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Proper Claim Filing Procedures for Blue Cross Community CentennialSM Behavioral Health Providers

November 21, 2018

Blue Cross and Blue Shield of New Mexico (BCBSNM) is actively involved in programs to detect and address potential fraud and/or other issues related to inappropriate reimbursements of claims for health care services billed to BCBSNM.

In the course of reviewing claims and records submitted by multiple behavioral health (BH) providers, BCBSNM determined that many providers are submitting Medicaid claims for services rendered by non-independently licensed BH providers.

Guidance issued to BH providers PDF Document by the State of New Mexico Medical Assistance Division on January 23, 2015, addressed billing for non-independently licensed clinicians.

This guidance identifies the following agencies as eligible to bill for the services of non-independently licensed providers when supervised according to clinical supervision requirements:

  • A Community Mental Health Center (CMHC);
  • A Federally Qualified Health Center (FQHC);
  • An Indian Health Services (IHS) hospital and clinic;
  • A PL 93-638 tribally operated hospital and clinic;
  • The Children, Youth and Families Department (CYFD);
  • A hospital and its outpatient facility; or
  • A Core Service Agency (CSA)

Additionally, effective October 1, 2015, Behavioral Health Agencies (BHA) (provider type 432) can apply for certification to provide supervision and bill for services provided by a non-independently licensed BH clinician, as identified in the accompanying attachment. Each BHA is responsible for contacting the New Mexico Behavioral Health Services Division (NMBHSD) to determine if it qualifies for the program as a Supervising entity. For more information about obtaining this certification, please contact the NMBHSD via email at: HSD.CSMbhsd@state.nm.us.

Once certified by NMBHSD, BHAs should provide their Provider Network Representative with a copy of the Supervisory Certification Letter, so that it may be included in the BHA file. If you don’t know your designated Provider Network Representative, reference the following link: https://www.bcbsnm.com/pdf/network_contacts.pdf PDF Document.

Providers that participate with BCBSNM for Blue Cross Community Centennial are reminded that their contracts with BCBSNM require timely, complete and accurate claims filing, as well as their timely identification, reporting, and refunding of overpayments.

BCBSNM will continue to review claims for BH services and reserves all rights and remedies available to BCBSNM for providers’ noncompliance with direction issued by NMBHSD or failures to adhere to other regulatory or contractual requirements, including, but not limited to recoupment and contract termination.

If you have questions, please contact your Provider Network Representative.