Private Payer Round-Up, July 2013

In case you missed  these  here is roundup of useful items from health care payment plans newsletters, compiled by TMAs reimbursement specialists.

 If you have questions about billing and coding or payer policies, contact the specialists at for help, or call TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems.


Manual updates — Humana’s provider manual revisions are now available. The revisions are effective Oct. 21, 2013. Humana mailed notifications to physicians on July 15 and July 22.

Doing business with Humana — Check out Humana’s Education on Demand webpage for quick audio PowerPoint presentations on topics about doing business with Humana. If your computer is not configured for streaming audio, you can listen to the presentations over the phone while viewing the slides on screen. Instructions are on the webpage.


Aetna Medicare for the Teacher Retirement System of Texas (TRS) — Aetna’s Medicare Advantage PPO Plan with Extended Service Area (ESA) for TRS retirees has the same precertification requirements as the Aetna Medicare Plan PPO. These patients will have access to Best Doctors, a medical consultation company. Patients with medical concerns can contact Best Doctors. Best Doctors may contact you for information and records relating to your TRS patient, and you may receive reports developed by Best Doctors.  

 How to submit Medicare coverage requests using EDI — Aetna wants you to submit your Medicare precertification/notification coverage requests for Medicare Advantage plan members via electronic data interchange (EDI). Follow these instructions for using EDI to submit these requests:

  • Submit routine requests (that don’t meet the definition for a Medicare expedited request) with the elective level of service indicator. You may add “Medicare standard request” in the comments field.
  • If you select urgent, Aetna classifies the request as a “Medicare expedited request.” These requests must meet the Centers for Medicare & Medicaid Services definition for an expedited or time-sensitive situation: A situation where the time frame of the standard decision-making process could seriously jeopardize the life or health of the enrollee, or could jeopardize the enrollee’s ability to regain maximum function. 
  • Select urgent when your patient needs care within 24 to 72 hours from the time of your request (e.g., your patient is admitted directly to the hospital at the request of the attending or primary care physician). You may add “Medicare expedited request” in the comments field.
  • Choose emergency when the patient is admitted to the facility after receiving services in the emergency department.

Verify dependent eligibility to reduce claim rejections — To prevent dependent claims from being rejected, verify dependent eligibility before submitting your claims. Use the eligibility and benefits inquiry transaction on Aetna’s secure provider website. If you submit a claim for a dependent who is not on the subscriber’s plan, you’ll see the following codes on your rejected claims report:

  • Category Code A3 — Acknowledgement/Returned as unprocessable claim. The claim/encounter was rejected and has not been entered into the adjudication system.
  • Status Code 109 — Entity not eligible. Note: This code requires use of an Entity Code.
  • Entity Code: D0: Data Search Unsuccessful — The payer is unable to return status on the requested claim(s) based on the submitted search criteria.


  • Parents of newborns generally get up to 31 days to add newborns to their plan.
  • Don’t enter information for dependents (including newborns) in the indicated fields for the subscriber. Aetna looks for a combination of member name and ID number to match in its eligibility system before it can accept the claim.

Get answers to your claims and policy questions Instead of calling Aetna with claims and policy questions, use its secure provider website to your advantage. For example, you can: 

  • Submit claims and  inquire about individual claims, run claims reports, and access claims policies;
  • Access claim explanation of benefits.
  • Use the electronic precertification transaction to make precertification requests.

Aetna offers free webinars to help you learn about these tools and more.

Source:  Aetna Officelinks Updates (PDF), June 2013


Important change for claim status requests — Effective Aug. 1, 2013, claim status will be available exclusively through the Blue Cross and Blue Shield of Texas (BCBSTX) automated phone system and electronic vendors, such as Availity. They provide real-time and detailed information about your finalized and in-process claims. (BCBSTX customer advocates will remain available for complex eligibility and benefit inquiries as well as claim adjustments when necessary.)

Claim status requests may include: claim number; receipt date; processed date; date paid; amount paid; payee; line-item processing detail; copay, deductible, and coinsurance, total patient share; and confirmation number/transaction ID. (The BCBSTX automated phone system provides individual confirmation numbers for each inquiry; Availity provides Transaction IDs for each submission.)

Registered Availity users can access its Claim Research Tool for enhanced, real-time claim status functionality to help manage and resolve BCBSTX claims. You can use this online tool to check status of multiple claims in one view, search claims for a particular date or date range, view claims according to status (such as paid, pended, or denied), and verify detailed line-level information (such as amount paid, ineligible reason codes, and detailed descriptions for each line of service).

The Claim Research Tool also:

  • Displays monetary amounts from Medicare, other carriers, and health care accounts that have been applied to any claim, and
  • Shows the specific item(s) required to complete the processing of a claim when additional information is requested.

If you’d like customized training on this and other BCBSTX complimentary tools, email the payer’s Provider Education Consultants. Include your name, practice name, billing NPI (or tax ID) and business phone number.

 Navigating the BCBSTX automated phone system — If you prefer to use the telephone rather than go online, you can use the BCBSTX interactive voice response system (IVR) system at (800) 451-0287 to obtain eligibility and benefits information, check claim status, and initiate select inpatient and outpatient preauthorization requests. Use caller guides for step-by-step instructions. You also can use the IVR to extend or check status of preauthorization requests, check behavioral health eligibility and benefits, and initiate behavioral health preauthorization requests. If you want to talk to someone in person, you will have the option to speak to an agent through the IVR after the automated system has provided claim status details.  

Billing with National Drug Codes (NDCs) — Effective Dec. 1, 2013, BCBSTX will begin paying claims submitted with an NDC in accordance with the NDC fee schedule posted on the website under “Drugs.” BCBSTX currently accepts NDCs for billing of all physician- or ancillary provider-administered and supplied drugs.  BCBSTX will update the NDC fee schedule monthly. Lower-cost generic medications may be paid with a larger margin compared with higher-cost generic and brand medications.

To locate “Drugs” on the BCBSTX provider website, go to Standards & Requirements > General Reimbursement Information (log-in required) >Reimbursement Schedules and Related Information > Professional > BlueChoice and HMO Blue Texas Schedules > 2012 Schedules effective Nov. 1, 2012 > Drugs.

BCBSTX encourages physicians to begin including the NDC information on claims as soon as possible for more accurate payment and better management of drug costs based on what was dispensed.

BCBSTX requires inclusion of the NDC along with the applicable HCPCS  or CPT code(s) on claim submissions for unlisted or “Not Otherwise Classified” physician- or ancillary provider- administered and supplied drugs. BCBSTX will continue to accept the HCPCS or CPT code elements without NDC information (excluding unlisted or “Not Otherwise Classified” drugs).

When submitting NDCs on claims to BCBSTX, you must also include the following:

  • The applicable HCPCS or CPT code;
  • Number of HCPCS/CPT units;
  • NDC qualifier (N4);
  • NDC unit of measure (unit [UN], milliliter [ML], gram [GR], international unit [F2]);
  • Number of NDC units (up to three decimal places); and
  • Your billable charge/price per unit.

Attention electronic claim submitters: Confirm with your software vendor that your practice management system accepts and transmits the NDC data fields appropriately. If you use a billing service or clearinghouse to submit electronic claims on your behalf, check with them to ensure that NDC data is not manipulated or dropped inadvertently.

For more information, see the guidelines (PDF) and FAQs (PDF) on the BCBSTX provider website, as well as this  interactive online tutorial (log-in required).

GuidedHealth platform supports clinical program expansion — You may receive letters from BCBSTX referencing GuidedHealth that give you medication-related recommendations for specific patients.

GuidedHealth is an analytics platform from Prime Therapeutics that integrates medical and pharmacy claims data, applies evidence-based clinical rules, and provides recommendations to physicians and members. It powers BCBSTX’s  Retrospective Drug Utilization Review (RDUR) program, which Prime administers. Prime is the pharmacy benefit manager for most BCBSTX members. The RDUR program helps identify patients with potential drug therapy concerns.

GuidedHealth’s RDUR for BCBSTX is arranged in three modules: Overutilization, Safety, and Cost Savings. Below are examples of categories included in these modules that BCBSTX deploy throughout the year.

For overutilization (focuses on potentially improper and unnecessary use of medications, such as misuse, abuse, drug conflict, and off-label use):

  • Narcotic analgesic/Benzodiazepine/Muscle relaxant combination therapy
  • Proton pump inhibitor duration of therapy

For safety (identifies and recommends discontinuation of potentially unsafe medication use):

  • U.S. Food and Drug Administration MedWatch Safety Alert
  • High-dose acetaminophen

For cost savings (promotes the awareness of generic drug alternatives in place of nonformulary brand products): Generic opportunities, such as proton pump inhibitors or statins. As part of the generic opportunities category, BCBSTX sends mailings to members to help increase awareness of cost-effective alternatives to brand name drugs.
 If your patient is identified via one or more of these categories, you may receive a BCBSTX/GuidedHealth letter. Included will be a drug therapy opportunity summary, along with a medication claims profile for the identified member, plus a feedback survey BCBSTX encourages you to fill out and submit.

Update on claims processing of partial batches — BCBSTX has postponed to second quarter 2014 its move from batch-level to claim-level rejections for medical electronic claims. In the April 2013 Blue Review, BCBSTX had announced this enhancement would occur in third quarter 2013.

How it will work: When you transmit electronic claims, BCBSTX will forward all valid and successful claims for processing and adjudication. You will receive payer response reports that indicate which claims were rejected so you can correct and resubmit as appropriate. You should not submit the entire batch of claims, as this will result in duplicate claims within the adjudication process.

If you use a billing service or clearinghouse to submit claims on your behalf, be sure they are aware of this information. If you have questions, contact the BCBSTX Electronic Commerce Center at (800) 746-4614.

Source: Blue Review, July 2013

Published July 23, 2013 

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