the patient liability amounts constitute payment in full. You may not collect any payment in excess of this amount. The COB provisions as applied may result in an overall payment that is less than 100 percent of your Cigna contract amount.

This is also true for Medicare-eligible patients, even when they have not enrolled in Medicare Part B. Cigna processes these patients' claim using the Medicare allowable rate to calculate the amount Medicare would have paid, and then determines the Cigna payment based on the customer's Cigna plan benefit. In these instances, you may bill the customer for the portion of the claim that Medicare would have paid, up to your contract amount with Cigna. This may include any applicable copay, coinsurance, and or deductible. If you have questions, call Cigna at (800) 882-4462.

Source: Cigna Network News (PDF), January 2014


Billing with National Drug Codes — Blue Cross and Blue Shield of Texas (BCBSTX) pays claims submitted with National Drug Codes (NDCs) in accordance with the NDC Fee Schedule posted on the BCBSTX provider website. In addition, effective June 1, BCBSTX will revise the methodology it uses for determining the allowable for HCPCS or 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.

The standard NDC reimbursement schedule is available in the Standards and Requirements/General Reimbursement information section of the BCBSTX Provider website at For additional information on NDC billing and payment, view these FAQs (PDF).

 AIM clinical guideline changes  On April 21, AIM Specialty Health (AIM) will enhance its clinical appropriateness guidelines for radiology and cardiology. You'll be able to review complete details and updates on AIM's website.

 Reminder: iEXCHANGE adds behavioral health requests for intensive outpatient program  Don't forget that iEXCHANGE, the BCBSTX web-based preauthorization tool, now supports behavioral health preauthorization requests that fall under the intensive outpatient program. You can submit both behavioral health and medical/surgical preauthorization requests electronically 24/7 (except every third Sunday of the month from 11 am to 2 pm).

 Not a registered iEXCHANGE user?  Sign up by either:

  • Completing the online enrollment form located on the Forms page in the Education and Reference section of to receive a User ID, iEXCHANGE ID, and password, or
  • Accessing the BCBS Behavioral Health Pre-auth Registration link via the Availity portal for single sign-on (SSO) access. The SSO feature allows Availity-registered users to access iEXCHANGE without a User ID and password.

 Source: Blue Review (PDF), February 2014


 Coventry update  Because Aetna acquired Coventry Health Care, Inc., Coventry coverage policies have been retired and Aetna clinical policy bulletins (CPBs) now apply to Coventry members. View Aetna CPBs.

Aetna 2014 HEDIS data collection underway  Expect Aetna staff or its contracted representatives, Verisk or MedSave, to contact your office for the annual  Healthcare Effectiveness Data and Information Set (HEDIS) data collection. Although Aetna acquired Coventry, you will still get separate requests for information about Aetna and Coventry patients. This will continue until Aetna has one claims processing and data collection system.

Changes to the National Precert List:

  • Effective Dec. 2, 2013, Omontys (peginesatide) no longer requires precertification. It's been withdrawn from the market.
  • Aetna now requires precertification for the following, effective on the dates indicated: 
    • Gazyva (obinutuzumab)  Feb. 3, and
    • Olysio (simeprevir) and Sovaldi (sofosbuvir)  March 3
  • Effective July 1, Aetna will require precertification for:
    • All protease inhibitors with the exception of Incivek (telaprevir) and Victrelis (boceprevir), and
    • All nucleotide polymerase inhibitors. 

Changes to Aetna's commercial drug lists  Changes to these lists will take place July 1. The changes may affect Aetna's pharmacy management preferred drug list, precertification, quantity limits, and step-therapy programs. Starting April 1,  you can view the list of drugs Aetna is changing. Select Pharmacy Drug (Formulary) List Information > 2014 Preferred Drug (Formulary) List Changes > 2014 Mid-Year Changes.

Enhancements to electronic eligibility and benefits response  You can now get more details for Aetna plans supporting tiers with maximum and standard savings, standard plus savings, and out-of-network benefits. When you submit your eligibility inquiry using your level-1 individual NPI, service type code, member ID and date of service, you'll get a personalized response based on your NPI's relationship to the member's benefits plan. The response also includes out-of-network benefits. For best results, submit eligibility inquiries using your level-1 individual NPI.

 Submit preauthorization for certain services  Aetna requires preauthorization for certain procedures for patients enrolled in all Aetna network-based medical plans. Procedures requiring preauthorization include:

  • MRI/MRA;
  • Nuclear cardiology;
  • PET scan;
  • CT scan, including CTA;
  • Stress echocardiography;
  • Diagnostic right and left heart catheterization;
  • Polysomnography; and
  • Insertion, removal, and upgrade of elective (including in the inpatient setting):
    • Implantable pacemaker,
    • Cardiac defibrillator, and
    • Cardiac resynchronization therapy. 

Except as noted above, services performed in the inpatient or emergency room setting will not require preauthorization.

Submit preauthorization requests for these services online at MedSolutions, or by calling (888)693-3211 or faxing (888) 693-3210. 

Results of 2013 medical record audit  Every two years Aetna audits its members' medical records to assess health care documentation compliance. The 2013 audit covered 23 documentation criteria categories in the Mid-America Region, which includes Texas. Three areas fell below the 85-percent compliance goal and will be on Aetna's radar for improvement:

  • Documentation of a patient's personal data: gender, date of birth, emergency contact, address, home/work phone numbers, marital status;
  • Advance directives in a prominent part of a patient's record; and
  • Documentation of advance directives for patients over 18 years of age.

 You can find documentation criteria in Aetna's online Office Manual (Health Care Professional Toolkit) on its secure provider website; select "Doing Business" from the Aetna Support Center, then Physicians & Providers > Practice Resources.

Among the criteria is a requirement that an advance directive, whether it's executed, be in a prominent place in a patient's record. You can find advance directive guidelines and a reproducible form on the TMA website.

Also in the manual are clinical practice and preventive service guidelines; policies and procedures; patient management and acute care case and disease management programs; and special member programs/resources, including the Aetna Women's Health Program, Aetna Compassionate Care, and others. Paper copies of the manual are available upon request.

Correction  The September 2013 issue (PDF) of Aetna Office Link  issue included information about Aetna's policy about multiple surgical reductions for mid-level practitioners. This change does not apply in Texas .

 Source: Aetna OfficeLink (PDF), March 2014


2014 compliance requirements available   The Centers for Medicare & Medicaid Services (CMS) requires that Humana physicians annually complete certain compliance training and certifications, including review of the following materials:

  • Compliance Policy for Health Care Providers and Business Partners
  • Principles of Business Ethics for Health Care Providers and Business Partners
  • General Compliance and Fraud, Waste and Abuse Training*
  • Special Needs Plan (SNP) training

You can complete this information online at or Detailed instructions and additional information are available on the Humana website.

*Humana recognizes that physicians enrolled in the Medicare program are deemed to have met the FWA training and education requirements.

Prepare for 2014 professional and facility claim code edits  Humana has begun updating claim payment systems to better align with correct-coding initiatives, CMS guidelines, national benchmarks, and industry standards. The changes are being phased in under the following timeline:

Implementation Date      Available Online 

Jan. 18, 2014                        Now online
April 5, 2014                          Now online
June 21, 2014                       Mar. 21, 2014
Sept. 13, 2014                      June 13, 2014
Nov. 8, 2014                          Aug. 8, 2014                              

 Regarding the updates effective April 5, these are of note:

  • Problem-oriented evaluation and management services (CPT 92002-92014, 99201-99215, or HCPCS S0620-S0621) will not be separately reimbursed when performed on the same date of service as preventive medicine evaluation and management services.
  • Mohs surgical codes are subject to multiple surgery reduction.
  • Ultrasonic guidance for needle placement is not required for completion of injections/aspirations of joints, trigger points, tendons, or cysts. Therefore, CPT 76942 will not be reimbursed separately when submitted with CPT 20550- 20553 or 20600-20612.

HEDIS reviews begin next month  Humana will begin its HEDIS data collection in March. Depending on location, either Humana associates or an outside vendor will request the medical records. Before conducting any on-site review, someone will contact your office to schedule a visit. Practices also may be asked to mail, fax, or send electronic copies of chart components for off-site reviews.

 Commercial risk adjustment medical record requests  You may have started seeing medical record requests for Humana's commercial small group and HumanaOne members as a result of the health-care-reform-mandated commercial risk adjustment (CRA) program. Under the U.S. Department of Health and Human Services (HHS), CRA was established for individual and small group plans (grandfathered plans are excluded) to account for the differences in the health of the population being treated, using that measure to evaluate the necessary treatment and payment for each individual.

The program transfers funds from the lowest risk plans, with more healthy enrollees, to highest risk plans, with fewer healthy enrollees. Each enrollee has a risk score based on the individual's demographic and health status information. Accurate diagnosis coding equates to an accurate risk score for each individual - thus the medical record reviews.

Humana conducts CRA reviews retrospectively, after provider claims have been submitted and adjudicated. CRA does not interrupt the processing of claims by Humana. Practices have the opportunity to choose how Humana will collect the information for review -via mail, fax, phone, or on-site visits at the physician's office. Diagnosis codes substantiated per the medical record, but missing from the claim submission, will be updated and submitted to HHS. Diagnosis codes included in the claim submission, but not substantiated in the medical record, will be removed from the HHS submission. Humana will mail to the physician's office a summary of diagnosis code adjustments based on the medical record reviews.

You can view a presentation on CRA on the Humana website, or call (800) 4HUMANA ([800] 448-6262) for more information.

837 transactions required for Medicare risk adjustment  Humana will be emailing physicians to remind them that Medicare electronic claims related to chart reviews must be identified as such for Medicare risk adjustment (MRA). Be aware of the following changes when submitting electronic transactions to Humana (these changes will not affect your payment from Humana):

  •   Effective immediately, on encounters generated from a chart review, you should submit HIPAA-compliant 837 transactions with the following values:
    • LOOP 2300
    • CLM02 = 0
    • PWK01 = 09
    • PWK02 = AA
    • LOOP 2400
    • SV101-2 = 99499
    • SV102 = 0 
  • Any diagnosis identified during the chart review should also be submitted on the HIPAA-compliant 837 transaction in the following loop and segment:
    • LOOP 2300
    • HI0-HI12 (as needed) 

 For more information about MRA, call (866) 836-6658.

Source: Humana's Your Practice (PDF), February 2014

Posted Feb. 25, 2014

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Last Updated On

May 13, 2016

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