Private Payer Roundup, May 2017

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.


Policy changes to note: Aetna has published clinical payment, coding, and policy changes, effective Sept. 1 (except where noted) related to the procedures below. To see what’s changed, to go the June 2017 Aetna OfficeLink Updates.

  • Dialysis frequency limits;
  • Evaluation and management services payment policy (effective Nov. 1);
  • Laboratory, pathology and blood procedures;
  • Laminotomy with arthrodesis;
  • Assistant surgeon;
  • Maternity;
  • Pelvic examination under anesthesia; and
  • Nonphysician assistant at surgery reimbursement.

In addition, Aetna will update its pharmacy plan drug lists on Oct. 1. Starting on July 1, you can view the list of upcoming changes on its Formularies & Pharmacy Clinical Policy Bulletins page.

Get savvy about NaviNet. To learn about the transactions and tools available to you on NaviNet, Aetna’s secure provider website, register for a free, 45-minute webinar. Each webinar begins at 1 pm, CT.

  • Working with Aetna on NaviNet: Learning tools and transactions on NaviNet; fourth Tuesday of each month;
  • Claims management tools: Understanding claims status, claims reports, explanations of benefits, and more; third Thursday of each month; and
  • Precertification: Managing the precertification process; second Tuesday of each month.

Find details, including how to register, on the Aetna website.

Source: Aetna OfficeLink Updates, June 2017


Preauthorization changes for Medicare Advantage: Blue Cross and Blue Shield of Texas (BCBSTX) has made the following corrections to the preauthorization list for specialized clinical services under Medicare Advantage HMO and PPO plans:

  • Preauthorization of codes E0748 and 22614 will be handled by eviCore healthcare, instead of BCBSTX, effective June 1.
  • The cardiac rhythm implantable device (CRID) will not be part of the eviCore preauthorization program on June 1, as previously announced, but look for updates regarding the CRID in the near future.

BCBSTX has updated its preauthorization requirements lists for Medicare Advantage HMO and PPO plans to reflect these changes. See also the list of CPT codes that apply to all the services.

Policies now online: BCBSTX is now publishing clinical payment and coding policies on its website. These policies describe BCBSTX’s application of payment rules and methodologies for CPT, HCPCS, and ICD-10 coding. To say abreast of changes to the policies, regularly read the Blue Review newsletter and the News and Updates section of the BCBSTX website.

Use the correct paper forms: If you need to submit claim review requests via paper to BCBSTX, remember to submit them on one of these specific claim review forms: Claim Review form, Additional Information form, or Corrected Claim form.

You can find information on which one to use at the top of each form. Be sure to put the BCBSTX claim number (the document control number), along with the key data elements specified, on your form.

It is always a good idea to check claim status online before submitting a claim review request, e.g., by using the Availity Claim Research Tool. You can skip the paper request altogether by using Availity Claim Inquiry Resolution.

Source: BCBSTX Blue Review, May 2017


All online tools moving to Availity: Humana is phasing out its secure online provider portal; all of Human’s online tools on will be on the Availity web portal.

  • If you already have an Availity account, your internal Availity administrator can set up new users.
  • If you don’t know whether you have an Availity account  complete the online registration form. If your tax identification number is already registered, a contact number and customer ID will appear on the results screen.
  • If you don’t have an Availity account, designate an Availity administrator to register for a new account at This should be someone with the legal authority to sign agreements for your practice (typically an owner or senior partner), or that person’s designee. The administrator can then add users for the practice and maintain its access permissions.

For more information and FAQs, visit, or take a webinar about the Availity portal. Email eBusiness[at]humana[dot]com with Humana-specific questions.

New Availity feature speeds up preauthorization: A new automation feature on the Availity web portal provides immediate determinations for preauthorization requests that require clinic review. In these cases, after submitting your request, you’ll be prompted to answer a short list of clinical questions. Humana will deliver an instant approval if conditions are met. If not, you may need to upload additional information through the portal for manual review. You can use the tool for select services now; Humana said it will add more plans and services this year. For more information, see this presentation and FAQs.

 Correction to Medicare basic radiology claim payments: After discovering it had been paying many basic radiology claims for Humana Medicare patients in error, Humana is now paying all basic radiology claims for these patients as outlined in its guide for members. As of Jan. 1, patients with Humana Medicare coverage need to pay a copayment for basic radiology services, when applicable, regardless of whether an evaluation and management code is present on the claim.

 When to find coding edit updates: Humana now publishes changes to code edits, with the effective date of the change, on the first Friday of each month. To view the latest changes, select the “See most recent edits” link at Review them carefully to make sure they apply to you; some edits may not be specific to physicians, may apply only to specific product lines (i.e., Medicare, Medicaid, or commercial), or may not apply in Texas.

New compliance training webpage: Humana has created a new webpage at that consolidates in one place the instructional material for all the training you are required to do, and attest to, as a Humana physician, such as fraud, waste, and abuse prevention. The page includes FAQs as well.

Nondiscrimination reminder: Humana reminds that if you treat patients under any federally funded program, you must comply with — and post a notice about — the law that prohibits discrimination against people on the basis of race, color, national origin, sex, age, or disability. See the training material and model notices (English and translations) from the U.S. Department of Health and Human Services. TMA members also can read TMA’s white papers (log-in required), “Accommodation of Persons With Limited English Proficiency” and “Americans With Disabilities Act and the Hearing Impaired.

Source: Humana’s Your Practice, April 2017


Product and sourcing change for Spinraza: Starting July 1, you must acquire Spinraza from Accredo Specialty Pharmacy for all patients in a UnitedHealthcare (UNC) commercial plan. Spinraza is a biologic drug the Food and Drug Administration approved in December 2016 for treating spinal muscular atrophy in children and adults. It is the first drug approved to treat this disorder.

After July 1, UHC will deny payment for the drug for these patients if you purchase it directly, and you cannot balance bill your patient for the drug. For patients with active UHC Medicare coverage, you can continue to purchase Spinraza and directly bill it to UnitedHealthcare Medicare Solutions.

To obtain Spinraza through Accredo Specialty Pharmacy, complete a specialty prescription order form for the drug, available through the UHC website or by calling (855) 778-1510. Fax the form to Accredo Specialty Pharmacy at (866) 579-4655, and provide the member’s prescription order and clinical records to support the prior authorization review. Bill UHC directly only for the administration of Spinraza; Accredo Specialty Pharmacy will bill UHC directly for the product within 30 days of dispensing it to your facility. See UHC’s medical benefit drug policy for Spinraza.

Add-on policy revised: In August 2017, UNC will change its add-on payment policies for Medicare Advantage and commercial plans to recognize all add-on primary code pairs, in keeping with the industry standard.

UHC’s commercial Add-On Policy no longer will publish a subset of add-on/primary code pairs currently applied to claims editing. See also the Medicare Add-On Codes Policy.

Complete special needs plan training by Oct. 17: All physicians who treat patients in a special needs plan (SNP) — one of three types of Medicare Advantage coordinated care plans — are required complete annual Model of Care training. The Centers for Medicare & Medicaid Services-mandated training includes information about the types of SNPs tailored to individual needs. If you see UHC patients who have benefits under Medicare or Medicaid or both, you’re probably a SNP care provider, and you must complete the training by UHC’s Oct. 17 deadline. UNC’s on-demand training video lasts about 15 minutes; you have to register to get credit for completion. To access the video, scroll down the UHC Training & Education page to the Medicare & Medicaid Topics sections. You’ll also find FAQs, training slides, and contacts for more information.

Source: UHC Network Bulletin, May 2017

Published May 25, 2017

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Last Updated On

May 26, 2017