Private Payer Roundup, November 2016

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 for more resources and information. 


Flucelvax Quadrivalent billing update: The American Medical Association released Current Procedural Terminology (CPT) code 90674 (Influenza virus vaccine, quadrivalent [ccIIV4], derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage), which best describes Flucelvax Quadrivalent — a new flu vaccine for the 2016-17 flu season. This code will be effective Jan. 1, 2017. Until then, bill Blue Cross and Blue Shield of Texas (BCBSTX) for Flucelvax Quadrivalent using CPT code 90749.

Notification for inpatient admission for post-stabilization care: Effective Jan. 1, 2017, BCBSTX will require notification of inpatient admission for post-stabilization care within one business day following the treatment of an emergency medical condition. This requirement applies to Blue Cross Medicare Advantage (PPO) and Blue Cross Medicare Advantage (HMO) plans. 

Failure to timely notify BCBSTX and obtain preapproval for further post-stabilization care services may result in denial of the claim(s) for these services, which you cannot bill to the patient, under your provider agreement with BCBSTX. 

BCBSTX says this policy helps identify patients who may benefit from its specialty programs, such as Case Management, Care Coordination and Early Intervention, or Longitudinal Care Management, and allows BCBSTX to help patients with discharge planning. 

In the event of a claim denial that includes emergency care services, you can rebill the claim for the emergency services (including stabilization services), as well as post-stabilization care services for which BCBSTX may be financially responsible for possible readjudication by BCBSTX.

Annual HEDIS reporting begins Feb. 1, 2017: Healthcare Effectiveness Data and Information Set (HEDIS) data collection time is approaching. A BCBSTX representative or a representative from third-party vendor CIOX may contact your office or facility anytime December 2016 to February 2017 to identify a key contact person, and to ascertain which data collection method your office or facility prefers (fax, secure email, or on site). Appointments for on-site visits will be scheduled with your staff, if applicable. You’ll then receive a letter outlining the information requested, and the medical record request list with members’ names and the identified measures that will be reviewed.

Source: Blue Review, October 2016

 Urinary drug test fee schedule update: Effective Feb. 1, 2017, BCBSTX will implement changes in the urinary drug test (UDT) series CPT codes maximum allowable fee schedule used for Blue Choice PPO, Blue Premier, Blue Essentials (formerly HMO Blue Texas), Blue Advantage HMO, and ParPlan patients.

As of that date, BCBSTX will not pay professional claims submitted for UDT 80000 series CPTs and billed with or without the Centers for Medicare & Medicaid Services (CMS)-specified G code replacements on the same claim. However, BCBSTX will consider payment, according to its fee schedule, for these CMS-specified Healthcare Common Procedure Coding System (HCPCS) G-code replacements for the UDT 80000 series codes:  

HCPCS Code    Drug Test Class 
G0480 1-7
G0481 8-14
G0482 15-21
G0483 22 or more

Source: Blue Review, November 2016


Payment may change based on where you perform a service: Beginning Jan. 1, 2017, Cigna will adjust certain fee schedules and update its administrative guidelines for how it pays physicians for certain services based on where the service is performed. This “site-of-service payment” methodology will apply to approximately 1,900 CPT codes for services that have a site-of-service designation.

Payment for certain covered physician services performed in a location other than a physician’s office will be calculated based on the facility relative value unit (RVU). For covered services performed in the office, payment will be calculated based on the nonfacility (office) RVU. (Historically, payment for each CPT and HCPCS code was established with either the facility RVU or the nonfacility RVU, regardless of where the service was performed.)

Your Cigna patients can save on their out-of-pocket costs when you perform a covered service in the less expensive office setting, when medically appropriate. For a full listing of the codes that have site-of-service designation, log into Go to Resources > Latest News > Medical.

Policy and precertification updates: Take note of the following changes.

As of Sept. 15, 2016, Cigna has updated its Routine Immunizations policy. It will deny CPT codes 90660 and 90672, which are used to bill for FluMist. It will cover routine immunizations based on a vaccine being licensed by the U.S. Food and Drug Administration and recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.

As of Oct. 1, 2016, Cigna has updated precertification requirements by:

  • Adding these codes to its precertification list: 89337, 93228, 93229; and C9139, C9481, and C9483. The latter three are newcodes for reporting drugs and biologicals in the ambulatory surgical center setting.
  • Removing these codes from the precertification list: E0652, 74712, 74713, 33254, 33255, 33257, 33258, 33265, and 33266.

As of Nov. 14, 2016, Cigna will deny claims as experimental, investigational, or unproven for ultrasound guidance (CPT code 76942) when billed with trigger point injections (CPT codes 20552 and 20553). This updates the policy titled Minimally Invasive Intradiscal/Annular Procedures and Trigger Point Injections.

For more information about these updates, see Cigna Network News, October 2016 (page 5-6).

EFT to become required payment method: Cigna has announced that in January 2017, electronic funds transfer (EFT) will become its required standard method for physicians to receive payment. To receive EFT payments, you must create an EFT account by enrolling either directly with Cigna at, or with the Council for Affordable Quality Healthcare, where you can enroll in and manage EFT accounts with multiple payers, including Cigna.

TMA’s reimbursement specialists are seeking more information about this new requirement from Cigna. 

Electronic payment attachment pilots coming: In 2017, Cigna will pilot two electronic transactions that will make it easier to submit supporting documentation:

  1. The ANSI 275 Electronic Claim Attachments transaction will give you the ability to send supporting documentation, either with your original claim submission or in response to a request for more information from Cigna.
  2. Cigna will use the ANSI 277 Request for Additional Information transaction to request supporting documentation for electronically submitted claims. You’ll fulfill the request using the 275 transaction.

Reminder — when preventive care exams can be scheduled less than a year apart: Patients with Cigna coverage may not have to wait a full 12 months between their preventive care or routine obstetrical-gynecological exams. For example, if your Cigna patient received a preventive screening in August 2016, and the patient’s plan renews on Jan. 1, 2017, he or she can have another preventive screening in January 2017. Most Cigna plans will cover it at the preventive benefit level, although Cigna recommends calling ahead of time to be sure. Additional information about Cigna’s preventive care guidelines and coverage is at

Source: Cigna Network News, October 2016


Update to prior authorization requirement for sinus surgery: UnitedHealthcare (UHC) has changed its prior authorization requirement for certain functional endoscopic sinus surgery procedures, as of May 2, 2016. CPT code 31237 is no longer included in the requirement. The following procedures will continue to require notification/prior authorization for many UHC commercial and Community Plan patients: 31239, 31240, 31254, 31255, 31256, 31267, 31276, 31287, and 31288.

Revision to Maximum Frequency per Day and Bilateral Procedures policies: Effective for UHC commercial policy claims processed in the first quarter of 2017, UHC no longer will allow bilateral surgery indicator 2 codes to be reimbursed for two sides when billed with modifiers LT and RT. While this concept applies to both the Bilateral Procedures and the Maximum Frequency per Day (MFD) policies, the MFD policy contains the complete list of codes for which the concept of laterality does not apply. This list includes all codes that have “bilateral” or “unilateral or bilateral” in their description and also will include all bilateral surgery indicator 2 codes. 

Premium designation program deadline and updates: You may have received your UnitedHealth Premium designation assessment results, or will soon receive them. You have until Dec. 5, 2016, to request reconsideration of your results before your Premium designation goes public. UHC will continue to accept requests after Dec. 5 and will make applicable changes to your publicly displayed designation. Visit TMA’s Physician Ranking webpage for a guide to appealing your designation.

UHC has updated the program’s methodology for 2017. Among other changes, it will use:

  • Specialty-specific quality benchmarks, providing for a comparison of physicians with the same specialty rather than comparing all physicians who may treat patients with the same conditions, and
  • A narrowed list of conditions for patient total cost assessment that includes only those patients’ costs that are more directly under the physician’s control. 

Also, beginning Jan. 4, 2017, ophthalmology is no longer included in the Premium program because of the limited number of ophthalmologists that can be assessed. More information about the update is in UHC’s November 2016 Network Bulletin (page 15).

Reminder about the MPPR for diagnostic imaging: CMS has announced that effective for dates of service on or after Jan. 1, 2017, the multiple procedure payment reduction (MPPR) for the professional component of the second and subsequent procedures will change from 25 percent to 5 percent. This change applies to UHC commercial and Medicare Advantage plans.

Source: UHC’s Network Bulletin, November 2016

Published Nov. 23, 2016

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Last Updated On

April 26, 2018