Payer Roundup, September 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.


Pass-through billing change delayed: Aetna will deny pass-through billing for most lab charges from a facility or a nonfacility provider effective Oct. 1. Originally, this policy was to have taken effect Sept. 1. The provider performing the tests must bill for these services. Aetna will pay for pass-through billing during an inpatient hospital admission and will pay facilities for pass-through billing for Aetna patients receiving outpatient services at the facility when the specimen collection occurs at the facility on the same day as other services. Aetna does not pay for specimen collection.

 Source: Aetna OfficeLink Updates, September 2017


Humana updates dispute process: When submitting a written request (as an in-network physician) with new supporting clinical information for a dispute review of a Humana plan’s coverage determination, note the following:

  • When a charge for a service is denied after a medical necessity review, you may submit up to two dispute requests per claim.
  • You must request a dispute review in writing, in a timely manner, and with all required information. Mail requests to: Humana Correspondence, PO Box 14601, Lexington, KY 40512.
  • Indicate clearly on the cover sheet accompanying the request which information is new and where it can be found within the submission. Also, the new information needs to be clearly highlighted or marked within the submission.

For more information, review Humana’s claims payment policy (enter “claim disputes” in the search box).

Web tools on Availity: Humana is phasing out its secure online provider portal on, but you’ll be able to access online tools on the Availity Web Portal. Register on Availity now if you haven’t already. New apps soon to be available are an authorization management app and a claim status tool. Registered users who do not see these tools should contact their organization’s Availity administrator to request access.

Website update: has a reorganized navigation bar. A drop-down menu under the Medical Providers tab on displays links to frequently used claims resources, such as the claims coding guide, and authorizations and referrals. Humana also combined its former Provider Education tab and Service and Support tab under the new Support and Education tab.

 Source: Humana’s YourPractice, August 2017


2017-18 flu resources: The Centers for Medicare & Medicaid Services (CMS) has published a special edition MLN Matters article to help you through the flu season. You may want to refer to it throughout the flu season regarding payment rates, FAQs, billing guideline, and more.

New QMB information in remittance advice: Starting Oct. 3, for original Medicare claims, the remittance advice will identify qualified Medicare beneficiary (QMB) status and show $0 liability for periods during which the beneficiary is a QMB.

The deductible, coinsurance, and copayment amounts of $0 generally will appear in the Other

Adjustment field. As appropriate, one or more new QMB-related remittance advice remark codes will be returned in correlation claim adjustment reason code 209.

Medicare eligibility system will include QMB data: Effective Nov. 4, the HIPAA Eligibility Transaction System (HETS) will indicate periods during which a beneficiary is enrolled in QMB and owes $0 for Medicare deductibles, coinsurance, and copayments. Through HETS, CMS releases Medicare eligibility data to Medicare physicians, providers, suppliers, or their authorized billing agents (including clearinghouses and third-party vendors).

New Medicare card unveiled: CMS has given the public its first look at the newly designed Medicare card, which contains a unique, randomly assigned number that replaces the current Social Security-based number. CMS will begin mailing the new cards to people with Medicare benefits in April 2018 to meet the statutory deadline for replacing all existing Medicare cards by April 2019. In a press release, CMS said people with Medicare also will be able to see the new card design in the 2018 Medicare & You Handbook, in the mail now.


Now is time to challenge rankings, if needed: New UnitedHealthcare (UHC) Premium designations now are displaying (as of Sept. 6) on the payer’s public websites. You have until Nov. 13 to submit reconsideration requests for changes to your publicly displayed designation. Visit TMA’s Physician Ranking webpage for help challenging your designation.

New app provides prescription coverage details: PreCheck MyScript is a new app on Link you can use to run a pharmacy trial claim, getting real-time prescription coverage details for your UHC patients. The app gives you:

  • Current out-of-pocket prescription costs for patients at their selected pharmacy;
  • Information on lower-cost prescription alternatives, when available;
  • Immediate alerts when a proposed prescription requires prior authorization, or is noncovered or nonpreferred; and
  • A quick online way to request prior authorization.

Request more service codes with eligibility and benefit inquiries: As of Sept. 8, you can request from UHC up to 10 service type codes (STCs) in one 270/271 electronic transaction. You can request the specific information you need, such as:

STC    Description

5          Diagnostic lab

30        Health plan benefit coverage

47        Hospital

96        Specialist

PT        Physical therapy

Physical therapy and specialist benefits now are available both as a generic response and an explicit response. Obtain generic responses that automatically include physical therapy and specialist benefits by requesting STC 30. Obtain explicit responses by requesting the specific STC only, such as PT or 96. In most cases, a message segment will be returned when benefits are for a specialist. You are encouraged to share this information with your software vendor or clearinghouse. If you have questions, call UHC at (800) 842-1109.

New neonatal resource services guidelines: Effective Nov. 30, UHC’s Neonatal Resource Services (NRS) Clinical Guidelines will be revised. The revisions cover:

  • Apnea and bradycardia,
  • Discharge planning,
  • Early-onset neonatal sepsis,
  • Feeding the neonate,
  • Inhaled nitric oxide, and
  • Neonatal abstinence syndrome.

A new NRS medical necessity clinical guideline on neonatal hyperbilirubinemia also will take effect Nov. 30. This guideline will address the optimal management of term and preterm infants in the neonatal intensive care unit who have an elevated serum bilirubin concentration.

Source: UHC Network Bulletin, September 2017

Published Sept. 28, 2017

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Last Updated On

September 29, 2017