Code Effectively to Earn Additional Incentive Payments on Medicare Advantage Claims

Participating providers in our Medicare Advantage networks can earn an additional incentive payment when submitting claims with certain Current Procedural Terminology (CPT^®), CPT Category II and Healthcare Common Procedure Coding System codes. Learn what quality measures are involved and where to find a list of codes and incentive amounts.

Updates Coming to Behavioral Health Substance Abuse Criteria for Utilization Management

As part of our medical necessity reviews, we will use updated clinical criteria from the American Society of Addiction Medicine’s Treatment for Addictive, Substance‑Related, Co‑Occurring Conditions starting Jan. 1, 2025.

Prior Authorization Requirements Are Changing for Some Commercial Members

As of Jan. 1, 2025, we’re changing prior authorization requirements that may apply to some commercial members to reflect new, replaced or removed codes. Learn about the changes and how to access the revised list of codes.

Risk Identification and Outreach Program Supports Member Safety

If you provide care to our commercial members, you may receive information from our RIO team about safely managing opioid medications and facilitating follow‑up care.

Remind Our Members That the Flu Vaccine Can Reduce Risks

The Centers for Disease Control and Prevention recommends a yearly flu vaccine for most people 6 months and older to reduce the risk of flu and its potentially serious outcomes. We have resources to support discussions with our members.

Encourage Annual Eye Exams for Members with Diabetes

Early detection and treatment can greatly lower the chance of vision loss for our members with diabetes. Learn about the important role annual eye exams play and tips for closing gaps in care.

Care Coordination May Help Our Members after Hospital Discharges

When our members receive inpatient hospital care, it’s important for hospital teams to share discharge summaries with primary care providers to coordinate care. Learn how this information and other resources can help our members’ transition from inpatient care.

Members May Pay Drug Costs Monthly with New Medicare Prescription Payment Plan

As of Jan. 1, 2025, we will offer a new payment option for members with a Blue Cross Medicare Part D plan or a Medicare Advantage plan with Part D coverage. The Medicare Prescription Payment Plan offers enrollees the option to pay out‑of‑pocket prescription drug costs through monthly payments over the plan year instead of all at once at the pharmacy.

Check ID Cards for New Coupe Health Plan Members

Providers may see members of our new Coupe Health benefit plan. Learn how this plan streamlines the payment process for your office and our members.

Select Self‑Administered Drugs Moving to Pharmacy Benefit

We’re updating our medical policies for self‑administered drugs. Starting March 1, 2025, we will review the medical necessity of administering drugs in a health care setting when they could appropriately be self‑administered.

CDC Recommends Prescribing Doxy PEP to Prevent STIs

This medication helps reduce the risk of syphilis, which has been on the rise in Montana, according to the Montana Department of Public Health and Human Services.

Pharmacy Program Quarterly Update Changes – Part 2

Some changes were made to our drug lists, including coverage additions and coverage tier changes. Learn about utilization management and other pharmacy program updates.

Clinical Payment and Coding, and Compensation Policies Updates

You can access new or revised clinical payment and coding policies in Availity^® Essentials through the Plan Documents Viewer application, in the category Coding and Compensation Policies. These policies provide billing, coding and documentation guidelines. Visit Availity regularly to ensure you’re up to date on any changes or new policies.

Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month under the Standards and Requirements tab. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.