Category: BCBS (Various States)

Find medical billing and medical coding guidance for BCBS Empire Plan (Multiple States).

Posted in #reimbursement, BCBS (Various States), BCBS Empire NY, NY Providers, Pharmacy (Various Insurance Payers)

BcBS HighMark NY: coverage for COVID-19 vaccine

Posted on by KR2Medical Billing

According to Highmark BCBS- the COVID-19 vaccine will be covered with out any pocket costs through 2025-2026.

This currently only applies to Managed Medicaid, Child Health Plus, Essential and HARP plan types.

The vaccine will still be part of standard preventive care benefits, COVID‑19 vaccines are covered for all members older than 6 months of age.

Members are encouraged to contact their primary care or pharmacy for vaccine availability.

Highmark will partner with Wellpoint companies to administer this benefit.

As per Highmark-Wellpoint Insurance Services, an independent company, administers utilization management services for Highmark Blue Cross Blue Shield’s managed Medicaid.
Wellpoint Partnership Plan, LLC provides management services for Highmark Blue Cross Blue Shield’s managed Medicaid.

Certain sef-insured plans have special vaccine coverage and should check their benefits coverage for more info.

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Posted in #reimbursement, BCBS (Various States), BCBS Empire NY, Cinga Insurance, EmblemHealth NY, HEDIS Measures, NY Providers, Training

HEDIS Measure: Immunizations for Adolescent

Posted on by KR2Medical Billing

This measure represents the percentage of children who turned 13 years old and received the following immunizations before their 13th birthday.

  • One dose of meningococcal vaccine
  • One tetanus, diphtheria toxoids and one acellular pertussis vaccine (Tdap): and
  • Completed the human papillomavirus (HPV) series.*

*HPV requires 2 shots, at least 146 days apart.

Meningococcal recombinant (serogroup B) (MenB) vaccines- DO NOT COUNT towards the HEDIS measure.

For Meningococcal Serogroups A, C, W, Y:

  • At least one meningococcal serogroups A, C, W, Y vaccine, with a date of service on or between the member’s eleventh and 13th birthdays
  • Anaphylaxis due to the meningococcal vaccine any time on or before the member’s 13th birthday meets criteria

For Tdap: generic documentation (Tdap/Td) can be counted towards this HEDIS measure.

  • At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, with a date of service on or between the member’s tenth and 13th birthdays.
  • If patient has anaphylaxis due to Tdap vaccine during or before pt turns 13 years old
  • Encephalitis due to the tetanus, diphtheria, or pertussis vaccine

For HPV:

  • At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart
  • At least 3 HPV vaccines – w/ different DOS before or on the date when patient turns 13 years of age
  • Anaphylaxis due to the HPV vaccine any time on or before the member’s 13th birthday meets criteria

Accepted documentation:

  • A note with the specific antigen/vaccine and the date of administration of the vaccine
  • A certificate of immunization prepared by an authorized health care provider or agency with information of each vaccine and their administration dates

Not accepted documentation:

A note that says the member is up to date and does not have the actual vaccines listed w/ administration dates

Via Anthem (NY) provider news.

PROVIDERS-some things you can do in your practice in order to meet this measure:

  • Have standing orders for adolescent vaccines- the visit can be performed by a Nurse
  • Use appointment reminders to schedule vaccine appointments
  • For HPV  vaccines make sure to schedule a f/u appt for the next dosage.
  • Educate parents on the importance of the vaccines and their on time administration.

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Posted in #Medicareadvantage, BCBS (Various States), Training, Updates

BCBS of MN: Reimbursement update (modifiers 52, CO, CQ)

Posted on by KR2Medical Billing

Please note which type of providers will be affected by each reimbursement policy for specific modifiers and the effective date it begins.

The following reimbursement updates take effect as of July 1, 2022:

  1. Modifier 52- for services performed on 07/01/2022 and thereafter, Blue Cross will be begin reimbursing procedure codes billed with a -52 modifier at the lesser of 50% of the physician fee schedule allowance or charge submitted for the following lines of business: • Commercial• Federal Employee Program (FEP)
  2. The Reimbursement Policy, General Coding – 003 Coding Edits will be updated to reflect this change.

PT/OT/ST services reimbursement with modifiers CO, CQ for DOS 07/01/2022 and thereafter:

  1. Commercial plans-

Blue Cross will be implementing a 15% reduction in the allowed amount for services
modified with CO or CQ modifier for professional providers.

The following reimbursement Policy took affect for DOS 01/01/2022 and thereafter

1. Medicare Advantage Plans-

Blue Cross implemented a 15% reduction in the allowed amount for services modified with CO or CQ modifier for professional and facility providers to comply with requirements of the Centers for Medicare & Medicaid Services (CMS).

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