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First Quarter 2013

Conversion Factors Increase May 1, 2013

Effective May 1, 2013, BCBSMT is increasing the resource-based relative value system (RBRVS) conversion factor to $55.35 and the anesthesia conversion factor to $59.00.

In the RBRVS system, services are assigned units of value, known as Relative Value Units (RVU), based on the resources (physician’s work, the practice expense, and professional liability insurance) required to provide the services.  BCBSMT uses the Transitioned Non-Facility RVU and Transitioned Facility RVU totals.  The applicable total RVU is multiplied by the BCBSMT conversion factor to calculate the BCBSMT allowable fee for participating providers.

Payment for the administration of anesthesia is based on the American Society of Anesthesiology methodology.  The compensation method for physicians and certified registered nurse anesthetists is a base and time unit calculation (base units plus time units multiplied by the conversion factor).  Anesthesia time is reported in minutes, and each 15-minute increment equals one unit.  More information is available in the Relative Value Unit and Anesthesia Compensation policies published at (login to Provider Secure Services and click on Compensation Policies located on the left navigation).

If you have questions, email your Provider Account Consultant at or call 1.800.447.7828, Extension 6100, Option 3.

Participating Provider Access and Availability Standards Detailed

BCBSMT thanks all of its participating providers for joining with us to provide cost-effective, high-quality care for our members.

Just as a reminder, as part of our Network agreement, participating providers treat BCBSMT members as they would any other patient and have agreed to cooperate in monitoring accessibility of care for members, including scheduling of appointments and waiting times.   Participating providers must meet the following appointment standards:

  1. Emergency services must be made available and accessible at all times.
  2. Urgent care appointments must be available within 24 hours.
  3. Appointments for non-urgent care with symptoms must be made available within 10 calendar days.
  4. Appointments for immunizations must be available within 21 calendar days.
  5. Appointments for routine or preventive care must be available within 45 calendar days.

Emergency Services and Emergency Medical Condition

Participating providers are required to have 24-hour availability of emergency services and qualified on-call coverage available to BCBSMT members.
Emergency Services means health care items and services furnished or required to evaluate and treat an emergency medical condition.

Emergency Medical Condition is a condition manifesting itself with symptoms of sufficient severity, including severe pain, in which the absence of immediate medical attention could reasonably be expected to result in any of the following:

  1. The covered person’s health would be in serious jeopardy.
  2. The covered person’s bodily functions would be seriously impaired.
  3. A body organ or part would be seriously damaged.

Urgent Care

Participating providers must see BCBSMT members within 24 hours of their request for an appointment.

Urgent Care is health care that is not an emergency service but is necessary to treat a condition or illness that could reasonably be expected to present a serious risk of harm if not treated within 24 hours.

Non-Urgent Care with Symptoms

Participating providers must see BCBSMT members within 10 calendar days of their request for an appointment.

Non-Urgent Care is health care required for an illness, injury, or condition with symptoms that do not require care within 24 hours to prevent a serious risk of harm but do require care that is neither routine nor preventive in nature.

Routine Care

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment.

Routine Care is health care for a condition that is not likely to substantially worsen in the absence of immediate medical intervention and is not an urgent condition or an emergency.  Routine care can be provided through regularly scheduled appointments without risk of permanent damage to the person’s health status.

Preventive Care and Immunizations

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment for preventive care and within 21 calendar days of their request for an appointment for immunizations.

Preventive care and Immunizations are health care services designed for the prevention and early detection of illness in asymptomatic people.

More information is available in the BCBSMT Provider Manual.  If you have suggestions for improvement or content, email your Provider Account Consultant at or call 1.800.447.7828, Extension 6100 Option 3.

OptumInsight iCES KnowledgeBase Scheduled for Update

BCBSMT began using the iCES KnowledgeBase (KB) code editing software in November 15, 2010.  The iCES KB is scheduled for update with an ICD10 compliant version on March 10, 2013, revised to April 20.  Please check the announcement page for notification of any change to this date. The "Code Edit Viewer" tool will be temporarily unavailable due to technical.

Login to Provider Online Services, *Code Navigator, for a list of professional and facility rules/flags and associated new and revised flags.
The iCES KB is used to evaluate the accuracy and adherence of reported services to accepted national reporting standards and BCBSMT coding policies.  This editing system enables BCBSMT to manage cost effective reimbursement by identifying potentially incorrect coding relationships on submitted claims.  It also benefits health care providers by providing equitable, efficient reimbursement; and accurate and consistent claims processing.

The iCES KB includes common coding relationships for CPT® codes, HCPCS codes, and ICD-9/ICD-10 codes.  These three nomenclature and classification systems are the health care industry standards used to report procedures, professional/facility services, supplies, drugs, anesthesia services, and diagnoses.  The iCES KB rules are created based on widely used common-practice sources such as CMS, CCI, CPT® Professional Edition, HCPCS, and specialty society directives or publications.  Additionally, where common-practice sources are not clear, OptumInsight has consulted with specialty physicians.

iCES KB customizations are applied by BCBSMT based on the plan’s clinical coding and reimbursement policies.  Refer to the Customized Edits Policy on the Code Navigator home page for a complete list of applied edits that are not delivered with the standard iCES KB.

The iCES KB is updated quarterly in January, April, July, and October for consistency with medical and claim payment policies, new procedure codes, current health care trends, and/or medical and technological advances.  iCES KB relationship logic is applied based on the date the service was performed.

*Code Navigator is the home page to provide information regarding OptumInsight code editing software, iCES KB, and the related BCBSMT coding policies.  This information applies to all lines of business except Medicare Supplement and the Federal Employee Program (FEP).  Claims processed for FEP members will continue to be processed using the CAI editing software.

ICD-10 Is Coming!  Are You Ready?

In January 2009, the Department of Health and Human Services (HHS) published its final rule on the conversion of the Health Insurance Portability and Accountability Act (HIPAA) standard medical code sets from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedure Coding (ICD- 10-PCS).  This conversion requirement will take effect October 1, 2014.
On October 1, 2014, medical coding in U.S. health care settings will change from ICD-9 to ICD-10.  The transition will require business and systems changes throughout the health care industry.

On January 1, 2012, standards for electronic health transactions changed from Version 4010/4010A1 to Version 5010.  Unlike Version 4010, Version 5010 accommodates the ICD-10 code structure.  This change occurred before the ICD-10 implementation date to allow adequate testing and implementation time.

The compliance date is firm and not subject to change.  Preparing for the conversion now will help you avoid potential reimbursement issues.

The following information is from CMS and lists basic steps to prepare for ICD-10 by October 1, 2014. More information is available at Medicare ICD-10 Coding.

  • Identify your current systems and work processes that use ICD-9 codes.  This could include clinical documentation, encounter forms/superbills, practice management system, electronic health record system, contracts, and public health and quality reporting protocols.
  • Talk with your practice management system vendor about accommodations for ICD-10 codes.  Contact your vendor and ask what updates they are planning to make to your practice management system for ICD-10, and when they expect to have it ready to install.
  • Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition.  Be proactive; don’t wait.  Contact your payers, clearinghouse, and billing service with whom you conduct business.  Ask about their plans for ICD-10 compliance, and when they will be ready to test their systems for both transitions.
  • Talk with your payers about how ICD-10 implementation might affect your contracts.  Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, payment schedules, or reimbursement.
  • Identify potential changes to work flow and business processes.  Consider changes to existing processes including clinical documentation, encounter forms, and quality and public health reporting.
  • Assess staff training needs. Identify the staff in your office who code or have a need to know the new codes.  Coding professionals recommend that training take place approximately six months prior to the October 1, 2014, compliance date.
  • Budget for time and costs related to ICD-10 implementation, including expenses for system changes, resource materials, and training.  Assess the costs of any necessary software updates, reprinting of superbills, training and related expenses.

Did You Know?
    For FEP Business, Preauth Required on Some Procedures

The following seven types of procedures* REQUIRE  prior authorization by the FEP plan.  FEP plan members are those whose member ID numbers start with “R” followed by 8 digits. 

  1. Outpatient surgery for morbid obesity
  2. Outpatient surgical correction of congenital anomalies
  3. Outpatient surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth
  4. Outpatient Intensity-Modulated Radiation Therapy (IMRT) except related to the head, neck, breast, and prostate
  5. Hospice care
  6. Organ/tissue transplants
  7. Clinical trials for certain organ/tissue transplants

*Please also note that inpatient hospital stays need to be precertified, and medical necessity is the deciding factor on coverage of all services.

To send a prior authorization for the procedures or services listed above, please use the designated FEP fax number of 1.406.437.7886.

If you need help with benefit-related questions, the FEP Customer Service staff is always happy to help you at 1.800.624.5060.

Reminder to Physical, Speech and Occupational Therapy Providers
   Healthy Montana Kids REQUIRES Prior Authorization

As a reminder, for members covered by Healthy Montana Kids, prior authorization is required for outpatient therapy treatment.  In these cases, a written request must be submitted to BCBSMT in advance of services and should include pertinent documentation explaining the proposed services, the initial evaluation or at times a re-evaluation, the functional aspects of the treatment, the projected outcome, treatment plan and any other supporting documentation.  If this is continuation of therapy, some recent treatment notes need to be included in order for the authorization to be extended.

The following form can be used for your prior authorization request: Healthy Montana Kids (HMK) - General Form

To preauthorize services, fax the completed form to 406.441.4624.

If you have any questions about prior authorization or require clarification, contact BCBSMT Customer Service at 1.800.447.7828.

“Removal of Barriers to Access” Clarified

The Montana Managed Care Plan Network Adequacy and Quality Assurance law requires health carriers in the state of Montana to adopt standards that promote access to the services offered by a managed care plan. 

BCBSMT provides an equal opportunity to access health plan services by making accommodations for members who have physical and mental disabilities, those who are illiterate, or those who have diverse cultural and ethnic backgrounds.  An example of a service for members with sensory and speech impairment is the use of the Montana Telecommunications Relay Program.  The Montana Relay makes calling possible between a standard telephone and a text telephone as is often used by individuals with hearing or speech impairments. 

Other accommodations available for sensory and speech impairment include providing written communications, sign-language interpreter services, and on-line member services.  BCBSMT offers reading services for members with impaired vision.

Members with limited English proficiency are accommodated through a BCBSMT subscription to an on demand language services vendor that provides both verbal and written interpreter services.

If you have any questions about these services or require clarification, contact BCBSMT Customer Service at 1.800.447.7828.

TriWest Creates Transition Claims Processing Matrix


On April 1, 2013, the managed care support contract for the TRICARE West Region will transition to UnitedHealthcare Military & Veterans (UnitedHealthcare). TriWest Healthcare Alliance (TriWest) will remain the TRICARE West Region managed care support contractor through March 31, 2013.

TriWest has created a Transition Claims Processing Matrix to help providers determine how to submit claims based on dates of service, admit and discharge dates, and the date the claim or adjustment was received.

If you have identified any TRICARE West Region claims issues, please submit them as soon as possible. Registered users of may submit claims issues online using online claims correspondence/Webmail.

Visit the Transition Update Center at to find important information regarding the TRICARE West Region transition on the following topics:

This information on these pages is considered valid as of the publication date and may change as the transition to UnitedHealthcare progresses.  Please refer to frequently for updates.

Thank You for Serving Those Who Serve

With our TRICARE contract coming to a close on March 31 of this year, we wanted to thank those dedicated providers who have devoted themselves to serving our nation’s heroes.

Throughout the past 16 years, we have built our provider network to 190,000 strong — with the shared goal of caring for our military personnel.

But … we could not have accomplished this without your dedication and support!

Thank you for caring so deeply.  Thank you for partnering with us to serve those who serve.  Thank you for making the choice to care for the men and women who watch over our country —just as they made the choice to enter a life of service for us.

We look forward to putting our expertise to work and continuing our legacy of serving America’s finest, with the best-in-class customer service and award-winning innovations our extraordinary customers deserve.

We remain committed to serving the military and veteran population.  And we hope that our partnership with you may continue in the future to serve our nation’s heroes.

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