Category: BCBS (Various States)

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

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

BCBS California: Authorizations for post-acute care services (Medicare Advantage Plans/GRS)

Posted on by KR2Medical Billing

The following blog will discuss where and how the providers should submit their prior authorizations for post-acute care services for Medicare Advantage Individual, Group Retiree Solutions, and Dual Eligible Plan members.

Note: Dual Eligible- member qualifies for Medicaid and Madicare.

This change is applied for services rendered on Sept 1, 2022 and thereafter. The services included are: admission to or concurrent* stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH).

These services will be reviewed by myNEXUS.**

*Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to September 1, 2022, should be directed to the health plan.

** myNEXUS is an independent company providing post-acute benefits management services on behalf of Anthem Blue Cross.

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests on Tuesday, August 30, 2022, for members whose anticipated discharge date is September 1, 2022, or after.

Providers can send their request online- Go to https://portal.mynexuscare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.

If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at 1-833-311-2986.

Note: myNexus does not review requests for DME, Ambulance- These services do not fall under the Medicare Home-health services: infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

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Posted in BCBS (Various States), Training, Updates

Anthem BCBS California: administration of drug Spravato-proper medical billing and coding.

Posted on by KR2Medical Billing

If you are a physician that accepts patients with Anthem BCBS plans then this blog post is for you.

Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression.  Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.

There are 2 ways physicians can code the administration of this drug:

Option 1 (Professional Services) – The physician buys the drug and administers it to the patient as well as provides the observation services- Anthem BCBS of California will NOT cover the drug itself or the post administration observation. Instead physicians should use the 2 following codes:

HCPCS CodeDescription
G2082Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
G2083Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
via Anthem BCBS California

Option 1 Outpatient Hospital – the facility is allowed to bill codes G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. Anthem BCBS of California will not reimburse a separate professional claim with code G2082 and G2083.

Option 2: The drug is obtained through a pharmacy. Pharmacy bills the code S0013 – Esketamine, nasal spray, 1 mg. 

Post-administration observation: if physician falls into the option 2 category then the physician is allowed to bill the following code:

CPT CodesDescription
99202 – 99205Office or other outpatient visit for the evaluation and management of a new patient
99212 – 99215Office or other outpatient visit for the evaluation and management of an established patient
99417Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
via Anthem BCBS California

In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding.  Please refer to Anthem’s Prolonged Services – Professional Reimbursement Policy for additional information.

Please remember that codes exist but that doesn’t mean that all of them will be reimbursed. In order to reduce denials and get your claims paid please follow the reimbursement policy of a specific Insurance Payer.

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Posted in BCBS (Various States), Training, Updates

BCBS Staying compliant with after hours messaging for Behavioral health providers

Posted on by KR2Medical Billing

Is your Behavioral Health Practice Compliant?

In the recent assessment by a third party Vendor-North American Testing Organization based in California, for the third Q of 2021, it was found that most of the Empire BlueCross BlueShield (“Empire”) plans assessed fell short of the expectation of having a live person or a directive in place after hours.

The main challenges that the third party vendor had were the following:

  • inaccurate provider information in Empire’s demographic database to allow assessment of the after-hours messaging
  • no voicemail or messaging at all
  • voicemail not reflecting the practitioner’s name
  • calls being auto forwarded with no identification, no voicemail or messaging

What does this mean for BCBS members?

In an annual member survery, BCBS members have indicated that when they needed advice, they are unable to to reach the provider office for urgent instructions.

In order to be compliant, as per Provider Manual, providers need to have the following:

  • Emergency situations : Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the practitioner.
  • Emergent / Urgent situations: Compliant responses for urgent needs after hours:
    • Live person, via a service, advises their practitioner or on call practitioner is available and connects.
    • Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
    • Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)

Examples of non-compliant responses include the following:

Non-compliant responses for urgent needs after hours include:

  • No provisions for after hour accessibility.
  • Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. These scenarios are non-compliant because there is no direct connection to their practitioner. This prompt can be used in addition to, but not in place of instructions.

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