Maintenance Notification:
Blue Access for Members and quoting tools will be unavailable from 3am - 6am on Saturday, October 20.
We apologize for any inconvenience.
Maintenance Notification:
Blue Access for Members and quoting tools will be unavailable from 2am - 5am Saturday, October 20.
We apologize for any inconvenience.
2018 News and Updates
Government Programs: Interpreting the 'PLB' Segment on the 835 Electronic Remittance Advice (ERA)
Reversals and corrections may occur when claim adjudication results have been modified from a previous claim report. The method for revision is to reverse the entire claim and resend with modified data. Provider level adjustments are reported in the PLB segment within the 835 ERA from Blue Cross and Blue Shield of Montana (BCBSMT) for the following lines of business
Close HEDIS® Gaps easily through the Availity® Provider Portal
Providers may now quickly comply with Healthcare Effectiveness Data and Information Set (HEDIS®) measures using Availity’s new Clinical Quality Validation (CQV). CQV will allow providers to electronically document their patient’s care and assessments to close quality HEDIS gaps for Blue Cross and Blue Shield of MT (BCBSMT) members. Additionally, CQV helps support BCBSMT’s Centers for Medicare & Medicaid (CMS) star rating for HMO and PPO Blue Cross Medicare AdvantageSM plans.
Change to Prostate Cancer Screening Benefit Level
Currently, Blue Cross and Blue Shield of Montana (BCBSMT) covers prostate cancer screening at no member cost share when billed with a preventive diagnosis.
Beginning Jan. 1, 2019, this screening will no longer be covered at the no member cost share level. Instead it will be treated as a standard medical benefit, and any applicable cost sharing (copay, coinsurance and deductible) may apply, based on the member’s health plan.
Government Programs: Electronic Claim-related Process Improvements and Reminders
eviCore healthcare is continuously working to simplify the prior authorization process for providers and their staff. We are excited to announce the new web portal enhancement, initiation of urgent/expedited prior authorization requests online is now available on eviCore's CareCore National portal.
EviCore Urgent Online Prior Authorization Request
eviCore healthcare is continuously working to simplify the prior authorization process for providers and their staff. We are excited to announce the new web portal enhancement, initiation of urgent/expedited prior authorization requests online is now available on eviCore's CareCore National portal.
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2018
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2018
Appropriate Use of Opioids Program Launched August 1, 2018
On August 1, 2018, Blue Cross and Blue Shield of Montana (BCBSMT) implemented the new Appropriate Use of Opioids Program. This program was developed to encourage the appropriate use of prescription opioids and advocate patient safety for our members. Elements in the new program follow safety guidelines as recommended by the Centers for Disease Control and Prevention (CDC) and other nationally recognized guidelines.*
Voluntary Recall of Medications Containing the Valsartan Active Ingredient
As you may be aware, the U.S. Food and Drug Administration (FDA) announced on July 13, 2018, a nationwide voluntary recall of several drug products containing the active ingredient valsartan and/or valsartan/hydrochlorothiazide (HCTZ), used to treat high blood pressure and heart failure.
Prohibition on Billing Dually-Eligible Members Enrolled in the Qualified Medicare Beneficiary Program
Medicare providers may not bill, charge, collect a deposit, or seek reimbursement from any Medicare and Medicaid dually-eligible members enrolled in the Qualified Medicare Beneficiary (QMB) program. The QMB program is a State Medicaid benefit that exempts Medicare beneficiaries from Medicare cost-sharing liability and covers premiums, deductibles, coinsurance and copayments for Medicaid and Medicare dually-eligible QMB members. Medicare providers must accept Medicare payments and any Medicaid payments provided as payment in full for services rendered to QMB members.
Changes Coming to the Blue Cross and Blue Shield of Montana Commercial Predetermination Request Form
Changes to the Member Data and Documentation sections of the Blue Cross and Blue Shield of Montana (BCBSMT) Predetermination Request Form – Medical and Surgical are coming in July 2018. These changes will capture important information that is now collected by phone. The new form includes fields for drug names and dosing information. In addition, the procedural code fields have been modified to capture units. To download the form, go to www.bcbsmt.com/provider forms and documents page.
‘Annual Visit’ Campaign Leads to Importance of Proper Coding
Blue Cross and Blue Shield of Montana (BCBSMT) is currently conducting a preventive care awareness campaign to remind our members of the importance of scheduling annual visits for routine physical exams. We know you already see a lot of patients and, since this annual visit campaign may increase patient traffic to your office, we wanted to take this opportunity to emphasize the importance of careful medical record documentation.
Important Update Regarding NDC Pricing
Blue Cross and Blue Shield of Montana will not be updating NDC pricing for 7/1/2018 and 8/1/2018. NDC pricing updates will begin again on 9/1/2018.
For questions please contact hcsx6100@bcsmt.com or 406-437-6100
New eviCore Email-Notification for Utilization Management (UM) Decisions
On 9/15/18 eviCore healthcare (eviCore) will begin notifying providers by email for all cases that are initiated through the eviCore web portal.
Quickly, Efficiently Manage and Respond to Coding Opportunities Online through the Availity® Provider Portal
Maintaining current and comprehensive diagnosis information for Blue Cross and Blue Shield of Montana members is imperative. BCBSMT utilizes multiple sources of data to identify conditions that a member had in the past, or may currently have, which have not been documented as a diagnosis code on a claim during the current calendar year. In turn, BCBSMT often reaches out to providers to close these potential coding opportunities.
Select Specialty Medications to Transition to Accredo Specialty Pharmacy – Effective June 1, 2018
Beginning June 1, 2018, Accredo®, a full-service specialty pharmacy, will be Blue Cross and Blue Shield of Montana (BCBSMT)’s preferred in-network provider of select specialty medications covered under the medical benefit for administration to BCBSMT members.
Prime Therapeutics® and Walgreens® Combined Specialty and Home Delivery Pharmacy Services Company Brand Launch Completed Important E-Prescribing Changes
As previously announced, the Blue Cross and Blue Shield of Montana (BCBSMT) pharmacy benefit manager (PBM), Prime Therapeutics LLC (Prime), and Walgreens’ combined specialty and home delivery pharmacy services company was formed in 2017. Headquartered in Orlando, Fl., the company’s full brand name, AllianceRx Walgreens Prime, has officially launched to consumers as of March 31, 2018.
Responding to Electronic Quality and Risk Adjustment Medical Record Requests via AvailityTM Provider Portal
Blue Cross and Blue Shield of Montana (BCBSMT) is committed to making it easier for providers to do business with us. Providers may now receive electronic quality and risk adjustment medical record requests from BCBSMT. The necessary documentation can be submitted electronically through the AvailityTM Provider portal.
Insurers Required by CMS to Conduct ACA Risk Adjustment Program Audit
In 2018, the Centers for Medicare and Medicaid Services (CMS) will conduct another Initial Validation Audit (IVA) to validate the data used when assessing the payment transfers for the Affordable Care Act's (ACA) Risk Adjustment (RA) program. The provider’s role is essential to the success of the IVA. Therefore, if any of your patients are selected to be included in the IVA, Blue Cross Blue Shield of Montana (BCBSMT) is asking for your cooperation and commitment to fulfilling the requirements of the IVA.
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2018
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2018
Medicare Advantage — Discontinued Authorization Requirements through eviCore Healthcare
Preauthorization (PA) is no longer required for certain services rendered on and after April 1, 2018. This does not apply to services rendered prior to April 1, 2018. While a PA is no longer required, services are still subject to Medical Necessity and coverage criteria for payment. Blue Cross and Blue Shield of Montana (BCBSMT) may conduct post-service claim review for the appropriateness of care.
Blue Cross and Blue Shield of Montana Announces New Chief Medical Officer
Blue Cross and Blue Shield of Montana (BSBSMT) is excited to announce that Dr. JP Maganito has been promoted to chief medical officer (CMO), filling a position vacated by Dr. Monica Berner's recent promotion to president.
Updated Online NDC Units Calculator Tool Available
Providers treating Blue Cross and Blue Shield of Montana (BCBSMT) members now have access to a user-friendly online National Drug Code (NDC) units calculator tool for assistance with converting applicable classified or specified Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) units to NDC units.
Hours of operation changing for electronic commerce services in March
Electronic Commerce enables healthcare organizations to conduct Electronic Data Interchange (EDI) transactions efficiently with Blue Cross and Blue Shield of Montana (BCBSMT). Utilizing electronic solutions in your day-to-day business increases operational productivities and simplifies administrative responsibilities.
Interpreting the ‘PLB’ Segment on the 835 ERA
There are reversals and corrections when claim adjudication results have been modified from a previous claim report. The method for revision is to reverse the entire claim and resend the modified data. Provider level adjustments are reported in the PLB segment within your 835 ERA from Blue Cross and Blue Shield of Montana (BCBSMT).
Diabetic Supplies Incorrect Billing Issues
Blue Cross Blue Shield of Montana (BCBSMT) continually reviews our processes to ensure proper claims adjudication and payment in accordance with correct coding guidelines, medical policy and member benefits.
AvailityTM Claim Research Tool Offers Enhanced Claim Status Results
One of the most convenient, efficient and secure method of requesting detailed claim status from Blue Cross and Blue Shield of Montana (BCBSMT) is by using an online option such as the Availity Claim Research Tool (CRT).*
Medicare Advantage (MA) Preauthorization Grid Updated. Effective 1/1/2018
Medicare Preauthorization GridEffective 1/1/2018
TriWest Contract for Community Care Network (CCN) Delayed
The Department of Veterans Affairs (VA) has notified Blue Cross and Blue Shield of Montana (BCBSMT) that it will delay the start of the Region 4 Community Care Network (CCN), which includes the state of Montana.
2018 Annual Fee Schedule And Compensation Policy Update
Blue Cross and Blue Shield of Montana (BCBSMT) reviews BCBSMT Fee Schedules and Compensation Policies annually for update. Policy updates are published March 1, 2018 and are effective May 1, 2018.
Health Care Service Corporation Launches $1.5 Billion Commitment to Accelerate Affordable Health Care Solutions
Three-year endeavor, Affordability Cures, aims to address root causes of high-cost health care system
Chicago, IL — Health Care Service Corporation (HCSC), the nation’s largest customer-owned health insurer, today announced it has committed $1.5 billion over three years to accelerate its efforts to reduce health care costs for its members. The new endeavor, Affordability CuresSM 
, builds on the company’s ongoing efforts to control medical and administrative costs for the long-term and was bolstered by benefits due to the more recent Tax Cuts and Jobs Act.
Quarterly Pharmacy Changes Effective Jan. 1, 2018
Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some additions or drugs moving to a lower out-of-pocket payment level, revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) were made to the Blue Cross and Blue Shield of Montana (BCBSMT) drug lists. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes. Changes that were effective Jan. 1, 2018 are outlined below.
Altegra Health Selected for Medical Record Retrieval
Blue Cross and Blue Shield of Montana (BCBSMT)is requesting your cooperation by providing access to specific member medical records to facilitate a risk adjustment chart review.
New Medical Record Retrieval Vendor for Out-of-Area Blue Plan Member Records
Under the Affordable Care Act (ACA), Blue Cross and Blue Shield of Montana (BCBSMT) must meet certain data submission and coding accuracy standards for "risk adjustment" purposes. To meet these standards, BCBSMT must verify the submissions by reviewing the actual clinical records of members.
Quarterly Pharmacy Changes Effective Oct. 1, 2017
Effective Oct. 1, 2017, select prescription drugs that are available over-the-counter (OTC) were added to the OTC equivalent exclusion drug list. Because these equivalent products with the same active ingredients in the same strength are available OTC without a prescription, the prescription versions of these medications are no longer covered under the prescription drug benefit.
Advanced radiology authorization requirement for commercial plans postponed
Implementation of Advanced Radiology Imaging (PET/CT scans, MRIs, CT, CTA, MRA, Nuclear Medicine) authorization requirements for fully ensured and retail plans WILL NOT occur on 3/1/18. A new implementation date has not been established.
Montana Family Pharmacies partner with PPOK, resulting in impact to BCBSMT pharmacy networks
Pharmacies in the Montana Family Pharmacies group recently notified Blue Cross and Blue Shield of Montana of a change in their contracting affiliation to Pharmacy Providers of Oklahoma, Inc., which does not hold a preferred Montana value network contract with the BCBSMT Pharmacy Benefit Manager for 2018 Health Insurance Marketplace and Commercial Plans.
Medicare Advantage Authorizations through eviCore
The “member not found” issue impacting Medicare member authorizations with eviCore has been resolved as of 1/15/18. eviCore has the missing Medicare members loaded in their system. To submit a prior authorization for an impacted member, please call or email "clientservices@evicore.com and include the following:
Pharmacy benefit tips for providers
Pharmacy Benefit Tips
For BCBSMT members with prescription drug benefits administered by Prime Therapeutics, BCBSMT employs a number of industry-standard management strategies to ensure appropriate utilization of prescription drugs. These strategies can include drug list management, benefit design modeling, specialty pharmacy benefits, clinical programs, among others. You can help us achieve these goals by:
Medical Policy Notification for CPT 97032, 97014 and G0283
MEDICAL POLICY NOTIFICATION
This notice advises that as of Oct 15, 2017, claims for commercial policies for CPT 97032, 97014 and G0283 will be denied as Experimental/Investigational in accordance with existing BCBSMT Medical Policies. Commercial policies include fully insured, ASO group and retail policies within the Blue Focus POS, Blue Preferred PPO (excluding FEP), Blue Options, and the Managed Care Network.
Provider Network Management Contact Guide
2018 Provider Contact Reference Guide
Hours of operation changing for electronic commerce services in March
Electronic Commerce Services – Hours of Operation Update
Electronic Commerce enables healthcare organizations to conduct Electronic Data Interchange (EDI) transactions efficiently with Blue Cross and Blue Shield of Montana (BCBSMT). Utilizing electronic solutions in your day-to-day business increases operational productivities and simplifies administrative responsibilities.
BCBSMT Preparing for 2017 HEDIS Measurement Year
Blue Cross and Blue Shield of Montana (BCBSMT) is preparing the Healthcare Effectiveness Data and Information Set (HEDIS®) report for the 2017 measurement year. HEDIS is a set of standardized measures developed by the National Committee for Quality Assurance (NCQA) to assess health plan value.
2017 News and Updates
Notification of Annual Benefit Updates
Blue Cross and Blue Shield of Montana (BCBSMT) will be updating member files with annual benefit changes over the next several weeks. In addition, updates are in progress due to open enrollment. As always, we encourage you to verify your patients’ coverage first, using
E/M Codes Billed with Modifier 52
Effective June 4, 2017 Blue Cross and Blue Shield of Montana implemented new secondary code-auditing software. This software further enhances the auditing of professional and outpatient facility claims for correct coding according to Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services (CMS) guidelines.
MA 2018 Prior Authorization Guide Requirements
Prior Authorization rules -Medicare Medical / Surgical / Behavioral Health.PRIOR AUTHORIZATION REQUIREMENTS* THROUGH EVICORE - EFFECTIVE 01/01/2018
Medical Policy Notification: Services for electrical stimulation as Experimental/Investigational
Medical Policies are based on data from the peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations. Since its respective publication, Blue Cross and Blue Shield of Montana Medical Policy has considered the services for electrical stimulation as Experimental/Investigational. However, BCBSMT did not enforce this policy on a pre-pay basis.
Coverage of Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) for Blue Cross Medicare Advantage PPOSM and Blue Cross Medicare Advantage HMOSM
The Centers for Medicare and Medicaid Services (CMS) has determined the cost and reimbursement for supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) will be covered, for calendar years 2017 and 2018 only, by original fee-for-service Medicare.
2018 Holiday Schedule Reminders (for 835 and 837 transactions)
The reminders below are intended to assist providers in planning ahead for scheduling variances that may affect electronic claims (837) and/or claims payment and remittance (835) transactions in 2018.
Effective March 8, 2017: Medicare Outpatient Observation Notice (MOON) Required
Effective March 8, 2017, the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act requires hospitals and Critical Access Hospitals (CAH) to provide the MOON to Medicare beneficiaries, including Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM members receiving observation services as outpatients for more than 24 hours.
CMS Notifications for Blue Cross and Blue Shield Medicare Providers
The Centers for Medicare and Medicaid Services (CMS) routinely publishes notifications that provide guidance to all Medicare physicians, providers and suppliers, including those serving beneficiaries enrolled in Original Medicare and private Medicare Plans.
Diabetes Education Classes
Join a registered dietitian and in-store pharmacist on this exclusive. FREE tour just for Blue Cross and Blue Shield members.It’s all part of our Living365SMprogram
BCBSMT to Require Adherence to Vaccine Guidelines
Timely vaccines protect the health of children and adults, saving lives and ensuring the safest, most effective disease prevention possible. To help keep Blue Cross and Blue Shield of Montana (BCBSMT) members safe, doctors treating them should adhere to guidelines recommended by the U.S. Food and Drug Administration (FDA) and Advisory Committee on Immunization Practices (ACIP).
How to Find BCBSMT Resources in Availity™ Payer Spaces
Have you recently been searching in the Availity Web Portal to locate a specific Blue Cross and Blue Shield of Montana (BCBSMT) tool or enrollment option? Some of our electronic resources offered through Availity have moved to the BCBSMT-branded Payer Spaces section in Availity.
Government Programs: 835 Electronic Remittance Advice (835 ERA) Update
New 2018 Additional Benefit Preauthorization Requirements
Health Advocacy Solutions Preauthorization Service Requirements for Administrative Service Only (ASO) Blue Choice PPO Network
Visit Our Website for New Claim Payment and Remittance Resources
2018 Medicare Advantage Change
Blue Cross and Blue Shield of Montana (BCBSMT) has a proud history of expanding access to high-quality, cost-effective health care for Montanans. In our 75-plus year history, we have a track record of stable membership growth across all lines of business.
Psychological and Neuropsychological Testing – Clinical Payment and Coding Policy Posted
Blue Cross and Blue Shield of Montana (BCBSMT) is implementing clinical payment and coding policies based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.
National Drug Code (NDC) Billing Update for Medicare Advantage Claims
Beginning Dec. 15, 2017, Blue Cross and Blue Shield of Montana (BCBSMT) will activate edits to validate NDCs that are submitted on electronic and paper professional and institutional Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM claims. These validation edits are being implemented to align with the Centers for Medicare & Medicaid Services (CMS) encounter data submission requirements. Providers should confirm that the NDCs submitted are appropriate for services rendered and active for the date(s) of service billed.
HELP Plan Update
Effective January 1, 2018, the administration of the HELP Plan will be transitioned from Blue Cross and Blue Shield of Montana (BCBSMT) to Conduent (Previously known as Xerox).
Requesting Predetermination of Benefit
Preventive Services Policy – Clinical Payment and Coding Policy Posted
Blue Cross and Blue Shield of Montana (BCBSMT) is implementing clinical payment and coding policies based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual.
Blue Cross Medicare AdvantageSM: Electronic Claim Submission Edits
Beginning Sept. 16, 2017, Blue Cross and Blue Shield of Montana (BCBSMT) will implement new electronic claim submission validation edits for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM Professional and Institutional claims (837P and 837I transactions). These claim edits will be applied to claims during the pre-adjudication process to help increase efficiencies and to comply with Medicare data reporting requirements.
eviCore Provider Meetings FAQ's
BCBSMT awards Rocky Boy Schools with $50,000 HKHF grant
Helena — Rocky Boy Schools – located on the Rocky Boy Indian Reservation near Box Elder – is rurally isolated and tasked with educating a population of children affected by high levels of poverty.
eviCore healthcare Web Portal Training Online Orientation Session Invitation
Mountain-Pacific Quality Health surprised with $50,000 HKHF grant
Helena — Montana has the unfortunate distinction of being home to the highest rate of death by suicide of any state in the nation, and sadly, the greater Helena area has suffered several youth suicides over the past five years.
BCBSMT awards $50,000 grant to Healthy Mothers, Healthy Babies
CNI Advantage, LLC to begin PERM Medical Review Process
CNI Advantage, LLC will begin the Payment Error Rate Measurement (PERM) medical record review process in August 2017. PERM participation is required under the Federal Improper Payments Elimination and Recovery Act (IPERA) of 2010.
Making the Health Care System Work Better Together
Payers and providers are increasingly collaborating to share clinical and claims data, with the shared goal of working to improve health outcomes and better manage the overall cost of care to consumers.
Code-Auditing Enhancement
Effective November 12, 2017, Blue Cross and Blue Shield of Montana (BCBSMT) will be implementing a code-auditing enhancement.* This software will help improve auditing of professional and outpatient facility claims that are submitted to BCBSMT by clinically validating modifiers submitted on such claims. Upon implementation of the code-auditing enhancement, providers may use the Claim Research Tool, available on the AvailityTM Web Portal, to research specific claim edits. For additional information, watch the Blue Review, as well as the News and Updates section of our Provider website.
Government Programs: Claims Rejecting as Duplicate Submissions
This notice applies to claims submitted by government programs providers for the following Blue Cross and Blue Shield of Montana (BCBSMT) members:
MT HELP Plan Uncollected Copayments
In accordance with Senate Bill 405 and the Blue Cross and Blue Shield of Montana (BCBSMT) provider contract, providers are required to report uncollected copayments for BCBSMT administered Health & Economic Livelihood Partnership (HELP TPA Plan) participants on an annual basis.
EFT and ERA Update for Non-Contracted Government Programs Providers
Effective July 24, 2017, if you are a participating provider in one or more of Blue Cross and Blue Shield of Montana's (BCBSMT) commercial networks and you are enrolled to receive Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) files from BCBSMT, you will also begin receiving EFTs and ERAs for government programs member claims, even if you are not participating in BCBSMT's government programs networks. This change applies to claims submitted for any of the following BCBSMT government programs members:
"Incident-To" Billing NOT Allowed by BCBSMT
One of the most common complaints received on the Blue Cross and Blue Shield of Montana (BCBSMT) fraud hotline is from patients complaining that services received from a non-physician provider (physician assistant, nurse practitioner) have been billed under the name of a physician in the clinic. The BCBSMT Special Investigations Department has identified the practice of submitting claims under the wrong provider name and National Provider Identifier (NPI) as the number one problem addressed by the unit. When identified, however, many providers justify the billing as being incident-to services.
Integration of Prime Therapeutics® and Walgreens® Specialty Pharmacy and Mail Order Services
Blue Cross and Blue Shield of Montana's (BCBSMT) pharmacy benefit manager (PBM), Prime Therapeutics LLC (Prime), and Walgreens announced a strategic alliance in August 2016 to create a first-of-a-kind model for pharmacy benefit management that aligns a national pharmacy chain, a leading PBM and health plans, including a long-term retail pharmacy agreement. As part of this alliance, Prime and Walgreens have formed a combined company for specialty pharmacy and mail order services, headquartered in Orlando, FL.
Clear Claim Connection (C3) will be unavailable on Monday 7/17/17 for maintenance updates
Clear Claim Connection (C3) will be unavailable on Monday 7/17/17 for maintenance updates.
Evaluation and Management Consultation Code Exceptions
As a reminder, BCBSMT will begin zero pricing Evaluation and Management consultation codes on May 1, 2017. Providers are encouraged to report the appropriate inpatient or office/outpatient evaluation and management code in lieu of evaluation and management consultation codes. This change was made to align with the Centers for Medicare and Medicaid Services (CMS) 2010 change to eliminate the use of all consultation codes (inpatient and office/outpatient codes). In place of the consultation codes, CMS increased the work RVU’s for new and established office visits, increased the work RVU for initial hospital and initial nursing facility visits, and incorporated the increased use of these visits into the practice expense (PE) and malpractice calculations. CMS also increased the incremental work RVUs for the E/M codes that are built into the 10-day and 90-day global surgical codes.
Careful Documentation Paves the Way for Accurate Coding Capture
Air Ambulance Services
Clear Claim Connection (C3) will be unavailable on 7/15/17 from 6 PM – 11 PM for maintenance updates
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017
Update from Centers for Medicare and Medicaid Services (CMS)
Real Time Notification of Preauthorization's and Predeterminations
Beginning July 1, 2017, BCBSMT will implement electronic facsimile (fax) notification of benefit preauthorization and predeterminations to the requesting provider. This enhancement provides a real time notification letter and eliminates the need for phone calls regarding status of preauthorization or predetermination requests while waiting on the mailed notification letters. The faxed notification will be in addition to the notification letter delivered via mail, to the mailing address we have on file for you.
New ClaimsXtenTM Rules to be Implemented
Beginning on or after September 18, 2017, Blue Cross and Blue Shield of Montana (BCBSMT) will implement 4 new rules to the ClaimsXten software database. These new rules are defined as:
One Way BCBSMT is Taking on Asthma in May – National Asthma and Allergy Awareness Month
Blue Cross and Blue Shield of Montana (BCBSMT) works with providers to support efforts to improve asthma treatment. During May - National Asthma and Allergy Awareness Month – we encourage you to read and share an article that recently ran in the LifeTimes® under-65 (U65) member newsletter – Different Cultures, One Disease: Treating Asthma While Respecting Tradition. In addition, BCBSMT has a page dedicated to Taking on Asthma.
2017 Blue Cross Medicare Advantage Preauthorization List
Government Programs: 835 ERA Files Displaying '0' in the Check Number Field
Some providers may receive duplicate 835 Electronic Remittance Advice (ERA) files for claims that were originally processed in 2016 and correctly adjusted by Blue Cross and Blue Shield of Montana (BCBSMT) in 2017. These duplicate 835 ERA files will display a "0" in the TRN02 check number field. If you experience this situation, you should refer to the previously delivered BCBSMT 835 ERA where the claim was correctly adjusted to verify the claim payment and check number information.
Online Enrollment Options in AvailityTM
Blue Cross and Blue Shield Montana (BCBSMT) offers you multiple enrollment opportunities for electronic options through the Availity Web portal, in addition to supporting utilization of standard administrative transactions through Availity or your preferred vendor portal. Instead of faxing or mailing paper enrollment forms, you may complete the online enrollment options listed below through Availity, at no cost. In addition, Availity provides single sign-on access to several online tools, including those highlighted below. This feature offers you greater convenience and security, without the need for another User ID and password.
New Medicare Advantage Preauthorization Requirements through eviCore
The new effective date for the Medicare Advantage preauthorization requirement through eviCore will be June 1, 2017.
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective January 1, 2017 and April 1, 2017
Reminder: Pharmacy Program Benefit Changes – Effective January 1, 2017
Blue Cross and Blue Shield of Montana (BCBSMT) implemented pharmacy benefit changes as of January 1, 2017, for some members with prescription drug benefits administered through Prime Therapeutics.*
ClaimsXtenTM Announces Software Version Upgrade
Beginning on or after July 17, 2017, Blue Cross and Blue Shield of Montana (BCBSMT) will perform a system software upgrade for ClaimsXtenTM from version 4.4 to version 6.0. Key enhancements include but not limited to:
Flublok Quadrivalent Billing Update
Effective January 1, 2017, the American Medical Association (AMA) approves the use of Current Procedural Terminology (CPT®) code 90682 (influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use), which best describes Flublok Quadrivalent. Flublok Quadrivalent is for persons 18 years of age and older.
Insurers Required by CMS to Conduct ACA Risk Adjustment Program Audit
In 2017, the Centers for Medicare and Medical Services (CMS) will conduct another Initial Validation Audit (IVA) to validate the data used when assessing the payment transfers for the Affordable Care Act's (ACA) Risk Adjustment (RA) Program.
BCBSMT: Availity Provider Training
In these one-hour webinar sessions, we will present an overview of electronic options available in the Availity Engagement Portal for BCBSMT providers.
Secondary Code-auditing Software Scheduled for Implementation
Blue Cross Blue Shield of Montana (BCBSMT) will be implementing a secondary code-auditing software system, effective June 4, 2017. This software will further enhance the auditing of professional and outpatient facility claims for correct coding according to Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services (CMS) guidelines. Upon implementation, providers may use the Claim Inquiry Resolution tool, available on the AvailityTM Web Portal, to research specific claim edits.
BCBSMT Transactions are Now Available in AvailityTM
Requesting Demographic Information Changes
Keeping your practice information up-to-date with Blue Cross Blue Shield of Montana (BCBSMT) is important for many reasons, such as helping to ensure our members have access to correct contact information and other details when they are viewing your listing on our online Provider Finder®.
2017 Fee Schedules
The following BCBSMT compensation policies have been updated and published on the BCBSMT Secured provider portal March 1, 2017, and can be accessed by logging in to the Secure Provider Portal.
Update to Durable Medical Equipment (DME) and Medical Supplies for Healthy Montana Kids (HMK)
Effective March 1, 2017, for HMK, prior authorization is required for DME and medical supplies that cost more than $500. HMK will pay for the most economical equipment or supplies that are Medically Necessary to treat a problem or physical condition; and must be appropriate for use in the Member's home, residence, school, or workplace.
Government Programs: Electronic Remittance Advice (ERA) Files
Blue Cross Blue Shield of Montana (BCBSMT) Medicare Advantage plan providers who are enrolled to receive ERA's (835's) may be missing ERA files from December 1, 2016 to December 30, 2016.
Provider Claim Summary Paper Discontinuance Effective Date DELAY
As a reminder, Provider Claim Summaries (PCSs) are accessible through the Report offering in our Blue Cross and Blue Shield of Montana (BCBSMT) Secure Provider Portal.
Contact Lens Benefit for the Montana HELP Plan
Effective January 1, 2017, the following contact lens services will be eligible for reimbursement under the Montana HELP Plan:
Contact lens exam and fittings and contact lenses for the diagnosis of keratoconus, aphakia, anisometropia of two diopters or more or if the sight cannot be corrected to 20/40 with eyeglasses. Preauthorization is required for contact lens exams and fittings and contact lenses.
Effective March 8, 2017: Medicare Outpatient Observation Notice (MOON) Required
Effective March 8, 2017, the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act requires Acute Care Hospitals and Critical Access Hospitals (CAH) to provide the MOON to Medicare beneficiaries, including Blue Cross Medicare Advantage (PPO)SM, Blue Cross Medicare Advantage (HMO)SM members receiving observation services as outpatients for more than 24 hours.
New Medicare Advantage Preauthorization Requirements through eviCore
Effective April 3, 2017, Blue Cross Blue Shield of Montana (BCBSMT) has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide preauthorization services for the following benefit plan(s).
New Medicare Advantage Preauthorization Requirements through eviCore
Effective June 1, 2017, Blue Cross Blue Shield of Montana (BCBSMT) has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide preauthorization services for the following benefit plan(s):
Blue Cross Medicare AdvantageSM: Claim Rejections for Taxonomy Code
Taxonomy codes are not required on claims submitted for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM members. However, due to a recent system issue, electronic Blue Cross Medicare Advantage claims submitted with Payer ID 66006 January 1, 2017, through January 11, 2017, may have been rejected for a missing provider taxonomy code.
Medicare Advantage Preauthorization List Effective January 1, 2017
Additional Code-auditing Software Scheduled for Implementation as of April 30, 2017
Blue Cross Blue Shield of Montana (BCBSMT) will be implementing an additional code-auditing software system, effective April 30, 2017.* This software will enhance auditing of professional and outpatient facility claims for correct coding according to Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services (CMS) guidelines.
New vision vendor for Medicare Advantage members
Effective Jan. 1, 2017, Blue Cross and Blue Shield of MT (BCBSMT) members will transition from Davis Vision to EyeMed.