Volume 19, 2013
Issue 25 Preauthorization Reminder for Chiropractic and Osteopathic Manipulation
As a reminder, some patients’ contracts require preauthorization for spinal manipulation services.
Issue 24 Billing Reminder for Mid-level Practitioners
This is an important reminder about our billing guidelines for mid-level practitioners.
Issue 23 Surgical Follow-up Days
BlueCross BlueShield of Western New York monitors changes to the Medicare claims processing guidelines to ensure consistency.
Primary Care Enhancement
You have attested to the New York State Department of Health (NYSDOH) that 60 percent of your practice is primary-care related.
Health Insurance Exchange
On October 1, 2013, New York state opened NY State of Health: The Official Health Plan Marketplace, an online health insurance exchange that offers insurance products to uninsured individuals and small businesses.
Revised Methodology for Decreasing Hospital Readmissions through Care Coordination
We previously notified you that, effective July 1, 2012, Patient-Centered Medical Home (PCMH) practices would be eligible for additional reimbursement for follow-up visits with the primary care physician within seven days of discharge from an inpatient hospital stay to home.
Issue 19 – PCMH AH Pilot Clarification
We want to clarify the types of visits that are now part of the after-hours pilot.
Issue 18 – Medicare Advantage Fee Schedule Error Corrected
A computer error was made regarding the Medicare Advantage Fee Schedule that became effective August 1, 2013.
Issue 17 – Drug Therapy Guideline Updates
The attached updated guidelines will be effective September 15, 2013.
Issue 16 – 2013 Form for Elective Left Heart Cardiac Catheterization
This elective procedure continues to require preauthorization (effective since July 15, 2009).
Issue 15 – Electronic Provider Demographic Update
The Electronic Provider Demographic Update is now available on HEALTHeNET.
Postoperative Pain Management
We want to keep you informed about our reimbursement policy for postoperative pain management.
Issue 13 – Referrals for Genesee and Niagara County
Referral requests for Child Health Plus (CHP), Family Health Plus (FHP), and Medicaid Managed Care (MMC) programs in Genesee and Niagara counties can be requested by fax or phone only.
Issue 12 – Patient-Centered Medical Home After-Hours Pilot Revision
We are changing our payment methodology for Patient-Center Medical Home (PCMH) providers.
Issue 11 – New Government Programs Fax Number
Effective May 15, 2013, the government programs grievance and appeal fax number changed.
Issue 10 – Fee Schedule Update for Durable Medical Equipment
Effective August 15, 2013, our Medicaid, Commercial, and Medicare Advantage fee schedules will be updated for durable medical equipment (DME), orthotic and prosthetic (O&P), and medical/surgical supplies.
Issue 9 – Program Participation to End in Genesee and Niagara Counties
Effective July 1, 2013, BlueCross BlueShield of Western New York will no longer participate in the Child Health Plus (CHP), Family Health Plus (FHP), and Medicaid Managed Care (MMC) programs in Niagara and Genesee counties.
Issue 8 – Drug Therapy Guideline Updates
Updated guidelines will be effective June 15, 2013.
Issue 7 – Medicare Advantage Fee Schedule Update
Effective August 1, 2013, our Medicare Advantage Fee Schedule will be updated.
Issue 6 – Gold Card Changes for NIA
Effective May 15, 2013, there will be a change in the National Imaging Associates (NIA) preauthorization process.
Issue 5 – Gold Card Changes
Effective May 15, 2013, there will be a change to Gold Card procedures.
Issue 4 – Chiropractic Updates
There is a new chiropractic section on the BlueCross BlueShield of Western New York provider website.
Issue 3 - Update Your Information for Access and Availability Standards
This notice is to ensure your office is aware of the New York State Department of Health (NYSDOH) access and availability requirements and the penalty for non-compliance.
Issue 2 - Billing Guidelines for Implantable Devices
Effective May 15, 2013, we will be implementing some changes to our claim system that will require strict adherence to our established billing guidelines for implantable devices.
Issue 1 - Drug Therapy Guidelines
The attached updated guidelines will be effective March 15, 2013. This update is a result of the annual guideline review and new drug evaluations performed quarterly by our Pharmacy and Therapeutics Committee.
Issue 26 - Medicare Duplicate Claims
Our electronic claims vendor, Administrative Services of Kansas (ASK), implemented new edits to ensure Medicare coordination of benefit (COB) claims have sufficient time to process.
Issue 27 - Medicare Advantage Direct Pay Benefit Changes
Effective January 1, 2014, coverage for the following services for Medicare Advantage Senior Blue and Forever Blue Medicare Direct-Pay plans will change: •Part B Drugs •Routine Transportation Services
Issue 28- Drug Therapy Guideline Updates
The attached updated guidelines will be effective December 15, 2013.
Issue 29 - Durable Medical Equipment and Orthotics Reminder for Chiropractors
Our Chiropractic Program follows the Medicare guidelines for ordering and dispensing Durable Medical Equipment (DME) and Orthotics to patients.
Issue 30 - F raud, Waste and Abuse Training
We have been notified by the Centers for Medicaid & Medicare Services (CMS) that fraud, waste, and abuse training is required for all persons who provide health or administrative services to Medicare Part C or Part D enrollees.
Issue 31 Verisk Health
Effective January 1, 2014, BlueCross and/or BlueShield companies will begin using Verisk Health, an experienced health care analytic services company, to retrieve medical records for out-of-area members or from providers in other Blue Plan service areas to support HEDIS, risk adjustment, and government-required programs related to the Affordable Care Act.
Issue 32 - Updated Claim Process for Digital Breast Tomosynthesis
The way claims are processed for digital breast tomosynthesis (three-dimensional mammography) will change effective Feb.1, 2014.
Issue 33 - 2014 Fee Schedule Announced
BlueCross BlueShield of Western New York has issued an updated Standard Commercial and Medicare Advantage Fee Schedule that takes effect April 1, 2014.
Issue 34 - 2014 Behavioral Health Fee Schedule Announced
BlueCross BlueShield of Western New York has issued an updated Behavioral Health Fee Schedule that takes effect April 1, 2014.