| April 2012 Please distribute this newsletter, which contains claims, billing, Medical Policy, and other important information, to all health care providers and administrative staff that this e-mail address represents. Thank you. Blue Review: Share the wealth!Each issue of Blue Review is packed with valuable information. It is very important that you share Blue Review with your billing departments/entities. Many issues contain articles relevant to department employees, such as system and coding updates, billing and reimbursement, new account groups, federal mandates, and electronic commerce solutions. You can find Blue Review online. Do we have your correct information? Clinical Practice Guidelines update Recognizing that practitioners are busy, we have designed CPGs as quick summaries. CPGs summarize national, evidence-based recommendations that are appropriate for most patients with the condition. Individual patients, however, may have unique needs, indications, and contraindications. The practitioner must always apply clinical judgment to an individual patient. We consider CPGs a starting point or “shared baseline.” Certain elements within a given CPG will be measured to determine the extent to which our members are receiving evidence-based care. These elements are called “core elements” and are marked in bold text in the Guidelines. Annually, we monitor these elements to determine effectiveness of the CPGs, and will inform you of the results in this newsletter later this year. CPGs are free and downloadable as PDF documents. In addition, you will find links to the detailed national guidelines for each clinical topic. We encourage you to access the full guidelines, as they provide in-depth coverage of the management of these common illnesses. Medical Policy updates While information on new or revised Medical Policies is also published in this newsletter for your convenience, please visit our website for access to the most complete and up-to-date information. For example, due to time constraints, the following list of new or revised policies may not be complete as of the date of publication. If you have any questions about BCBSNM's Medical Policies, please call the Office of the Medical Director at (505) 816-2093.
Case management services for members | ||||||||||||
Case managers work closely with the member's medical team to develop and coordinate plans of care for members. Case managers work with care teams by phone and sometimes on-site. They may also coordinate activities with home health agencies and outpatient care providers, who will be providing services for members, to help facilitate a speedier return to home and family. For more information on our Case Management Program, please view our Case Management flier or call 866-252-8107, extension 2585. Credentialing process presentation now available | ||||||||||||
The Credentialing Process Presentation, additional credentialing information, and forms can be found in the Network Participation/How to Join section of our website. Pharmacy program: Fax form updatesBCBSNM is completing the last steps in our transition of pharmacy utilization management to Prime Therapeutics®. Faxed requests for review are required in some situations for BCBSNM commercial members with prescription drug coverage administered by Prime. A new Dispensing Limit Override Physician Fax Form is available to help expedite the review process. Please continue to contact BCBSNM Pharmacy Services for all BlueSaludSM preauthorization requests. Visit the Pharmacy Program section of our website for more information, along with links to the appropriate fax forms. The form links on our website will direct you to the Prime Therapeutics site. This will help ensure you are using the most current version of each form. The fax number for submitting pharmacy review requests to Prime is 877-243-6930. The telephone number for Prime's Clinical Review Department is 800-544-1378. The above contact information for Prime is indicated on each fax form. Due to recent updates, this information may be different from what you currently have on file. Please remember to recycle any fax forms you may have printed previously. Some pharmacy programs may not apply to all prescription drug benefit plans. To determine specific benefit plan details, call the Pharmacy Program number listed on the back of the member's ID card. The final decision regarding what medicines should be prescribed, regardless of the benefit determination, is a decision between the patient and his or her doctor. Prime Therapeutics, LLC, is a pharmacy benefit management company. BCBSNM contracts with Prime Therapeutics, a separate company, to provide pharmacy benefit management and other related services. BCBSNM, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics, LLC. Provider education webinars available
Visit our Provider Training page for more information and to register. If you have questions, please email us. Provider tip sheets offered As a complement to the general Eligibility and Benefits tip sheet for the Availity tool, the following specialty-focused versions are available: | ||||||||||||
If your specialty is not listed above and you would like to request customized instruction, please email PACS@bcbsnm.com. Not yet registered with Availity? Visit availity.com for details, or call Availity Client Services at 800-AVAILITY (282-4548) for assistance. Availity is a registered trademark of Availity, LLC, an independent third-party vendor. BCBSNM makes no endorsement, representations, or warranties regarding any products or services offered by Availity. The vendor is solely responsible for the products or services offered by it. If you have any questions regarding the services offered here, you should contact the vendor directly. Get answers faster with online Claim Inquiry Resolution (CIR) Currently, we accept five different types of inquiries through the CIR tool: | ||||||||||||
To help you navigate this helpful tool, view our CIR Tip Sheet. If you have questions or need assistance, email our Provider Access Channel Specialist team. *You must be enrolled for eRM in order to gain access to the CIR tool. CIR may not be accessed through our Customer Advocates on the phone. CIR cannot be used to obtain eligibility and benefit information, claim status, claim appeal, predeterminations, or pended claims. Please refer to the CIR Tip Sheet for additional details. Office Staff Call Network Services at 800-567-8540 or (505) 837-8800 to make demographic changes, check new contract status, obtain existing contract copies, make changes to an existing contract (e.g., business name or tax ID), or to terminate an existing contract. Network Services contacts and related service areas Billing IV infusion and injection procedures When providing IV infusions and injections, it is crucial that your claims include the CPT® or HCPCS code for the procedure, along with the applicable National Drug Code (NDC) for each J code for the drugs which have been infused and injected (and a detailed description of the drug(s) if the generic code J9999 is used). By omitting the proper codes, you deny yourself potential reimbursement for the drug(s) to which you may otherwise be entitled. You also deny BCBSNM the opportunity to determine whether the infusion or injection is within your scope of practice and whether it is experimental, investigational, medically necessary, in conformance with BCBSNM medical policy, and otherwise a covered benefit for the member. If IV infusions and/or injections are billed without the NDC for each J code, BCBSNM reserves the right to request such information from you before the claim is released for adjudication. If the requested information is not provided, the claim may be denied. We sincerely appreciate and value your continued participation with BCBSNM. If you have any questions, please contact your Provider Representative at (505) 837-8800 or 800-567-8540. BlueSalud Ideally, the discussion about AD should occur when an individual is healthy, which makes the primary care office an ideal setting for AD discussion. While studies have shown that primary care providers (PCPs) think that discussing AD will make their patients uncomfortable, studies have also shown that PCP initiation of advance care planning discussions has a positive effect on patients completing AD. Inquiring about or presenting this topic to each new patient can provide a systematic approach for addressing advance care planning and AD. In addition, this information can be revisited with each patient annually to ensure there are no changes. The New Mexico Administrative Code (NMAC) 8.305.8.17 states that managed care organizations shall enforce that Medicaid contracted providers document advanced directive information for all adult patients. For your convenience, the BlueSalud Provider Reference Manual has a New Mexico Optional Advance Health Care Directive Form that you and your patients may use to document AD (see page 67 of the Provider Reference Manual PDF). If you have any questions about AD, please contact Nicole Casados, RN, at (505) 816-2238. Updates to the BlueSalud Drug List Ideas for articles and letters to the editor are welcome; e-mail NM_Blue_Review_Editor@bcbsnm.com. BCBSNM makes no endorsements, representations, or warranties about any products or services offered by independent third-party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions about the products or services mentioned in this newsletter, contact the vendor directly. |
BlueSalud services are funded in part under contract with the State of New Mexico.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.