As of Friday, May 23, 2008, you will not be able to use your HMSA provider ID (legacy ID) on any HIPAA covered transactions. The National Provider Identifier (NPI) is the only identifier that can be use.

See  HIPAA Update - 02/08 for details.

 

April 28, 2008

 

HMO REFERRAL REMINDER FOR SPECIALISTS

The referring physician’s name must be included on all HMO claims for out-of-network services arranged by the member’s primary care physician or other health center physician. Please enter the name in Block 17 of the CMS 1500 claim form or in the corresponding field for electronic claims. If this information is not included, the claim will be denied for lack of an indication that a referral was made.

 

As a general rule, HMO members may self-refer to any in-network provider. Members who self-refer to out-of-network providers must pay the total amount of charges for services received.

 

When no participating physician is available to provide services an HMO member needs, the patient’s PCP or other health center physician must request an  HMO Administrative Review prior to services being rendered by an in-state nonparticipating provider or by any out-of-state provider. The retrospective referral option is not available in such instances.

 

 

April 24, 2008

 

Clinical Measures by Specialty for 2009 PQSR Program

A list of clinical measures that are applicable for each eligible marketing specialty in the 2009 Practitioner Quality and Service Recognition (PQSR) program is now available. See  2009 Clinical Measures by Specialty. The 2009 PQSR program is evaluated on claims data collected from January 1, 2008 through December 31, 2008.

 

 

April 9, 2008

 

The maximum allowable charge (MAC) for the following CPT codes have increased, effective March 1, 2008.

 

CPT Code	Description	New MAC
90649	Human Papilloma virus (HPV) vaccine, types 6, 11, 16,18 (quadrivalent), 3 dose schedule, for intramuscular use	$141.08
90680	Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use	$ 78.12
90704	Mumps virus vaccine, live, for subcutaneous use	$ 24.86
90705	Measles virus vaccine, live, for subcutaneous use	$ 19.17
90706	Rubella virus vaccine, live, for subcutaneous use	$ 21.38
90707	Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use	$ 51.86
90716	Varicella virus vaccine, live, for subcutaneous use	$ 87.03

 

 

March 12, 2008

 

Medical policies now grouped by type

HMSA's medical policies in the Provider Resource Center are now listed in separate categories to make it easier for healthcare providers to find policies related to specific types of services. A complete, alphabetical list of policies also appears (under the category headings) on the new Medical Policies - CURRENT page.

 

February 13, 2008

 

The maximum allowable charge (MAC) for the following CPT codes have increased effective for the dates indicated.

 

CPT Code	Description	New MAC
J2675	Injection, progesterone, per 50 mg effective February 1, 2008	$    3.10
J3301	Injection, triamcinolone acetonide, per 10 mg (use this code for Kenalog) effective February 1, 2008	$    1.88
J7307	Etonogestrel (contraceptive) implant system, including implant and supplies (use this code for Implanon) effective from January 1 through January 17, 2008. This code replaces S0180 for 2008	$523.00
J3707	Etonogestrel (contraceptive) implant system, including implant and supplies (use this code for Implanon) effective January 18, 2008. This code replaces S0180 for 2008	$566.93

 

February 11, 2008

 

High-risk criteria no longer required for the use of non-ionic contrast

HMSA no longer requires that claims submitted for  Non-Ionic Contrast Agents meet high-risk diagnosis criteria. This payment policy change is effective from services rendered February 1, 2008 forward. The change was made to align the HMSA payment policy for this service more closely to that of Medicare.

 

January 18, 2008

 

Codes that do not meet payment determination criteria

The following new CPT and HCPCS codes for 2008 were added to the table of  Codes That Do Not Meet Payment Determination Criteria :  27416, 28446, 83993, 95980-95982, 99174, A9277 and A9278.

 

January 15, 2008

 

MAC Fee Change

 

The MAC for the following CPT code has increased, effective January 1, 2008.

 

CPT Code	Description	New MAC
90669	Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use	$ 88.25

 

Bill ranibizumab (Lucentis) injections with the new HCPCS code

 

Effective January 1, 2008, bill for ranibizumab (Lucentis) using the new HCPCS code J2778. The MAC for this code is $462.71.

 

 

See  HMSA News and Alerts Archive for previously published entries.