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© Copyright San Juan Independent Practice Association, 2016. All Rights Reserved.

Recent News: UPDATED 9.1.2017 Family Practice Internal Medicine/Geriatric Pediatrics Urgent Care/Occupational Specialists Anesthesiology Cardiology Critical Care Dermatology Emergency Medicine Gastroenterology Geriatrics Hospitalists Lab Services / Diagnosic Centers Nephrology Neurology OB/GYN Oncology / Hematology Orthopedics Endoscopy Pain Management Pathology Physical Medicine / Rehab Podiatry Radiation Oncology Radiology Rheumatology Surgical Specialists Otolaryngology Chiropractic Acupuncture Home Health / DME Optometry / Opthhalmology Prosthetics / Orthotic Albuquerque Providers PT / OT / ST

The San Juan IPA was founded in 1986 by a group of 21 community physicians to partner with

insurance companies with the goal of improving the quality of care to patients while simultaneously

decreasing the cost of care to those payers. Originally formed with a “Quality Assurance Committee”,

the San Juan IPA has grown to over 450 members representing 39 specialties and sub-specialties

in 70+ offices across New Mexico, a HEDIS quality review function, a Credentialing Committee,

and a care management committee component.

As an NCQA-accredited organization, San Juan IPA’s core services of contracting and

credentialing are complemented by an array of expanding resources for the physician office,

helping keep practice costs low and quality of care high.  We continually look for ways to

promote new quality initiatives both within and outside the practice walls for patients and employers.

  1. To ensure that a heath care delivery system is in place, which provides available, accessible and adequate numbers of facilities, locations, and personnel for the provision of health care services.
  2. To ensure that a health plan members are provided covered services without regard to race, color, creed, sex, religion, age, national origin, ancestry, marital status, sexual preference or physical or mental handicap.
  3. To ensure that the SJIPA has in place the organizational and administrative systems capable of messaging medical services contracts between providers and third party vendors
  4. To ensure that the quality of care to all patients continues at the highest level of  care possible.  
  5. Provide support for community health education and wellness.

Santa Fe Providers Gallup Providers Wound Care JOIN US! Behavorial Health Employment Opportunities Pay Membership Dues/Invoices Las Cruces Providers More News!

San Juan IPA SPECIAL Alert!

All Blue Cross Blue Shield of New Mexico Contracted Providers: 

To all San Juan IPA members who are contracted with BCBSNM:

San Juan IPA has been informed that BCBSNM has changed the internal BCBSNM reimbursement formula, and that formula went into effect on September 1, 2017.  According to the IPA/BCBSNM contract the payer is to inform all providers of any modification or amendment of reimbursement schedules with at least 30 days’ notice.  San Juan IPA did not, and still has not, received notice of any modification and we protested any changes to provider reimbursement without proper notice.  Further, we have come to find out that other IPA/PHOs in the state have been similarly affected and also similarly did not receive notice.  Some of the providers in those organizations are already reporting an impact on reimbursement from BCBSNM.

Please examine your EOBs and compare your reimbursements from BCBSNM pre-September 1 to post-September 1, and notify the IPA of any material changes.  San Juan IPA is weighing considering this change a breach of contract but it is imperative that we understand the impact across the network.  At minimum, we will likely file a complaint with the Office of the Superintendent of Insurance regarding this issue.

Please notify Heather DeLaBarcena regarding any changes in your reimbursement (heatherd@sanjuanipa.com), and for additional questions please contact Casey Crotty (ccrotty@sanjuanipa.com).  Thank you.

Casey Crotty

Chief Executive Officer

San Juan IPA and Affiliates

All Blue Cross Blue Shield Contracted Providers:  Blue Review, September 2017

September 2017

Please distribute this newsletter, which contains claims, billing, Medical Policy, reimbursement, and other important information, to all health care providers, administrative staff, and billing departments/entities that this email address represents.
You can find
Blue Review online!

Your Feedback Is Important
Blue Review strives to offer important information each month to our contracted providers. To deliver the content that’s most relevant to you and all staff, BCBSNM needs your feedback. Please take a few minutes to complete our brief survey. As a thank you for your time, we’re providing an opportunity to win one of five, $25 Amazon.com® gift certificates. (Note: government employees are not eligible.)
Take the survey.

Ideas for articles and letters to the editor are welcome; email NM_Blue_Review_Editor@bcbsnm.com

Do we have your correct information?
Maintaining up-to-date contact and practice information helps to ensure that you are receiving critical communications and efficient reimbursement processes. Additionally, the Centers for Medicare & Medicaid Services require Blue Cross and Blue Shield of New Mexico (BCBSNM) to make sure that our online Provider Finder
® and provider directory are kept current with our provider demographic information. Please complete our quick and easy online form if you have:

Moved to another location

Left a group practice

Changed your phone number

Changed your email address


Any other changes to your practice information

Medical Policy Updates
Approved new or revised Medical Policies and their effective dates are usually posted on our website the first and fifteenth of each month. These policies may impact your reimbursement and your patients’ benefits. On our website, you may view active, pending and updated policies and/or view draft policies and provide comments. The policies are located under the Standards & Requirements tab at bcbsnm.com/provider.

Office Staff

Claims inquiries? Call the Provider Service Unit (PSU) at 888-349-3706

Our PSU handles all provider inquiries about claims status, eligibility, benefits, and claims processing for BCBSNM members. For out-of-area claims inquiries, please call the BCBSNM BlueCard PSU at 800-222-7992.

Network Services Contacts and Related Service Areas

Network Services Regional Map

BCBSNM Website
It’s important for you to stay informed about news that could affect your practice. Blue Cross and Blue Shield of New Mexico (BCBSNM) offers many ways to stay informed. When you visit our website,
bcbsnm.com/provider, and sign up to receive email updates and our provider newsletter, Blue Review, you get better access to timely information on topics. Read more

Member Rights and Responsibilities

BCBSNM members have the right to:

Available and accessible services when medically necessary, as determined by the primary care or treating physician in consultation with BCBSNM, 24 hours per day, 7 days a week, or urgent or emergency care services, and for other health services as defined by the member’s benefit booklet.

Be treated with courtesy and consideration, and with respect for their dignity and need for privacy.

Have their privacy respected, including the privacy of medical and financial records maintained by BCBSNM and its health care providers as required by law.

Be provided with information concerning BCBSNM’s policies and procedures regarding products, services, providers, appeals procedures and other information about the company and the benefits provided.

All the rights afforded by law, rule, or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language they understand.

Receive from their physicians or providers, in terms that they understand, an explanation of their complete medical condition, recommended treatment, risks of the treatment, expected results and reasonable medical alternatives, irrespective of BCBSNM’s position on treatment options. If they are not capable of understanding the information, the explanation shall be provided to their next of kin, guardian, agent or surrogate, if able, and documented in their medical record.

Prompt notification of termination or changes in benefits, services or provider network.

File a complaint or appeal with BCBSNM or with the New Mexico Superintendent of Insurance and to receive an answer to those complaints within a reasonable time.

Request information about any financial arrangements or provisions between BCBSNM and its network providers that may restrict referral or treatment options or limit the services offered to members.

Adequate access to qualified health professionals near their work or home within New Mexico.

Affordable health care, with limits on out-of-pocket expenses, including the right to seek care from an out-of-network provider, and an explanation of their financial responsibility when services are provided by an out-of-network provider, or provided without required preauthorization.

Detailed information about coverage, maximum benefits, and exclusions of specific conditions, ailments or disorders, including restricted prescription benefits, and all requirements that they must follow for preauthorization and utilization review.

Make recommendations regarding BCBSNM’s member rights and responsibilities policies.

A complete explanation of why care is denied, an opportunity to appeal the decision to BCBSNM’s internal review, the right to a secondary appeal, and the right to request the assistance of the Superintendent of Insurance. BCBSNM members have the responsibilities to:

Supply information (to the extent possible) that BCBSNM and its network practitioners and health care providers need in order to provide care.

Follow plans and instructions for care that have been agreed on with their treating provider or practitioners.

Understand their health problems and participate in developing mutually agreed upon treatment goals with their treating provider or practitioner to the degree possible.

Adult BMI Assessment
Screening for health risk factors in adults ages 20 to 74 can begin with a brief discussion of the patient’s current Body Mass Index (BMI). In young adult patients ages 18 to 20, a discussion of BMI percentile is warranted. The BMI, an indicator of body fat, can create an opportunity to assess and discuss activity, diet, alcohol, use of pain medications, smoking patterns and other lifestyle choices that may impact health.  Read more

Annual Well-Child Visit Important for Children and Caregivers
The Well-Child Visit offers an excellent opportunity to assess obesity risk. Attention to growth measurements, nutrition and physical activity offers our young members the best chance at a healthy lifestyle. Read more

Identifying and Prescribing Correct Glucose Meter Test Strips
When prescribing glucose meter test strips, it is important to verify the type of glucose meter the patient is using and which test strips it requires. Some glucose meters have similar names, but require different types of test strips. Read more

Medicaid only

Blue Cross Community CentennialSM (Medicaid)

Not yet contracted?
Blue Cross and Blue Shield of New Mexico’s (BCBSNM) Medicaid plan is Blue Cross Community Centennial.

Providers who are participating in commercial BCBSNM products are not automatically participating providers in Blue Cross Community Centennial. To become a Blue Cross Community Centennial provider, you must sign a Medicaid amendment to your Medical Services Entity Agreement (MSEA).

If you have any questions, please call 505-837-8800 or 1-800-567-8540 if you are interested in becoming a Blue Cross Community Centennial provider.

Reminder: Update your Enrollment Information
Due to Centennial Care requirements, all enrollment information (changes to demographics, licensure or certification, provider status, etc.) must be updated on the NM Medicaid Provider Web Portal.

Member Rights and Responsibilities
Blue Cross and Blue Shield of New Mexico (BCBSNM) is committed to ensuring that enrolled members are treated in a manner that respects their rights as individuals entitled to receive health care services.
Read more

HSD No Longer Issuing Separate Medicaid Cards for MCO-Enrolled Members
Effective Jan 1, 2018, the New Mexico Human Services Department, Medical Assistance Division (HSD/MAD) will no longer issue Medicaid identification cards to Medicaid recipients who are enrolled with a Managed Care Organization (MCO).  

Please note that as of Jan. 1, 2018, Medicaid recipients who enroll with Blue Cross Community CentennialSM will only receive a Blue Cross and Blue Shield of New Mexico-issued member ID card, which shall include the member’s name, group number, and MCI ID number. Letters accompanying ID cards will explain that members will not receive a separate Medicaid card from HSD.

Providers should continue to ask for the ID card from Blue Cross and Blue Shield of New Mexico, but should no longer ask Blue Cross Community Centennial members to present an ID card from HSD. Be sure to verify eligibility before furnishing covered services.

If you have any questions regarding this change, please contact your regional network provider representative at 1-800-567-8540.

Such services are funded in part with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association

Screening for Clinical Depression Initiative
Blue Cross and Blue Shield of New Mexico (BCBSNM) is committed to promoting annual screening and follow-up treatment for depression in the primary care setting for Blue Cross Community Centennial members. Read more

Blue Cross Medicare AdvantageSM

Member Rights and Responsibilities
Blue Cross Medicare Advantage members have the right to timely, high quality care and treatment with dignity and respect. Participating providers must respect the rights of all members. Blue Cross Medicare Advantage members have been informed that they have the following rights and responsibilities. Read more

Blue Cross Medicare Advantage: Electronic Claim Submission Edits
Beginning Sept. 16, 2017, Blue Cross and Blue Shield of New Mexico (BCBSNM) will implement new electronic claim submission validation edits for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM Professional and Institutional claims (837P and 837I transactions). Read more

Government Programs: Claims Rejecting as Duplicate Submissions
This notice applies to claims submitted by government programs providers for the following Blue Cross and Blue Shield of New Mexico (BCBSNM) members: Blue Cross Medicare Advantage (PPO)
SM (MA PPO) and Blue Cross Medicare Advantage (HMO)SM (MA HMO) Read more

Prohibition on Billing Dually-Eligible Members Enrolled in the Qualified Medicare Beneficiary Program
Medicare providers may not bill, charge, collect a deposit, or seek reimbursement from any Medicare and Medicaid dually-eligible members enrolled in the Qualified Medicare Beneficiary (QMB) program. Read more

Federal Employee Program®

Federal Employee Program Member Rights and Responsibilities
BCBSNM Federal Employee Program members have the right to Read more



All United Healthcare Contracted Providers:  Network Bulletin, September 2017

If you are unable to read this message or see the images, view it online.


Quick Links:

Front & Center

UnitedHealthcare Commercial

UnitedHealthcare Commercial
Reimbursement Policies

UnitedHealthcare Community Plan

UnitedHealthcare Medicare Solutions

Doing Business Better

UnitedHealthcare Affiliates

Tell Us What You Think of Our Communications
As a regular reader of The Network Bulletin, your opinion is important to us. We’d like to get your thoughts about The Bulletin and UnitedHealthcare communications related to network changes, quality initiatives and other issues. Please take a few minutes to complete our 
online survey. Thank you for your time.

September 2017


Thank you for subscribing to the UnitedHealthcare Network Bulletin. The Bulletin is our monthly publication for participating care providers, featuring timely updates to procedures, programs and policies, and important administrative and clinical information.


In this issue, you will find articles about:

Your new care provider website: UHCprovider.com

The new PreCheck MyScript app

How to improve patient engagement

And much more

If you have Internet Explorer as your primary browser, please ensure it's set as your default browser when clicking on the above link to access the Bulletin. To do so, open Internet Explorer, then go to Tools > Internet Options > Programs > Make Default.

We hope you find the Bulletin to be a useful resource. We welcome your feedback at NetworkBulletin@uhc.com. Thank you.

Please note that when information in the Network Bulletin conflicts with applicable state and/or federal law, UnitedHealthcare will follow the applicable state and/or federal law.

Doc#: PCA-1-007709-08242017_08242017

If you do not contract directly with UnitedHealthcare, and participate in our network through an arrangement in which we "Lease" a network from some other entity, some of the information provided in this communication may not be applicable to you and/or impact you differently. If you have questions regarding any of the information or need to better understand its impact on you, please contact your local Network Account Representative, Physician Advocate or Hospital & Facility Advocate. If you are not sure who your contact is, please click here.

Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates. 

Please do not reply to this email address. This mailbox is used for outbound email only and we are not able to respond to messages sent to this address. Questions or Comments? Write to us at: UnitedHealthcare, MN012-S117, P.O. Box 1459, Minneapolis, MN 55440-1459. For more information, visit our website UnitedHealthcareOnline.com or call us toll free at: 877-842-3210.

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This email was sent to: rjohnson@sanjuanipa.com

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San Juan IPA:  Annual FitKids Health Fair (Flyer attached)

San Juan IPA will be hosting its 5th Annual FitKids Health Fair on Saturday, September 16, 2017 from 9:00am to 1:00pm.  Last year turned out great with approximately 400 parents and children in attendance. This year we will be holding the event at San Juan College. The target audience for this event is children and youth ages 0-18 years in our community; however, everyone in the community is welcome to participate.

The objectives for the fair include:

Encouraging activity, exercise, and fitness

Promote nutrition and healthy eating habits

Provide resources for youth sports

Increase awareness for childhood health including preventive services

Improve community access to local, state, and national health services and resources

Save the Date

San Juan IPA Members:  Annual Membership Meeting

The San Juan IPA will be hosting our annual membership meeting on Thursday October 26, 2017 at 6:00 pm at the San Juan Country Club.  The meeting is for all San Juan IPA members and office managers.  If you would like to attend please RSVP Heather DeLaBarcena at heatherd@sanjuanipa.com or call 505-564-7980 opt 1.  We will serve Heavy Hors D’oeuvres and drinks and we plan to include a CME presentation.  We will have more details in our upcoming Alerts

Did you know?  Did you know?  You must notify the IPA if you are closing your practice to a specific line of business such as Centennial Care or Medicare Advantage plans.

Contents of this email:

BCBS Reimbursement Formula Changes

BCBS Blue Review Update

UHC Network Bulletin

Annual FitKids Health Fair (Flyer attached)

Save the Date:  SJIPA Annual Membership Meeting

Member Login: