Private Payer Round-Up, May 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.


Challenge your ranking by July 4  Not happy with the results you received in November 2013 in the UnitedHealth Premium physician ranking program? UnitedHealthcare (UHC) will accept requests for reconsideration through July 4, 2014. After that date, the current ranking cycle ends and a new one begins, with new results released later this year. The July 4 end date does not apply to physicians who will receive their annual ranking letters in the June 2014 release. UNC will announce their end date after the letters are mailed.

Advance notification and prior authorization change  Effective for dates of service on or after June 1, 2014, UHC has eliminated certain services  from the advance notification (AN) or prior authorization (PA) requirements for UHC commercial plans and Medicare Advantage Plans. See UHC's Network Bulletin (scroll to page 32).

The most up-to-date list of procedures that will continue to require AN or PA for these plans is at>Clinician Resources>Care Management>Advance Admission Notification.  You can notify UHC electronically at>Notifications Prior Authorizations>Notification/Prior Authorization Submission.

UnitedHealthcare is offering a free webinar Wednesday, June 4, at 1 pm (CT)  to help you learn how to save time submitting advance notification and prior authorization requests on the UHC website. The webinar includes demonstrations of functions, with time afterward for questions and answers. Space is limited, so register now. 

Source: UHC's Network Bulletin, May 2014.


Verify your Blue Cross directory listing  Thoroughbred Research Group is phoning Blue Cross and Blue Shield of Texas (BCBSTX) physician practices in May and June on behalf of the payer to verify information published in the BCBSTX provider directory. BCBSTX asks that you help make its Provider Finder as accurate as possible.

Source: BCBSTX

 A new way to view your electronic remittance information  A new tool enables you to view electronic remittance advice (ERA) data files for purposes other than automated posting and payment reconciliation. The Availity Remittance Viewer allows you to search for ERA data by check, patient, or claim information. You also can drill down for more detail, sort multiple results, and create printable reports.

The remittance viewer is available for independently contracted BCBSTX physicians who are registered with Availity and enrolled to receive ERA files in their Availity "ReceiveFiles" mailbox. A billing service you've designated as your receiver also can view your ERAs using the remittance viewer.

If you submit electronic claims through clearinghouse other than Availity, you may access your ERA data using the remittance viewer as long as you or your billing service receives the 835 ERA file through Availity. (The remittance viewer is not available to clearinghouses other than Availity or to practice management vendors.)

If you are enrolled for ERA, are a registered Availity user, and would like to use the remittance viewer, you can start now:

  • Check with your Availity primary access administrator to ensure you've been assigned the "claim status" role, which includes remittance viewer permission and gives you access to additional features under the Claims Management menu.
  • Once the appropriate role is assigned, you will see a Remittance option under the Claims Management menu on the Availity portal.
  • If another organization such as a billing service is your designated receiver, the system will request information from a check or funds transfer to authenticate your account and enable access to ERA data received and posted to the other organization's mailbox.

If you are not a registered Availity user, visit to sign up.

ICD-10 testing delayed  With the ICD-9 to ICD-10 conversion delayed until at least Oct. 1, 2015, BCBSTX will pause provider testing and other implementation activities until a new compliance date is announced. As information about the new compliance date becomes available, BCBSTX will provide updates in Blue Review and on its provider website.

National Drug Code (NDC) reminder  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.

BCBSTX accepts NDCs for billing of all physician- or ancillary provider-administered and supplied drugs. It pays claims submitted with an NDC in accordance with the NDC Fee Schedule posted on the BCBSTX provider website.

Attention electronic claim submitters: If you have converted to ANSI 5010, there should be no additional software requirements when NDCs are included on electronic claims. However, verify with your software vendor to confirm that your practice management system accepts and transmits the NDC data fields appropriately. If you use a billing service or clearinghouse to submit electronic claims on your behalf, check with them to ensure that NDC data is not manipulated or dropped inadvertently

For more information about using NDCs, see these BCBSTX guidelines (PDF) and FAQs (PDF), as well as this interactive online tutorial (log-in required). See also the NDC Units Calculator Tool.

 Source: Blue Review (PDF), May 2014

iEXCHANGE training webinars  You can submit medical pharmacy prior authorization (PA) requests online using the BCBSTX web-based PA submission tool iEXCHANGE (PDF).

To find out what's new and improved for 2014, iEXCHANGE users may want to take a free training webinar on these topics:

  •  iEXCHANGE New Enhancements/Features: Relevant for new and existing users, this webinar highlights existing and enhanced iEXCHANGE preauthorization functionality.
  •  iEXCHANGE Behavioral Health Intensive Outpatient Program: This training is relevant for staff responsible for initiating preauthorization requests for the initial four visits per episode of care without clinical review to intensive outpatient program services that are exclusive to H0015 (alcohol and/or substance abuse) and S9480 (psychiatric services per diem).

Registration is required (all times given in Central Time):

 If the above does not meet your needs for training, request customized training at ProviderOutreachEducation[at]bcbstx[dot]com.

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

Source: BCBSTX

Published May 28, 2014

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