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Blue Cross Blue Shields of Wyoming
Questions? We’re here to help. Contact Us
Blue Cross Blue Shields of Wyoming

Site Section: Providers

Coding Advice: Claims Coding Tips For Faster Approval

Please note the following errors that often lead to claims denial when not properly coded:

  • BCBSWY will deny Column II procedure codes billed with associated Column I procedure code by same provider and a modifier is not supported. Supporting information such as claims history and all diagnosis codes are reviewed. Please ensure you are billing all diagnosis codes to support modifiers 59 and 25.
  • J2001 will deny when used as a local anesthetic and is bundled into the service rendered at the same time.
  • Claim lines reported with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes guideline policy will be denied.
  • Procedures or services received with a secondary diagnosis code as a principal or primary diagnosis will be denied.
  • Any service when billed with an invalid or deactivated NPI will be denied.
  • Claim lines containing invalid NDC numbers will be denied.

Prior Authorization Submission

Get Started!

Submitting a prior authorization through Availity is the best way to determine prior authorization requirements for a participant.

Additionally, understanding the proper Service Type makes a difference in how the prior authorizations get routed and the associated approval time.

Please view the short videos below to understand these workflows better.

High-level explanation

Follow this video to understand the basics of submitting a prior authorization.

Service Type Explanations

When submitting an authorization, you will need to select a Service Type. This routes your case to BCBSWY subject matter experts who will review and render a determination. Therefore, selecting the correct service type is key to receiving the most effective and efficient service from our authorizations team.

The videos below have additional information to help you better understand the prior authorization workflows. Choose the service type that aligns with your facility.

Download Service Type Guide Sheet
Questions?
Call +1-800-442-2376
Learn More
Quick Access:

Video Library: Prior Authorization Training Topics

Explore our comprehensive video library, a valuable resource providing in-depth training on various Prior Authorization topics. Access expert insights and educational content to enhance your understanding and skills in this crucial field.

This video discusses workflows of Maternity, Specialty and General, and how they are processed for prior authorizations.
In this video, we delve into MHSA workflows and how they are processed for prior authorizations.
Here, we explore Step-Down Level of Care workflows and how they are processed for prior authorizations.
This video discusses Oncology workflows and how they are processed for prior authorizations.
The content of this video entails Therapy workflows and how they are processed for prior authorizations.
Here, we take a closer look at Pharmacy and Redirection of Care workflows and how they are processed for prior authorizations.
Redirection of Care: Learn More

Questions?

If you have any questions regarding prior authorizations, call +1-800-442-2376.

Download Online Training Guide
Or
Download Service Type Infographic

Availity/Prior Authorization Update

Our new Prior Authorization tool, Predictal, will launch September 5th. We
look forward to the convenience it will offer you. We will provide you with
additional training resources very soon. For now, we would like you to
please note the important following details:

  • Availity will be unavailable for prior authorizations during this
    platform enhancement from September 1 – September 18. During
    that time, we kindly request you to use alternative channels to submit
    prior authorizations.

  • Providers should still follow the same guidance for special
    circumstances.
  • If an authorization is submitted before September 1st, this will show
    on your Availity dashboard as normal. However, Providers will not be
    able to link to this authorization for concurrent reviews.
  • In some cases, you may see cancellations from BCBSWY as we
    move current authorizations for inpatient stays through 9/5 to our
    new system. BCBSWY will contact you directly to discuss these
    specific authorizations.
  • Prior authorizations may take slightly longer than average in early
    September, but they will still be approved within our standard 14-day
    time frame.
  • Authorizations submitted prior to September 5th will be completed by
    the fifth as part of the transition.

We will share additional information very soon. Please reach out if you
have any questions.

Claim Reprocessing Requests; Mental Health and Substance Abuse

Claim Reprocessing Requests

As we enter our busy season, we want to remind providers that if you
receive a claim that is denied for “no authorization,” the quickest route of
reprocessing a claim for payment is to submit the missing authorization
through the standard authorization process. Please note that you are
submitting based on a denied claim on your cover page of documentation
or on your fax. Include the claim number.

Our clinical team will process the authorization and reprocess your claim
based on the review outcome. This will either allow your claim to be
processed for payment or provide you the appropriate appeal rights based
on the denial reason.

We recommend this method instead of submitting an appeal due to the
turnaround times. We would expect that your claim will receive an
authorization determination and claims reprocessing within 30 days. Note:
If submitting an appeal, the expected timelines could extend significantly
past 30 days.

Coding Advice

Mental Health and Substance Abuse

BCBSWY is not accepting billing of consolidation codes for mental health
and substance abuse such as G2087 and G2088. To receive
reimbursement for the different services listed under these codes, submit
the individual codes for the services rendered to the member.

These will be reviewed per the members benefit plan and reimbursed in
accordance with the BCBSWY fee schedule.

Infusion Pump Billing, Unclassified HCFA Unit Billing

Coding Advice

Infusion Pump Billing

BCBSWY is seeing an uptick in billing of implantable infusion pumps (HCPCS Code E0782) billed without a required modifier for pricing. For claims to be reimbursed, providers must submit this code with one of the following modifiers:

  • NU (New Equipment)
  • UE (Used Equipment)
  • RR (Rental)

Unclassified HCFA Unit Billing

When submitting a HCFA-1500 with an unclassified drug HCPCS code, such as J3490 or J3590, the units billed with the code will specify the units for which you are seeking reimbursement.

For example, Xylocatine-MPF 1% Solution is provided in a package size of 2.0 ML. On a claim form 1 unit would indicate usage of 2.0 ML, 2 units would indicate usage of 4.0 ML. The units billed in loop 2410 within an 837p file is not referenced for pricing and will not cause a multiplication of the per unit price.

FDA Approval for RSV Prevention

Beyfortus (nirsevimab-alip) received an FDA approval for the prevention of RSV in neonates and infants born during or entering their first RSV season and in children up to 24 months of age who remain vulnerable to severe RSV Disease through their second RSV season.

BCBSWY will NOT require authorization on Beyfortus.

Please bill using the following codes for Beyfortus:

  • 90380: Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use
  • 90381: 1 mL dosage, for intramuscular use

Authorization is still required for Synagis for treatment of RSV. For authorizations, you should expect up to 14 days for processing. We encourage you to review our RSV medical policy found at BCBSWY.com/providers to help you understand what our clinician are reviewing for and where you may need to provide additional documentation if your patient does not meet the criteria outlined. The medical policy number for reference is 05.01.10.

Transition Faxes to Availity, Electronic Claim Corrections, Welcome North Platte Valley Medical Center

Transition Faxes to Availity

Starting in July of 2023, we will no longer accept faxes from Providers. Please use the Availity attachments tool to upload all documents, such as medical records, appeals, adjustments, invoices and general medical documentation. For more information on the Availity attachment tool, please click the button below.

How to Use the Availity Tool Guide Here

Electronic Claim Corrections

As of July 14, BCBSWY now accepts electronically corrected claims. Please use the appropriate frequency code or type of bill to correct your electronic claim. For more information, please download the instructions below.

View Electronic Claims Adjustment Instructions Here

Welcome North Platte Valley Medical Center

BCBSWY would like to welcome the North Platte Valley Medical Center to Saratoga where they began seeing patients as of May 30, 2023. We wish you success in your community!

Directory Provider Directory Tool Reminder

Reminder: You can now find the guide under the Provider Resources section on the right rail of the website.

Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information with us every 90 days.

Click Here to Visit Now

Telemedicine Services Matrix

Effective Jan. 1, 2023, BCBSWY has updated our telemedicine guidance. BCBSWY will permit telephonic and telemedicine visits to occur at the patient’s home. Inpatient telemedicine encounters are permitted within the same facility. The below guidance is intended to assist professional providers understand the types of services permitted during this time. Other benefit and cost share rules will continue to apply. It is important to note that only services that can be rendered through telemedicine should occur. Services that cannot be safely or adequately provided through telemedicine should be avoided. These guidelines apply only to BCBSWY members. Providers should seek guidance from other Blues plans for potential changes to their policies.

Please refer to the Provider Manual for more detailed guidance here.

Telemedicine Matrix PDF

Type of ServiceWhat is the ServiceHCPCS/CPT CodesPlace of Service/ModifiersCoverage
Inpatient (Professional Services)

Telehealth/Telemedicine Visits		A service that can safely and appropriately be rendered at a distance. Services provided should be within the provider’s scope of license and meet the standard of care. HCPCS or CPT code(s) that can safely and appropriately be rendered at a distance as determined by BCBSWY.Append a GT or 95 modifier as applicable with correct coding.

Bill with the place of service of inpatient hospital.		BCBSWY covers telemedicine services subject to member’s benefits.
Outpatient (Professional Services)


Telehealth/Telemedicine Visits		A service that can safely and appropriately be rendered at a distance. Services provided should be within the provider’s scope of license and meet the standard of care. Services can be rendered to the patient’s home.HCPCS or CPT code(s) that can safely and appropriately be rendered at a distance as determined by BCBSWY.Append a GT or 95 modifier as applicable with correct coding.BCBSWY covers telemedicine services subject to member’s benefits.
Telephone Services Telephone evaluation and management service by a physician or other qualified health professional for an established patient.99441 99442 99443Use standard place of service codes. The GT or 95 modifier is not required.BCBSWY will benefit these services.
e-VisitsOnline digital services for an established patient, through an online patient portal.99421 G2061
99422 G2062
99423 G2063		Not applicable.Not a benefit. These codes are not reimbursed by BCBSWY at this time.
Virtual Check-InsBrief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient.G2010 G2012Not applicable.Not a benefit. These codes are not reimbursed by BCBSWY at this time.
Hospital Staff Mental Health and Substance Use TreatmentDiagnosis, evaluation, or treatment of a mental health or substance use disorder provided remotely by hospital staff who are licensed when the patient is in the home place of service.C7900 C7901 C7902Not applicable.BCBSWY will deny these codes as included in. Provider should bill the specific service rendered on a professional claim (HCFA-1500, 837P) with a GT or 95 modifier. You must bill with the national place of service 10 (Telehealth Provided in Patient Home).
Home Health TelemedicineHome health services rendered using audio and/or video telecommunications including remote monitoring.G0320 G0321 G0322Not applicable.BCBSWY will deny these codes as included in. Provider should bill the specific service rendered on a professional claim (HCFA-1500, 837P) with a GT or 95 modifier. You must bill with the national place of service 10 (Telehealth Provided in Patient Home).

Availity Provider Portal
Verify eligibility and benefits, submit claims, and more.
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COVID-19 for Providers

What is BCBSWY doing to help providers during this time?

Read More →

Provider Resources

Provider Training Guides

Learn How it Works

How to Upload Attachments to Availity

View our Online Medical Document Attachment Training Guide.

How to Submit a Online Prior Authorization Request

View our Prior Authorization Online Training Guide.

How to Submit Electronic Funds (EFT) Requests

Learn how to submit EFT requests through the Availity portal.

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