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


Upcoming medical policy updates - Take note of the following planned updates to Cigna medical policies. Information about these changes is available on the Cigna for Health Care Professionals website ( > Resources > Clinical Reimbursement Policies > Coverage Policy Updates) at least 30 days prior to the effective date of the updated policy. On the policy updates page, you also may view new and updated policies in their entirety.

Policy name/Update effective date 
Neuropsychological Testing/ May 19, 2014
Positron Emission Tomography (PET)/May 19, 2014
Repository Corticotropin (Acthar® Gel)/June 16, 2014

Submitting claims for injectable medications  Cigna is aligned with the Centers for Medicare & Medicaid Services (CMS) unit guidelines for processing injectable claims, i.e., you should submit claims based on Healthcare Common Procedure Coding System (HCPCS) units administered, not dosage units.

Each injectable HCPCS code has a specific unit of measure as found in the Common Procedural Terminology (CPT) or HCPCS code books. For example

  • HCPCS description of drug is 6 mg … 6 mg are administered =  bill 1 unit
  • HCPCS description of drug is 50 mg … 200 mg are administered = bill 4 units
  • HCPCS description of drug is 1 mg … 10 mg vial of drug is administered = bill 10 units 

Revised CMS-1500 paper claim form  Cigna currently accepts both the revised CMS-1500 claim form (version 02/12) and the older (version 08/05) CMS-150. As of Oct. 1, 2014, Cigna will accept only the revised CMS 1500 form (02/12). However, Cigna encourages you to switch to the revised form now, or to submit claims electronically. For information about electronic claim submission, go to > Resources > Clinical Reimbursement Policies and Payment Policies > Claim Policies and Procedures > How to File a Claim).

Newborn claim submissions  Cigna recently updated its newborn claim submission process, as follows.

Submit the subscriber's:

  • Cigna ID number without the suffix (for example, if the Cigna ID number is U1234567801, remove the suffix 01 and submit as U123456780), and
  • First and last name (not the mother's unless she is the subscriber).

Submit patient information with the newborn's:

  • First name (or, e.g., "Newborn," "Baby Boy," "Baby Girl," or "Twin A," "Twin B");
  • Last name;
  • Date of birth; and
  • Gender.

Reminder: "participant incentives" prohibited  Cigna requirements specify that physicians and health care providers shall not directly or indirectly establish, arrange, encourage, participate in or offer any participant incentive.

"Participant incentive" means any arrangement:

  • To reduce or satisfy a participant's cost-sharing obligations (including, but not limited to copayments, deductibles and/or coinsurance);
  • To pay on behalf of or reimburse a participant for any portion of the participant's costs for coverage (e.g., insurance premiums) insured or administered by Cigna or a Cigna affiliate; or
  • That provides a participant with any form of material, financial incentive (other than the agreed-to reimbursement terms) to receive covered services from the physician or health care provider or any associates or affiliates.

Consequences for noncompliance are as follows:

  • Cigna may terminate your provider agreement due to a "material breach" of the agreement.
  • You won't be entitled to payment from Cigna from your services provided to the patient in connection with a participant incentive.
  • Cigna may take other actions appropriate to enforce this provision.

Source: Cigna Network News (PDF), April 2014

HPCPS codes requiring an NDC on claims  For dates of service April 1 to June 30, 2014,Cigna requires the National Drug Code (NDC) number in addition to the HCPCS code on certain claims, when the patient's health plan requires precertification. This is in addition to the requirement to include the NDC for unclassified (unspecified) codes. Three HCPCS specialty medication codes are affected:

J0725 - Injection, chorionic gonadotropin, per 1,000 USP units;
J1830 - Injection interferon beta-1b., 0.25 mg; and
J2941 - Injection, somatropin, 1 mg.

Cigna has provided a table (PDF) listing the HCPCS codes and the corresponding NDC number for each, along with additional information about using the NDCs on claims.

Source: Cigna


Policy updates  Be sure to check out UnitedHealthcare's (UHC's) Medical Policy Update Bulletin (PDF) for changes in medical policy, coverage determination guidelines, and quality of care guidelines effective April 1 and May 1, 2014.

New health care summary reports - If UHC identifies you as an outlier among its physicians, you may receive a new type of report from UHC that details tests, procedures, referrals, and/or billing patterns in your practice that may be inconsistent with evidence-based medicine. Initially, UHC is looking at primary care physicians (internal medicine, family practice, and pediatrics), cardiologists, and endocrinologists, with other specialties to be added later. UHC began sending letters with reports in April to Houston-area physicians; identified outliers in the rest of Texas will receive letters within eight to 10 weeks later. These physicians can expect to receive one or two follow-up reports as well.

UHC says the project goal is "not to penalize physicians but drive improvement in behavior and practice patterns." However, failure to improve practice patterns could affect a physician's future participation in UHC programs and products. 

UHC in the cloud  Optum Cloud Dashboard is UHC's cloud-based website. You can learn about its newest features, the Eligibility & Claims Center, and the Claims Management applications, in free, 30-minute webinars offered on Wednesdays and Thursdays over the next few weeks.

Source: United Healthcare


Hospice medication coverage for Medicare Part D patients  Recently, CMS clarified coverage of medications for Medicare members enrolled in hospice care. Effective Jan. 1, 2014, Medicare Part D payers must require a prior authorization (PA) for four classes of medications when prescribed to Medicare members receiving hospice care: analgesics, antinauseants (antiemetics), laxatives and antianxiety drugs.

Medicare Part D will cover these medications only if they are prescribed for diagnoses unrelated to the patient's terminal illness. If they are related to the terminal illness, the bill the medications through the patient's hospice provider, if covered.

Humana members with Medicare Part D coverage, who are also enrolled in hospice, may need a PA from Humana for these medications, if they are unrelated to their terminal illness.

To begin the PA request process, call Humana Clinical Pharmacy Review (HCPR) at (800) 555-2546, 8 am to 6 pm local time, Monday through Friday, or register to use CoverMyMeds, a free online drug PA program that allows physicians to begin the process electronically for all drugs, and nearly all payers, including Medicare Part D.

What if your patient has recently disenrolled from hospice and needs medication, but his or her prescription coverage through Part D is rejected due to hospice enrollment? In that case, the

patient should call HCPR to request an override. You also can advise the patient to remind his or her hospice provider to update the patient's  hospice status to prevent further hospice claim denials.

Tax ID number needed for authentication  When you or your office staff contact Humana, the automated phone system will request your tax identification number (TIN) for authentication purposes and to help more accurately route the call. If you can't provide, the phone system will ask you to call back. Note that the phone system accepts only TINs, not National Provider Identifiers.

Tips for coding weekly radiation therapy management  Below are tips from Humana for claims that use the CPT code 77427, radiation therapy management, provided by a physician for the ongoing care and supervision of a patient during the entire course of radiation treatment.

Some services included in code 77427 are:

  • Revising and reviewing the treatment plan;
  • Reviewing port film or portal verification images;
  • Reviewing patient charts and dosimeter, including the dosage administered to date and treatment plans;
  • Setting up and evaluating treatment;
  • Treating infections;
  • Writing prescriptions;
  • Counseling about nutrition and fluid electrolyte management;
  • Handling telephone calls to or from the patient; and
  • Managing pain.

 Humana's payment policy when using CPT code 77427 includes the following:

  • Only one unit (a unit consists of five treatments) in a seven-day period is allowed.
  • For commercial fully insured and self-funded members: A unit must represent the fractions (one treatment is a fraction) by billing the first fraction in the "From" date and the last fraction in the "Thru" date. If these dates are the same, Humana will reject the claim.
  • For all Medicare members: A unit must represent the fractions by billing either the first fraction in the "From" and the last fraction in the "Thru" date or by using the same "From" and "Thru" date as long as these dates always represent the date of the first fraction.
  • Each unit must be billed on a separate line.
  • At the end of a course of treatment, a unit should be submitted only when three or more fractions have been administered.

You can submit questions regarding coding radiation therapy or other code editing questions to Humana at>Claims Tools>Code Editing Questions (under Associated Links).

 Source: Humana's YourPractice, April 2014

Claim processing edits  It helps to be aware of Humana's schedule of updates and notifications, as follows.

Implementation Date................... Date available to view* 
Jan. 18, 2014.................................Oct. 18, 2013
April 5, 2014................................. Jan. 3, 2014
June 21, 2014 ............................... March 21, 2014
Sept. 13, 2014 .............................. June 13, 2014
Nov. 8, 2014 .................................Aug. 8, 2014

*View updates from November 2008 through current. The update for June is already posted: Physician/Health Care Providers All Markets (Excluding Puerto Rico)  effective June 21, 2014.

Source: Humana


Get paid for more performance measurement  Effective July 1, 2014, Blue Cross and Blue Shield of Texas (BCBSTX) will begin paying for additional Category II CPT codes (see the list). These are performance measurement codes for data collection about quality of care that provide information unavailable from claims data. BCBSTX encourages you to report these codes.

When billing Category II codes, submit your usual charge. Do not submit the codes with a $0 charge.

Fee schedule updates  Effective July 1, 2014, BCBSTX will implement changes in the maximum allowable fee schedule used for Blue Choice PPO, HMO Blue Texas, Blue Advantage HMO (Independent Provider Network and THE Limited Network only), and ParPlan. Read the details.

New rules concerning Medicare secondary claim submission  CMS routes (crosses over) Medicare supplemental claims (Medigap and Medicare Supplemental) directly from Medicare to BCBSTX so that physicians don't need to also submit their claim to BCBSTX. Despite this longstanding cross-over process, physicians have continued to submit the claim to both Medicare and BCBSTX, resulting in duplicate claims.

The new rules are aimed at reducing duplicate claims:

  • CMS requires that when a Medicare claim has been crossed over, you are to wait 30 calendar days from the initial Medicare remittance date before submitting the claim to BCBSTX.
  • BCBSTX will reject physician-submitted claims when Medicare is considered primary, including those with Medicare exhausted-benefits that have crossed over if they are received within 30 calendar days of the initial remittance date or with no Medicare remittance date.

Follow these tips: 

  • Submit claims to Novitas Solutions when Medicare is considered primary and the Blue plan is secondary. Be sure you enter the correct Blue plan name as the secondary carrier (check the patient's ID card).
  • Be sure to include the alpha prefix as part of the member number. It is on the member's ID card as the first three characters. Not including it may delay payments.
  • When you receive the remittance advice from Medicare, determine if the claim has been automatically forwarded (crossed over) to the Blue plan: Remark codes MA18 or N89 on the Medicare remittance will indicate the claim was crossed over. You do not need to resubmit that claim to BCBSTX.
  • If the remittance indicates the claim was not crossed over, submit the claim to BCBSTX with the Medicare remittance advice. In some cases, the member ID card may include a Coordination of Benefits Agreement ID number. If so, be sure to include that number on your claim.
  • For crossed-over claims, Medicare will release the claim to the Blue plan for processing about the same time you receive the Medicare remittance advice (RA). Thus it may take up to 30 additional business days after you receive the Medicare RA for you to receive payment or instructions from the Blue plan.
  • If you submitted the claim to Novitas and haven't received a response to your initial claim submission, do not automatically submit another claim. Check the status of the initial claim before resubmitting.
  • If you use a billing service or clearinghouse to submit claims on your behalf, be sure it is aware of this information.

BlueCompare evaluation underway  BCBSTX evaluates the performance of Blue Choice PPO network physicians in 13 measured specialties on evidence-based measures (EBMs) and physician cost assessment as compared with peers in the same working specialty.

Consistent with national guidelines, a cost-efficiency assessment is performed only if the physician meets specialty-specific, quality-related criteria. This year's evaluation is underway; BCBSTX will mail the affected physicians a communication with instructions for accessing their performance reports in a secure online portal (if applicable).

BCBSTX also has two additional transparency programs that provide quality-related performance information on the National Doctor & Hospital Finder and the BCBSTX Provider Finder.

  • The Physician Quality Measurement Program (PQM) collects data on nationally endorsed physician quality measures. The PQM results shown on your BlueCompare 2014 EBM Summary Report will be displayed on the National Doctor & Hospital Finder, effective third quarter of 2014.
  • The Blue Physician Recognition (BPR) will use a BPR indicator to identify physicians who have demonstrated their commitment to delivering quality and patient-centered care, as determined by BCBSTX. If you receive a Blue Ribbon for the BCBSTX 2014 BlueCompare program, the BPR symbol will be displayed on the National Doctor & Hospital Finder and the BCBSTX Provider Finder, effective third quarter of 2014. Similar information will be displayed for PQM in the future on the BCBSTX Provider Finder.

TMA has developed a toolkit to help you challenge unfair rankings from private insurance companies. Go to the TMA Physician Ranking webpage.

Partial batches accepted  BCBSTX now accepts partial claim batches, rejecting only individual claims that do not meet HIPAA compliance standards.

When you transmit claims electronically, BCBSTX will forward all valid and successful claims for processing and adjudication. Payer response reports will indicate which claims were rejected so you can correct and resubmit those claims as appropriate. Do not resubmit the entire batch of claims, as this will result in duplicate claims within the adjudication process.

If you use a billing service or clearinghouse to submit claims on your behalf, be sure it is aware of this information. If you have any questions about this process, contact the BCBSTX Electronic Commerce Center at (800) 746-4614.

New quarterly pharmacy highlights  BCBSTX has introduced a new feature on its provider website: a quarterly, brief summary of the new pharmacy products and program enhancements that were announced in Blue Review during the previous quarter along with a link to the article. Check out the first quarterly highlight.

Billing with National Drug Codes  Effective June 1, 2014, BCBSTX will revise the methodology it uses for determining the allowables for HCPCS or CPT codes associated with multiple National Drug Codes, including immunizations. The HCPCS or CPT code allowable generally will be equivalent to the lowest NDC allowable associated with the HCPCS or CPT code.

Remember, when you bill drugs under the patient's medical benefit, be sure to include NDCs and related data. Using NDCs on medical claims results in more accurate payment and better management of drug costs based on what was dispensed.

Source: Blue Review (PDF), April 2014

Published April 30, 2014

TMA Practice E-Tips main page