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Third Quarter 2011

Individual Coordination of Benefits Soon Available

Effective January 1, 2012, Blue Cross and Blue Shield of Montana (BCBSMT) will be coordinating benefits for individual insurance plans containing other insurance information (secondary) on the UB-04 (facility) and CMS-1500 (professional) claim forms.  BCBSMT provider manual Chapter 10  has additional information.  If you have questions, contact Customer Service.

Electronic Coordination of Benefits Now Available

BCBSMT can accept electronic claims containing other insurance information (secondary) on the UB-04 (facility) and CMS-1500 (professional) claim forms.  Providers and facilities that submit electronic claims no longer have to print and submit COB claims by mail.  Sending this information to BCBSMT electronically will get your claims paid much faster. 

When submitting electronic COB claims, refer to your software vendor’s billing instructions and complete all required COB information.  For Professional claims, COB information should be sent at the line-level and not at the claim-level.  In addition to the required COB information, you must submit the other carrier allowed information and paid amount and all claim-level adjustment group codes, reason codes, and payment amounts.

Go to and select the Training link, to print the most current ex12 Professional or Institutional Secondary training manuals.

If you have questions, call Health-e-Web at 877-565-5457 or submit a question online at

Conversion to HIPAA 5010 Right Around the Corner!

On January 1, 2012, all electronic claims must be submitted using Version 5010. Version 4010 will no longer be accepted. To make sure you will meet that deadline, all providers are strongly encouraged to begin testing Version 5010 now. Vendors and clearinghouses should be working with your office to maintain compliance and ensure that thorough testing is complete by December 31, 2011.

It’s Also Time to Start Thinking about ICD-10!

ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service and inpatient claims with dates of discharge on and after October 1, 2013. If transactions and claims are not submitted with correct ICD-10 codes, they will be rejected, which may delay reimbursements to your office. This change does not affect CPT coding for outpatient procedures.

Preparing to use ICD-10 and Version 5010 — which will include potentially updating software installation, training staff, changing business operations and workflows, testing both internally and externally, and reprinting manuals and other materials — will take time. Be sure to visit for important implementation and testing dates to ensure a smooth transition.

National Alliance on Mental Illness Offers Family-to-Family Education

While mental health clinicians undergo rigorous training in their fields before treating patients with psychiatric disorders, family members, on the other hand, may find themselves suddenly thrust into crisis situations with a loved one, struggling to understand an illness they know little about-—while dealing with their own powerful emotions.

The result, not surprisingly, is that families often do not know how to respond effectively when a loved one develops a mental illness. Anger, guilt, shame, and other negative emotions--reinforced by society’s continuing stigma about mental illness--may hobble families' abilities to support patients. And while clinicians would like to better involve and support family members, doing so can become a daunting task in the real world of conflicting demands of patient privacy, overbooked schedules, and insurance paperwork.

Recognizing the challenges, the National Alliance on Mental Illness (NAMI) offers a free 12-week course, the Family-to-Family Education Program. The curriculum includes medically reviewed and regularly updated content about major depression, bipolar disorder, schizophrenia, obsessive-compulsive disorder, panic disorder, and substance abuse disorders.

Developed by a clinical psychologist, Dr. Joyce Burland, the program also reflects her experiences with several of her own family members who developed mental illnesses. Dr. Burland explains that: "A core concept of the course is that severe mental illness is traumatic for both the patient and the family. At the same time, we want to help families better appreciate the lived experience of someone who has a mental illness. The course is designed to change people's consciousness about mental illness."

Although the course has been offered for 20 years, and two pilot studies found it to be effective, only recently has it undergone evaluation in a randomized controlled trial—the "gold standard" of medical research. This federally funded study concluded that the Family-to-Family program significantly improves family members' ability to cope by increasing their knowledge about and acceptance of mental illness.
"Every clinical practice guideline recommends family psychoeducation as part of the treatment plan," notes lead author Dr. Lisa Dixon, a professor of psychiatry at the University of Maryland Medical School. "This study shows that the Family-to-Family program is another evidenced-based option."

How It Works

Family members volunteer to teach the course after undergoing training in how to conduct the classes. Participants meet with instructors once a week for two to three hours at a time. Participants first learn about the biological causes of mental illness. "We want them to understand that mental illnesses are brain disorders," explains Dr. Teri Brister, director of programs for young families at NAMI. "It's nobody's fault, they are not bad parents, and these disorders have a physical basis just like other illnesses." As the course progresses, participants learn why physiological problems in the brain can manifest in behaviors and how these disorders are diagnosed and treated.

Although most of the classes consist of lectures, there is time for participants to share stories related to content or participate in skills-building sessions. For example, participants learn and practice reflective listening techniques, so they can understand the emotions a patient is expressing as well as the words he or she is using.

Since 1997, over 2,000 family members have taken the NAMI Family-to-Family Education Program. This program has proven invaluable to families who have a family member living with serious mental illness. Thanks to a dedicated group of family volunteers, Family to Family will be offered in Billings, Bozeman, Butte, Helena, Great Falls, and Missoula this fall. If you are interested in introducing the families of your patients to this program or would like to learn more about NAMI Montana, go to




Healthy Montana Kids Updates Vaccine Reimbursement for FQHCs and RHCs

Effective September 1, 2011, the Healthy Montana Kids (HMK) program is now processing vaccination claims through Blue Cross and Blue Shield of Montana (BCBSMT) for vaccines and eligible administration fees from Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

This change in vaccine reimbursement through HMK’s third-party administrator, BCBSMT, resolves a payment gap that occurred when HMK implemented the Medicaid Outpatient Prospective Payment System (PPS) methodology in October 1, 2010. While FQHC and RHC facilities receive vaccines at no cost from the Vaccines for Children (VFC) program for HMK Plus (formerly children’s Medicaid) enrollees, the clinic must purchase the vaccine for HMK (formerly CHIP) members.

HMK will now reimburse FQHCs and RHCs for both vaccines and administration fees, when appropriately billed. If the FQHC or RHC receives a payment for a face-to-face visit through ACS, vaccine administration reimbursement is not available for that visit through BCBSMT.

Example A: Mary is an enrolled HMK member and the only service she receives is a vaccination from a nurse at an FQHC/RHC. The vaccine and administration fee are billed to BCBSMT on a CMS 1500. Nothing is billed to ACS since it does not qualify as an ‘office visit’ under the PPS.

Example B: Tony is an enrolled HMK member and during an FQHC/RHC office visit for a well child check-up with a mid-level provider, he also receives a vaccination. The office visit is billed to ACS on a UB04 and reimbursed through the PPS formula. Only the vaccine is billed to BCBSMT on a CMS 1500 form since the administration fee is already included in the PPS office visit reimbursement.

All vaccination claims for HMK members for dates of service retroactive to October 2010 or later are now submitted to BCBSMT on a CMS-1500. Claims should be submitted electronically or mailed to P.O. Box 7982, Helena, MT 59604.

All other FQHC/RHC provider visit claims for HMK children are submitted to ACS on a UB04. HMK will review all vaccine administration fees billed to BCBSMT to ensure that duplicate billing does not inadvertently occur when a corresponding office visit on the same date of service is submitted to ACS.

Please contact HMK Program Officer Liz LeLacheur with any questions at 877-543-7669, Extension 6002, or by email at

TRICARE Online Education Available

If you are new to TRICARE®, have new staff in your office, or want to learn more about TRICARE, you and your staff are invited to register for a TRICARE provider webinar or eSeminar. TriWest Healthcare Alliance (TriWest) developed these training programs to help you better understand the basics of the TRICARE program to administratively care for your TRICARE patients.

TRICARE Webinars
Webinars are training sessions from your own computer with a live instructor. You will hear the instructor by joining a conference call on your telephone. You can ask questions and also hear questions asked by other providers attending the training.

Webinars are available on the following topics:

  • TRICARE 101
  • Behavioral Health TRICARE 101
  • Autism
  • Electronic Data Interchange (EDI)
  • Physical Therapy/Occupational Therapy/Speech Therapy (PT/OT/ST)
  • Secure Website-Claims
  • Secure Website-Referrals and Authorizations
  • TriWest Online Care Program
  • Vision Coverage
  • Ambulatory Surgery Center Reimbursement Methodology coming soon
  • Skilled Nursing Facilitycoming soon

TRICARE eSeminars
eSeminars allow providers and their staff to learn about TRICARE and TriWest in the comfort of their own office, home or any location with Internet access. To take an eSeminar, you will need headphones or speakers on your computer.

Here is a list of the current eSeminars that are available:

eSeminars allow providers and their staff to learn about TRICARE and TriWest in the comfort of their own office, home or any location with Internet access. To take an eSeminar, you will need headphones or speakers on your computer.Here is a list of the current eSeminars that are available:
  • TRICARE 101
  • Behavioral Health TRICARE 101
  • Autism
  • Electronic Data Interchange (EDI)
  • Extended Care Health Option (ECHO)
  • Home Health Agency Prospective Payment System
  • Outpatient Prospective Payment System (OPPS)
  • TRICARE's Hospice Benefit
  • TriWest Online Care Program
  • Vision Coverage

Just select your preferred eSeminar. It's that easy!

TRiWest has many options available for you to get the information you need to learn about TRICARE. For more information about these options, visit the Stay Updated section of

“TRICARE” is a registered trademark of the TRICARE Management Activity. All rights reserved.

TRICARE Preparing for HIPAA 5010? Are You Ready?

TRICARE Management Activity, TriWest and Wisconsin Physicians Service Insurance Corp. (WPS) are taking action to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) version 5010 transaction standards. HIPAA requires all covered entities in the health care industry to implement and use mandated standards in the electronic transmission of health care transactions, including claims, remittance, eligibility, claims status requests, their related responses, and privacy and security standards.

As you prepare for the implementation of HIPAA 5010, an important step to take will be to contact your vendor, clearinghouse, billing service or payer if they

supply your software. They will provide detailed information on what steps your office or facility needs to take toward a smooth transition.

Here are some readiness questions that you should ask:

  • Will HIPAA 5010 and ICD-10 software upgrades or changes be provided in one or multiple releases?
  • What will be the cost of upgrades or changes to my practice?
  • When will upgrades or changes be available for testing?
  • When can I begin testing each transaction (e.g., 837 Claims, 835 Remittance Advice)?
  • Will I be required to test with each trading partner or payer?
  • What are the steps and time frame for completing a testing cycle?
  • Can 4010 and 5010 transactions be processed concurrently?
  • How will I know my implementation has been successfully completed?
  • What is your contingency plan if your systems are not compliant on January 1, 2012

For more information, WPS has prepared a 5010 Readiness Schedule at and a 5010 Companion Guide at You can also refer to TriWest's EDI/ERA/EFT web page at

TriWest Online Referral/Authorization Submission Made Easier

TriWest made several upgrades to the online referral/authorization submission tool to improve the user experience and save providers time when submitting requests online.

These improvements include:

  • The user no longer needs to enter an asterisk after typing your entry in the Member ID, Provider, Group, or Facility ID fields. In the Member ID field, you can enter:
    • Sponsor’s Social Security Number
    • Department of Defense (DoD) identification number (DoD-ID)
    • First nine digits of the DoD Benefits Number (DBN)
  • Users may also search for the member by clicking the magnifying glass tool
  • More entry fields now have drop-down menus. These new menus have been pre-loaded with favorites based off your previous selections. You can simply make a selection from the drop-down menu or you can begin typing in the entry field and the drop-down menu will open and filter the list as you type.
  • Users can quickly use the drop downs for selecting “favorites” or use the magnifying glass for expanded search capabilities and add to your favorites. This applies to referring and servicing providers, request types and procedure codes.
  • There are new help information links for data entry fields.
  • There is an expanded field length for additional detail view.

TriWest has also updated the Online Referral/Authorization Reference Guide to reflect these changes.

TriWest has online tools and a dedicated team to assist providers in registering for our secure website and learning how to submit their requests online. For more information on how to register, go to

For more information on online referral/authorization requests, here is a link to an online referral/authorization submission website demonstration focusing on the recent changes to the online submission tool. You can also take a Secure Website-Referrals and Authorizations webinar.

Fraud: NHCAA Lists Most Common Types of Fraud

BCBSMT recently added new personnel to the Special Investigations Unit (SIU) and is continuing to respond to fraud-related referrals, in addition to conducting proactive audits in areas known to be prone to fraudulent activity.

The National Healthcare Anti-Fraud Association (NHCAA) recently published a list of the most common types of fraud committed by dishonest providers.

  • Billing for services that were never rendered, either by using genuine patient information, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place. Many times, this information is obtained through identity theft.
  • Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding." Upcoding is falsely billing for a higher-priced treatment than what was actually provided.
  • Performing medically unnecessary services solely for the purpose of generating insurance payments.
  • Misrepresenting noncovered treatments as medically necessary covered treatments for the purposes of receiving insurance payments. This has been documented in cosmetic-surgery schemes in which noncovered cosmetic procedures such as "nose jobs” are billed to insurers as deviated-septum repairs.
  • Falsifying a patient’s diagnosis to justify tests, surgeries, or other procedures that are not medically necessary.
  • Unbundling. Unbundling is billing each step of a global procedure code as if it were a separate procedure.
  • Accepting kickbacks for patient referrals.
  • Waiving patient copayments or deductibles and over billing the insurance carrier.

Please join us in helping to protect the system from the greedy minority who profit from fraud while driving up premiums and reducing compensation for honest patients and providers. If you’re aware of someone who may be committing insurance fraud, be a part of the solution and report it to the appropriate insurer or law enforcement agency.

If you have questions or concerns about fraud or questionable practices, call our fraud hotline at 1-800-621-0992 or you may e-mail us at More information is also available on our website at

Christy McCauley currently serves as a BCBSMT Special Investigator and is a Health Care Anti-Fraud Associate. Christy has been employed by BCBSMT for over 17 years with more than 4 years in the Special Investigations Unit. Christy can be reached at 1-800-447-7828, Extension 5213, or by email at

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