Volume 19, 2013

Issue 30 - 2014 Behavioral Health Fee Schedule Announced
BlueShield of Northeastern New York has issued an updated Behavioral Health Fee Schedule that takes effect April 1, 2014.
Issue 29 - Updated Claim Process for Digital Breast Tomosynthesis
The way claims are processed for digital breast tomosynthesis (three-dimensional mammography) will change effective Feb.1, 2014.
Issue 28 - Verisk Health
Effective January 1, 2014, BlueCross and/or BlueShield companies will begin using Verisk Health, an experienced health care analytic services company, to retrieve medical records for out-of-area members or from providers in other Blue Plan service areas to support HEDIS, risk adjustment, and government-required programs related to the Affordable Care Act.
Issue 27 - Fraud, Waste and Abuse Training
We have been notified by the Centers for Medicaid & Medicare Services (CMS) that fraud, waste, and abuse training is required for all persons who provide health or administrative services to Medicare Part C or Part D enrollees.
Issue 26(a) – 2014 Fee Schedule Announced (Region1)
BlueShield of Northeastern New York has issued an updated Standard Commercial Fee Schedule that takes effect March 1, 2014.
Issue 26(b) - 2014 Fee Schedule Announced _Mgd Care Only_Region3
BlueShield of Northeastern New York has issued an updated Standard Commercial Fee Schedule that takes effect March 1, 2014.
Issue 26(c) - 2014 Fee Schedule Announced _Region3_Traditional Only
BlueShield of Northeastern New York has issued an updated Standard Commercial Fee Schedule that takes effect March 1, 2014.
Issue 25 - Durable Medical Equipment and Orthotics Reminder for Chiropractors
Our Chiropractic Program follows the Medicare guidelines for ordering and dispensing Durable Medical Equipment (DME) and Orthotics to patients.
Issue 24 - Drug Therapy Guideline Updates
The attached updated guidelines will be effective December 15, 2013.
Issue 23 - Medicare Advantage Direct Pay Benefit Changes
Effective January 1, 2014, coverage for the following services for Medicare Advantage Senior Blue and Forever Blue Medicare Direct-Pay plans will change: •Part B Drugs •Routine Transportation Services
Issue 22 - Medicare Duplicate Claims
Our electronic claims vendor, Administrative Services of Kansas (ASK), implemented new edits to ensure Medicare coordination of benefit (COB) claims have sufficient time to process.
Issue 21 Preauthorization Reminder for Chiropractic and Osteopathic Manipulation
As a reminder, some patients’ contracts require preauthorization for spinal manipulation services.
Issue 20 Billing Reminder for Mid-level Practitioners
This is an important reminder about our billing guidelines for mid-level practitioners.
Issue 19 Surgical Follow-up Days
BlueShield of Northeastern New York monitors changes to the Medicare claims processing guidelines to ensure consistency.
Health Insurance Exchange
On October 1, 2013, New York state opened NY State of Health: The Official Health Plan Marketplace, an online health insurance exchange that offers insurance products to uninsured individuals and small businesses.
Revised Methodology for Decreasing Hospital Readmissions through Care Coordination
We previously notified you that, effective July 1, 2012, Patient-Centered Medical Home (PCMH) practices would be eligible for additional reimbursement for follow-up visits with the primary care physician within seven days of discharge from an inpatient hospital stay to home.
Issue 16 – PCMH AH Pilot Clarification
We want to clarify the types of visits that are now part of the after-hours pilot.
Issue 15 – Drug Therapy Guideline Updates
The attached updated guidelines will be effective September 15, 2013.
Issue 14 – 2013 Form for Elective Left Heart Cardiac Catheterization
This elective procedure continues to require preauthorization (effective since July 15, 2009).
Issue 13 – Electronic Provider Demographic Update
The Electronic Provider Demographic Update is now available on HEALTHeNET.
Issue 12 – Postoperative Pain Management
We want to keep you informed about our reimbursement policy for postoperative pain management.
Issue 11 – Patient-Centered Medical Home After-Hours Pilot Revision
We are changing our payment methodology for Patient-Center Medical Home (PCMH) providers.
Issue 10 – New Government Programs Fax Number
Effective May 15, 2013, the government programs grievance and appeal fax number changed.
Issue 9 – Fee Schedule Update for Durable Medical Equipment
Effective August 15, 2013, our Commercial and Medicare Advantage fee schedules will be updated for durable medical equipment (DME), orthotic and prosthetic (O&P), and medical/surgical supplies.
Issue 8 – Drug Therapy Guideline Updates
Updated guidelines will be effective June 15, 2013.
Issue 7 – Gold Card Changes for NIA
Effective May 15, 2013, there will be a change in the National Imaging Associates (NIA) preauthorization process.
Issue 6 – Gold Card Changes
Effective May 15, 2013, there will be a change to Gold Card procedures.
Issue 5 – Chiropractic Updates
There is a new chiropractic section on the BlueShield of Northeastern New York provider website.
Issue 4 – Updated DRG Readmission Criteria
This Stat Bulletin replaces Volume 11, Issue 2
Issue 3 - Billing Guidelines for Implantable Devices
Effective May 15, 2013, we will be implementing some changes to our claim system that will require strict adherence to our established billing guidelines for implantable devices.
Issue 2 - DRG Readmission Criteria
BlueShield of Northeastern New York reviews inpatient claims on a post-payment basis to validate DRG assignments, as well as identify diagnosis-related group (DRG) payments that meet criteria to be combined. Some changes to the criteria utilized to perform these functions will be made and applied to reviews beginning with discharge dates of March 1, 2013.
Issue 1 - Drug Therapy Guidelines
The updated guidelines will be effective March 15, 2013. This update is a result of the annual guideline review and new drug evaluations performed quarterly by our Pharmacy and Therapeutics Committee.