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March 2013

Please distribute this newsletter, which contains claims, billing, Medical Policy, reimbursement, and other important information, to all health care providers, administrative staff, and billing departments/entities that this email address represents.  
You can find Blue Review online!

Ideas for articles and letters to the editor are welcome; e-mail NM_Blue_Review_Editor@bcbsnm.com

Do we have your correct information?
Maintaining up-to-date contact and practice information helps to ensure that you are receiving critical communications and efficient reimbursement processes. Please complete our quick and easy online form if you have:

  • Moved to another location
  • Left a group practice
  • Changed your phone number
  • Changed your e-mail address
  • Retired
  • Any other changes to your practice information

Keep up-to-date with the latest news and updates!
Along with all the valuable information included in our Blue Review newsletter, the News and Updates section of our website gives the latest updates in webinar schedules, current programs, and policies.

The eCommerce Alerts section provides notification of system enhancements, upgrades, new functionality, and any Electronic Data Interchange (EDI) transaction issues that may affect claims processing, payment, or remittance delivery.

We periodically update the forms on our provider website, so it’s important to check often to help ensure you are using the most current version. Forms are organized by category in our Education and Reference section.

Be sure to visit us online at bcbsnm.com/provider to access the most updated information.

Member rights and responsibilities
Our health plan members have rights and responsibilities that are listed in their Benefit Booklet or Member Handbook. Some members—for example, members with BlueDirect® and BlueEdgeSM plans—can also find these documents in the member section of our website.

Medical Policy updates
Approved new or revised Medical Policies and their effective dates are posted on our website the first day of each month. These policies may impact your reimbursement and your patients’ benefits. You may view all active and pending policies or view draft Medical Policies and provide comments.
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Provider Reference Manual updates
The Blues Provider Reference Manual on our website is updated throughout the year. We recently posted the 2013 version of the manual, so there are no updates at this time. Please note that any changes might not be current in the print and CD-ROM versions; always refer to bcbsnm.com for the most current information.

Talking with Health Services staff
BCBSNM Health Services staff members are available to receive incoming calls, make outbound calls, and discuss care management issues with members and providers Monday through Friday, 8 a.m. to 5 p.m. MT, toll-free, at 800-325-8334. The medical director is available to address care management requests at 505-816-2093. When returning your call or otherwise calling your office or home, Health Services staff members identify themselves as BCBSNM employees and give their names and titles.

Utilization management determinations

Utilization management (UM) determinations are made by licensed clinical personnel based on the benefit policy (coverage) of a member’s health plan, evidence-based medical policies, and the medical necessity of care and service. BCBSNM does not provide any reward or incentive to employees, providers, or other individuals for decisions that result in determinations that services are not covered, nor do we reward providers for underutilization of services.

If you have questions about criteria for UM decisions and official medical policy, or if you wish to discuss a UM coverage determination, you may contact a medical director at 505-816-2093. In addition, all medical policies are available for review online under the Standards and Requirements tab in the Providers section of bcbsnm.com.

System edit for self-administered specialty drugs when billed on professional/ancillary claims
For medications that are approved by the U.S. Food and Drug Administration (FDA) for self-administration, BCBSNM members are required to use their pharmacy benefit and acquire self-administered drugs (oral, topical, and injectable) through a pharmacy provider. Self-administered drugs must be billed under the member’s pharmacy benefit for your patients to receive coverage.
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Preparing for ICD-10: Staff training
We’re just six months away from the Centers for Medicare & Medicaid Services (CMS) recommended deadline for providers to begin internal system testing for ICD-10. At this point, you should have a plan in place to train all staff impacted by the changes from ICD-10.
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HEDIS® Update
Using the nationally standardized Healthcare Effectiveness Data and Information Set (HEDIS) measures to assess effectiveness of care, BCBSNM has found that its members are receiving noteworthy care for some of those measures. While there were improvements in several areas of measurement, some areas showed a decrease in improvement.
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CAHPS® survey results
During 2012, BCBSNM performed its annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) for both the HMO/PPO and Medicaid lines of business. Overall results were very good with members showing increased satisfaction in the Overall Health Plan rating composite. The HMO/PPO Plan members had the most satisfied respondents last year with an increase of 56–63 percent, ranking BCBSNM an 8, 9, or 10 in which 10 is the best health plan possible.
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Office Staff

Claims inquiries? Call the Provider Service Unit (PSU) at 888-349-3706
Our PSU handles all provider inquiries about claims status, eligibility, benefits, and claims processing for BCBSNM members. For out-of-area claims inquiries, please call the BCBSNM BlueCard PSU at 800-222-7992.

Network Services contacts and related service areas

Network Services regional map

Enhancements to ClaimsXtenTM Code Auditing Tool
BCBSNM will implement an expanded version with the new 2013 CPT/HCPCS codes and additional bundling logic to the ClaimsXten code auditing tool into our claim processing system beginning on or after May 5, 2013.  
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Take advantage of electronic options for faster, more convenient payments
The electronic options offered by BCBSNM can make it easier to do business with us. Your office workflow is streamlined when you opt to receive claim payments, remittance information, and payment summaries online.  
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ABQ Health Partners Extends Urgent Care Center Hours at Three Locations
As of December 26, 2012, ABQ Health Partners will have longer hours at three of its urgent care centers. The three centers, Montgomery Urgent Care, Rio Rancho Urgent Care, and Journal Center Urgent Care will now be open from 7 a.m. to 7 p.m, seven days a week. The longer hours are part of ABQ Health Partners' efforts to implement a coordinated system of care that treats patients according to their needs.

Providers who have joined or left the BCBSNM network, January 2012
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care (BlueSaludSM).
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Not yet contracted for BlueSalud?
Providers who are participating in commercial BCBSNM products are not automatically participating providers in BlueSalud. To become a BlueSalud provider, you must sign a Medicaid amendment to your Medical Services Entity Agreement (MSEA). Please contact the Network Services Department at (505) 837-8800 or 800-567-8540 if you are interested in becoming a BlueSalud provider.

BlueSalud continues to reimburse providers for entering vaccine data into New Mexico Statewide Immunization Information System (NMSIIS)
NMSIIS is an Internet database that records and tracks immunization dates for children and adults in New Mexico. NMSIIS makes vaccine records more available; helps keep New Mexicans on track for recommended immunizations; and gives practitioners, school nurses, parents, and others a tool to further improve immunization rates. The goal of NMSIIS is to ensure that all New Mexicans are properly immunized against vaccine-preventable diseases.
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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program for BlueSalud members
EPSDT is a federally mandated program ensuring comprehensive health care to Medicaid recipients from birth to 21 years of age.
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BlueSalud services are funded in part under a 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.

P.O.Box 27630, Albuquerque, NM 87125-7630

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