Private Payer Roundup, February 2015

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 and TMA's Payer page for more resources and information.


Policy update: global surgery reimbursement  Effective April 1, 2015, UnitedHealthcare (UHC) will adopt the Centers for Medicare & Medicaid Services (CMS) process for modifier 78 for Medicare Advantage (MA) plans. 

When modifier 78 is reported for a procedure having a global days value of 010 or 090, UHCwill pay only for the intraoperative percentage of the modified procedure, determined by the intraoperative percentage listed in the Medicare physician fee schedule. This will result in payment reductions accordingly.

UHC updated its MA reimbursement policy for global surgery (PDF) on Jan. 28, 2015, to reflect this change.

Policy revision: nonphysician health care professionals billing E&M codes 

— Effective in second quarter 2015, UHC will expand the scope of its policy to not reimburse evaluation and management (E&M) CPT codes 99201-99499 when reported by the following nonphysician health care professionals:

Alcohol and drug counselor
Behavior analyst
Christian Science practitioner
Crisis diversion counselor
Employee assistance program counselor
Empowerment coach
Genetic counselor
Home health/private duty nurse
  Licensed professional counselor
  Licensed vocational nurse
  Marriage and family social worker
  Marriage and family therapist/licensed marriage and family therapist
  Other mental health counselor
  Registered social worker
  Pharmacist substance abuse counselor, alcohol and drug
  Visiting nurse

These professionals should select a more accurate code that describes the services they provide. E&M services are payable to these nonphysician practitioners: nurse practitioners, clinical nurse specialists, certified nurse midwives, and physician assistants.

Source: UnitedHealthcare Network Bulletin (PDF), February 2015


Changes to National Precertification List  Effective July 1, 2015, Aetna will require the following:

  • Observation stays greater than 24 hours. Longer stays are considered an inpatient stay and are subject to all inpatient policies, including the timely notification requirement. Admission notification later than 5 pm (local time) on the business day following the admission is subject to the late notification and/or non-notification penalty for your facility.
  • These drugs/medical injectables: Fusilev (levoleucovorin), granulocyte-colony stimulating factor drugs/medical injectables, Ilaris (canakinumab), and Myalept (metreleptin).

These new-to-market drugs also require precertification as of the effective date noted:

  • HyQvia (immune globulin)  Dec. 12, 2014;
  • Viekira Pak (pariteprevir/ritonavir/ombitasvir/dasabuvir) and Obizur (antihemophilic factor [recombinant], porcine sequence)  Dec. 21, 2014;
  • Mircera (epoetin beta)  Jan. 1, 2015; and
  • Lemtrada (alemtuzumab) Feb. 10, 2015.

 Payment changes for modifiers 22 and 78 — These changes are effective June 1, 2015: 

  • Unusual procedural services (modifier 22):  Payment currently is calculated at 120 percent. This will decrease to 115 percent of either the reasonable and customary fee allowance (100 percent of reasonable and customary plus an additional 15 percent) or the contracted fee for the procedure(s) performed. This policy does not apply to facility claims.
  • Return to operating room for related procedure during post-op period (modifier 78): Payment currently is calculated at 75 percent. This will decrease to 70 percent of either the negotiated rate or recognized charge without review for a procedure billed with modifier 78.

New ID cards for accountable care plans  Aetna is rolling out a new "gold" ID card for Aetna Whole Health medical plan members to help you spot these patients. 

  • Look for your network name on the top front of the card.
  • Check the first line on the back of the card for the Aetna Whole Health plan name.

Aetna has created an ID card tool to help your office find information on the new cards.

Source: Aetna OfficeLink Updates (PDF), March 2015


Lung cancer screening  For plans subject to the Affordable Care Act, Cigna covers annual lung cancer screenings with low-dose computed tomography. To qualify (subject to precertification), the covered patient must be 55-80 years old, have a 30 pack-year smoking history, and either currently smoke or have quit within the past 15 months. The screening is covered as a preventive care service effective on a plan's start date or anniversary date in 2015; be sure to code the screening as preventive so the plan will cover it. More information on preventive care services including coding guidance for lung cancer screening, and Cigna's coverage policy Computed Tomography Low Dose for Lung Cancer, are at

Coverage policy updates  Cigna has updated the coverage policies below, effective Feb.16. The full policies are in the Coverage Policy Updates page at

  • Autonomic Nervous System Testing,
  • Mechanical Devices for the Treatment of Back Pain, and
  • Allergy Testing and Non-Pharmacologic Treatment.

HEDIS data collection  Cigna mailed requests in February for its annual medical records review to collect data for the Healthcare Effectiveness Data and Information Set (HEDIS). Cigna requests that you respond within the time frame in the request letter. The most efficient way to respond is to allow Cigna access through its secure network to your secure electronic health record system. You also can fax the requested information to Cigna.

Tips for smoother processing of your electronic claims — Cigna offers this advice:

Coordination of benefit (COB) claims

  • For Medicare COB claims, do nothing. Cigna receives your Medicare COB claims electronically through the CMS crossover process.
  • For commercial COB claims, you do not need to submit a paper copy of the primary carrier's explanation of benefits in addition to your electronic COB claim. Talk to your electronic data interchange (EDI) vendor about COB information. It should be billed in loops 2320 and 2330 on the electronic claim form. Values in those loops must balance with loop 2300 CLM02 Monetary Amount reported.

Corrected claims

  • In the Claim Frequency Type Code in loop 2300, segment CLMOS, specify the frequency of the claim. (This is the third position of the Uniform Billing Claim Type.) Talk to your EDI vendor for more information.
  • Use one of these codes for the claim type:
    • 1: Original (admit through discharge claim)
    • 2: Replacement (of prior claim); include required segment REF*F8, Payer Claim Control #
    • 8: Void (or cancellation of prior claim); include required segment REF*F8, Payer Claim Control #

Repeat procedures: Use these modifiers to indicate a procedure or test is occurring again: 

76        Repeat procedure or service by same physician
77        Repeat procedure by another physician
91        Repeat clinical diagnostic test

Source: Cigna Network News, January 2015


Affordable Care Act: the grace period —  The second open enrollment period for consumers shopping on the health insurance marketplace ended on Feb. 15, 2015. Under the Affordable Care Act, people who purchase coverage on the marketplace and receive the advance premium tax credit (APTC) are allowed a 90-day grace period for payment of their health care insurance premiums, as long as they have already paid one month's premium in full within the benefit year. Here are some tips and reminders from Blue Cross and Blue Shield of Texas (BCBSTX):

  • Note that not all people who purchase coverage on the marketplace will receive the APTC.
  • Be sure to check eligibility and benefits for every patient at the start of every visit. When a BCBSTX member is in the second or third month of a grace period, BCBSTX will notify you of the member's status during verification, including the date the grace period began.
  • Checking eligibility and/or benefit information is not a guarantee of payment.
  • If the member does not pay the outstanding premium in full within the grace period, BCBSTX will request from you a refund for claims paid for services rendered in months two and three of the grace period.
  • If a member elects to receive a 90-day supply of a prescription during month one of the grace period and does not pay premiums in full by the end of the grace period, the member will receive the full 90-day prescription, and BCBSTX will pay this claim.  
  • You may notify your patients they will be responsible for the full cost of provided services, up to billed charges, if their health care coverage terminates. You may encourage your patients to make their premium payments to avoid termination of their health insurance policies.
  • The terms of your network contract prevent you from refusing to provide services to a BCBSTX member, regardless of where the patient purchased coverage, and prohibits advance payment for covered services except for the member's required cost sharing, if any.

TMA's "Hey, Doc" educational campaign provides objective and nonpartisan answers to patients' frequently asked questions about the ACA health insurance marketplace. See the FAQs under "Putting My Insurance to Use."

Pharmacy program changes effective Jan. 1, 2015 —  BCBSTX added these preferred brand medications to its drug list:  Invokana and Invokamet (for diabetes), the antibiotic Sivextro, Purixan (for cancer), Spiriva Respimat (for COPD), and  Plegridy (for multiple sclerosis). Drug categories added to the prior authorization program are insulin (Humalog and Humalin) and pulmonary arterial hypertension (Adempas [riociguat] and Orenitram [treprostinil]).

BCBSTX made numerous other pharmacy program changes, including placing some medications in a higher out-of-pocket payment tier, assigning new dispensing limits, and instituting specialty medication benefit process changes. For details, see BCBSTX Blue Review (PDF), January 2015 (scroll to page 3). For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of the BCBSTX provider website.

Source: BCBSTX Blue Review (PDF), January 2015

Diagnosis and medical management of sleep-related breathing disorders — BCBSTX has updated its Diagnosis and Medical Management of Sleep Related Breathing Disorders Medical Policy (MED205.001), effective May 1, 2015.* Changes are as follows:

  • For adult patients with symptoms suggestive of obstructive sleep apnea and without significant comorbidities, home sleep studies may be considered medically necessary.
  • Facility/laboratory polysomnography is considered not medically necessary when the criteria for unattended home sleep studies are met. The use of an abbreviated daytime sleep study as a supplement to standard sleep studies, positive airway pressure-negative airway pressure, is considered experimental, investigational, and/or unproven.

*Was extended from an original April 15, 2015, effective date.  

Source: BCBSTX Blue Review, January 2015 (PDF) and February 2015 (PDF)

HEDIS data collection - BCBSTX will contact physician offices over the next few months in preparation for the annual HEDIS data collection.

  • A nurse from BCBSTX will contact your office to obtain key contact information and confirm your preferred data collection method: fax, secure email, or on-site visit.
  • Appointments for on-site visits also may be scheduled with your staff.
  • You will receive a letter or fax from BCBSTX outlining the information requested, including patients' names and the measures that will be reviewed. Send medical records only upon request and only for the patients listed in the letter from BCBSTX. A timely response —  within five business days — is requested.

Source: BCBSTX 

Published Feb. 26, 2015

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