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June 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 Fcommunications 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

Important Information for Lovelace Health Plan Providers
As of June 1, 2014, Blue Cross and Blue Shield of New Mexico (BCBSNM) acquired Lovelace Health Plan commercial members and the Medicare Advantage contract. This acquisition does not include Lovelace’s hospitals, providers, pharmacies, or clinics.
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Provider Reference Manual updates
The Blues Provider Reference Manual on our website is updated throughout the year. Any updates that have occurred so far this year are located in the Table of Contents with Changes and Updates Preface page. Please note that these changes might not be current in the print and CD ROM versions; always refer to bcbsnm.com for the most current 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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In the know: Talk to your patients about medication adherence
Adherence to medications used within patient treatment plans is vital to successful outcomes. On the average, however, studies have shown that 50 percent of medications for chronic conditions are not taken as prescribed, if they are taken at all.1 Adverse effects may not be immediate, but non-adherence with prescriber instructions may be detrimental to a patient’s health over time. For example, in a study by Gehi, et al, patients who self-reported being non-adherent (taking their medications as prescribed 75 percent of the time or less) were more likely than adherent patients to develop cardiovascular events during 3.9 years of follow-up.2
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Medication adherence program moves to GuidedHealth® platform
Last year, BCBSNM introduced GuidedHealth as the clinical rules platform for our Retrospective Drug Utilization Review (RDUR) program. GuidedHealth integrates medical and pharmacy claims data to generate evidence-based, medication-related recommendations for physicians and members. On a quarterly basis, GuidedHealth letters are sent to identified members and prescribing physicians to help increase awareness and support patient safety.
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Save time on prescription drug benefit prior authorization (PA) requests
In previous issues of Blue Review, we announced the availability of CoverMyMeds® for electronic completion and submission of PA requests for drugs that are part of the BCBSNM pharmacy PA program. CoverMyMeds is available for most members who have their pharmacy benefit administered by Prime Therapeutics.*
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Blue Cross and Blue Shield of New Mexico is committed to the
highest standards of business ethics and integrity as well as strict observance and compliance with the laws and regulations governing its business operations.

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

Clarification regarding ‘Medicare crossover claim submission reminder’ article
In our April 2014 Blue Review, we included an article titled, “Medicare Crossover Claim Submission Reminder.” The article stated that, per the Centers for Medicare & Medicaid Services (CMS), providers are required to wait 30 calendar days from the initial Medicare remittance date before submitting claims to BCBSNM. BCBSNM supports the 30-day requirement; however, please note that it was established by the Blue Cross and Blue Shield Association, not CMS. As noted in the April reminder article, and in the effort to help decrease duplicate claim submissions, BCBSNM will reject provider-submitted claims when Medicare is considered primary, including those with Medicare-exhausted benefits that have crossed over, if they are received within 30 days of the initial remittance date or with no Medicare remittance date. 

Coming Soon: Electronic Provider Access tool for out-of-area members
Electronic Provider Access (EPA) is a new tool that will enable providers to initiate online pre-service reviews for out-of-area Blue Plan members. The term “pre-service review” with respect to use of this tool, refers to benefit preauthorization, pre-certification, pre-notification, and prior approval functions. Conducting a pre-service review is not a substitute for checking eligibility and benefits.
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New Webinar: Introducing Remittance Viewer
In last month’s Blue Review, we announced availability of the remittance viewer for BCBSNM independently contracted providers. This online tool offers providers and billing services a convenient way to view claim detail information from the 835 Electronic Remittance Advice (835 ERA). Introductory webinars have been scheduled to help new users learn how to gain or grant access, conduct a search, view general and payer-specific information, and save or print results. To register now, select a webinar date and time from the list below.

June 4, 2014 – 10 to 11 a.m. MT
June 11, 2014 – noon to 1 p.m. MT
June 18, 2014 – 10 to 11 a.m. MT
June 25, 2014 – noon to 1 p.m. MT

July 9, 2014 – 10 to 11 a.m. MT
July 16, 2014 – noon to 1 p.m. MT
July 23, 2014 – 10 to 11 a.m. MT
July 30, 2014 – noon to 1 p.m. MT

A Closer Look: Documentation and coding for cardiac conditions
Previous issues of the Blue Review included topics that addressed coding and documentation practices for pulmonary diagnoses, diabetes, chronic kidney disease, and behavioral health disorders. This month, we will be posting an article on our Provider website that will take a closer look at coding for cardiac conditions.
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Clinical Practice Guidelines update
Recognizing that practitioners are busy, we have designed Clinical Practice Guidelines (CPGs) as quick summaries. CPGs summarize national, evidence-based recommendations that are appropriate for most patients with the condition. The CPGs have been reviewed by practicing New Mexico physicians and are meant to serve as general guidelines. They are not intended to substitute for clinical judgment in individual cases.

Certain elements within a given CPG will be measured to determine the extent to which our members are receiving evidence-based care. We monitor these elements annually as part of Quality Improvement. CPGs are incorporated into our Blue Care Connection® Condition Management programs.

These CPGs are available in PDF form as a free download for personal, noncommercial use in the Clinical Resources section of our website. We encourage you to access the full guidelines, as they provide in-depth coverage of the management of these common illnesses.

Providers who have joined or left the BCBSNM network, April 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.

Drug List Updates


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

© Copyright 2014. All Rights Reserved.
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