Health Plan News

TMA payment specialists know how difficult it is to keep up with health plans’ constant changes. We are here to help you stay informed about the latest news from the major payers. Check back frequently for billing, coding, and health plan policy updates.

• Here’s Your Billing and Collections Checklist for 2024

• Pediatric, Booster COVID Vaccine Codes Established 
  Now that federal health authorities have approved pediatric doses of the Pfizer COVID-19 vaccine, administrators of the vaccine should take note of these newly established CPT codes:

  Vaccine product code 
  91307– Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use

  Vaccine administration codes 
  0071A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose 

  0072A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose

  In addition, a new code has been assigned to the Janssen booster for the COVID-19 vaccine:

  0034A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x10¹⁰ viral particles/0.5 mL dosage; booster dose

  _{CPT copyright American Medical Association. All rights reserved.}           

• Aetna to Reduce Infusion Therapy Payment 
  On Sept. 1, report second and third concurrent infusion therapies, reducing the allowable payment by 25% for modifier SH and by 50% for modifier SJ, according to a recent health plan update. Aetna says the update will affect both commercial and Medicare members.

• Aetna to Cut Payment for Urgent Care Surgical Services
  Starting Sept. 1, Aetna will pay 75% of the contracted rate for surgical procedures performed in urgent care facilities or independent clinics with or without modifier 54, used to indicate surgical care, according to a recent health plan update. Aetna says the change is part its plans to expand its modifier 54 policy to include place-of-service codes 20 and 49, used when services are provided at an urgent care facility or at an independent clinic. The payer also will institute similar payment cuts for surgical procedures when billed by nurse practitioners or physician assistants.

• Aetna Reworking G0439 Claims Wrongly Denied
  Aetna on Jan. 30, 2023, began reworking certain claims with Healthcare Common Procedure Coding System code G0439 that were wrongly denied because of a software glitch. This code represents a subsequent Medicare Annual Wellness Visit (AWV) covered by Medicare Advantage plans. Aetna reported that its ClaimsXten clinical editing software was denying in error claims for this service when billed within 334 days of the previous AWV.

  Do not resubmit any claims with this denial, as Aetna will continue to rework and pay them until the software is fixed.

• BCBSTX Updates POS Code Guidance
  Blue Cross and Blue Shield of Texas (BCBSTX) reported on Nov. 29, 2023, that it is updating telemedicine and telehealth commercial claims filing guidelines for place-of-service (POS) codes to line up with recommendations from the Centers for Medicare & Medicaid Services, as follows:

  • Use POS 10 for telehealth provided in patient’s home.
  • Use POS 02 for telehealth other than in patient’s home.
    
    

  Source: BCBSTX

• Fee Schedules to Update Feb. 1, 2024
  Blue Cross and Blue Shield of Texas (BCBSTX) will change the maximum allowable professional and ancillary fee schedules – effective Feb. 1, 2024 – for these plans: Blue Choice PPO, Blue Essentials (including HealthSelect of Texas Network), Blue Premier, Blue Advantage HMO, Blue High Performance Network, MyBlue Health, and PAR Plan networks. See the payer’s General Reimbursement Information page for details and files (password required to view information. Contact your BCBSTX Network Management Office if you don’t have a password).

  You can request professional fee schedule(s) using the Professional Fee Schedule Request Form. Be sure to indicate your request is for schedule(s) effective Feb. 1, 2024.

  Source: BCBSTX

• Claim Editing Changes to Come for Emergency Department Services
  Beginning Nov. 1, 2023, Blue Cross and Blue Shield of Texas (BCBSTX) will change its claims editing and review process for emergency department evaluation and management (E/M) for some commercial plans.

  Under the change, your payment may be processed at a lower level of service if BCBSTX cannot validate the level of E/M services billed per the American Medical Association guidelines for level of service and medical decision-making.

  If you disagree with the payment received, you should submit additional medical records to support your claim for a higher level of service.

  For more information, see BCBSTX’s revised CPCP003 Emergency Department Evaluation and Management (E/M) Services – for Facility Services policy and new CPCP042 Emergency Department Evaluation and Management (E/M) Services Coding – for Professional Services. 

  Source: BSBSTXS

• Access Your Prior Authorization Info in a New Location
  You now can find all communications from Blue Cross and Blue Shield of Texas (BCBSTX) about your prior authorization (PA) exemptions in Provider Correspondence Viewer under the Payer Spaces section of Availity, including:

  • PA exemption notices effective Sept. 1, 2023;
  • All previously issued exemptions (effective Oct. 1, 2022, and March 1, 2023); and
  • Maintain or Rescission Audit Review Notices. 

  The previous Prior Authorization Exemption Status Viewer in Availity is retired.

  If you submit a request by specified deadlines for another preferred method of receiving your PA exemption communications, BCBSTX will also send future notices by that method.

  Source: BCBSTX 

• BCBSTX : Document Out-of-Network Referrals
  Be sure to fill out the appropriate Blue Cross and Blue Shield of Texas (BCBSTX) form when you refer a Blue Choice PPO or Blue Advantage HMO* patient to an out-of-network physician or provider, you are a participating BCBSTX physician, and an in-network option for referral is available.

  As applicable, fill out the Out-of-Network Care – Enrollee Notification form for regulated business (look for “TDI” on the patient’s ID Card) or for nonregulated business (no “TDI” on the patient’s ID card).

  Then give a copy of the completed form to your patient and keep a copy in the patient’s medical record files.

  *for Blue Advantage Plus point-of-service benefit plan

• New Health Plan for UT System Retirees
  Effective Jan. 1, 2023, University of Texas System retirees who are eligible for Medicare will receive health care coverage from UT CARE, a Blue Cross and Blue Shield of Texas (BCBSTX) open access Medicare Advantage PPO plan.

  These patients’ insurance ID cards will display the BCBSTX UT CARE logo and the words “Plan: Blue Cross Group Medicare Advantage Open Access (PPO).”

  BCBSTX says to get paid, follow the billing instructions on the ID card and submit the claims to BCBSTX.

  • Physicians who are contracted for any Blue Cross and Blue Shield (BCBS) Medicare Advantage plan will be paid their contracted rate.
  • Physicians who accept Medicare but are not contracted for any BCBS Medicare Advantage plan will be paid the Medicare-allowed amount for covered services, less any member cost share.

  Because this is an open access plan, plan members may see any physician or provider in the U.S. who accepts Medicare assignment. Members’ coverage levels are the same inside and outside their plan service area.

• Cigna to Deny Claims Without Z Code Documentation
  Starting July 14, 2024, Cigna Healthcare will begin to deny claims when certain E/M codes (99202-99215) are billed with a preventive service code and a supporting Z diagnosis code, but not supplemental medical record documentation. Physicians will need to refer to multiple policies by the payer to utilize both preventive services and problem-oriented E/M services for new and established patients on the same date of service, adding more tasks to physicians’ already exhaustive workload.

  Moreover, these services will not be payable by Cigna when billed with a Z diagnosis code alone, used to document social, environmental, and personal circumstances that influence a patient's health status, but are not diseases or injuries themselves. Instead, Texas Medical Association coding experts recommend billing supporting medical record documentation with the diagnosis code for the problem E/M claim in order to identify why a preventive service – like dietary counseling, for example – was performed.

  Physicians can also check Cigna’s preventive services policy for examples of Z codes or refer to Cigna’s E/M Reimbursement Policy for more payment information from the payer.

• Tips for Managing TPA Benefits
  Does your patient have Cigna Healthcare benefits managed by a third-party administrator (TPA)? 

  If your patient has a TPA-administered plan, you should contact the TPA – not Cigna Healthcare – for questions related to eligibility; benefits administration; claim status, payment, and administrative appeals; and precertification and prior authorization requests.

  Patients with a TPA Cigna plan will have an “S” on their ID card, along with contact information for the TPA. Or search for your patient on CignaforHCP.com; the Coverage Details screen will indicate if the patient has a TPA plan, and display the TPA name and phone number.

  Source: Cigna third quarter Network News, page 36.

• Primary Care Physicians Key to Effective Referrals
  Referrals to specialists typically originate with a patient’s primary care physician (PCP), who can ensure an effective referral by following these steps recommended by Cigna Healthcare:

  • Know referral requirements. First ascertain if your patient’s Cigna plan requires PCP referrals and in-network specialists. In any case, referring to an in-network specialist ensures the lowest out-of-pocket expenses says for your patient.
  • Prepare your patient. Make sure your patient understands the reason and importance for specialty care, and agrees to it and knows the next steps.
  • Provide a high-value referral request to the specialist office. Clearly state the clinical questions being asked of the specialist, and provide supporting data.
  • Define the specialist’s role. Be specific about what you’re asking the specialist to do, e.g., perform an evaluation or a specific procedure.
  • Close the referral loop. Track the referral to make sure the patient kept the appointment and the specialist has sent you a report. Be sure to acknowledge the specialist’s recommendations.
    
    

  Cigna does not require participating physicians to notify it of referrals to network-participating specialists, unless a patient’s benefit plan has a specific requirement to do so.

  Source and for more information: Cigna third quarter Network News, pages 11-12.

• Tools Aid in Care Coordination and Continuity
  Cigna has developed tools to serve as models for exchanging clinical information that can facilitate continuity and coordination of care during patient transitions. The payer says it based these tools on its quality program’s monitoring of:

  • Coordination of care during transitions between inpatient settings, in outpatient settings such as surgery or rehab centers or emergency departments, and when patients move between physicians;
  • Notification of patients and their transition from physicians Cigna has terminated from a network; and
  • Patients who qualify for continued coverage of services rendered by physicians Cigna has terminated from a network for reasons other than quality.
    
    

  The tools are available for download from CignaforHCP.com > Get questions answered: Resource > Medical Resources > Commitment to Quality > Quality > Continuity and Coordination of Care.

  Source: Cigna third quarter Network News, page 37.

• Humana to Update Prior Auth List
  Humana says it began updating its commercial prior authorization and notification list July 1, which includes delegating the review and management of requests for certain diagnostic, imaging, and sleep services to the clinical intelligence company Cohere. Practices billing for these services must send those requests to Cohere's online portal or call (833) 283-0033. TMA continues to monitor payers' use of artificial or augmented intelligence (AI).

• Beware of Services Not Payable With a Medicaid Child Checkup
  A Texas Medicaid policy may trip up physicians who perform child checkups under Texas Health Steps, the program that covers children aged 0 through 20 who are eligible for Medicaid.
  
  The policy says: “Components of a medical checkup that have an available CPT code are not reimbursed separately on the same day as a medical checkup,” with some exceptions (Section 5.3.6 THSteps Medical Checkup in the Texas Medicaid Provider Procedures Manual, Volume 2).
  
  For example, the Texas Health and Human Services Office of Inspector General recently sent a refund request on the basis of this policy to a physician who billed a Medicaid payer for audiometry (CPT 92551) with a child well-check.
  
  Exceptions under the policy are initial point-of-care blood lead testing, mental health screening for adolescents, postpartum depression screening, tuberculin skin test, developmental and autism screening, vaccine administration, and oral evaluation and flouride varnish. 

  _{CPT copyright American Medical Association. All rights reserved.}

• CMS Adjusts Seasonal Flu Vaccine Pricing for 2024 – 2025
  On Aug. 1, the Centers for Medicare & Medicaid Services (CMS) increased the amount it will pay physicians for influenza vaccines and updated which codes physicians should use when billing for the service during the 2024 – 2025-25 flu season.

  Physicians should bill Current Procedural Terminology (CPT) codes 90653 – 90673 depending on which flu vaccine they use. These codes have payment allowances varying from $10.93 to $83.49, an overall increase from last year. Previously, the highest amount CMS paid physicians for flu vaccines was $77.36.

  All CPT codes became active Aug. 1 and will remain in-use until July 31, 2025. CMS revises the code list annually. 

• CMS to Deny Hospice Claims from Unenrolled Physicians Starting June 3
  Under a new requirement starting June 3, the Centers for Medicare & Medicaid Services (CMS) will deny hospice claims if a patient’s certifying physician isn’t enrolled in Medicare hospice services or has not opted out by that date. The requirement applies only to Medicare fee-for-service; no action is needed from physicians currently enrolled or opted out. It applies to claims made by hospice medical directors, patient-designated attending physicians, or physician members of a hospice interdisciplinary group who certify patients’ terminal conditions. The new requirement also:

  • Doesn’t prohibit the patient’s independent attending physician from treating them while in hospice and billing for those services under Part B; and
  • Applies to all written or oral certifications defined by CMS.

• CMS Updates DME Master List
  The Centers for Medicare & Medicaid Services (CMS) added 76 new items and deleted three from its master list of durable medical equipment (DME), prosthetics, orthotics, and supplies. CMS may require physicians to submit prior authorizations or written orders and undergo a face-to-face encounter with a patient to assess their condition prior to such equipment’s delivery. If so, clinicians ordering that equipment may be required to:

  • Meet with their patients and give them a written order before delivering the item; and
  • Ask their Medicare Administrative Contractor to authorize the item in advance.

  Visit TMA’s free Payment Resource Center for more information about medical equipment compliance.

• PLOS 10 Payments
  With the introduction of a new place of service (POS) code, practices should watch their payments to ensure they are correct. It is likely that PLOS 10 payments will be lower than the facility rate. The Centers for Medicare & Medicaid Services (CMS) and Novitas are reviewing guidance for a potential mass adjustment if it is determined that claims are processed incorrectly.
  

• Medicare Deductibles for 2024 See Increases
  The Centers for Medicare & Medicaid Services (CMS) has released the 2024 amounts for the Medicare Part A and Part B programs. The annual deductible for all Part B beneficiaries will be $240 in 2024 (an increase of $14 from the annual deductible of $226 in 2023). The Part A inpatient hospital deductible will be $1,632 in 2024 (an increase of $32 from $1,600 in 2023).

  Source: CMS Newsroom

• Prep for Novitas Smart Edits Feature Novitas Solutions’ Smart Edits, which will help you avoid denied electronic Medicare claims, will go live soon (exact date to be determined), and you can prepare now. Smart Edits will alert you of any Medicare claims you’ve submitted that can be repaired before a denial. The messages will display on the 277CA electronic claims acknowledgement response report and may require that you resubmit the claim.

  Here are some things you can do now:

  • Review the Smart Edit list and make any necessary corrections to your billing practice, so your applicable claims won’t be rejected once the edits are turned on.
  • If you are not familiar with the 277CA report, check with your billing department, or your billing service or clearinghouse. Novitas says this routine report, which advises whether claims submitted were sent to the processing system or not, is available shortly after submission. Claims rejected by a Smart Edit do not enter the claims processing system and are not assigned a claim number. The 277CA electronic report will provide a rejection code/flag. See the Novitas training module: Understanding the 277CA Claims Acknowledgement.
    
    
  Novitas shows how much time Smart Edits will save with a comparison example of the electronic claim flow with and without Smart Edits. Monitor the Novitas Smart Edits webpage for updates and information
  
• Use Correct POS Code for Medicare Telehealth 
  Although Medicare has recently implemented new place of service code 10 (telehealth provided in the patient’s home) to be effective April 4, 2022, physicians should follow the instructions from Novitas Solutions: Until the public health emergency is ended, continue to report the POS had that telehealth service been furnished in person. For example, if you typically see patients in your office, report POS 11 for a telehealth visit so Medicare will pay you the in-office rate. 
• CMS Debuts Coding Changes for Telehealth

• Fact Sheet Summarizes Medicare Payment for E&M Visits
  Medicare has generally adopted the new American Medical Association coding, language, and interpretive guidance framework for office and outpatient evaluation and management (E&M) visits (CPT codes 99201 through 99215), effective Jan.1, 2021. See this fact sheet for more information, including:

  • Payment of Medicare’s add-on codes for prolonged office and outpatient visits (G2212) and visit complexity (G2211), and
  • Medical review when time is used to select visit level. 
  _{CPT copyright American Medical Association. All rights reserved.}                                         

• Collect Medicare Info to Bill for Medicare Advantage COVID-19 Vaccine Administration
  Physicians contracted with Medicare Advantage plans should submit to original Medicare – not to the plan carriers – claims for administering a COVID-19 vaccine to their Medicare Advantage patients. To submit the claim to Medicare through Novitas Solutions, the Medicare payer for Texas, your practice will need to have on file your Medicare Advantage patient’s original Medicare card or Medicare ID number. Be sure to have your staff collect this when Medicare Advantage patients make appointments to receive a COVID-19 vaccine.
  
  Bill only for the vaccine administration when you’ve received the COVID-19 vaccine doses from the  government for free; don’t include the vaccine codes on the claim. Any other services you provide the patient on the same date should be filed to the Medicare Advantage plan. 

Molina Healthcare of Texas updates coming soon!

• Superior Healthplan May Request Members’ Medical Records
  Superior Healthplan has announced that as of July 8, it may request medical records from physicians for patients in Wellcare By Allwell, STAR + PLUS Medicare-Medicaid, and Ambetter plans as part of an effort to conduct risk adjustments in accordance with Centers for Medicare & Medicaid Services and Health and Human Services payment methodology. The request will come to physicians via phone or fax from the third-party vendors Advantmed and Datavant, who will schedule medical record retrievals through:

  • Secure email;
  • Fax;
  • FedEx;
  • Remote electronic medical record download; and
  • Onsite scanning performed by an Advantmed medical record technician.
    
    

  TMA experts recommend physicians respond promptly to Superior’s scheduling requests as they may carry deadlines. According to the payer, any information shared during this process will be “kept in accordance with all applicable state and federal laws regarding the confidentiality of patient records, including current [HIPAA] requirements.”

  For any questions, email Superior.

• Send Claims to TRICARE or to Veterans Affairs – Don’t Double Bill
  Some TRICARE enrollees are eligible for health care through both TRICARE and the Department of Veterans Affairs (VA) Community Care program. For these dual-eligible beneficiaries, you can file a claim with only one federal agency for payment – either TRICARE or VA – but not with both. (Filing a claim with both payers for the same services could lead to duplicate payments and possibly the appearance that you are intentionally trying to double-dip from the federal government. That could lead to recoupment, administrative fees, penalties, and fines, or possibly even federal provider exclusion, suspension, or termination.)

  For nonemergency care for dual-eligible patients:

  • VA Community Care requires a VA referral for authorization, and TRICARE Prime requires referrals for most services. You must submit the claim to whichever agency provided the referral.
  • If you are unsure or there is no referral (not all TRICARE plans require one), ask the patient if they want to use their VA or their TRICARE benefit.

  For emergency care for dual-eligible patients:

  • Referrals are not required.
  • Ask the patient if they want to use their VA or their TRICARE benefit.
  • If the dual-eligible TRICARE sponsor does not respond, you must contact VA within 72 hours online or by calling (844) 724-7842 to authorize the care provided if you expect the patient to use their VA benefit.
  
  

  Source, and for more information and a decision tree: TRICARE Provider News, August 2023, page 4

• UHC Requires New Modifier for Non-Covered Services
  Starting Feb. 1, 2025, United Healthcare (UHC) will require physicians to append a new GA modifier when charging UHC commercial plan members for non-covered services, including when a clinician knows or has reason to suspect that a commercial member’s benefits do not cover the service. Physicians also will need to acquire written consent from the patient for a service not covered by their benefits to meet documentation requirements.

  TMA billing staff say the change was made to align with guidelines by the Centers for Medicare & Medicaid Services. Per the payer, the new modifier requirement aims to help improve health care transparency by ensuring patients are made aware of their possible cost-sharing liability.

• UHC to Deny Claims Without JZ Modifier in Documentation
  Starting Oct. 1, United Healthcare (UHC) says it will require physicians to use modifier JZ when submitting claims to document when they’ve used all amounts of a drug in a single-use package or a single dose container. According to the payer, the update was made to align with guidelines from the Centers for Medicare & Medicaid Services. UHC says it will continue to require physicians to use modifier JW to indicate that they’ve discarded or used amounts of a drug from a single-dose container or single-use package.
• UHC to Deny Modifier 26 Radiology Claims without Proof of Interpretation

  Starting Oct. 1, to receive payment for claims appended with modifier 26, United Healthcare (UHC) has announced it will require radiologists to prove when they’ve provided a patient’s ordering physician with an interpretation and report of a radiology service such as by documenting the report in their electronic health record. If a radiologist performs a review of the service rather than a full written interpretation and report, the payer says it will consider the claims payment an evaluation and management (E/M) service and therefore not separately payable.

• United Slashes Prior Auth by 20%
  UnitedHealthcare (UHC) – Texas’ second largest health insurer by market share – has eliminated prior authorization requirements for certain procedure codes starting Sept. 1, 2023, across several of its national plans. The change is expected to reduce overall prior authorization volume by 20% and is part of an effort to “simplify the health care experience” for patients and clinicians, according to an Aug. 1 announcement.

  UHC eliminated the prior authorization requirements in two phases, on Sept. 1 and Nov. 1. The payer’s Medicare Advantage, commercial, Oxford, and individual exchange plans saw code changes on both dates. Its Community Plan was updated on Nov. 1 only.

  United urges physicians and practices to consult its code removal list for each health plan as “there will be some differences.”

  Starting next year, United also will implement a national gold-carding program for eligible clinician groups, with more information forthcoming.

  Source: UnitedHealthcare

• UHC to Require Digital Pre-Service Appeal Submissions
  Beginning Dec. 1, 2023, UnitedHealthcare (UHC) will accept only electronically submitted medical pre-service appeals from network physicians who have patients in UHC commercial, Medicare Advantage, and D-SNP plans. The payer encourages, but does not require, Community Plan (Medicaid) and out-of-network physicians to submit pre-service appeals electronically was well.

  To submit a pre-service appeal, use the Prior Authorization and Notification tool through the UnitedHealthcare Provider Portal.

  Source, and for details on how to submit: UnitedHealthcare

• VCP Statements Going Paperless for Medicaid Plan
  Beginning Nov. 3, 2023, UnitedHealthcare (UHC) will no longer mail virtual card payment (VCP) statements to UHC Community Plan (Medicaid) physicians who receive them by mail. Instead, you’ll access VCP statements in the Document Library in UHC’s Provider Portal. In the portal menu, select Documents & Reporting > Document Library > Payment Documents. When new statements become available in Document Library, UHC will send an email notification to the address on file.

  Remember, if you use an outside vendor, such as a revenue cycle management company or lockbox service, be sure they’re aware of this change.

  Source: UnitedHealthcare

• UHC to End Some Medicare Advantage Plans

  Effective Jan. 1, 2024, UnitedHealthcare (UHC) will reduce some Medicare Advantage service areas and discontinue some plans.

  The affected plans are certain AARP® Medicare Advantage plans, UnitedHealthcare MedicareDirect, UnitedHealthcare Dual Complete, or other UHC Medicare Advantage plans in multiple states.

  UHC says it will send nonrenewal notices to affected plan members dated Oct. 2, 2023, and let them know their options within UHC: other available Medicare Advantage plans, Medicare supplement insurance coverage, and Medicare Part D coverage, as applicable. These changes should not affect your participation agreement if you’re a participating physician with UnitedHealthcare Medicare Advantage, UHC says.

  Your patient may choose to enroll in a different organization’s Medicare Advantage plan or be returned to original Medicare on Jan. 1, 2024. Anyone can go to medicare.gov  for information about health plan availability.

  Source: UnitedHealthcare

• Medicaid Claim Letters Going Paperless

  Beginning Sept. 8, 2023, UnitedHealthcare (UHC) will no longer mail claim letters to physicians for UnitedHealthcare Community Plans (Medicaid).

  You’ll find these letters, including letters requesting additional information to process a claim, in the Document Library Claim Letters folder in the UnitedHealthcare Provider Portal.

  If you use an outside vendor, such as a revenue cycle management company or lockbox service, please ensure they’re aware of the following changes and digital workflow options.

  Source: UnitedHealthcare