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February 2014

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; email 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 email address
  • Retired
  • Made any other changes to your practice information

Be in the know!
Did you get the Blue Review in your email inbox?

Blue Cross and Blue Shield of New Mexico (BCBSNM) regularly communicates with providers via email. Due to the ever-evolving health care market in New Mexico, including the Exchange and the implementation of Centennial Care, there are many changes that we would like to get to you in a timely manner. The fastest way for us to get information to you is via electronic communication.

In addition to the monthly provider newsletter, we also send out important information on topics such as:

  • Claims and billing
  • Government mandates
  • Medical policies
  • Educational webinars
  • Clinical Practice Guidelines
  • Pharmacy program updates
  • HEDIS results
  • Provider satisfaction survey results
  • Quality improvement updates
  • Disease management
  • How to obtain clinical criteria
  • How to access Utilization Management staff
  • System enhancements and availability

Please complete our quick and easy online form to ensure that you are receiving critical communications.

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.
View full story

New networks explained
With the many changes occurring as a result of the Affordable Care Act, there may be some confusion on the types of plans and reimbursement rates. BCBSNM offers several plans on the Health Insurance Exchange at different reimbursement rates.

  • Plans that use the commercial PPO network are reimbursed at the provider’s contracted commercial rates. These plans are offered statewide both on and off the Exchange. The ID cards indicate PPO.
  • Plans that use the Blue Advantage HMO NetworkSM are available only in the four counties of Bernalillo, Sandoval, Torrance, and Valencia and are reimbursed at the Blue Advantage fee schedule rates. The ID cards indicate BAV.
  • Plans that use the Blue CommunitySM HMO network are offered exclusively on the Health Insurance Exchange and are reimbursed at the Blue Community rates. These plans are offered statewide. The ID cards indicate CNN. Blue Community HMO was developed with the intent to be affordable for all, in response to the Affordable Care Act. In order to achieve this, BCBSNM created a fee schedule that allows accessible care to those who need it most.

Behavioral Health Program to utilize ASAM criteria
The BCBSNM Behavioral Health Program has adopted the American Society of Addiction (ASAM) Medicine Criteria – The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions – as the behavioral health clinical screening criteria for patients with addiction disorders for all levels of care. This change will apply to all commercial, retail and Medicare Advantage plans effective April 1, 2014. BCBSNM currently uses The ASAM Criteria for Blue Cross Community CentennialSM. The most recent version of The ASAM Criteria was released in October 2013, following a review by a team of adult and adolescent addiction treatment specialists and an extensive field review process. 
View full story

iEXCHANGE adds behavioral health requests for intensive outpatient program
As we announced in the January Blue Review, iEXCHANGE, our Web-based preauthorization tool, has been enhanced to support behavioral health preauthorization requests that fall under the intensive outpatient program.
View full story

ICD-10 Resource Guide now available online
Later this year, all HIPAA-covered entities will be required to transition from using ICD-9 codes to using ICD-10 codes. The transition requires careful planning for practices of all sizes to meet the Oct. 1, 2014, deadline. BCBSNM has created an online resource guide to help providers prepare for the transition.

The resource guide will be available soon on the
ICD-10 page of the Standards and Requirements section on the Provider website. The guide contains information and many resources to help your practice get ready for ICD-10. Learn about:
  • The benefits of being prepared
  • Financial implications of ICD-10
  • Training and education resources
  • Industry and government guides

In addition to the resource guide, continue to read the Blue Review over the coming year for information about ICD-10. More ICD-10 topics can be found in previous issues of the Blue Review, available online in the News and Updates section of the Provider website.

ICD-10 testing at BCBSNM
The U.S. Department of Health and Human Services has mandated that as of Oct. 1, 2014, all HIPAA transactions must use ICD-10 codes where ICD-9 codes are currently used. In anticipation of this transition date, BCBSNM has published regular articles in the Blue Review and provided information on the Provider website.

In 2014, we will continue to publish information that may help providers with their transition to ICD-10. We will be conducting end-to-end testing with a select number of providers this year. Our testing will cover a wide range of provider types and specialties as well as a broad scope of claims scenarios. This approach will enable us to share testing results and information with our entire provider community over the coming months that will address many potential transition risks.

For more information about the transition to ICD-10, continue to read future issues of the Blue Review, and visit the Standards and Requirements/ICD-10 section of the Provider website.

A closer look: Documentation and coding for diabetes diagnoses
In last month’s Blue Review, we took a closer look at documentation and coding for pulmonary diagnoses as part of our effort to provide more information that may help with the transition to ICD-10, Risk Adjustment and more. This month, we look at diabetes, a group of metabolic diseases that includes chronic and short-term conditions such as diabetes mellitus, gestational diabetes and impaired glucose tolerance. The conditions that fall under this category can sometimes be asystematic and other times can develop complications. It is imperative that documentation is specific and accurate to facilitate accurate, complete and compliant diagnosis code assignment.
View full story

Tetanus, diphtheria and pertussis vaccinations for pregnant women
The Advisory Committee on Immunization Practices (ACIP) recommends that providers should administer a dose of Tetanus, Diphtheria, and Pertussis (Tdap) during each pregnancy irrespective of the patient’s prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks of gestation, although Tdap may be given at any time during pregnancy.
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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

Update on confirming eligibility for BCBSNM members
With the new federal requirement for individuals to have insurance coverage beginning January 1, 2014, along with new commercial groups with coverage starting January 1, 2014, BCBSNM is pleased to be serving many new members. There are some important things to be aware of when verifying eligibility:
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Electronic Fund Transfers (EFTs) changing to daily
BCBSNM is focused on improving the process of how electronically transferred funds are received by providers. BCBSNM is standardizing our practice to pay providers on a daily basis to ensure even more efficient receipt of claim payments and remittance advices/claims summaries. Beginning January 2014, BCBSNM will be moving providers that are receiving weekly EFTs to daily EFTs.
View full story

Are you submitting professional paper claims? You may need to take action!
As a reminder, payers began accepting the revised version of the CMS-1500 paper claim form (version 02/12) as of Jan. 6, 2014. According to the transition timeline announced by the National Uniform Claim Committee (NUCC), payers will accept claims submitted on either the revised form (02/12) or the previous version (08/05) through March 31, 2014. After this date, the dual-use period will end and payers will receive and process only those claims that are submitted on the revised CMS-1500 claim form (version 02/12).

As part of the transition, you may need to:

  • Order new paper claim forms – Refer to the NUCC website at nucc.org for details.
  • Talk with your vendor(s) – Is your software vendor, billing service or clearinghouse prepared to accommodate changes?
  • Consider switching to electronic claim submission – Visit the Claims and Eligibility/Electronic Commerce section of our website to learn more.

ACA Grace Period
The Affordable Care Act (ACA) includes a provision that allows health insurance exchange enrollees who receive the advance premium tax credit (APTC), a three-month grace period to pay their premium — provided they have already paid at least one month’s premium in full. It is important to note that not all members who purchase coverage on the health insurance exchange will receive the APTC.
View full story

Administrative Simplification updates, reminders and resources
BCBSNM has updated its systems and business processes for the Administrative Simplification Phase III Operating Rules for 835 Electronic Funds Transfer (EFT) and 835 Electronic Remittance Advice (ERA), as mandated under the Affordable Care Act (ACA). The 835 EFT/ERA operating rules were authored by the Committee on Operating Rules for Information Exchange (CORE), which is part of the Council for Affordable Quality Healthcare (CAQH) initiative. By increasing uniformity when exchanging health care data, the operating rules are intended to help promote greater adoption and utilization of electronic transactions.
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Providers who have joined or left the BCBSNM network, December 2013
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care.
View full story

Blue Cross Community CentennialSM (Medicaid)

Not yet contracted?
BCBSNM’s Medicaid plan is Blue Cross Community Centennial.

Providers who are participating in commercial BCBSNM products are not automatically participating providers in Blue Cross Community Centennial. To become a Blue Cross Community Centennial provider, you must sign a Medicaid amendment to your Medical Services Entity Agreement (MSEA).

If you have any questions please call 505-837-8800 or 1-800-567-8540 if you are interested in becoming a Blue Cross Community Centennial provider.

Pharmacy Preauthorization Process
BCBSNM uses online edits at the pharmacy point-of-sale and a preauthorization process to assure that Blue Cross Community Centennial members are receiving medications and dosages that are safe and efficacious. Preauthorizations for Blue Cross Community Centennial members may be requested by fax, electronically, or telephonically.

Information about services that require preauthorization or have other dispensing limitations may be accessed on the Medicaid page of our website under the Rx Drugs section:

To request pharmacy preauthorizations:

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

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