Anesthesia Reimbursement Changes

Anesthesia Reimbursement Changes

Please note that we began reimbursement for additional units of anesthesia for P3-P5: P3 1 unit, P4 2 units, P5 3 units on 11/1/2023.

This is in addition to the reimbursements that went into effect 4/1/2023 for qualifying circumstance codes 99100, 99116, and 99135.


Suprachoroidal Space Injection

Effective 1/1/2024, BCBSWY will require Suprachoroidal Space Injection of Pharmacologic Agent, also known as Xipere, claims to be billed with CPT code 67516 only.

 

Prior Authorization Added for LOQTORZI™

Holiday Closure

Our offices will be closed in observance of the Thanksgiving holiday on Thursday, Nov. 23 and Friday, Nov. 24. We will return to office, Monday, Nov. 27.


Prior Authorization Added for LOQTORZI™

Please note that BCBSWY requires authorization for LOQTORZI™ (toripalimab-tpzi). This is the first and only PD-1 inhibitor for the treatment of patients with recurrent or metastatic nasopharyngeal carcinoma.


Medical Policy Reminder

As a reminder, be sure to check our Medical Policy for regular updates. Our Medical Policy can be found at BCBSWY.com/providers/policy/

Online Prior Authorization Webinar

We appreciate those who were able to attend our one-hour Prior Authorization training. We hope that the webinar was helpful. We covered many topics; so if you have any outstanding questions, please reach out to Provider Relations at provider.relations@bcbswy.com or 1-888-666-5188.

We will provide helpful recaps of the webinar in the upcoming weeks. Stay tuned.

Coding Advice

M63 and Remittance

When a provider receives remark code M63 on the remittance advice, it means there is an invalid diagnosis code or the diagnosis code submitted on the claim is not permitted as the primary diagnosis code.

To correct this issue for reimbursement review, please submit a corrected claim and/or an adjustment form using the button below.

If you are submitting this form by mail, please send it to:

PO Box 2266
Cheyenne, WY 82003

Or by fax at (307) 432-2942

These appeals should not be submitted through Availity. If this is submitted through Availity, it will be closed in our Appeals Department and forwarded internally to our Claims Department for processing.


Please do not submit this form through Availity. If submitted through Availity this will show on your dashboard as cancelled.

See Forms here


Prior Authorization Update

Hearing Aids

Effective 01/01/2024, FEP will require Prior Authorization on Hearing Aids services.

Benefits for hearing aids and services associated with the preparation and fitting of hearing aids are only available when prior authorization is obtained before receiving the devices.

Failure to obtain prior authorization for services will result in a denial. Due to the FEP requirement, BCBSWY cannot accept appeals for these types of denials after 01/01/2024.

For more information on FEP’s Prior Authorization requirement for hearing aids, please see pages 53, 55-56 of the 2024 FEP Standard and Basic Option book, which can be found online here.

Additionally, routine hearing tests, hearing aids – including bone-anchored hearing aids, accessories, or supplies (including remote controls and warranty packages), and all associated services, and hearing aid exams are not covered.

For more guidance for FEP Blue Focus, please refer to page 49 here.

2024 FEP Standard and Basic Option Book

Prior Authorization Removed

Iron Sucrose and Ocular Angiogenesis Products

BCBSWY will be removing authorization requirements on Iron Sucrose (HCPCS Code J1756) and Ocular Angiogenesis products Eylea, Lucentis, Macugen, Visudyne (HCPCS Code J0178) as of 11/6/23.

Any pending prior authorizations for HCPCS codes J1756 or J0178 will receive an automatic approval regardless of date of service.

If you have any claims that deny for a date of service on or after 11/6/2023 for either of these codes, please contact our Provider Relations Department.

Any claims for date of service prior to 11/6/2023 may still deny as noncoverage, not medically necessary or no authorization. The standard retrospective authorization or appeals process will continue for those dates of service.

Please note that this change is effective for BCBSWY membership but does not include FEP.

Emergency Protocol Medication Authorizations

BCBSWY does not require prior authorization of emergency protocol medications. See drug examples below.

  • HCPCS DESCRIPTION J1720 | INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG
  • J1200 | INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG
  • J1642 | INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS
  • J2175 | INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG
  • J2997 | INJECTION, ALTEPLASE RECOMBINANT, 1 MG
  • J0171 | INJECTION, ADRENALIN, EPINEPHRINE, 0.1 MG
  • J2469 | INJECTION, PALONOSETRON HCL, 25 MCG
  • J0640 | INJECTION, LEUCOVORIN CALCIUM, PER 50 MG

Online Prior Authorization Updates II

We will soon send an invite for a brief one-hour Prior Authorization training. Please monitor your email if you would like to attend this webinar as it will have all the information you need to register for the event.

This training will focus on best practices when submitting a prior authorization. Our goal is to help users understand service categorization within prior authorization to help them get what you need to do faster.

If you want to attend but do not receive an email by the end of the week, please reach out and let us know.

Coding Advice

Blue Cross Blue Shield of Wyoming regularly develops and revises coding and reimbursement policies and updates to the coding sets. Our commitment is to update the provider community as coding and reimbursement policies are adopted and/or revised.

The following coding updates will be effective 11/1.

Ambulance Services:

  • Please include origin and destination modifiers on ambulance services.
  • Ambulance services should be billed with modifiers QM or QN.
  • Ambulance transportation services billed with revenue code 0540(Ambulance general classification) will deny.

DME and Supplies:

  • Prosthesis and orthosis should be billed with modifiers LT or RT.
  • Oxygen contents (E0441-E0444, E0447, K0742) will deny if billed more frequently than once every month.

Annual Wellness Reminders

Annual Wellness Reminders BCBSWY encourages Primary Care Providers to remind your patients to schedule an annual wellness visit. Annual exams are essential. We know that regular preventive care is one of the best ways to identify and treat health issues before they get worse. Click here to see the complete list of preventive benefits that BCBSWY covers.

Online Prior Authorization Updates

We are actively working to correct a system issue with online authorizations displaying the incorrect effective and expiration date of an authorization. This is affecting all authorizations. In the interim, you can validate the authorization period by the following:

  • Reviewing the fax correspondence, which is sent in real-time at the time of determination;
  • Reviewing the letter, which is mailed the day after determination;
  • Or calling our Member Services Department.

In the coming weeks, a detailed section will be added to our online tool and will include the following:

  • For inpatient, it will display the length of stay approved from admit date through the most recent concurrent review.
  • For outpatient, it will display the approved authorization period per CPT or HCPCS code submitted.

We appreciate your patience as we complete our system upgrade to improve prior authorization efficiencies. We’ll continue to update you on how to utilize this new authorization tool best and let you know as soon as this issue is corrected.

CPT Code 96380 and 96381 Billing Tips

Blue Cross Blue Shield of Wyoming regularly develops and revises coding and reimbursement policies and updates to the coding sets. Our commitment is to update the provider community as coding and reimbursement policies are adopted and/or revised.

  • Two new CPT codes for RSV were released this week with a retrospective effective date of 10/6/2023. This means for any date of service 10/6/2023 and forward, BCBSWY will accept this code on a claim form. Any date of service prior to this date will reject as invalid as the code is not effective.
    • Codes 96380 and 96381
  • We are currently programming our system to accept these new codes. We expect all programming to be implemented by Monday, Oct. 23. If you submit prior to this date and receive any type of error such as an ECP error for electronic submissions, please attempt resubmission on, or after 10/23/2023.
  • Best practice TIP: Hold claims with either of these CPT codes until on or after 10/23/2023

CPT Code 83036 Billing Tips

BCBSWY would like to encourage Providers billing CPT code 83036 to include the category claims as this will be a focus beginning Jan. 1, 2024.

For best habits, please begin using the below guidance now to ensure proper categorization.

CPT 83036 for a HbA1c laboratory test will need the appropriate Category II code on the same claim.

CAT II codes are an informational code and should be billed with either a $0.00 charge or a $0.01 charge if required by your system or clearing house.

CAT II codes are for diagnostic/ screening processes or results.

Category II Codes for HgbA1c

Codes Code Usage

  • 3044F-HbA1c —– Less than 7.0%
  • 3051F-HbA1c —– Greater than or equal to 7.0% and less than 8.0%
  • 3052F-HbA1c —– Greater than or equal to 8.0% and less than 9.0%
  • 3046F-HbA1c —– Greater than 9.0%

Annual Wellness Reminders

BCBSWY encourages Primary Care Providers to remind your patients to schedule an annual wellness visit. Annual exams are essential. We know that regular preventive care is one of the best ways to identify and treat health issues before they get worse.

Click here to see the complete list of preventive benefits that BCBSWY covers.

Provider Directory Validation Tool Reminder

Reminder:

  • You can now find the guide under the ProviderResources section on the right 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.
Provider Resources:

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.

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.

Here, we take a closer look at the Concurrent Review submission workflow for prior authorizations.

Questions?

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

Or