Private Payer Round-Up, August 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.

Texas Teacher Retirement System Changeover Is Here

Beginning Sept. 1, 2014, the contract for managing the Texas Teacher Retirement System's TRS-ActiveCare program transfers from Blue Cross and Blue Shield of Texas to Aetna. The change does not impact TRS retirees.

TMA has compiled a list of answers to commonly asked questions to help you work through this transition. Cigna 

Challenge Cigna Care designations by Sept. 8  If you received a letter in July regarding your 2015 Cigna Care designation, and physician quality and cost-efficiency displays, you must request changes by Sept. 8, 2014, for any corrected information to appear with the initial display of Cigna Care designations on Oct. 20, 2014. Be sure to include the reason for your request and any applicable documentation.

If Cigna receives your request for changes after Sept. 8, it will process the request but revise incorrect information sometime later. You can request reports, review results, submit inquiries, or request changes at PhysicianEvaluationInformation[at]Cigna[dot]com or by fax at (866) 448-5506. Cigna will contact you about your results and possible next steps.

Cigna begins a new relationship with HearPO  Starting Sept. 1, 2014, HearPO, an Amplifon Company, will be the only in-network provider of digital and digitally programmable analog hearing aids and supplies to Cigna patients whose health plans cover them.

For your qualified patients, you will order the hearing aids and supplies directly from HearPO. You can verify patient benefit and eligibility information directly with HearPO, and HearPO will secure the requested device and ship it directly to you, with no up-front costs to your practice. HearPO will bill Cigna; this means you should not bill Cigna directly or collect any patient deductibles, coinsurance, or copayments for these devices and supplies.

HearPO will pay dispensing fees directly to you. For all other covered services, including hearing testing and evaluation, fittings, analog and disposable hearing aids, follow-up visits, and repairs, you will submit claims to Cigna and collect deductibles or copayments from the patient. If you have questions, call HearPO at (855) 531-4695 or Cigna at (800) 882-4462.

Medical policy updates  Cigna updated the following policies on Aug. 14, 2014

  • Acupuncture,
  • Bone Growth Stimulators,
  • Facility Routine Services and Supplies and Equipment,
  • Genetic Testing for Mitochondrial Disorders,
  • Intraoperative Monitoring (part of Code Editing Guidelines),
  • Fecal Calprotectin Testing (part of Omnibus Codes policy),
  • Helicobacter Pylori Antibody Testing,
  • Hyaluronates, and
  • Transvaginal Ultrasound.

Information about these changes is available at > Resources > Clinical Reimbursement Policies > Coverage Policy Updates.

Precertification changes  Also on Aug. 14, Cigna made the following changes to its precertification list:

  • Codes added to the precert list: 22214, C9352, C9353, J7321, J7323, J7324, J7325, and J7326.
  • Codes that no longer  require precertification: 15780, 15781, 15782, 15783, 15788, 15792, 17360, 21175, 37250, 65778, 65780, 65781 86152, 86153, and V2790.
  • Codes that still require precertification, but are now managed by CareCore (network-participating provider of radiation therapy benefits): 32701, 61796, 61797, 61798, 61799, and 61800.

You can view the complete certification list at > Precertification Policies (under Useful Links).

Mail all paper claims to Chattanooga address  Cigna has consolidated the mailing location for all Cigna paper claims at its Chattanooga, Tenn., mailing address, as of July 1, 2014. (The post office has been forwarding any claims you sent after July 1 to the old Kennett, Mo., mailing address, which is no longer valid.) Over the next 18 months or so, Cigna will update ID cards with the new Chattanooga address as plans renew, as well as other affected documents.

Send all paper claims to the Chattanooga mailing address using these new PO boxes:

  • For general mail and claims (including Payer Solutions): PO Box 188061; Chattanooga, TN 37422-8061
  • For GWH-Cigna Appeals: PO Box 188062, Chattanooga, TN 37422-8062
  • For Cigna LifeSource Transplant Network: PO Box 188063, Chattanooga, TN 37422-8063
  • For GWH-Cigna Behavioral Health appeals: PO Box 23487, Chattanooga, TN 37422-3487

Source: July Cigna Network News, July 2014


Investigators review claims  BCBSTX reports its Special Investigations Department (SID) has identified that a small percentage of practices may be billing high-complexity CPT evaluation and management codes incorrectly. Be aware that SID occasionally reviews claims for such possible upcoding.

New claims processing edits  Beginning on or after Sept. 29, 2014, BCBSTX will add two new rules into its claim processing system.

  • Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BiPAP) Supply Frequency. This rule identifies supply codes submitted from all providers for the same patient associated with CPAP/BiPAP therapy that are being submitted at a frequency that exceeds Centers for Medicare & Medicaid Services (CMS) local coverage determination (LCD) policy for CPAP supplies. Quantities of supplies greater than those described in a CMS LCD policy will be denied.
  • Obstetrics Package Rule. This rule audits claim lines to determine if any global obstetric (OB) care codes (defined as containing antepartum, delivery, and postpartum services) were submitted with another global OB care code or  a component code during the average length of time of the typical pregnancy of 280 days and/or pregnancy plus postpartum period of 322 days.

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you can use Clear Claim Connection, a free, online reference tool that mirrors the logic behind BCBSTX's code-auditing software.

Bill correctly for assistant surgeons  Follow the current HIPAA 5010 rule for all claims for all payers:

  • Licensed assistant surgeons should bill claims with their own rendering National Provider Identifier.
  • A supervising physician should use the AS modifier when billing on behalf of a physician assistant, surgical assistant, advanced nurse practitioner, clinical nurse specialist, certified nurse midwife, or registered first assistant for services provided when one of these acts as an assistant during surgery. Use the AS modifier ONLY if these nonphysician practitioners assist at surgery. (BCBSTX modifier policies are in the General Reimbursement section (log-in required) of the BCBSTX provider website.)

Source: BlueReview (PDF), July 2014

Which Advantage plan is it?  Are you contracted with BCBSTX Blue Advantage HMO? How about Blue Cross Medicare Advantage (PPO)?  Sometimes practices confuse these two plans.

Blue Advantage HMO is the new HMO product individuals can purchase on or off the Affordable Care Act health insurance marketplace; it is not a Medicare product. Blue Cross Medicare Advantage (PPO), as indicated by the name, is a Medicare product.

Remember to always get a copy of your patient's ID card for your records and to determine the product. Here are easy ways to tell these two Advantage plans apart:

  • On the Blue Advantage HMO ID card, you'll see the network identifier BAV (in red) on the front. "HMO" is at the top of the card.
  • On the Blue Cross Medicare Advantage (PPO) card, the alpha prefix is ZGD, and "Blue Cross Medicare Advantage (PPO)" is at the top.

Medicare Part D formulary updates   BCBSTX has published a summary (PDF) of its Medicare Part D formulary changes for first quarter 2014. These have effective dates from Jan. 1, 2014-May 25, 2014. The  BCBSTX pharmacy provider, Prime Therapeutics, updates the Blue Cross Medicare Part D formulary monthly. You can find by a complete formulary listing at

Talk to BCBSTX — You can call BCBSTX medical management staff to discuss care management concerns, questions, or specific requests such a preauthorization requests; use the preauthorization/prenotify toll-free number listed on the back of your patient's identification card. Hours are:

  • 6 am to 6 pm (CT), Monday through Friday except on legal holidays; and
  • 9 a.m. to noon (CT) on Saturday, Sunday, and legal holidays.

After business hours, you can leave a message in a confidential voicemail box. A staff member will return your call within 24 hours, identifying himself or herself by name, title, and company name.

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

BCBSTX pays claims submitted with an NDC in accordance with the NDC Fee Schedule (updated monthly on the first of each month) posted on the General Reimbursement section (log-in required) of the BCBSTX provider website.

Source: BlueReview, August 2014


New oncology split fill program  Effective Oct. 1, 2014, Aetna will implement a "split fill" dispensing provision for certain oral oncology drugs. Split fill means the patient will get an initial 15-day supply, followed by a second 15-day supply within 30 days (one month) for the duration of their therapy. Partial copayment will coincide with each dispense.

Aetna's Specialty Health Care Management nurse team manages these oral oncology drugs, and will support patients throughout the course of therapy. Split filling will allow monitoring of the patient's response to therapy and any potential reactions or side effects. The new program includes these drugs: Afinitor (everolimus), Inlyta (axitinib), Jakafi (ruxolitinib), Nexavar (sorafenib), Sprycel (dasatinib), Sutent (sunitinib), Tarceva (erlotinib), Votrient (pazopanib), and Zelboraf (vemurafinib).

Precertification updates and reminders  The following changes to Aetna's precertification list will take effect on  Jan. 1, 2015:

  • Chemical peels, injection of filling material, and cognitive skills development will not require precertification.
  • These drugs will require precertification: Fusilev, Ilaris, and Myalept.


  • Also effective Jan. 1, 2015, precertification is required for nonparticipating, freestanding ambulatory surgical facility services when referred by a participating physician; without the precertification, Aetna may deny the participating physician's claim.
  • Effective June 2, 2014, precertification is not required for Medicare Part B home hospice and home health care for Medicare Advantage members. This change did not impact precertification requirements for:
  • Home uterine activity monitoring or maternity management; private duty nursing;
  • Psychiatric home care services following the Behavioral Health Precertification List; and
  • Home infusion/injection codes requested with drugs/medical injectables that require precertification. 
  • These new-to-market drugs require precertification (effective date noted): Tretten and Alprolix (May 20, 2014), Otezla (June 10, 2014), Orenitram and Monovisc (July 11, 2014), and Entyvio (July 18, 2014).

OrthoNet: tips to remember  Aetna selects certain claims for review by OrthoNet, an outside prepay auditor, from these specialties: dermatology; ear, nose, and throat; hand surgery; neurology; neurosurgery; orthopedic surgery; pain management; physiatry; plastic surgery; podiatry; sports medicine; and urology.

If your office gets a provider explanation of benefits or provider explanation of payment asking you to send Aetna records relevant to a claim being audited, do the following:

  • Fax the records to (859) 455-8650. (Note: As of Dec. 30, 2014, fax number [860] 754-1550  won't be valid.)
  • Or, mail the records to Aetna at PO Box 14079, Lexington, KY 40512-4079.
  • Whether faxing or mailing, include a cover sheet with "CODE: ONET" at the top of the page.
  • Also include: (1) Aetna member ID, (2) date of service, (3) servicing provider name, and (4) servicing provider Tax ID number and/or Aetna provider ID number.
  • If you are faxing multiple patient records at a time, fill out a separate fax cover sheet, with the requested information, for each patient. Place the cover sheet atop that patient's records to keep the records separated.

Update on ICD-10 testing   Aetna says it is well underway with targeted ICD-10 external testing,  which will continue into 2015 in preparation for the Oct. 1, 2015, implementation date for ICD-10. Aetna reports experiencing no problems with its testing partners or their clearinghouses when exchanging ICD-10 claim transactions (837 files), and reminds practices to test with your own clearinghouses to ensure you can successfully receive and validate your ICD-10 transactions. Also, work with your other vendors to ensure they are preparing to be ICD-10 ready, and make sure you update all internal processes and systems to support ICD-10.

Source: Aetna OfficeLink Updates (PDF), September 2014.


Billing multiple units instead of multiple lines can speed payment - For its Medicare plans, UnitedHealthcare (UHC) urges practices to avoid this common billing error that slows down claims processing: Instead of billing the same procedure code on multiple lines, bill the code on one line with multiple units up to the medically unlikely edit (MUE) limit using appropriate modifiers.

CMS defines an MUE as "the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service." UHC's maximum numbers of services per day that may be billed for specific procedure codes are similar to CMS MUEs.

Here are examples for billing a pathology exam on three breast biopsy specimens.

Example 1

  • Correct way: One line with HCPCS/CPT code 88305 and three units.
  • Wrong way: Three lines with HCPCS/CPT 88305 with one unit each. When a claim shows three lines with one unit for each line, the additional lines appear as duplicates, causing the additional lines to deny.

Example 2 (see illustration [PDF]): CPT code 88305 has an MUE of three but was delivered five times.

  • Correct way: One line with HCPCS/CPT code 88305 and three units. A second line with HCPCS/CPT code 88305 and two units, with the appropriate modifier (such as 91).
  • Wrong way: Five lines with HCPCS/CPT 88305 with one unit.

Source: UnitedHealthcare

Published Aug. 26, 2014

Last Updated On

May 13, 2016