Online Prior Authorizations Submissions will be unavailable between 9/1 – 9/18. Continue reading “Prior Authorization Update Soon”
Site Section: Providers
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.- Option 1: Fax – Please use the authorization request form
found on our website
at https://www.bcbswy.com/docs/providers/precertification.pdf,
Fax it to 307-432-2917. - Option 2: Call – For any inpatient or concurrent reviews, you
can also submit prior authorizations through our Inpatient
Authorization Notification Line at 1-800-251-1814. Information
regarding the information that is needed on the notification
line can be found at https://www.bcbswy.com/providers/preadmin/preadmin/
- Option 1: Fax – Please use the authorization request form
- 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.
DME Reimbursement Update
Announcements
Holiday Closures
BCBSWY is updating its DME reimbursement rates. Effective August 1, 2023, our DME reimbursement will be based on Medicare’s DMEPOS 2023 non-rural schedule.
- Reimbursement for respiratory equipment will be set at 108% of the fee schedule.
- Reimbursement for non-respiratory equipment will be set at 100% of
the fee schedule.
Memorial Day Closure
In observance of Memorial Day, our offices will be closed Monday, May 29, 2023.
Coding Advice – Excludes 1 Note
BCBSWY reviews claims for Excludes 1 Note instructions per the ICD -10- CM Official Guidelines for Coding and Reporting.
An Excludes 1 Note indicates that two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Billed services with one or more diagnosis code pairs that are subject to an Excludes 1 Note will be denied.
Itilliti Webinar
Please join BCBSWY for a webinar with Itiliti and ACAP on June 1, 2023 at noon. You do not need to be an ACAP member to register. All BCBSWY providers are encouraged to attend.
BCBSWY and ACAP will discuss how BCBSWY has reduced the burden of prior authorizations within the company and for providers. Please register using the button below.
Directory Provider Directory Tool Reminder
Reminder: You can now find the Availity Directory Validation Training 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.
Telemedicine Services Matrix
Effective January 1, 2025, 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. This 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.
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.
Timely Filing & Individual Claims
Timely Filing Reminder
BCBSWY would like to remind providers we have a timely filing deadline of one year from the date of service. However, some groups have a deadline of less than a year. Therefore, we encourage providers to submit claims within 60 days of the date of service as timely filing may impact benefit determination.
Bill Claims Individually
BCBSWY does not accept roster billing. All claims must be submitted individually.
Holiday Closure
Our offices will be closed on Monday, July 4 in observance of Independence Day.
Call Center Hours Change in June
Call Center Hours Changing in June
Blue Cross Blue Shield of Wyoming (BCBSWY) provider call center hours will soon change. The new hours will be from 7:30 a.m. to 5 p.m. This change will be in effect June 1, 2022.
BCBSWY Increasing Claims Process Accuracy
In an ongoing effort to ensure high quality claims processing and payment, BCBSWY is taking additional steps to verify the accuracy of payments made to our contracted facilities. Beginning in July 2022, BCBSWY will begin auditing DRG claims and associated medical records to ensure payments were applied in accordance with national correct coding standard rules.
BCBSWY has contracted with Cotiviti to assist us in this effort. If you have DRG claims selected for audit, you will receive a letter from Cotiviti requesting medical records for these claim audits on behalf of BCBSWY.
The Provider Directory Validation Tool is Ready
In order to help facilitate compliance with the No Surprises Act (NSA) provider directory validation requirements, BCBSWY has developed a Directory Validation tool on the Availity Portal.
This tool allows you to review and confirm name, address, contact information, and providers affiliated with your organization online. The NSA requires you confirm this information with us every 90 days so your information can continue to be listed in our public directory. Please see the guide here.
Wyoming Blue Circle of Excellence
For Ambulatory Surgical Centers Knee and Hip Replacement
Frequently Asked Questions
We appreciate your interest in the Blue Circle of Excellence for Knees and Hips evaluation process, please thoroughly review this entire application and the supplemental instructions for more details.
The application process to be evaluated as a Wyoming Blue Circle of Excellence for Knees and Hips is available throughout the year.
We encourage all interested providers to complete the Wyoming Blue Circle of Excellence application for our team to evaluate if you meet the qualification criteria. Please review the application and instructions to gather the information required before submitting online. The online survey must be completed in the same session. Contact [email protected] for more details.
Designation as a Wyoming Blue Circle of Excellence Center differentiates you among peers in your community and around the state. From staff and referring physicians to patients and prospective employees, this highly respected designation affirms your program’s expertise in delivering higher quality and more affordable health care for their knee and hip replacement needs.
BCBSWY is committed to providing consumers and physicians with increased transparency on provider quality and cost. Wyoming Blue Circle of Excellence designations provide consumers and their referring physicians with the information they need to select a provider recognized for delivering quality, cost-efficient specialty care.
Employers also adopt many tactics to help improve the quality of health care for their employees, while also managing cost. Some of these tactics may include offering richer benefits to employees who use designated WY Blue Circle of Excellence providers.
After an initial award, successful applicants must reapply 90-days before the award expiration to continuously remain in the program. The Wyoming Blue Circle of Excellence program award period is three years after the initial award date. Reapplication is required for on-going participation. This process allows all providers to be evaluated against the same selection criteria.
The evaluation process for Blue Circle of Excellence is a win-win proposition for providers. Whether they meet the program selection criteria or not, every provider evaluated receives a customized report providing useful and critical insights into its performance.
Upon completion of the Participation Agreement a toolkit of promotional resources will be made available. Including a sample press release template, social media posts, artwork, and information about how the ASC can promote the designation. BCBSWY will also assist with coordination of the announcement to help amplify this designation to members and employers.
If you are not accepted into the program, you will receive a report that can provide a foundation for internal discussions with your executive management or medical staff. This report can be used as a tool to assess and improve your program’s quality and cost performance through comparisons to national benchmarks. Applicants may reapply six months after an unsuccessful application or after application issues have been resolved, whichever is later.