New Payment Alert — Application of Medical Policies for Laboratory Claims

New Payment Alert — Application of Medical Policies for Laboratory Claims

7/28/2016

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan works with Avalon Healthcare Solutions to administer a comprehensive suite of laboratory benefit management services. Avalon is an independent company that provides benefit management services on behalf of BlueCross and BlueChoice®
 
On May 1, 2016, BlueCross and BlueChoice began deployment of the Avalon claim editing technology to enhance the administration of medical coverage policies. Beginning with dates of service on or after July 1, 2016, the Avalon claim editing technology has been configured to process BlueCross and BlueChoice laboratory claims. Edits will be phased in with pay and educate alerts. The program applies to the following places of service: Hospitals (POS 22 and 19), Physician Offices (POS 11) and Independent Laboratories (POS81).
 
In preparation of the full implementation of the laboratory services claim editor, the pay and educate process will allow providers to understand the impact of the claim editor on current laboratory service practices by providing a new alert on the remittance advice for impacted laboratory tests. This new alert will be included for laboratory tests that have been identified by the claim editor as non-compliant with the medical policies of BlueCross and BlueChoice. 
 
Claim adjudication and payment will continue with the new alert for several weeks, so that providers have time to adapt the services they are providing to comply with BlueCross medical policies. Please take note when you receive a remittance advice with this alert, and adjust your practices for ordering laboratory testing accordingly to prevent adverse payment decisions in the future. 
 
In addition to the reimbursement alerts, Avalon and BlueCross Provider Relations will host educational webinars and meetings to inform both rendering and ordering providers about the new claim editing technology and the types of laboratory services that may be affected. Information about these webinars will be posted on the BlueCross website at http://web.southcarolinablues.com/providers/educationcenter/providertraining/workshops.aspx
 
Avalon has also implemented a Claim Editor Trial Claim Tool to assist providers in understanding the editor’s functionality. The tool can be accessed on My Insurance Manager in the Resources section. The Avalon claim editing technology will be fully implemented after the pay and educate time period and only claims that meet medical coverage policies will be reimbursed. Additional information, including coverage policy updates, can be found in Provider Relations newsletters and a full listing of all medical coverage policies is available on the BlueCross website at http://web.southcarolinablues.com/providers/qualityinitiatives/medicalpoliciesandclinicalguidelines.aspx and the BlueChoice website at https://www.bluechoicesc.com/providers/medical-policies .
 
Contact Us
We are all working together to deliver the best possible health care to the communities we serve. By promoting the most effective patient treatments, we can improve clinical outcomes while optimizing cost and affordability. Please look for further communications about Avalon by visiting our websites at www.SouthCarolinaBlues.com and www.BlueChoiceSC.com. Providers with specific questions regarding this change should contact Provider Relations and Education by emailing provider.education@bcbssc.com or by calling 803-264-4730. You may also contact Avalon at 855-895-1676 for additional information.