Private Payer Roundup, July 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; visit the TMA Payment Advocacy Services webpage and TMA's Payer page for more resources and information.

Humana Terminating Physicians From Advantage Plan Network

On July 1, Humana sent letters to more than 400 Texas physicians informing them it will terminate their participation in the Humana Medicare Advantage Plan network effective Jan. 1, 2016.

Some practices in the following counties are affected: Bexar, Collin, Dallas, Denton, El Paso, Ellis, Grayson, Harris, Hays, Hunt, Kaufman, McLennan, Nueces, Tarrant, Taylor, Travis, Williamson, and Wise. Read the upcoming Aug. 1, 2015, issue of TMA's Action for more information.

Physicians have rights and responsibilities in network participation terminations, outlined in this TMA white paper MembersOnlyRed.


Sign up to do your ICD-10 testing. If you'd like to conduct ICD-10 testing with Blue Cross and Blue Shield of Texas (BCBSTX), you may sign up using its ICD-10 Testing Enrollment Form.

Within three to five days after receiving your request, BCBSTX will email you an enrollment kit with a brief survey and testing agreement. When you complete enrollment, you'll receive a welcome letter with instructions and next steps.

As a testing participant, you will submit "twin" claims for testing - one with ICD-9 codes and the other with ICD-10 codes. BCBSTX processes both claims with the intention of taking all submitted and accepted test claims to a finalized status. For each finalized test claim, BCBSTX returns an 835 electronic remittance advice. Participants also receive testing summary results for each set of twin claims.

BCBSTX has scheduled webinars to demonstrate the differences you may encounter when using ICD-10 codes in the payer's iExchange  online benefit preauthorization and referral tool. Register for one these sessions:

Tips for using modifier 25. BCBSTX offers these tips for using modifier 25 to indicate a "significant, separately identifiable evaluation and management (E&M) service by the same physician on the same day of the procedure or other service."

  • Documentation must support significant and separately identifiable preoperative and/or postoperative work, above and beyond the usual care associated with the performed procedure.
  • Documentation must support that the patient's symptom, problem, or condition required a separately identifiable E&M service.
  • The reported E&M service must meet the key components (history, examination, and complexity of medical decisionmaking) of the selected E&M service.
  • The E&M service must be distinct from the service performed.
  • Modifier 25 should be appended only to E&M services and not to procedures.
  • Modifier 25 is not used to report an E&M that resulted in the decision to perform surgery. Refer to modifier 57 guidelines for an E&M service that results in a decision for surgery.
  • Procedures include preoperative evaluation services necessary prior to performing a procedure or other service. This may include, but is not limited to, assessing the site/condition, explaining the procedure, and obtaining informed consent.

Source: Blue Review, July 2015

United Healthcare

Timely postpartum care can contribute to healthier outcomes for women after delivery and is a measure of quality care. UnitedHealthcare (UHC) uses HEDIS guidelines to measure postpartum visit compliance. The standard is a postpartum visit on or between 21 and 56 days after delivery.

(The American Congress of Obstetricians and Gynecologists recommends that a routine postpartum visit occur between four and six weeks after delivery.

To help make sure the postpartum visit occurs, it's a good idea to schedule it before discharging your patient from the hospital; try to obtain correct, current contact information at that time as well. 

UHC says to include the following information in the medical record: 

  • Date when the postpartum care visit occurred, along with one of the following:
    • Pelvic exam and evaluation of weight, blood pressure, breasts and abdomen (notation of "breastfeeding" is acceptable for "evaluation of breasts"); or
    • Notation of postpartum care such as "PP care," or "PP check"; and
  • Preprinted Postpartum Care Form in which information was documented during the visit.

Medicare peer-to-peer process change. Effective July 1, 2015, UHC has changed its preservice peer-to-peer process for all Medicare patient organization determinations. (See the definition of "organization determination" in the Medicare Managed Care Manual, Chapter 13, 10.1.) This process change affects only preservice organization determinations that the managed care plan has not delegated to another entity.

While you can call and request a peer-to-peer discussion at any time, once UHC has issued an adverse determination letter, the physician who made the adverse determination cannot reverse the original decision. Instead, you have 60 days to appeal the original decision in accordance with the appeal instructions in the adverse determination letter.

UHC clinical staff may contact a physician prior to issuing a written adverse determination notice. However, you are encouraged to submit all necessary clinical information upon your initial request for an organization determination to allow time for the peer-to-peer discussion to occur. Information about the required clinical information needed to submit with your organization determination requests is on the UHC website.

Source: UHC  Network Bulletin, July 2015

Published July 27, 2015

TMA Practice E-Tips main page

Last Updated On

April 19, 2018

Originally Published On

July 27, 2015