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January 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
  • Any other changes to your practice information

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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Self-administered specialty drug claim processing reminder
As a reminder, beginning January 1, 2014, Blue Cross and Blue Shield of New Mexico (BCBSNM) expanded its claims processing system edit to redirect professional electronic (837P) and paper (CMS-1500) claims for fertility, oral oncology and various other select self-administered specialty drugs.* Specialty drugs approved by the U.S. Food and Drug Administration (FDA) for self-administration must be billed under the member’s pharmacy benefit for members to receive coverage consideration.
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GuidedHealth® helps identify drug therapy opportunities
At Blue Cross and Blue Shield of New Mexico (BCBSNM), we understand that medication therapy can be an essential part of a member’s overall treatment plan. That’s why we use the GuidedHealth clinical rules platform to conduct periodic reviews to help to identify opportunities that can positively impact members’ medication therapy. 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.
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Quick Tip: Check your records for outdated drug codes
When billing with National Drug Codes (NDCs) on medical professional/ancillary electronic (837P) or paper (CMS-1500) claims, it is important to ensure that the NDC used is valid for the date of service. This is because NDCs can expire or change. An NDC’s inactive status is determined based on a drug's market availability in nationally recognized drug information databases. Additionally, an NDC is considered to be obsolete two years after its inactive date. It is a good idea to conduct a periodic check of records or automated systems where NDCs may be stored in your office for billing purposes. To help ensure that correct reimbursement is applied, the NDC on your claim should match the active NDC on the medication’s current label or packaging. Inactive products will continue to be reimbursed until they become obsolete.

For quick tips to assist you with billing for drugs on medical claims, please visit our Provider website at bcbsnm.com/provider. Refer to the Provider Reference Manual, located under the Standards and Requirements tab, to review NDC billing guidelines. You’ll also find answers to Frequently Asked Questions in the Claims and Eligibility, Submitting Claims section. 

BCBSNM disease management programs support physicians
Our disease management (DM) programs are based on the belief that to optimize health outcomes, patients with chronic health conditions are best served by a collaboration of their physician’s professional clinical care and self-care (the actions patients take to manage their conditions).
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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 regional map

Patient benefits accessibility during annual updates
Blue Cross and Blue Shield of New Mexico (BCBSNM) is working to incorporate the 2014 benefit changes elected by our groups and retail market policy holders. Providers performing an online inquiry for eligibility or benefits for these members may be instructed to contact Customer Service to obtain the information until the systems are updated.

During this time, we anticipate an increase in our call volumes, which may result in extended hold times through February due to the large number of policy changes underway. We are requesting you to postpone eligibility and benefits requests for patients who are not scheduled for an appointment in the future or in need of immediate treatment or service.

Learn what’s new on iEXCHANGE® for 2014
Effective January, 1, 2014, Blue Cross and Blue Shield of New Mexico is enhancing iEXCHANGE, its web-based preauthorization tool, to support requests for additional behavioral health, pharmacy and medical/surgical services.
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A Closer Look: Documentation and coding for pulmonary diagnoses
On October 1, 2014, all HIPAA-covered entities must transition from ICD-9-CM to the ICD-10-CM/PCS code sets. At that time, claims with ICD-9-CM codes will not be accepted unless they are for service dates or discharge dates prior to October 1, 2013.
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Code Correctly – Avoid the ICD-10 coding pitfalls!
Blue Cross and Blue Shield of New Mexico (BCBSNM) conducted preliminary ICD-10 testing with a subset of providers in 2012 and 2013. Although we are planning a larger scale testing phase in second quarter 2014, we wanted to share some of the common issues identified in our initial testing. Submitting claims with the following errors after October 1, 2014, may delay or negatively impact reimbursement.
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Providers who have joined or left the BCBSNM network, November 2013
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care (BlueSaludSM).
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Blue Cross Community CentennialSM (Medicaid)

Not yet contracted?
Blue Cross and Blue Shield of New Mexico’s (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.

Registration is required for Centennial Care
The Human Services Department (HSD) requires any provider who files a New Mexico (NM) Medicaid claim with a Managed Care Organization (MCO) for Centennial Care, and is not currently enrolled as either a Fee for Service (FFS) or Managed Care only provider to register on the NM Medicaid Provider Web Portal.
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ATTENTION: Blue Cross Community Centennial Providers
Blue Cross Community Centennial membership cards that were released on January 2, 2014, were printed with the incorrect group number, nm000001. The correct group number is N72100.

Corrected cards will go out on Monday, January 13, 2014.

This will not affect claims payment as claims are processed under the member name and ID, and not the group number.

  • Provider Customer Service – 1-800-693-0663
  • Preauthorization and Out-of-Network Referrals – 1-877-232-5518
  • Preauthorization Fax – 505-816-3854
  • Utilization Management Member Appeals – 1-877-232-5520
Medicaid providers:  Learn what’s new on iEXCHANGE® for 2014
Effective January 1, 2014, Blue Cross and Blue Shield of New Mexico is enhancing iEXCHANGE®, its web-based preauthorization tool, to support requests for additional Behavioral Health and Pharmacy services.
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Electronic Claim Submission Alert for Atypical Providers
According to the National Provider Identifier (NPI) Final Rule, issued by the U.S. Department of Health and Human Services, atypical providers are individuals or organizations that furnish nontraditional or atypical services that are indirectly health care-related (such as taxi, home and vehicle modifications, habitation and respite services).*
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Preauthorization process
The Blue Cross and Blue Shield of New Mexico (BCBSNM) Utilization Management department is honoring all preauthorizations for services that the member had in place when they transferred to BCBSNM for up to 90 days.
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Services are funded in part under 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.


2013 Medicaid medical record content review report
The Medical Record Content Review is performed to assess provider compliance with the BlueSaludSM medical record documentation standards. The results are reported to internal key parties annually for analysis and recommendations for future action. During the period, July 1, 2012 – June 30, 2013, 267 medical records were reviewed for 68 providers at 60 office sites.  The providers reviewed were primary care providers (PCPs) and OB-GYN providers who had seen Medicaid members during the above timeframe. Each provider had 1-5 member charts reviewed based on claims data. The results were impressive and are shown in the table below:
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Services are funded in part under contract with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico is a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee 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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