Payer Roundup, October 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.

Take a Survey on the 1500 Claim Form

The National Uniform Claim Committee (NUCC) is conducting a survey to gather information on the current usage of the 1500 Health Insurance Claim Form, both as a paper form and as a print image. NUCC will use information from this survey in its general work on the professional claim and its data content. TMA is the NUCC alternate state medical association representative. This survey is not an indication of any specific changes being considered for the 1500 form. Take the survey.


How to contact Aetna via NaviNet: Need to contact Aetna online with a question, comment, status request, or other inquiry when you’re logged into NaviNet, Aetna’s secure provider portal?

Go to the Support Center, then choose “Contact” at the bottom of the page. This brings up a screen where you can enter information about who you are, your patient’s plan, and what you need help with by choosing from a list of 13 items. Once you hit “Submit,” you’ll receive a reference number. A representative will respond via email in 24-48 hours. The rep will assign you a case number to use if you and the rep need to communicate further about your issue.


Government program claims rejecting as duplicate submissions: Practices submitting electronic claims under Blue Cross Medicare Advantage PPO and HMO plans may experience duplicate claim rejections if claims are resubmitted within 90 days of a previously processed claim that includes the exact data for the same patient and date(s) of service. Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid STAR, STAR Kids, and Children’s Health Insurance Program claims may also reject as duplicate claim submissions, but only if they are resubmitted within 24 hours of a previously processed claim. However, duplicate claim rejections should not occur if all these elements are different on the resubmitted claim:

  • Patient Control Number (Loop 2300 – CLM01 Data Element),
  • Clearinghouse Trace Number (Loop 2300 – REF02 where REF01=D9), and
  • Line Item Control Number (Loop 2400 – REF02 where REF01=6R).

Additional information is on the BCBSTX website.

New Employees Retirement System of Texas plans in effect: BCBSTX is now the insurer for the Employees Retirement System of Texas (ERS). The payer’s six-year contract ERS began Sept. 1.

ERS participants, covered under HealthSelect of Texas or Consumer Directed HealthSelect benefit plans, will access care through the Blue Essentials provider network. Their BCBSTX ID cards will display their plan name and a Blue Essentials network ID labeled “HME.”

Visit the Clinical Resources page of the BCBSTX website for a list of services that require prior authorization for ERS participants. For more information about the ERS benefit plans see this announcement and ERS Tools on the BCBSTX website, and view this short training slide deck.

 Requesting predetermination of benefits: Beginning Dec. 1, you must use BCBSTX’s Predetermination Request Form for written predetermination requests. Starting Jan. 1, 2018, BCBSTX will return paper requests without this form. Remember, you can submit predetermination of benefits requests electronically to BCBSTX through its online tool, iExchange.

Source: BCBSTX News and Updates


Physician Compare preview period closes Dec. 1 (extended from Nov. 17) at 7 pm CT: Take advantage of the opportunity to preview your 2016 performance data as it will appear on Physician Compare website profile pages and in the downloadable database later this year. Access the preview site through the Provider Quality Information Portal. For help, contact the QualityNet Help Desk at (866) 288-8912.

See the CMS Physician Compare Initiative website for a guide and tips for the preview period, and lists of 2016 performance year measures.

New Medicare numbers/cards transition: The Centers for Medicare & Medicaid Services (CMS) will begin mailing new Medicare ID cards to beneficiaries in April 2018. The cards will display new unique Medicare Beneficiary Identifiers (MBIs), which will replace the current Social Security-based Health Insurance Claim Numbers (HICNs).

During a transition period running April 1, 2018, through Dec. 31, 2019, CMS will process and transmit Medicare claims with either the HICN or MBI, based on what’s on the incoming claim. To ensure a smooth transition with secondary payers, CMS is working with supplemental insurers like Medigap plans, employer retiree plans, TRICARE for Life, and the Federal Employees Health Benefit Program, and with state Medicaid agencies regarding this change.

Source: MLN Connects, Oct. 26, 2017

New fact sheet: CMS has published a revised global surgery guide. In this 17-page booklet, learn about components of a global surgery package, coding and billing guideline, and payment rules.

Subscribe to the compliance newsletter — The Medicare Quarterly Provider Compliance Newsletter is a great way to learn how to avoid common billing errors and other erroneous activities and to address and avoid the top issues each quarter. Subscribe for this newsletter and other CMS email updates.

Source: MLN Connects, Oct. 19, 2017


Effective Nov. 1, 2017, UnitedHealthcare (UHC) will start an online prior authorization (PA)/notification program for genetic and molecular testing performed in an outpatient setting for its fully insured commercial plan members.

When making your PA/notification request, you’ll need to indicate the laboratory and test name for the following services:

  • Tier 1 molecular pathology procedures;
  • Tier 2 molecular pathology procedures;
  • Genomic sequencing procedures;
  • Multianalyte assays with algorithmic analyses that include molecular pathology testing; and
  • These CPT codes: 0001U, 0004M-0008M, 81161-81421, 81423-81479, 81507, 81519, and 81545-81599. Also, starting Jan. 1, 2018: 0009M and S3870. 

UnitedHealthcare has contracted with BeaconLBS to administer program, which you’ll access by signing into Link with your Optum ID. Or you can call Beacon at (800) 377-8809 (Monday through Friday, 7 am-7 pm local time). The lab and test you designate for PA/notification must be registered with Beacon. If your preferred lab isn’t registered, you could ask it register, or ask Beacon to contact the lab on your behalf.

Additional notes:

  • You’ll be able to print a document from Beacon’s online system listing information required for prior authorization or you can refer to the applicable UHC medical policy:
    • Carrier Testing for Genetic Diseases;*
    • Chromosome Microarray Testing;
    • Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood;
    • Genetic Testing for Hereditary Cancer;*
    • Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions;*
    • Pharmacogenetic Testing;* or
    • Whole Exome and Whole Genome Sequencing.*

               *Effective Nov. 1, 2017

  • You’ll receive a decision for online authorization in real time, or within two days for preauthorization, including peer-to-peer consultation, if UHC needs more information from you. You’ll need to log back in to the Link portal to check the status of your request. You’ll also later receive a letter confirming the results of your request.
  • Submit claims as normal. If test are changed at time of service, you must request a new PA/notification request. Notification must take place prior to claim submission.

See other carrier policies

Other carriers also require prior authorization for genetic and molecular testing. See these policies:

Published Oct. 30, 2017


Last Updated On

November 06, 2017