Private Payer Round-Up, June 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.


Code edit update for interoperative neurophysiology monitoring - Effective Aug. 18, 2014, codes 95940, 95941 and G0453 will be denied as incidental when billed in addition to a code from either the code range of 00100-01999 or the range of 10021-69990. This policy conforms with CPT guidance, which says: "When the service is performed by the surgeon or anesthesiologist, the professional services are included in the surgeon's or anesthesiologist's primary service code(s) for the procedure and are not reported separately."

Source: Cigna

United Healthcare

Medical policy updates  United HealthCare's latest Medical Policy Update Bulletin (PDF) describes new and revised medical policy updates, and updated and revised coverage determination guidelines effective June 1 and July 1, 2014. Each description links to the full text of the policy.


Reminder regarding Humana Military  TRICARE-eligible beneficiaries must maintain a "signature on file" in the physician's office to protect the patient's privacy, for the release of important information, and to prevent fraud. A new signature is required every year for professional claims submitted on a CMS-1500.

Source: Humana Military

Use e-prescribing to determine formulary coverage  Now that you may be seeing many new patients with Humana coverage through the health insurance marketplace, determining which formulary coverage these patients have can be challenging.

E-prescribing can be a helpful tool for determining formulary coverage. In its June newsletter, Humana offers this scenario as an illustration:

  • Dr. Smith logs into her e-prescribing software and selects Sally, her 10 am appointment.
  • The software performs an eligibility check and determines that Sally is a Humana member assigned to Formulary A.
  • Dr. Smith prescribes Aricept for Sally.
  • The software displays formulary-specific information for Aricept, including formulary status, cost-share information, formulary alternatives, and drug-specific messaging.

E-prescribing also can speed up the process of refilling applications. If you have questions, call Humana at (800) 4-HUMANA ([800] 448-6262).

Keep up with code-editing software updates  Bookmark Humana's Claims Processing Updates webpage to stay current on its claims-processing system. The latest downloadable documents on this site detail updates effective June 21, 2014, as well as those that will become effective Sept. 13, 2014. Detailed descriptions such as these become available on the webpage 90 days prior to their implementation date. The page says the next update will be published Aug.8, for an effective date of Nov. 8, 2014. If you would like additional information about the code-editing changes, you can submit questions by following instructions on the Claims Processing Updates webpage.

Revised medical coverage policies  The following Humana coverage policies have undergone recent significant revisions:

  • Benign prostatic hyperplasia treatment,
  • Bone growth stimulators,
  • Genetic testing and genetic counseling  for cardiac conditions,
  • Home prothrombin time monitoring devices,
  • Intensity modulated radiation therapy,
  • Pharmacogenomics,
  • Prophylactic mastectomy, and
  • Transcatheter valve implantation.

Source: Humana's YourPractice, June 2014.


New IVIG med discounts  Effective Sept. 1, 2014, Blue Cross and Blue Shield of Texas (BCBSTX) will offer a program through Coram Alternate Site Services, dba Coram Specialty Infusion Services, to provide these intravenous immune globulin (IVIG) medications to BCBSTX members at a lower price and allow shipment of this IVIG drug to a physician's or home infusion therapy provider's office.

ERA delivery timeline update - BCBSTX electronic remittance advice (835 ERA) files now are delivered to receiver mailboxes between 1-3 pm. If you use a billing service or clearinghouse to receive ERA files on your behalf, let it know about this change. If you have questions, call the BCBSTX Electronic Commerce Center at (800) 746-4614.

Learn how to use Availity tools  Register for a free online webinar about:

  • The new Availity Remittance Viewer. BCBSTX has scheduled webinars through July to show you how to gain or grant access to search ERA data, view general and payer-specific information, save results electronically, and generate a printable document. Prior to gaining access to the remittance viewer, you must be a registered Availity user and enrolled for ERA. Additional information on registration, along with electronic enrollment for ERA, is available on the Availity Web Portal.
  • Coming soon: Electronic Provider Access. This tool will enable you to initiate online preservice reviews for out-of-area Blue Plan members, i.e., benefit preauthorization, precertification, prenotification, and prior approval functions. July and August webinars are open for registration.

Both tools are available to BCBSTX independently contracted providers who are registered Availity Web Portal users.

Also new on Availity: option to contact BCBSTX  If the benefit information you need on the Availity Web Portal is not available upon selecting "View Details," you'll see a new option called Speak to an Agent. Clicking this orange button gives you priority access to the next available BCBSTX customer advocate during normal service hours. You'll be prompted to contact BCBSTX and enter your transaction number. Your call will bypass the standard automated phone system.

Source: BCBSTX


National Precertification List (NPL) changes  Note the following:

  • Oral appliances don't require precertification (effective March 3, 2014).
  • Precertification for Vimizim, a new-to-market enzyme replacement drug, is required (effective May 9, 2014).
Drug testing and drug assay frequency reminder  Aetna places daily and annual frequency limits on qualitative drug screens and quantitative drug assays. Refer to the Frequency Limits  Drug Testing & Therapeutic Drug Assays payment policy on Aetna's secure website under the Claim Payment and Coding Policies section for information.

 Osteoarthritis of the Knee: Selected Treatments policy update  The new policy states that Aetna considers arthroscopic partial meniscectomy experimental and investigational for degenerative meniscal tears. Read the full Clinical Policy Bulletin #0673 for details.

Changes for Aetna Student Health (ASH)  Later in 2014, these changes may affect your ASH patients.

  • Adoption of Aetna's National Precertification List. See this ASH Information Bulletin for details and a list of services that will require precertification for ASH members.
  • Adoption of Aetna's code editing system. Payment of certain CPT codes that previously were paid or denied may be affected with this coding change. If you have questions, call Aetna at (888) 632-3862.

ICD-10 update  Aetna says despite this delay until October 2015 for ICD-10, it will "continue working on our ICD-10 projects. …. We will test with targeted providers throughout  2014 and 2015. …Finally, we'll follow guidance from the Department of Health and Human Services and Centers for Medicare & Medicaid Services as it becomes available." 

New EOB process may cause payment delays  Aetna Medicare members used to receive a separate EOB for each claim. Now they receive a monthly  statement that summarizes all their Aetna claims for the prior month.  This new process may cause a slight delay in these patients paying their share of claims to your practice.

Online claim form update  Aetna has updated its online claim to match changes made to the CMS-1500 paper claim form. You can access the form on Aetna's secure website by clicking on "Claims" then "Claim Submission" from Plan Central. Current form users will find their existing history, patients, and similar information carried over to the revised form.

Features of the revised form include:

  • Box 21: Diagnosis Code  The form now accepts up to 12 diagnosis codes.
  • Box 24E: Diagnosis Pointer  Although users can send up to 12 diagnosis codes, each claim line can accept a maximum of four diagnosis pointers.
  • Box 30: Reserved for NUCC use  In the previous form, Box 30 showed the balance due. The new version of the form doesn't have this box. The form will automatically calculate the charges based on what you enter in boxes 28 (Total Charge) and 29 (Amount Paid).

An updated Claim Submission Tip Sheet is posted in the Help section of the Aetna website.

Changes coming in paper correspondence from Aetna  Starting soon, a new vendor, Emdeon, will send some provider communications on behalf of Aetna to your office. You'll get paper explanation of benefits (EOB) statements, checks, and letters from HealthPayers USA, a service provided by Emdeon.

  • They'll be in the same envelope as correspondence from other companies (at times, you may receive individual packages from Aetna).
  • The check color will change from tan to blue.
  • Packages may include checks immediately followed by corresponding EOBs.

Note: Offices that previously received a letter from Aetna about an electronic funds transfer enrollment or transitioning to electronic EOBs aren't affected by the change to HealthPayers USA.

It's annual fraud-waste-and-abuse (FWA) training attestation time  The Centers for Medicare & MedicaidServices (CMS) requires Aetna and other payers to make sure their Medicare physician practices receive training regarding general compliance, FWA, the payers' code of conduct and compliance policies dissemination, and more.

 If your practice accepts Aetna Medicare, an authorized representative must access the 2014 Medicare Compliance Attestation at and complete it. Information about the training requirements is on this education portal. To complete the attestation:

  1. Type "Attestation" in the Search field and click Go.
  2. Select the 2014 Aetna Medicare Attestation (log-in required). 

Note: Practices that have met the FWA certification requirements through enrollment in Medicare B are deemed to have met the FWA training requirements. However, they are not exempt from any of the other Medicare Compliance Program requirements, and must still complete Aetna's attestation.

Source: Aetna OfficeLink Updates (PDF) June 2014

Published June 24, 2014

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May 13, 2016