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

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

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

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

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 #aetna, #Medicare, #Medicareadvantage, Training, Updates

Aetna Medicare Advantage: participating providers’ post-service appeals new address

Are you an Aetna Medicare Advantage participating provider and had issues with your post-service appeals? If your answer is yes, it is because as of Jan 1, 2022 there is a new address where the providers need to submit those appeals to.

There is also a NEW FORM that the provider needs to fill out.

Where to find the new form?

You can find this form, which is called the Medicare Provider Complaint and Appeal Request Form, by going to the forms for health care professionals page and scrolling to the “Dispute and appeals” drop-down menu.


The New form should be sent to the address below:

Medicare Provider Appeals PO Box 14835 Lexington, KY 40512 Fax: 1-860-900-7995


OLD ADDRESS IS NO LONGER VIABLE:

Provider Resolution Team PO Box 14020 Lexington, KY 40512 Fax: 1-800-624-0756

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