Private Payer Round-Up, November 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. Also, visit the TMA Payment Advocacy Services webpage for more resources.


Chemotherapy prior authorization (PA) requirement delayed  Earlier this year, UnitedHealthcare (UHC) said that starting Dec. 1, 2014, it would require a PA requirement for outpatient chemotherapy drugs given for a cancer diagnosis. UHC has delayed this requirement, probably until spring 2015.

New payment policy: pediatric and neonatal critical and intensive care services  Effective for claims with dates of service on or after March 1, 2015, UHC will follow the American Medical Association's CPT instructions regarding payment of certain evaluation and management (E&M) services as well as non-E&M services when reported with pediatric and neonatal critical and intensive care E&M codes 99468-99476 and 99477-99480. The services are considered inclusive in these codes. Modifier overrides will be allowed as appropriate.

Clarification on charging Medicare Advantage patients for noncovered services — Earlier this year, UHC announced immediate discontinuation of its Advance Notice for Non-Coverage form. At the time, UHC said use of the GA modifier was no longer necessary on claims for noncovered services.

This instruction has changed. You must use the GA modifier on claims for noncovered services to indicate that prior to rendering or referring for the noncovered service(s), you have (effective Dec. 1, 2014):

  • Requested and received a "preservice organization determination," and you and the patient have received an" integrated denial notice," and
  • Obtained the patient's written consent for you to bill and collect from the patient for these noncovered services.

UHC says including the GA modifier will help ensure your claims for noncovered services are processed correctly as member liability.

Premium designation program results  Annual ranking notifications have been going out this month to physicians who are in areas where the UnitedHealth Premium designation program is available and who practice in one of the 27 Premium-eligible medical specialties (new for 2015: ear, nose, and throat, and gastroenterology). UHC says (PDF) these results, based on claims paid Jan.1, 2011, to Feb. 28, 2014, will appear on the UHC website in January 2015. Check the notification for how to view your assessment reports and how to request reconsideration. And, visit the TMA Physician Ranking webpage to access TMA's toolkit for appealing unfair rankings.

Source: UnitedHealthcare Network Bulletin, November 2014

Humana Simplifies Medicare Code Editing

Humana has begun reviewing all Medicare Advantage claims based on the same correct coding guidelines and coding policy rules. This change includes:

  • NCCI coding guidelines: Humana will apply to Medicare Advantage HMO plans the coverage and processing rules outlined in the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) policy manual. These plans will apply code pair edits identified in the procedure-to-procedure tables (Column I/Column II).
  • CMS assistant surgeon coding guidelines: CMS states that some surgical services do not require assistant support. When a surgical procedure does not require an assistant, per CMS determination, Medicare Advantage HMO claims will not qualify for payment when billed with an assistant surgeon. Surgical services not eligible for assistant surgeon payment are identified by the "1" indicator on the Medicare physician fee schedule.

Additional editing on Medicare Advantage HMO plans will apply in accordance to CMS guidelines. For more information about the changes, call Medicare customer service at (800) 457-4708, from 7 am to 7 pm CT, seven days a week.

Source: Humana's YourPractice, October 2014

Cigna Medicare: Six Tips for Avoiding Administrative Claim Denials

  • No authorization: Know which services require preauthorization, and obtain it prior to providing service. Also know when the authorization expires, and obtain a new one for ongoing services.
  • Invalid or missing modifier: Ensure that the modifier attached to a service is appropriate for that service. If a modifier is required, be sure to bill it.
  • Primary carrier explanation of benefits (EOB) required. Identify patients who have dual coverage, and ensure your office is billing the primary carrier first and attaching that carrier's EOB when billing the secondary carrier.
  • Untimely filing: Know your contracted timely filing guidelines. When filing electronically, check the electronic summary reports to make sure the claim was accepted. Also, review the rejection reports, make any necessary corrections, and resubmit immediately. When filing by paper, ensure you have the correct claim address for Cigna Medicare claims, which is noted on the patient's Cigna ID card.
  • Be aware of what services Medicare covers. Cigna Medicare Services will not cover services that Medicare does not cover, except in certain situations where Cigna has added the service as a benefit.
  • Be sure to list the referring physician when applicable, as this can also help streamline claims processing.

Source: Cigna Network News, October 2014


Claims for bulk powder compound drugs to be denied  For dates of service on or after Feb. 1, 2015, Blue Cross and Blue Shield of Texas (BCBSTX) will deny claims submitted for compounded drug products using bulk powders.

BSBSTX says compounded medications formulated from bulk powder compounds are not covered prescription drugs because they are not drug products approved under the federal Food Drug and Cosmetic Act (sections 505, 505(j), or 507). Compounds that use nonbulk, Food and Drug Administration (FDA)-approved products may be considered for coverage (for example, tablets or capsules). Compounded medications using FDA-approved medications are considered "traditional" compounds when used for FDA-approved indications.

In a limited exception, compound drugs formulated using commercially available FDA-approved compound drugs will continue to be covered.

Tip: Ask your wholesalers whether products being used are considered a bulk chemical powder before submitting claims. A denied claim summary will read as follows:

Services for Bulk Powder or Compound Drugs are considered experimental, investigational, or unproven and not covered under the member's benefit plan. This is a contracted provider; the member is not responsible for payment of these charges.

For additional information, such as limited exceptions, refer to the article in the October 2014 Blue Review (page 7) titled, "Compound Medications May Warrant Dose of Caution." Also refer to the BCBSTX Compounded Drug Products Medical Policy (RX501.063), available in the Standards and Requirements/Medical Policy section of the BCBSTX website.

Source: BCBSTX

Medicare Part D formulary second quarter updates  The BCBSTX pharmacy provider, Prime Therapeutics, updates the payer's MedicareRx formulary monthly. See a summary of new changes in the November issue of Blue Review (PDF). For a complete listing, visit MyPrime to access the Prime Therapeutics Medicare Part D member website. Click on "Continue without sign in" and answer the questions from the drop-down menu (choose "Blue Cross MedicareRx Value" as your health plan type).

Preauthorization simplified for psychological and neuropsychological testing  BCBSTX is developing an alternative care management program for psychological and neuropsychological testing procedures. Effective immediately, except for the situations described below, routine preauthorization of psychological and neuropsychological testing is no longer required.

BCBSTX may require preauthorization if it determines a physician's pattern of testing varies significantly from his or her peer group. In addition, BCBSTX will conduct periodic auditing to evaluate that testing is consistent with the presenting clinical issue, medical policy, and benefit plan design. If not, BCBSTX will contact the physician for additional information. Watch for more information about this program in coming months.

Register for a free remittance viewer webinar  BCBSTX is offering a free webinar on Dec. 10 on how to use its new online tool for viewing claim detail information from the electronic remittance advice. Register to save your spot.

New medical records process for BlueCard claims  BCBSTX is now able to transmit medical records electronically to all Blue Cross and/or Blue Shield plans, making it more efficient to send supporting documentation for BlueCard claims. As always, you will submit your medical records to BCBSTX if needed for claims processing. Submit records requested by other Blues Plans as part of the preauthorization process directly to the requesting plan.

Source:Blue Review, November 2014


Updates to Precertification List - The following will require precertification in 2015:

  • Gender reassignment surgery and related procedures, effective Jan. 1, 2015;
  • All oral or injectable hepatitis C medications, except for ribavirin, Incivek and Victrelis, effective March 1, 2015; and
  • Fusilev, Ilaris, and Myalept, effective July 1, 2015, instead of Jan. 1, 2015.

In addition, Aetna added the following to the General Information section of its National Precertification List

1.e. The level of review of individual items on this precertification list may vary from time to time at our discretion. The lack of a denial for a particular service or supply should not be interpreted as our approval for any subsequent service.

Also, remember that these new-to-market drugs now require precertification: Eloctate (effective Aug. 12, 2014); Ruconest (effective Oct. 9, 2014); sofosbuvir with ledipasvir (effective Oct. 10, 2014); and Plegridy and Keytruda (effective Nov. 7, 2014).

Now is a good time to check out the Aetna Medicare and commercial formularies, which Aetna updates at least once a year, and from time to time throughout the year:

 For a paper copy of these lists, call 800-AETNA RX/(800) 238-6279.

New tool offers alternatives to high-risk meds for the elderly - You can find out quickly if a drug poses a risk to your patients 65 and older by using Aetna's new High-Risk Medication Tool. It lists dangerous drugs and their side effects, as well as safer alternatives that Aetna health plans cover. Aetna says the Centers for Medicare & Medicaid Services wants you to prescribe these drugs sparingly - or not at all - because they can be dangerous to seniors as they age, and can increase the risk of falls and fractures, and longer hospital stays. 

Note: If you prescribe high-risk medications to patients who are 65 or older, Aetna may ask you to fill out a prior authorization form.

Was your Aetna electronic claim submission rejected or returned? Aetna has updated its "Rejected/returned claims resolution tips" guide that shows the most common reasons for rejected or returned claims. Use this guide, which includes suggested actions, along with your 277 Health Care Claim Acknowledgement to help resolve rejected/returned claims. You can request this acknowledgement from your vendor. The guide is available in a PDF version or as an interactive searchable  version. Both are in the Reference Tools  section of Aetna's education website.

 In-home health assessments for Medicare patients may result in a call to you - Aetna has a relationship with several companies that provide free in-home health assessments to its Medicare members, and encourage them to visit their primary care physician. During these "Healthy Home Visits," a licensed representative, usually a doctor or nurse practitioner, will review the member's medical history and medications, and document any previously unknown medical factors. The medical representative will not treat the member, nor change the member's care or medication plan. But the rep will get in touch with you if more evaluation is needed. For more information, call Aetna at (800) 624-0756.

Source: Aetna OfficeLink Updates (PDF), December 2014

Published Nov. 21, 2014

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Last Updated On

May 13, 2016