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April 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 e-mail address
  • Retired
  • Any other changes to your practice information

Talking with Health Services staff
Blue Cross and Blue Shield of New Mexico (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. (Mountain Time). After hours callers can leave a message and receive a call back the next business day.

  • For Commercial members, call 800-325-8334
  • For Medicaid members, call 877-232-5518
  • For Medicare members, call 877-774-8592

A Medical Director is available to address care management requests with providers at 505-816-2957.

When calling your office, Health Services staff members identify themselves as BCBSNM employees and give their names and titles. TTY/TDD and language translation services are available for callers who may need assistance.

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 505-816-2957. In addition, all medical policies are available for review online in the Providers section of bcbsnm.com.

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

Commercial Drug List Updates

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.

First quarter pharmacy optimization initiative highlights
BCBSNM would like to introduce a new feature on our Provider website. This year, at the end of each quarter, we’ll be posting a summary of recent pharmacy initiatives and program enhancements. These quarterly highlights will include helpful links to articles and related resources.

Here is a quick preview of first quarter topics:
  • Self-administered specialty drug claim processing reminder
  • Checking your records for outdated drug codes
  • Fourth quarter 2013 GuidedHealth® program updates
  • Electronic options for prescription drug prior authorization requests

Watch for the new Pharmacy Optimization Initiative 1st Quarter 2014 Highlights link on the Home Page of our website.

GuidedHealth is a registered trademark of Prime Therapeutics, LLC (Prime), a pharmacy benefit management company. BCBSNM contracts with Prime to provide pharmacy benefit management, prescription home delivery, and specialty pharmacy services. BCBSNM, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSNM makes no endorsement, representations, or warranties regarding GuidedHealth. If you have any questions about this product or services, you should contact Prime Therapeutics, LLC, directly.

When our members speak, we listen!
Commercial members
The results from the 2013 Consumer Assessment of Healthcare Providers and Systems (CAHPSTM) combined HMO/PPO survey in 2013 indicated that many of the measures improved over the 2012 results. Key findings include the percent of BCBSNM commercial members who said they were “always” or “usually” satisfied with:
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Findings from the 2013 annual HEDIS audit
Commercial members
Using the nationally standardized Heathcare Effectiveness Data and Information Set (HEDIS), we are able to assess how the quality of our members’ health care in 2012 compared with national averages. As shown in the table below, our commercial members are exceeding the national average on several measures:
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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 in claims processing efficiency
In the April and July 2013 issues of the Blue Review, we informed you that BCBSNM will begin accepting partial batches, rejecting only individual claims that do not meet HIPAA compliance standards. These enhancements will be effective in April 2014.

When you transmit ANSI 5010 837 professional or institutional claim file(s), BCBSNM will forward all valid and successful claims for processing and adjudication. Our payer response reports will indicate which claims were rejected so that those claims may be corrected and resubmitted as appropriate. The entire batch of claims should not be resubmitted, as this will result in duplicate claims within the adjudication process.

If you use a billing service or clearinghouse to submit claims on your behalf, please be sure they are aware of this information.

If you have any questions about this notice, please contact our Electronic Commerce Center at 800-746-4614 for further assistance.

Medicare crossover claims process reminder
Blue Cross and Blue Shield Plans have been using the Centers for Medicare & Medicaid Services (CMS) crossover process to receive Medicare primary claims since January 2006. The CMS crossover process routes Medicare Supplemental claims (Medigap and Medicare Supplemental) directly from Medicare to BCBSNM so that providers do not need to submit their claims to BCBSNM. Over the years, this Medicare crossover process has increased efficiency by requiring one claim submission which reduces duplicate submissions, improves payment accuracy, and increases member and provider satisfaction.
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A closer look: Documentation and coding for behavioral health disorders
In this month’s issue of Blue Review, we are taking a closer look at behavioral health disorders. Behavioral health disorders are categorized by intense alterations in thinking, mood, and/or behavior over time and can be difficult to diagnose as they are often accompanied by multiple and similar symptoms. While the Diagnostic and Statistical Manual of Mental Disorders (DSM-5,®) is used to assess and diagnose the patient, the ICD-9-CM coding system is required for reimbursement.
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Providers who have joined or left the BCBSNM network, February 2014
This list reflects contracted providers for all lines of BCBSNM business: Commercial and Medicaid managed care.
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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.

Medicaid reminders
Federal requirements for Medicaid health plans specify that certain benefits and services be available to Medicaid members. These include:
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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program
EPSDT is a federally mandated program ensuring comprehensive health care to Medicaid recipients from birth to 21 years of age. EPSDT is defined as:
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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.


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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