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November 2001 | ||||||||||||||||||
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Important Updates Medical Coverage Guidelines Neuropsychological Testing
Examples of indications for neuropsychological testing include:
Neuropsychological testing is not covered for the following:
The following codes may be used to describe neuropsychological testing: 96117 Neuropsychological testing battery (i.e., Halstead-Reitan, Luria, WAIS-R) with interpretation and report, per hour ICD-9 diagnosis codes that support medical necessity for neuropsychological testing include the following (for all lines of business except Medicare & More): 290.0-294 Mental disorders (excludes codes for schizophrenic disorders and affective psychoses) For Medicare & More members, coverage is consistent with local and national Medicare policy. Reimbursement for neuropsychological testing battery (96117) is limited to eight hours during a 12-month period. Services in excess of this limitation are subject to medical review of documentation that supports medical necessity (i.e., office or progress notes, test results indicating specific tests performed, scoring, interpretation, length of time involved in testing). HFCC/HFCWO Devices
HFCC/HFCWO devices are considered investigational due to a lack of sufficient data to permit conclusions regarding an effect on health outcome and a lack of medical consensus regarding effectiveness. The following codes may be used to describe HFCC/HFCWO devices.
For Medicare & More members, coverage is consistent with local and national Medicare policy. Labs depend on physicians for accurate information; use lab requisition forms when referring patients Recent data show that labs are among the top providers in submitting claims with incorrect or incomplete information. Lab claims most often are denied because of incorrect contract/member numbers, missing or invalid diagnosis codes, and incorrect patient birth dates. Since labs do not always have direct contact with their patients, they rely on physicians to provide the correct information. It is important that physicians use the lab requisition form when they refer patients or send specimens for lab testing. Physicians can reduce the number of pended or denied lab claims by simply completing the necessary patient information on the requisition form. Forms may vary among labs, but usually the following information is requested:
Billing Physician payments go to weekly cycle In November 2001, Blue Cross and Blue Shield of Florida plans to change its physician payment schedule for its insurance business. Claims will continue to process daily, but only one check and remittance advice will be mailed weekly per payee. Reducing the number of checks you receive should provide improved efficiencies and administrative expenses as you handle and/or post fewer checks for the weekly cycle. The new payment schedule follows the cycle already in use for Health Options. You will continue to receive separate remittance advices for your patients covered by PPO, Traditional and Care Manager plans; the Federal Employee Program (FEP); the State Employees’ PPO Plan and Administrative Services Accounts (ASO). Your mailing address zip code determines which day of the week your BCBSF remittance advice will be released. The check paid date will be one day after the release day indicated below:
For questions about the new weekly payment schedule, call 800-477-3736, ext. 51289, or 904-905-1289. Please leave your name, telephone number, provider number and question; a representative will return your call. Front-End Edits (FEE) requirements revised A memo was sent during the week of Oct. 29 to all electronic senders, PMS vendors and in-house programmers advising of Front-End Edit enhancements. Please review this memo, as it provides valuable information regarding changes to the FEE requirements. The memo also highlights the importance of retrieving your Claim Return Reports (CRRs). If you are an electronic sender and have not been picking up your CRRs, you may have claims that are not going to be processed because they did not make it to our adjudication systems. As a result, claims represented on the CRRs are not on our files, and a customer service representative will be unable to locate any information regarding it. If you did not receive a copy of this memo, please contact the Claims Data Acquisition Department at Products & Services BCBSF BlueNews Q&A Our BlueNews Seminars held throughout the state over the last several months generated numerous questions about the Front-End Edit system, Virtual Office and other claims and billing issues. To further the educational process, we begin with this issue of BlueLine a new column devoted to answering your questions. Q. When batches of claims are submitted electronically and errors are found, is the entire batch rejected or only the specific claims with errors? A. It depends on which format is submitted and where the editing occurs. We have editing criteria in our EDI Gateway (which is considered our ‘electronic front door’) and additional editing within our front-end edits program that occurs later in the process. EDI Gateway
For 1450 NSF institutional claims, we have some claim-level edits at our EDI Gateway. We will accept all claims that pass the edit criteria based on our specifications and return all claims that fail the edit criteria. For example, if 100 claims are submitted, 90 are accepted and 10 are rejected due to edit failure, the 10 claims are returned and must be corrected and resubmitted. For all other BCBSF or HMO claims, including common format professional, common format institutional and NSF professional claims, the editing that occurs at the EDI Gateway is ‘File Level.’ This means that if there are any errors on the file, the entire file is returned and no claims are accepted. For example, if 100 claims are submitted and there is one error in the file, the entire file (all 100 claims) are returned for correction. Most of the edits at this level deal with the structure of the file, required records, sequencing and balancing. The error(s) must be corrected and the entire file resubmitted. Front-End Edits Program
Q. What if I am unable to get a copy of the Claims Return Report from my vendor or billing service? A. You must work with your vendor or billing service to obtain these reports. It is critical that you are aware of the failed claims because these claims are not in our system and will not be considered for payment. If your vendor or billing service does not provide this capability, please contact Claims Data Acquisition for other available options at 800-778-6795, Option 2, or email us at: claims.dataacquisition@bcbsfl.com. Q. Does VO have a target date for checking claim status on out-of-state members? A. It is possible to check claim status on most out-of-state members today if the out-of-state claim was sent to BCBSF for processing. Enter the member number just as you do today for BCBSF products. Q. How should we submit a claim for the handling of repeat procedures on the same day for professional component services? A. Use modifier 26 (professional component) and modifier 76 (repeat procedure, same physician) with the appropriate procedure code. Here’s an example: If a physician performs the professional component (reads, interprets and writes a report) for procedure 71030, chest X-ray, for a patient, and the same procedure is repeated two or more times for the same patient on the same day, here’s how to submit the claim:
Online hospital and facility guide now available The Guide for Hospitals and Facilities, a comprehensive Blue Cross and Blue Shield of Florida (BCBSF) and Health Options reference guide, is now available on our website, www.bcbsfl.com. In addition to the Guide for Hospitals and Facilities, a UB-92 Billing Instructions manual is available under the Manuals & Billing Guides section. These instructions also may be accessed directly through a link in the online Guide for Hospitals and Facilities. The guide contains helpful information on BCBSF/Health Options products, participation agreements, utilization management programs, and claims filing and reimbursement guidelines. The online version of the guide will be updated throughout the year, so make sure to access the site often. Paper copies of the guide will be mailed to all participating Health Options, PPC and PHS/Traditional acute care hospitals, ambulatory surgical centers, dialysis centers, and psychiatric and substance abuse facilities in November. If you have questions regarding information contained in the guide, contact your local Network Management office. Call routing system offers new options Earlier this year, Blue Cross and Blue Shield of Florida implemented a new call routing system that offers a variety of service options not previously available. Our automated customer service line at 800-727-2227 gives providers a way to obtain answers to questions about patients’ eligibility, deductible and claims status using a touch-tone telephone. You also have the option of speaking to one of our customer service associates. The automated system is available 7 a.m. to 6:30 p.m. EST, Monday – Friday; 7 a.m. to 4 p.m. EST, Saturday. Call 800-727-2227 or the number on the patient’s ID card, using a touch-tone telephone. VO providers
Other providers (non-VO)
You may speed up the automated line by entering your response at any time without being asked for information by a prompt or a menu. You do not have to wait for all menu options to be listed before entering your response. Pharmacy News A call for judicious Cipro prescribing Support Centers for Disease Control (CDC)
Prevent hoarding
Blue Cross and Blue Shield of Florida’s data indicate some patients appear to be trying to stockpile personal supplies of Cipro and doxycycline in reaction to anthrax media reports. Prescribing data will continue to be monitored closely. Patient education
Any Blue Cross and Blue Shield of Florida or Health Options member covered under our pharmacy plan who is exposed to anthrax and prescribed Cipro or doxycycline will certainly have the drug covered as a first-line defense. Following medical evaluation, further antibiotic therapy also would be covered as medically necessary. Though Cipro and doxycycline have been getting most of the attention in connection with the anthrax outbreak, there are several other antibiotics that can be used, including penicillin, amoxicillin and ampicillin. BCBSF requests that participating physicians follow the guidelines provided by the Centers for Disease Control and Prevention found at www.bt.cdc.gov. |