Private Payer Round-Up, March 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 the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems.


COB form  Aetna's coordination of benefits (COB) form is now available online (PDF) for you to print and share with patients. You can access the form from Aetna's COB webpage.

Revised claim form  Aetna's online claim form is up and running. The revised form matches the fields on the revised paper professional claim form (CMS-1500, version 02-12). You don't need to do anything to be able to access the new form - you automatically get access to it. It keeps all of your existing information, patients, and so forth.

Look for a new claim submission tip sheet on Aetna's secure provider website by clicking on Help at the top of the screen. From the Health Plan drop-down box, select either Aetna Health Plan or Innovation Health and click Go. You'll find the new tip sheet in the Claims & Payments section.

Source: Aetna


Electronic options for pharmacy prior authorization requests — You now can submit medical pharmacy prior authorization (PA) requests online using the Blue Cross and Blue Shield of Texas (BCBSTX) web-based PA submission tool iEXCHANGE.

In addition to PA requests for medical/surgical and behavioral health services, iEXCHANGE supports outpatient pharmacy PA requests for the following specialty drugs under the patient's medical benefit:

  • Avastin,
  • Mybloc,
  • Reclast,
  • Botox, and
  • Remicade.

To submit PA requests for drugs under patients' pharmacy benefit (if their pharmacy benefit administrator is Prime Therapeutics), use the online tool CoverMyMeds.

BCBSTX's new tipsheet (PDF) offers step-by-step instructions for submitting a medical pharmacy PA request using the iEXCHANGE tool.

ICD-10 testing to begin April 1 — ICD-10 provider testing with BCBSTX will take place April 1 through Sept. 15. The payer will conduct end-to-end testing from submission and processing of electronic claims with ICD-10 codes through generation of the electronic remittance advice. During the six-month testing period, BCBSTX will share findings, suggestions, and recommendations with its physicians.

BCBSTX will test with a cross-section of providers and has been contacting candidates for testing. Physicians who are not part of the initial testing phase may have the opportunity to test with BCBSTX in subsequent phases. Visit the BCBSTX ICD-10 page for information about transitioning to the new coding system.

BCBSTX introduces Blue Advantage HMO  BCBSTX has introduced the Blue Advantage HMO, a new network it created as a result of the Affordable Care Act. Here are samples (PDF) of the Blue Choice PPO, HMO Blue Texas, and Blue Advantage HMO identification cards to help you identify the applicable network.

CMS-1500 claim form — Like all other payers, BCBSTX  will receive and process only claims submitted on the revised CMS-1500 claim form (version 02/12) as of April 1.

Source: March  Blue Review (PDF), March 2014


2014 coding procedures update  The following UnitedHealthcare (UHC) Medicare Advantage plans have updated coding procedures for 2014:

  • AARP MedicareComplete
  • UnitedHealthcare MedicareComplete
  • UnitedHealthcare Dual Complete
  • UnitedHealthcare MedicareDirect

Medicare Advantage wellness exams  All UHC Medicare Advantage plans cover s the following types of wellness exams:

  • Medicare Part B Welcome to Medicare visit (initial preventive physical exam) within the first 12 months of Medicare Part B coverage for a $0 copayment. 
    • Bill for this exam with code G0402
    • When you perform a separately identifiable medically necessary evaluation and management (E&M) service in addition to this exam, you also may bill CPT codes 99201-99215 with modifier 25. When medically indicated, this additional E/M service would be subject to the applicable copayment for office visits.
  • Medicare Part B annual wellness visit (personalized prevention plan services) every 12 months thereafter for a $0 copayment. Bill using codes G0438 (first visit) or G0439 (subsequent visit)
  • Annual routine physical exam performed by the patient's primary care physician in addition to the above Medicare Part B-covered services.
    •  Bill for with codes 99385-99387 and 99395-99397.
    • You must provide a head-to-toe exam and cannot bill for a separate breast and pelvic exam, a digital rectal exam, or counseling to promote healthy behavior.
  • A Pap/pelvic exam (including pelvic exam and the pap collection with coverage periodicity following Medicare guidelines: covered annually for those at high risk and every two years for all other women) for a $0 copay. You may bill a separate E&M code only if you provide a separately identifiable E&M service. Bill the exam with code G0101.

Read details about these exams (PDF) from UHC.

Source: United Healthcare

 Published March 25, 2014

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Last Updated On

May 13, 2016