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October 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.
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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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Countdown to ICD-10: Less than a year to go
The October 1, 2014 deadline to transition to ICD-10 is now less than a year away. Professional providers, facilities, payers, and health information technology vendors all must comply with the federal mandate. According the Centers for Medicare & Medicaid Services (CMS), providers of all sizes should have already begun transition activities by January 2013.
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2013-2014 season reminders for Synagis®
The Respiratory Syncytial Virus (RSV) season is upon us. We would like to take this opportunity to remind you of some important details regarding Synagis (palivizumab) intramuscular (IM) injections for the prevention of serious lower respiratory tract infection caused by RSV.
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Administrative Simplification operating rules update
The Affordable Care Act (ACA) mandates implementation of new Administrative Simplification operating rules to promote greater uniformity in the exchange of electronic health care data. The Committee on Operating Rules for Information Exchange (CORE) is part of the Council for Affordable Quality Healthcare (CAQH) initiative. CAQH CORE has authored operating rules to be implemented in phases for HIPAA-standard electronic data interchange (EDI) transactions.
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Self-administered specialty drug update: Infertility and oral oncology drugs 

As a reminder, drugs approved for self-administration by the U.S. Food and Drug Administration (FDA) should not be submitted on professional/ancillary electronic (ANSI 837P) or paper (CMS-1500) claims.  Blue Cross and Blue Shield of New Mexico (BCBSNM) members are required to use their pharmacy benefit for U.S. FDA-approved self-administered specialty drugs (oral, topical, and injectable) and obtain these medications through a pharmacy provider that is contracted to provide specialty pharmacy services.  
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Evidence-based clinical support with GuidedHealth®  
Recently, we introduced GuidedHealth, a clinical rules platform from our pharmacy benefits manager, Prime Therapeutics (Prime). This platform drives our Retrospective Drug Utilization Review (RDUR) program, which integrates medical and pharmacy claims data for generating evidence-based, medication-related recommendations for physicians and members. The GuidedHealth program targets drug therapy issues in modules such as overutilization, safety, and cost. Listed below are the programs that will be implemented during the third quarter of 2013.
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National Drug Code (NDC) pricing paves the way for related initiatives
NDC pricing will be implemented by Blue Cross and Blue Shield of New Mexico (BCBSNM) as of November 1, 2013, for drugs billed under the medical benefit on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims. As of the November 1, 2013 NDC pricing effective date, professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims for drugs must include NDC data in order to be accepted for processing by BCBSNM. If NDC data are not included as required by BCBSNM, your claim will be returned to you.
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Provider education webinars available
BCBSNM offers complimentary educational webinar sessions for our provider community and their staff. Some of the current training modules are:

  • Availity®
  • BlueCard®
  • Electronic Commerce
  • ICD-10
  • Interactive Voice Response (IVR)
  • Refund and Recoupment
  • Provider Website tour

Visit our Provider Training page for more information and to register. If you have questions, please email us.

Radiology Quality Initiative (RQI) program to include new cardiac services
Effective Jan. 1, 2014, Blue Cross and Blue Shield of New Mexico (BCBSNM) is expanding the RQI, administered by AIM Specialty Health® (AIM), to include certain additional cardiac services.
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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

Automated phone system fax back options
We recommend utilizing an online vendor portal such as Availity® (availity.com) to obtain eligibility, benefit, and claim status information. However, some practices may have limited Internet access, or may feel a phone call is more convenient at times.
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Pharmacy program transitions to electronic prior authorization (PA) process
Blue Cross and Blue Shield of New Mexico (BCBSNM) is transitioning to a new electronic process for submission of PA requests for drugs that are part of our PA program. In addition to reducing paper, the electronic PA process will help increase security of your patient’s protected health information. It is also faster—your office will receive a response in real time upon receipt and processing of each online PA request. Watch for more details in the Blue Review and News and Updates section of our website at bcbsnm.com/provider.

ClaimsXtenTM enhanced C3 screen
Effective on or after October 14, 2013, Blue Cross and Blue Shield of New Mexico (BCBSNM) will enhance the Web-based code auditing reference tool, Clear Claim ConnectionTM (C3). This is available to registered users of Availity or RealMed®. The changes include the addition of the following fields:
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Providers who have joined or left the BCBSNM network, August 2013
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care (BlueSaludSM).
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BlueSaludSM and Blue Cross community CentennialSM

Not yet contracted for BlueSalud? What about Centennial Care?
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).

BlueSalud is effective through December 31, 2013. Beginning January 1, 2014, BCBSNM will continue with the new State of New Mexico Medicaid program, Centennial Care. BCBSNM’s Medicaid plan for 2014 is Blue Cross Community CentennialSM. A New Mexico Medicaid Managed Care Amendment was mailed to BCBSNM participating providers for review. To begin treating BCBSNM’s future Medicaid managed care members on and after January 1, 2014, we ask that you please sign and return the amendment (or you may fax the entire amendment to 505-816-2688).

After the signed amendment has been received, it will be executed by BCBSNM and a signed copy will be returned to your office, with an effective date of January 1, 2014.

If you have any questions, please call 505-837-8800 or 1-800-567-8540

Centennial Care Pharmacy
Providers will experience some pharmacy-related enhancements under Centennial Care:

  • BlueSalud will become Blue Cross Community Centennial.
  • Providers will be able to submit preauthorization requests to BCBSNM electronically and receive a response electronically.
  • A single, standardized pharmacy preauthorization form will be used by all Centennial Care Managed Care Organizations (MCOs).
  • The Blue Cross Community Centennial Drug List will be expanded to provide additional therapeutic options.
  • Drugs will be covered under a single plan. Pharmacies will no longer need to submit behavioral health prescriptions from behavioral health providers to a different plan for payment.

Please watch upcoming issues of the Blue Review as well as the News and Updates section of our Provider website at bcbsnm.com/provider for additional information on pharmacy enhancements.

Services are funded in part under a contract with the State of New Mexico.

Blue Cross and Blue Shield of New Mexico refers to HCSC Insurance Services Company (HISC), which is a wholly owned subsidiary of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company. Both HISC and HCSC are Independent Licensees of the Blue Cross and Blue Shield Association.


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

© Copyright 2013. All Rights Reserved.
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