Payer Roundup, January 2016

TMA’s reimbursement specialists give you a heads up andsuggestions regarding some insurance hassles; also, find out about preauthorizationchanges, and new Medicare drug testing codes. 

If you have questions about billing and coding or payer policies, contact the specialists at 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.

 Scott & White Health Plan

Exchange products experience congestion: TMA has become aware that Scott & White Health Plan (SWHP) products on the insurance exchange have generated long hold times, difficulty reaching customer service, and incomplete benefit information through its portal. TMA’s Payment Advocacy team is in touch with SWHP and will provide updates as the payer works to resolve these problems. Meanwhile, if you haven’t already:

  • Register as a provider on SWHP’s online portal. Once you register, you’ll receive authorization to access the portal, typically within 48 hours.
  • Be sure to refer to the preauthorization list on the SWHP website.


Large number of small group plans yield delays: Blue Cross and Blue Shield of Texas (BCBSTX) reports it is seeing “an unprecedented volume of new small group submissions for 2016,” and is experiencing delays in getting all these plans fully loaded into its system. If you see a patient from one of these plans, you may not be able to verify the new group’s benefits for up to 30 days. If that is the case, you may collect from the patient in full until the BCBSTX system is updated.

Confused about your patients’ plan? TMA has been receiving calls from practices confused about their patients who previously were covered under an individual BCBSTX PPO. BCBSTX has discontinued these plans; patients may have selected another BCBSTX plan or selected coverage under a different health plan. Note that the BCBSTX Blue Advantage Network is not the same network as the HMO Blue Texas Network. 

Use the BCBSTX Provider Finderpage to: 

  • Verify you current network participation status. 
  • Find a complete breakdown of network type and plan type information by selecting “Which network covers your plan?” 


Claim edit causing hassles: Humana instituted a claim edit effective Nov. 9, 2015, making evaluation and management (E&M) codes ineligible for payment when billed with immunization administration. 

TMA has heard from practices experiencing claims processing hassles as a result of this edit. Although Humana says it made the edit to conform to the National Correct Coding Initiative (NCCI), TMA’s reimbursement specialists have confirmed that NCCI in fact allows billing for E&M services with a modifier when the documentation supports it. If you believe Humana has incorrectly denied a claim related to this edit, or is unreasonably asking you for additional records, you may submit your problem claim to the TMA Hassle Factor Log. TMA’s Payment Advocacy staff are in talks with Humana on this subject.

Medicare (CMS) 

CMS adopts new drug testing codes for 2016: The Centers for Medicare & Medicaid Services (CMS) does not recognize Current Procedural Terminology (CPT) drug testing codes. In 2015, CMS replaced them with G codes for Medicare patients. For 2016, CMS originally proposed deleting all then-current drug testing G codes and creating a single G code for presumptive testing (testing to determine if drug is present) and a single G code for definitive testing (testing to provide a positive identification of a substance in question). After fielding comments, CMS adopted these changes for drug testing for 2016:

  • Delete G-codes G0431, G0434, and G6030 through G6058. 
  • Continue to not recognize the CPT drug testing codes 80300-80377. 
  • For presumptive testing, create three G codes: G0477-G0479. You may bill only one of the three presumptive G codes per day. 
  • For definitive testing, create four G codes: G0480-G0483. You may bill only one of the four definitive G codes per day. 
  • For definitive testing, the unit used to determine the appropriate G code to bill is “drug class.” You may use each drug class only once per day in determining the appropriate definitive G code to bill.

For code descriptions, a drug class list, and additional information, see CMS’ final determination document.


2016 administrative guide available: The 2016 UnitedHealthcare (UHC) administrative guide for commercial and Medicare Advantage plans is now available online. Unless otherwise noted, the new guide is effective on April 1, 2016, for current participating physicians and effective immediately for physicians who began participating in UHC plans on or after Jan. 1, 2016.

More procedures to require prior authorization: Effective April 4, 2016, UHC will add select musculoskeletal and pain management procedures to its prior authorization list for commercial plans. Added to the list are procedures in these categories:

  • Knee arthroplasty;
  • Arthroscopy of the ankle, elbow, hip, knee, shoulder, and wrist;
  • Foot surgery;
  • Spine surgery; and 
  • Back pain implants.

For the specific codes that require preauthorization, see UHC’s January 2016 Network Bulletin, page 6.

Premium designation reconsideration process changes: If you want to request a change or correction to the quality and/or cost efficiency information in your UHC Premium designation program assessment, be aware of some new opportunities within the process:

  • When you submit a reconsideration request, you may include the detailed patient and episode information you feel is necessary to explain the reason for your request. 
  • Although not required, you may submit additional documentation to support your request for a correction or change. 
  • Upon completion of its review, UHC will notify you of your reconsideration results, a report of which you will be able to view in detail online. This report will explain how UHC arrived at its decision for each item you requested for correction or change. UHC says updated resource material will be posted on its website in February. The Premium program will continue to accept reconsideration requests until July 15, 2016.

Source: UHC Network Bulletin, January 2016

Published Jan. 27, 2016

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April 19, 2018