Payer Roundup, December 2016

In case you missed these — here is a roundup of useful items from Medicare and commercial health care  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. 


Changes to the appeal process: Aetna has changed its physician appeal policy for patients enrolled in Aetna commercial plans by: 

  • Eliminating level 2 appeals. You will have only one opportunity to appeal.
  • Effective March 1, 2017, requiring that you use a specific written form, the Practitioner and Provider Complaint and Appeal Request form, when submitting appeal requests, along with all supporting documentation. The form is available for use now. 

These changes affect participating and nonparticipating physicians. Read Aetna’s FAQs for an overview of the appeals process.

Include ID number when submitting patient requests: When you send Aetna a patient request on paper, you must include the patient’s Aetna ID number (member number) to ensure your request gets directed to the correct area. For example, if you’re sending patient medical records, include the ID number along with the records. It’s also helpful if you include the explanation of benefits or copy of the Aetna letter of request. 

In addition to the member ID number and relevant Aetna-generated documents, be sure to submit the complete Aetna member name, complete patient name, and Aetna claim ID, if applicable.

Call Aetna’s Provider Service Center first: When you need Aetna assistance, its Provider Service Center (PSC) is your first point of contact, whether you are in or out of network. For example, if you need help with a claim, contact the PSC instead of your network account manager. 

Aetna’s aim is for its PSC to be your single point of contact for all Aetna-related requests and to resolve your concern in one call, while educating you about Aetna’s self-service tools like the provider website, NaviNet, and the Our Aetna Voice Advantage self-service telephone system.

Contact the PSC at (888) 632-3862.

Source: Aetna OfficeLink Updates, December 2016


Provider claim summary going electronic this spring: Effective March 1, 2017, Blue Cross and Blue Shield of Texas (BCBSTX) will deliver provider claim summary (PCS) information through an online report viewer application, rather than via paper mailing. However, the payer may consider exceptions to continue receiving paper mailings for extenuating circumstances. Exception requests are due by Feb. 17, 2017.

The report viewer application is now available in the BCBSTX-branded Payer Spaces section on the Availity web portal. With this new tool, you can view, download, save, and/or print the PCS online as needed. Also, you can obtain claim outcome results for multiple patients in one central location.

Although BCBSTX strongly recommends that those who rely on paper claim summaries register for Availity to gain access to the report viewer application, you can request an exception — or training for online applications — by emailing PECS[at]bcbstx[dot]com. Otherwise, beginning March 1, 2017, claim summary information will be accessible exclusively on the report view application on Availity. Note that the response to your exception request may take up to five business days.

Source: Blue Review, December 2016 


 Payment reduction for film x-rays: Effective Jan. 1, 2017, Medicare will reduce payment by 20 percent for the technical component (TC) (including the TC portion of a global service) of x-ray imaging services provided using film. To this end, the Centers for Medicare & Medicaid Services (CMS) has created modifier FX (x-ray taken using film). Beginning in 2017, claims for x-rays using film must include modifier FX to apply the payment reduction under the Medicare Physician Fee Schedule (MPFS).

Because the MPFS amount cannot be greater than the Outpatient Prospective Payment System (OPPS) amount, Novitas will compare the OPPS facility and nonfacility payment fields with the MPFS facility and nonfacility amounts and use the lower amount. The FX modifier will reduce whichever of these two amounts applies by 20 percent. Novitas will assign the group code CO (contractual obligations) to the claim with:

  • Claim Adjustment Reason Code 237 (Legislated/Regulatory penalty), and 
  • Remittance Advice Remarks Code N775 (Payment adjusted based on x-ray radiograph on film).

Source: MLN Matters No. 9727

Major code changes affect 23 lab NCDs: The Centers for Medicare & Medicaid Services has made “significant” changes to 23 national coverage determinations (NCDs) outlined in the Medicare NDC manual, Sections 190.12-190.34, for laboratory services

The changes involve ICD-10 diagnosis editing. This is the first regular ICD-10 code update since the partial code freeze Oct. 1, 2011. 

Medicare implemented the changes on Dec. 5, 2016, for dates of service on and after Oct. 1, 2016. Novitas Solutions, the Medicare payer for Texas, says it will identify and initiate adjustments for claims that denied before Dec. 5, 2016, for medical necessity. See this CMS communication to Novitas and other Medicare contractors for the lengthy list of codes added or deleted. Note that where codes are deleted, the effective date of deletion is Sept. 30, 2016 and the effective date for codes added is Oct. 1, 2016.

Because of voluminous number of new codes involved, Medicare will split implementation of the new codes over two updates, the next one being in spring 2017.

Source: Novitas Solutions. See also: CMS’s MLN Matters MM9806 Revised

Reminder  Medicare to give diagnostic imaging procedures a raise: Starting 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.


Administration terminations for inactivity: To help keep its directories current, UnitedHealthcare (UHC) administratively terminates provider agreements for physicians who haven’t submitted a claim for a period of one year. It also inactivates any tax identification numbers (TINs) under which no claims have been submitted for a period of one year. 

New, effective April 1, 2017: UHC will administratively terminate a physician if:

  • It receives oral notification that the physician is no longer with a practice, and
  •  It obtains no documentation from the practice confirming the physician’s departure after three attempts, and
  •  The physician hasn’t submitted claims under that practice’s TIN(s) for a period of six months before UHC’s receipt of oral notification that the physician left the practice or the effective date of departure provided to UHC, whichever is sooner.

Source: UHC Network Bulletin, December 2016

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Published Dec. 16, 2016 

Last Updated On

December 19, 2016