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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-
Please notify Heather DeLaBarcena regarding any changes in your reimbursement (email@example.com), and for additional questions please contact Casey Crotty (firstname.lastname@example.org). Thank you.
Chief Executive Officer
San Juan IPA and Affiliates
All Blue Cross Blue Shield Contracted Providers: Blue Review, 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?
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.
Claims inquiries? Call the Provider Service Unit (PSU) at 888-
Our PSU handles all provider inquiries about claims status, eligibility, benefits, and claims processing for BCBSNM members. For out-
Network Services Contacts and Related Service Areas
Network Services Regional Map
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-
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
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
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-
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.
HSD No Longer Issuing Separate Medicaid Cards for MCO-
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-
If you have any questions regarding this change, please contact your regional network provider representative at 1-
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-
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-
Medicare providers may not bill, charge, collect a deposit, or seek reimbursement from any Medicare and Medicaid dually-
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
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Front & Center
UnitedHealthcare Community Plan
UnitedHealthcare Medicare Solutions
Doing Business Better
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The new PreCheck MyScript app
How to improve patient engagement
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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.
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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-
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 firstname.lastname@example.org or call 505-
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