2015 News and Updates
Based on CMS mandates (i.e. safety concerns, drugs that no longer meet the CMS definition of a "Part D medication," etc.) and a regular review of changes in the pharmaceutical marketplace, Blue Cross Medicare Advantage 2016 Part D plans will have formulary and utilization management changes for 2016.
Listed below are details regarding three new facility rules that were originally scheduled to be added to our claims processing system effective Oct. 12, 2015, as an enhancement to our ClaimsXten code auditing tool. Please note that the deployment of these rules has been postponed to on or after Feb. 22, 2016. A notice regarding this change in effective date was published in the News and Updates section of our Provider website on Sept. 30, 2015.
Blue Cross and Blue Shield of Montana (BCBSMT) reviews new and revised Current Procedural Terminology (CPT®) and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten code auditing tool software by McKesson and are not considered changes to the software version. BCBSMT will normally load this additional data to the BCBSMT claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSMT Provider website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will continue to be posted on the BCBSMT Provider website.
On Nov. 13, 2015 Blue Cross Blue Shield of Montana (BCBSMT) implemented an upgrade for its care management system. Following the launch of the upgrade, technical issues were experienced that impacted clinical and service operations. Specifically, system performance and down time were impacted which has affected the processing of provider intake requests.
Across the industry, the move to ICD-10 appears to have been relatively smooth for most providers. Now that we have transitioned to ICD-10, our dedicated ICD-10 email help desk at firstname.lastname@example.org will be discontinued as of Dec. 31, 2015.
There are reversals and corrections when claim adjudication results have been modified from a previous reporting. The method for revision is to reverse the entire claim and resend the modified data. Provider level adjustments are reported in the PLB segment within your 835 Electronic Remittance Advice (ERA) from Blue Cross and Blue Shield of Montana (BCBSMT).
For the month of December, BCBSMT will be covering the 2016 Pharmacy Changes. The December webinars will be hosted by Luke Ostby, Director of Pharmacy, and he will discuss the 2016 updates with regard to the pharmacy benefits. This program may be of interest to your clinical and business office staff.
Blue Cross Blue Shield of Montana makes every attempt to ensure accurate, timely payment of claims. However, mistakes do occur and claims that have been incorrectly paid may be eligible for recovery.
ICD-10 Frequently Asked Questions
Updates to the Blue Cross Blue Shield of Montana Medicare Advantage Preauthorization List Effective January 1, 2016
On January 1, 2016 the Blue Cross Blue Shield of Montana (BCBSMT) Medicare Advantage (PPO) plan and Medicare Advantage HMO plan will have some changes to the list of procedures requiring preauthorization. Please see the updated preauthorization list here.
In accordance with the U.S. Department of Health and Human Services (HHS) mandate, valid ICD-10 codes are required on claims submitted to Blue Cross and Blue Shield of Montana (BCBSMT) for dates of service or inpatient discharge dates on or after Oct. 1, 2015.
The Centers for Medicare & Medicaid Services (CMS) and the CMS National Partnership to Improve Dementia Care in Nursing Homes have set a new goal to achieve a 25 percent reduction in antipsychotic drug use within nursing homes by the end of 2015, with a 30 percent reduction by the end of 2016. Eleven states met the previous 2012 goal to reduce antipsychotic drug use within nursing homes by 15 percent.
The National Institute of Health (NIH) National Asthma Education and Prevention Program recommends that patients with persistent asthma should be treated with an inhaled corticosteroid.
Recently, you may have noticed a new column titled "Ntwk Diff" that has been appearing on some of your patients' Provider Claim Summaries (PCSs).
Pharmacy Program Updates: Pharmacy Changes Effective October 1, 2015
If you utilize Health-e-Web (HeW) as your clearinghouse, please join this month's Provider Education series being offered by Blue Cross Blue Shield of Montana (BCBSMT) and HeW.
Beginning on or after Oct.12, 2015, BCBSMT will enhance the ClaimsXten code auditing tool by adding three new Outpatient Facility Rules into our claim processing system. The new facility rules will apply for any claims with dates of service on or after Oct.12, 2015.
On July 6, 2015, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association jointly announced a plan intended to help ease the transition to ICD-10.
Effective October 9, 2015 Blue Cross Blue Shield of Montana’s (BCBSMT) Medicare Advantage Product will be implementing an internal process change for benefit determinations related to inpatient status vs. observation status.
Effective January 1, 2016, the Blue Cross Blue Shield Service Benefit Plan (Service Benefit Plan) will change the benefit reimbursement for services received from dialysis providers that do not participate in Blue Cross Blue Shield of Montana's (BCBSMT) network.
Beginning on or after Dec.14, 2015, Blue Cross and Blue Shield of Montana (BCBSMT) will enhance the ClaimsXten code auditing tool by adding incidental edits to our claim processing system for Healthcare Common Procedure Coding System (HCPCS) codes for Compression Device Accessories (such as E0655 through E0673). This new edit will be effective for claims submitted with dates of service on or after the implementation date.
According to the Centers for Disease Control (CDC), although most persons who become infected with influenza viruses will recover without sequelae, influenza can cause serious illness and death. Complications are particularly common among persons aged ≥65 years and <2 years (and those with medical conditions that confer high risk for complications from influenza).
We are continuing to make enhancements to iExchange, our online benefit preauthorization tool. For example, you can use this tool to obtain a Health Summary, which is a modification of the Patient Clinical Summary offered previously.
As mandated by the U.S. Department of Health and Human Services (HHS), all Health Insurance Portability and Accountability Act (HIPAA) covered entities must use ICD-10 codes on claims and other health care transactions as of the Oct. 1, 2015, compliance deadline.
Beginning in early 2016, iExchange® will support submission of online requests for predetermination of benefits, along with all required documentation.
As mandated by the U.S. Department of Health and Human Services (HHS), all Health Insurance Portability and Accountability Act (HIPAA)-covered entities must use ICD-10 codes on claims and other health care transactions as of the Oct. 1, 2015, compliance deadline.
Blue Cross and Blue Shield of Montana Announces Upcoming Training Dates for a New Tool Being Offered
Here's timely ICD-10 news that can directly impact your practice. Mark this date and register today: Aug. 27, 2015, 12:30 to 2 p.m., MT. The Centers for Medicare & Medicaid Services (CMS) through MLN Matters® will host a MLN Connect national call five weeks before the ICD-10 Oct. 1, 2015, implementation date.
Health Care Service Corporation (HCSC), the operator of Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas, announced today the retirement of President and CEO Pat Hemingway Hall, effective Dec. 31, after 23 years of service to the company.
Intranasal Application of Topical Anesthetic
The U.S. Department of Health and Human Services (HHS) published a final ruling in early August 2014, confirming an Oct. 1, 2015, mandated transition to ICD-10. As of this compliance deadline, all Health Insurance Portability and Accountability Act (HIPAA) covered entities must use ICD-10 on claims and other health care transactions.
The transition to ICD-10 is federally mandated. The compliance deadline is Oct. 1, 2015. As of the compliance deadline, claims without valid ICD-10 codes, as required, will not be accepted by Blue Cross and Blue Shield of Montana (BCBSMT). Use of ICD-10 also affects eligibility and benefits requests, preauthorization, electronic health records, referrals and other processes.
Blue Cross and Blue Shield of Montana (BCBSMT) continues to enhance the pharmacy program services and support we make available to you and your patients. This brief 2nd quarter summary highlights recent quarterly activities and provides helpful reminders with links to related resources.
You've improved your documentation to support better coding. Your staff is trained and ready to submit claims with ICD-10 codes. You've checked with your software vendor, installed ICD-10 software and confirmed with your billing service or clearinghouse to ensure they're ready to submit claims on your behalf. So you're done, right? No, not yet.
If you submit electronic claims, confirming ICD-10 readiness with your software vendor, billing service and/or clearinghouse is just the first step. End-to end or “round-trip” testing with payers is necessary to help ensure your claims will make a successful journey from start to finish. The best place to encounter issues is within the test environment while there is still time to resolve them. The testing process also offers you and your staff the opportunity to practice coding with ICD-10.
BCBSMT has made a decision to price all screening mammogram services at a single reimbursement rate, independent of technique used. Additional views, digital reconstruction or digital tomosynthesis (including CPT and HCPCS codes 77063, G0279) services are not accorded additional reimbursement as they are considered discretionary by the facility and professional providing the services and have not been proven to improve the outcomes beyond conventional mammograms.
BCBSMT is in the final stages of achieving our URAC accreditation. As part of that effort, we have developed some clinically-focused quality improvement projects in addition to our standard quality measures. We have always strived for quality and promoted healthy living. But we need your help. We know that working with our provider community is the key to success.
Blue Cross and Blue Shield of Montana (BCBSMT) periodically reviews claims submitted by providers to help ensure that benefits provided are for services that are included in our member's benefit plan and meet BCBSMT's guidelines.
Today, the U.S. Supreme Court upheld the federal rule making subsidies available to eligible individuals through federally facilitated Health Insurance Marketplaces, like the one in Montana. This means that health insurance subsidies will continue to be available on these Marketplaces. Existing policies remain in effect.
The RBRVU and Anesthesia Conversion Factors Compensation Policy, effective May 1, 2015, is posted on the secure provider portal (post login) under the Compensation Policy tab.