Blue Review – August 2023
A Provider Publication |
August 2023
News & Updates
COVID‑19 Information for Providers
Please check the following Blue Cross and Blue Shield of New Mexico (BCBSNM) resources frequently for updates to important information related to COVID‑19:
| • | Provider Information on COVID‑19 Coverage |
| • | BCBSNM News and Updates |
| • | BCBSNM COVID‑19 Member Website |
Updates made to the Provider Reference Manual
The BCBSNM Provider Reference Manual 
(PRM) has been updated as part of an annual review, effective September 2, 2023. Changes to the PRM include, but are not limited to, the following sections:
| • | 10 — Prior Authorization |
| • | 11 — Utilization, Case, Population Health, and Condition & Lifestyle Management |
The updated PRM is available on the Provider Reference Manual webpage. BCBSNM reminds providers to review the PRM for all changes.
 |
Reminder: |
| • | Letter of Direction (LOD) #85 — Community Benefit Provider Audits |
Education & Reference
Webinar on Coding for Morbid and Severe Obesity
Join us for a webinar on coding for morbid and severe obesity. The webinar is free to providers and coding professionals.
| Read More |
Network Participation
|
Reminder: |
| • | Provider Access and Availability Survey |
| • | Verify Your Directory Details Every 90 Days |
Coding and Claims
Introducing Claim Reconsideration Requests via Availity® Essentials
BCBSNM is excited to announce a new and convenient electronic capability to submit claim reconsiderations for situational finalized claim denials using Availity’s Dispute capability anchored off the enhanced Claim Status tool.
| Read More |
Prior Authorization Codes Updated, Effective Oct. 1, 2023
As of Oct. 1, we’re changing prior authorization requirements that may apply for some commercial and Blue Cross Community CentennialSM members to reflect new, replaced or removed Codes.
| Read More |
Clinical Resources
PEAQSM Physician Performance Insight Reports are Now Available
Physician Performance Insight reports are now available in Availity for physicians that have met eligibility requirements for the Physician Efficiency, Appropriateness, and QualitySM (PEAQ) program.
| Read More |
In-Home Test Kits for Colorectal Cancer Screening
We’re providing in-home test kits this summer to certain Blue Community HMOSM members who, based on our data, need a colorectal cancer screening.
| Read More |
Statin Therapy for Patients with Cardiovascular Disease and Diabetes
You can help ensure quality care for our members who have cardiovascular disease and diabetes by following guidelines on statin therapy from the National Committee for Quality Assurance. It’s important that members prescribed statin therapy adhere to their medications during their treatment period to lower cholesterol levels and reduce the risk of heart disease.
| Read More |
See Our Revised Preventive Services Clinical Payment and Coding Policy Effective July 1, 2023
BCBSNM has revised its Preventive Services Clinical Payment and Coding Policy, CPCP006, effective July 1, 2023.
| Read More |
Clinical Payment and Coding Policy Updates
The Clinical Payment and Coding Policies on our website describe payment rules and methodologies for CPT, HCPCS and ICD-10 coding for claims submitted as covered services. This information is a resource for our payment policies. It is not intended to address all reimbursement-related issues. We regularly add and modify clinical payment and coding policy positions as part of our ongoing policy review process.
The following policy was updated:
| • | CPCP001: Observation Services Policy — Effective 07/14/23 |
| • | CPCP006: Preventive Services Policy — Effective 07/01/23 |
| • | CPCP014: Global Surgical Package — Effective 06/27/23 |
| • | CPCP021: Laboratory Panel Billing Guideline — Effective 06/27/23 |
| • | CPCP027: Inpatient Readmission — Effective 07/01/23 |
| • | CPCP031: Trauma Activation — Facility Services — Effective 07/14/23 |
Pharmacy Program
Direction from Centers for Medicare & Medicaid Services (CMS) regarding enrollment requirements for prescribing pharmacists or pharmacy providers under Medicaid
The Medical Assistance Division of the New Mexico Human Services Department (HSD) is requiring the MCOs to deny pharmacy claims for drugs or other items when the prescribing pharmacist or pharmacy provider is not enrolled in New Mexico Medicaid. This went into effect on July 1, 2023.
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Read More
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Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2023 — Part 2
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 BCBSNM drug lists. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes.
View the Pharmacy Program Updates effective as of July 1, 2023
Blue Cross Medicare AdvantageSM (Medicare)
Current Procedural Terminology (CPT®) Codes Updated for Prior Authorization for Medicare Oct. 1
As of Oct. 1, we’re changing prior authorization requirements that may apply for some Medicare members to reflect new, replaced or removed codes.
| Read More |
Blue Cross Community Centennial (Medicaid)
|
Reminder: |
| • | COVID-19 Public Health Emergency Ending |
Not Yet Contracted?
Providers who are participating in commercial BCBSNM products are not automatically participating providers in Blue Cross Community Centennial. If you are interested in becoming a Blue Cross Community Centennial provider, please call 505‑837‑8800 or 800‑567‑8540.
Reminder: Update your Enrollment Information
Due to Centennial Care requirements, all enrollment information (changes to demographics, licensure or certification, provider status, etc.) must be updated on the NM Medicaid Provider Web Portal 
.
BCBSNM Website
It’s important for you to stay informed about news that could affect your practice. BCBSNM offers many ways to stay informed via our website, bcbsnm.com/provider, and our provider newsletter, Blue Review. Signing up is easy.
Medical Policy Updates
Approved new or revised medical policies and their effective dates are usually posted on our website the 1st and 15th of each month. These policies may impact your reimbursement and your patients’ benefits. These policies are located under the Standards & Requirements tab at bcbsnm.com/provider.
Clinical Payment and Coding Policies
BCBSNM has adopted additional clinical payment and coding policies. These policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG) and the CMS Provider Reimbursement Manual and are not intended to provide billing or coding advice but to serve as a reference for facilities and providers. These policies are located under the Standards & Requirements tab at bcbsnm.com/provider.
Claims Inquiries
Our Provider Service Unit (PSU) handles all provider inquiries about claims status, eligibility, benefits and claims processing for BCBSNM members. For the BCBSNM BlueCard® PSU, call 800‑222‑7992. For out‑of‑area claims inquiries, call 888‑349‑3706.
Verify Your Directory Details & Look for Reminders
Your directory information must be verified every 90 days under a new federal law. It’s easy and quick to get it done for all health plans in Availity® , or if you prefer, you can use our Demographic Change Form. If we haven’t received your verification, look for emails and postcards from us with the checkmark symbol 
. They’re a friendly reminder that it›s time to verify or update.
Member Rights and Responsibilities
BCBSNM policies help address the issues of members participating in decision making regarding their treatment; confidentiality of information; treatment of members with dignity, courtesy and a respect for privacy; and members’ responsibilities in the practitioner‑patient relationship and the health care delivery process.
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