ClaimsXten™ Third Quarter 2014 Updates

June 5, 2014

Blue Cross and Blue Shield of New Mexico (BCBSNM) reviews new and revised Current Procedural Terminology (CPT®) and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson and are not considered changes to the software version. BCBSNM normally loads this additional data to the BCBSNM claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSNM website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will continue to be posted on the BCBSNM Provider website.

Beginning on or after Sept. 29, 2014, BCBSNM will enhance the ClaimsXten code auditing tool by adding two new rules into our claim processing system.

The first new rule is Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BiPAP) Supply Frequency. This rule identifies supply codes, submitted from all providers for the same member, associated with CPAP/BiPAP therapy that are being submitted at a frequency that exceeds Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD) policy for CPAP Supplies. Quantities of supplies greater than those described in a CMS LCD policy will be denied.

The second new rule is Obstetrics Package Rule. This rule audits claim lines to determine if any global obstetric care codes (defined as containing antepartum, delivery and postpartum services) were submitted with another global OB care code or a component code during the average length of time of the typical pregnancy of 280 days and/or pregnancy plus postpartum period of 322 days.

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management.

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim Connection™ (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSNM's code-auditing software. Refer to the Clear Claim Connection page for additional information on gaining access to C3.

For updates on ClaimsXten, watch for more News and Updates, as well as upcoming issues of the Blue Review.

Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered.

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.

CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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