Information Is Power…Visibility Is Priceless

To help you stay up-to-date with the constant changes in medical billing and reimbursement, XIFIN compiles information and articles that cover important billing-related topics. These proctored articles are an excellent digest of key updates and issues, and are generally published monthly. Information is power. Subscribe to the XIFIN newsletter and get the information and visibility you need, delivered to you every month.

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Moderate Sedation Becomes Separately Payable in 2017
Friday, January 27, 2017
One of the biggest 2017 CPT changes is in interventional radiology and the new ability to separately bill and be paid for moderate sedation provided during certain procedures.  While trend has been to bundle payments, this is an opportunity to unbundle and receive additional payment for services that were previously bundled in the base procedur    more

Moderate Sedation Reimbursement Policy
Friday, January 27, 2017
The current UnitedHealthcare Moderate Sedation reimbursement policy for Commercial plans will be retired effective Jan. 1, 2017. Per the 2017 CPT book, moderate sedation codes 99143-99145 and 99148-99150 have been deleted and replaced by new CPT codes 99151-99157.    more

Expansion of Radiology and Cardiology Notification/Prior Authorization Protocols to All Savers Plans (Offered Off-exchange) - Effective April 1, 2017
Friday, January 27, 2017
Effective April 1, 2017, care providers must provide notification prior to scheduling a planned service that is subject to UnitedHealthcare’s Outpatient Radiology Notification/Prior Authorization Protocol and Cardiology Notification/Prior Authorization Protocols for a UnitedHealthcare All Savers (offered off-exchange) member.    more

Claim adjustment requests
Friday, January 27, 2017
Blue Cross Blue Shield of North Dakota (BCBSND) is providing a clarification to the current claim adjustment request policy. Effective January 1, 2017, all claim adjustment requests must be submitted 180 days from the original payment listing date.    more

Diagnostic Mammography Coverage Mandate
Friday, January 27, 2017
There is a New York state coverage mandate going into effect January 1, 2017, expanding the existing health insurance benefit for screening mammography to include diagnostic imaging for the detection of breast cancer.    more

Retroactive Rate Adjustment of Electrocardiogram Claims
Friday, January 27, 2017
The Department of Health Care Services (DHCS) has updated provider reimbursement rates for CPT electrocardiogram codes 93000, 93005 and 93010. This update is effective retroactively for dates of service on or after November 1, 2014. No action is required on your part. Xerox State Healthcare, LLC (Xerox) will adjust the affected claims.    more

Void and Resubmission of Erroneously Paid Medical Claims
Friday, January 27, 2017
The Department of Health Care Services (DHCS) has identified a claims processing issue with some medical claims billed with a begin date of service greater than the end date of service. The issue affected claims for dates of service from January 1, 2013, through May 23, 2016. No action is required on your part.    more

Resubmission of Claims Billed for ICD-10-CM Codes N36.43, M96.1 and Q76.2
Friday, January 27, 2017
The Department of Health Care Services (DHCS) identified a claims processing issue with some claims for ICD-10-CM diagnosis codes N36.43, M96.1 and Q76.2. This issue caused some claims to erroneously pay and some claims to erroneously deny. This issue affected claims for dates of service from October 1, 2015, through July 25, 2016.    more

DHCS Fiscal Intermediary Name Change
Friday, January 27, 2017
Xerox State Healthcare, LLC is the current Medi-Cal Fiscal Intermediary for the Department of Health Care Services’ (DHCS) fee-for-service system.    more

Labs Stop VA from Allowing APRNs to Perform Lab Tests
Friday, January 27, 2017
The laboratory sector has successfully fought a Department of Veterans Affairs (VA) rule that would have allowed advanced practice registered nurses (APRNs) to “perform and supervise” lab testing.    more

Aetna-Humana merger blocked on antitrust grounds
Friday, January 27, 2017
A U.S. District Court Judge ruled against the $37 billion merger between national insurers Aetna and Humana on Monday, effectively blocking the controversial tie-up that would have altered the Medicare Advantage landscape. U.S. District Judge John D.    more

FDA Synthesizes Feedback on LDTs in New Discussion Paper
Friday, January 27, 2017
Following up its decision not to issue final guidance in 2016 regarding oversight of laboratory developed tests (LDTs), the U.S. Food and Drug Administration released a discussion paper Friday, Jan. 13, 2017.    more

Maximum Frequency Per Day Policy updated 1/1/17
Friday, January 27, 2017
UHC has a Maximum Frequency Per Day Policy that is similar to the CMS MUE policy regarding the number of units that can be billed for a CPT/HCPCS code by the same physician for the same patient on the same day.    more

Updates Preauthorization and Notification Lists for 2017
Friday, January 27, 2017
On Jan. 23, 2017, Humana will update preauthorization and notification lists for all commercial fully insured plans, Medicare Advantage (MA) plans, dual Medicare-Medicaid plans and Illinois Integrated Care Plan (ICP).    more

Notice of UCare Implementation of Medicare Pricing Software
Friday, January 27, 2017
On March 1, 2017, UCare will begin implementing third-party software to calculate pricing on most Medicare professional services. Through the use of this software, they will improve payment accuracy and consistency by aligning more closely with Centers for Medicare and Medicaid Services (CMS) professional reimbursement methodologies.    more

Claim adjustment requests
Friday, January 27, 2017
Blue Cross Blue Shield of North Dakota (BCBSND) is providing a clarification to the current claim adjustment request policy. Effective January 1, 2017, all claim adjustment requests must be submitted 180 days from the original payment listing date.    more

Genetic Testing guidelines updated
Friday, January 27, 2017
Molecular pathology services, including genetic testing, are rapidly becoming the standard of care in diagnostic medicine and other related areas. OHCA is committed to ongoing evaluation of the clinical evidence supporting the use of these services to ensure that medically necessary tests and technologies are available to our members.    more

Correction to Presumptive Eligibility Denials, CR 63802
Friday, January 27, 2017
MaineCare is still working to correct the issue for claims with presumptive eligibility due to pregnancy denying in error. An issue was identified where some claims denied for no coverage when the member received MaineCare coverage based on Presumptive Eligibility due to pregnancy.    more

Claim Edit for Rendering Provider Service Location - Implementation Date Change
Friday, January 27, 2017
The implementation date for the Rendering Provider Service Location Edit (edit 04528) has changed from February 5, 2017, to May 1, 2017. Providers are encouraged to submit Managed Change Requests before May 1, 2017 to ensure the provider record includes all service locations where the provider renders services billed in NCTrack    more

Claim Edit for Provider Affiliation - Implementation Date ChangeAffiliation
Friday, January 27, 2017
The implementation date for the affiliation claim edit has changed from February 5, 2017, to May 1, 2017. Providers are encouraged to submit Managed Change Requests (MCRs) before May 1, 2017 to affiliate the attending/rendering providers with the billing provider(s) who are submitting claims on their behalf.    more

2017 CPT Code UpdateCPT- claims to pend
Friday, January 27, 2017
Effective with date of service January 1, 2017, the AMA has added new CPT codes, deleted others and changed the descriptions of some existing codes.    more

HFS Secure Electronic web-based portal
Friday, January 27, 2017
HFS recognizes the importance of providers having an outlet for reporting issues they may have with Medicaid Health Plans if they cannot get these issues resolved by working through the Plan processes.  The provider portal was created for providers to submit complaints to HFS about issues you are experiencing with Illinois Medicaid Managed Care    more

Remittance Advice (RA) Layouts Have Changed
Friday, January 27, 2017
Use the RA link in this email to see examples of Delaware Medicaid Enterprise System (DMES) RA layouts compared with Medicaid Management Information System (MMIS) layouts; use the Field Descriptions table for specifics about information on your new RAs.    more

REGISTER on the Portal
Friday, January 27, 2017
The new Delaware Medicaid Enterprise System (DMES) has replaced the Medicaid Management Information System (MMIS). The new Delaware Medical Assistance Program (DMAP) Healthcare Portal is used to enroll, inform, educate, reimburse, and update DMAP providers and process claims.    more

All Providers RE: Elimination of Paper Claims Update
Friday, January 27, 2017
Any paper claims that have been received by Hewlett Packard Enterprise (HPE) after October 1, 2016, with the exception of Out-of-State (OOS) provider and claims submitted for special handling, have been returned to the provider (RTP). Effective February 1, 2017, HPE will no longer RTP paper claims back to providers.    more

DHCS Fiscal Intermediary Name Change
Friday, January 27, 2017
Xerox State Healthcare, LLC is the current Medi-Cal Fiscal Intermediary for the Department of Health Care Services’ (DHCS) fee-for-service system.    more

Timely Filing Reminder and Changes to Late Bill Override
Friday, January 27, 2017
As of March 1, 2017, Hewlett Packard Enterprise (HPE) will no longer use the late bill override date. It is imperative that providers submit claims within the 120-day submission period and every 60 days thereafter, if necessary. The new system, interChange, will then verify the previous claim was submitted within the timely filing guidelines.    more

Void and Resubmission of Erroneously Paid Medical Claims
Friday, January 27, 2017
The Department of Health Care Services (DHCS) has identified a claims processing issue with some medical claims billed with a begin date of service greater than the end date of service. The issue affected claims for dates of service from January 1, 2013, through May 23, 2016. No action is required on your part.    more

Resubmission of Erroneously Denied Immunology Claims for CPT Code 86147
Friday, January 27, 2017
The Department of Health Care Services (DHCS) identified a claims processing issue causing some claims billed with CPT code 86147 (cardiolipin [phospholipid] antibody, each 1g class) to erroneously deny. The issue affected claims for dates of service from January 1, 2015, through November 5, 2015. No action is required on your part.    more

Resubmission of Claims Billed for ICD-10-CM Codes N36.43, M96.1 and Q76.2
Friday, January 27, 2017
The Department of Health Care Services (DHCS) identified a claims processing issue with some claims for ICD-10-CM diagnosis codes N36.43, M96.1 and Q76.2. This issue caused some claims to erroneously pay and some claims to erroneously deny. This issue affected claims for dates of service from October 1, 2015, through July 25, 2016.    more