by Tammy Bartlett, Billing Manager


Effective May 1, 2017, Independent Health (IHA) will recognize “incident to” billing practices for their Commercial, Medicare Advantage and Self-Funded plans.  IHA’s state products (MediSource, MediSource Connect, Child Health Plus and Essential Plan) will not be eligible for “incident to” billing.

Please ensure your staff carefully reads IHA’s requirements for “incident to”, which can be found in their Participating Practitioner Reimbursement Manual, located on their website at:


The guidelines for “incident to” begin on Page 10. Any questions pertaining to these requirements should be directed to the following email address:  Reimbursement.Manual@independenthealth.com

After the implementation of this new policy, IHA will conduct audits to ensure their requirements are being met by the provider community.



On May 17, 2017, CMS updated their policy for Hepatitis B coverage as reflected in bold print below.

Payment for Hepatitis B will apply to the following HCPCS and CPT codes, effective for dates of service on or after September 28, 2016: G0499, 86704, 86706, 87340 & 87341.  CMS will allow coverage for HBV screenings only when services are ordered by the following provider specialties found on the provider’s enrollment record.

  • 01- General Practice
  • 08- Family Practice
  • 11- Internal Medicine
  • 16- Obstetrics/Gynecology
  • 37- Pediatric Medicine
  • 38- Geriatric Medicine
  • 42- Certified Nurse Midwife
  • 50- Nurse Practitioner
  • 89- Certified Clinical Nurse Specialist
  • 97- Physician Assistant

Claims submitted by providers other than the specialty types noted above will be denied.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com


By Tammy Bartlett, Billing Manager


MVP Health Care has created reference guidelines that may provide you and your staff with helpful tools that explain HEDIS measures as well as providing the CPT, HCPCS and ICD-10 codes that count towards the completion of these measures.

You will find these coding reference guides by going to mvphealthcare.com, selecting the Provider drop-down, and then selecting the Quality Programs and the Reference Library sections. The Behavioral Health Guide will also be available on their website in the next couple of weeks.

If you have any questions with respect to this notice, please contact Mike Farina at 518-388-2463 or email at mfarina@mvphealthcare.com.


Beginning August 1, 2017, the New York State Department of Health is requiring all Child Health

Plus (CHP) members who originally enrolled in this program through Excellus BlueCross BlueShield to

now complete their renewal for the CHP Program through the New York State of Health Marketplace.

This transition begins with the CHP members who are renewing for an August 1, 2017 effective date.

As a result of this renewal transition, CHP members will be mailed a new Member Identification Card with a new identification number.

In addition, if a CHP member has obtained preauthorization under his or her current identification number, but the preauthorized services will be delivered to the member after the date the member is transitioned to the New York State of Health Marketplace, a new preauthorization must be requested with the member’s new identification number.

As a reminder, please ensure you forward Practicefirst any changes in insurance coverage for your patients, including new identification numbers. This will ensure claims are submitted correctly to the appropriate insurance plan.


Medicare is taking steps to remove Social Security numbers from Medicare cards.  Through this initiative CMS will prevent fraud, fight identify theft and protect essential program funding and the private healthcare and financial information of Medicare beneficiaries.

CMS will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN). This will occur both on the cards and in various CMS systems currently used.  CMS will start mailing new cards to Medicare beneficiaries in April 2018.  All Medicare cards will be replaced by April 2019.

Based on feedback from healthcare providers, practice managers and other stakeholders, CMS is developing capabilities where doctors and other healthcare providers will be able to look up the new MBI through a secure tool at the point of service.  To make this transition easier for you and your business operations, there is a 21 month transition period where all healthcare providers will be able to use either the MBI or the HICN for billing purposes.

Even though your systems will need to be able to accept the new MBI format by April 2018, you can continue to bill and file healthcare claims using either number during the transition period.  Medicare encourages providers to start working with their software vendors to make sure systems will be updated to reflect these changes.

To learn more about this new initiative, please visit:  www.cms.gov/Medicare/SSNRI/Providers/Providers.html

For Billing questions, please contact Tammy Bartlett at 716-389-3223 or tammyb@pracfirst.com


By Tammy Bartlett, Billing Manager


Modifications to YourCare’s professional fee schedule will take effect April 1, 2017.  The changes will apply to services rendered to YourCare Option, Child Health Plus and Essential Plan members.

YourCare Health Plan fees are calculated utilizing 2016 Medicare RBRVS methodologies and RVU tables with conversion factors for appropriate code sets.  Nurse Practitioners and Physician Assistants will be reimbursed at 85% of their supervising physician’s conversion factor for most services.

Anesthesia services utilize the prevailing based conversion factor multiplied by the Anesthesia Society of America (ASA) base anesthesia service units and subsequent time methodology.  Non anesthesia services will be reimbursed at the community based professional fee schedule.

The fee schedule will be available on their website at www.yourcarehealthplan.com on or around April 1, 2017.

The latest referral and authorization requirements effective May 1, 2017 are also available on their website as listed above.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com


By Tammy Bartlett, Billing Manager


PF will aggregate your IRS Form 1099’s through February 17th.  These forms (1099-Misc) represent all of the payments made to you during calendar year 2016.  The IRS matches the aggregate of all 1099’s to the appropriate line of your entity’s tax return, to make sure recipients properly report their income.  In addition, any interest paid on claims is separately reportable on IRS Form 1099-Int.  This information is also matched and it is critical to properly report this income on the correct line of your tax return to avoid IRS scrutiny for under reporting income.

By law, insurance carriers are required to mail them by January 31st.  However, our past experience indicates that they do not comply with the due date and therefore they are not all generally received until the third week in February.  At that time, we will send them to you by mail or through our courier service. If you have any questions, please feel free to contact us.


Univera Healthcare will offer Medicaid Managed Care, Child Health Plus and Health and Recovery Plan (HARP) to Erie County residents beginning in the summer of 2017, pending approval by the New York State Department of Health.

Per Univera, you will have an opportunity to provide services for these product lines under your existing Participating Provider Agreement. The reimbursement schedule will be available on the secure portion of their website on or around February 1, 2017 at: UniveraHealthcare.com/Provider

Univera will provide further administrative details and other important information prior to the date when these products will be offered in Erie County. Please direct questions to your Provider Relations representative directly, or call the Provider Relations department at 716-857-4647.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com



By Tammy Bartlett, Billing Manager



Univera is introducing two new products in January 2017 which will be available to small-group community-rated customers, called Univera Access and Univera Preferred Access. Reimbursements for these products will be in accordance with their Special Programs Fee schedule.


Based on a NYS coverage mandate effective January 1st, Univera Healthcare is expanding the existing health insurance benefit for screening mammography to include diagnostic imaging for the detection of breast cancer.

The expanded services include: diagnostic mammograms, breast ultrasounds, digital breast tomosynthesis and MRI’s in addition to already covered screening mammograms. The mandate applies only to their commercial line of business.


Medicaid Managed Care (MMC) and Child Health Plus (CHP) patients and the impact on individual provider performance will be excluded from the final P4P program. Participating providers were paid incentives at the end of the third quarter of 2016 for current closed HEDIS gaps for MMC and CHP patients regardless of achievement of threshold targets. Incentive payments will be distributed by the end of the first quarter of 2017. This change in program is due to the transition of quality management of Blue Cross’s MMC and CHP members to a shared partnership with Amerigroup.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfir


By Tammy Bartlett, Billing Manager



We have received numerous letters from CMS for our clients that indicate PQRS criteria has not been met and  payment adjustments will occur, reducing Medicare payments by 2% for 2017 dates of service. The payment adjustments are based on services rendered in 2015. We will forward the letters to the applicable clients, as we receive them.

If you received a letter from CMS regarding reduction in payments and believe you have been incorrectly assessed, please review the payment adjustment resources located on the PQRS webpage at:


As mentioned in previous communications with our providers, Practicefirst recommended to report via a PQRS Qualified Registry.  By utilizing a registry, providers become eligible for measures group reporting, thus decreasing the required number of patients to report on.

As a reminder, due to the increasing requirements of PQRS reporting, Practicefirst no longer provides PQRS reporting services to providers at a reasonable cost.


MVP issued FASTFAX #50W on October 20, 2016 to the provider community regarding Preventive Visits and Modifier 25. Preventive visits (codes 99381-99397) are payable on the same date of service as a separately identifiable E&M service (i.e. 99213). The E&M would be submitted with modifier 25. The additional services for the E&M must be documented in the medical record and the claim should include both the preventive visit diagnosis code(s) and the relevant condition diagnosis code(s).

If the preventive code is not billed, the visit will not count for the preventive service quality measures (well child, adolescent and adult measures).

For additional information, please visit MVP’s website at http://www.mvphealthcare.com/provider/provider-resource-manual.html, select Section 15 for Payment Policies and then select the Modifier Policy from their bookmarks.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com



Last month, our client memo indicated the new partnership between Blue Cross and Amerigroup for Medicaid Managed Care (MMC) and Child Health Plus (CHP) members. Blue Cross has indicated that the effective date has been delayed until November 1, 2016.


On September 29th, the NYS Dept. of Health notified the provider community that NYS has redesigned the Common Benefit Identification Card for Medicaid beneficiaries. Cards with the new design will begin statewide in late September. An image of the new card is reflected below.

There will be no mass replacement of existing cards as a result of the new card design. Existing cards will remain active throughout the transition period.

Additional information on the new card design is located at:  www.otda.ny.gov/workingfamilies/ebt.asp



As a first step in the claims adjudication process, a third party will conduct an independent audit of the existing inventory of policy claims. Based on the audit results, Explanation of Benefits (EOB’s) will be issued for each policy claim to providers.

The EOB’s will advise providers of the amounts of their respective claims against the estate and their rights. It is anticipated that EOB’s will begin to be mailed to providers in the first quarter of 2017.

If a provider accepts the EOB, they are not required to take any further action. If a Provider disagrees with the EOB, they will have the opportunity to appeal the determination through Health Republic’s website or by paper to the address indicated in the Claims Adjudication Procedure.

The written appeal and supporting documentation must be submitted within 60 days of the date of mailing of the EOB. The Liquidator will review each appeal and, within 60 days, either grant the appeal and issue a revised EOB or deny the appeal and provide the reasons for the denial.

It is anticipated that the total amount of allowed claims will not be known until at least mid-2017.

For additional information, please access Health Republic’s website at: www.healthrepublicny.org

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com






Blue Cross News

Blue Cross has entered into a partnership with Amerigroup Partnership Plan, LLC to administer services to Medicaid Managed Care (MMC) and Child Health Plus (CHP) members. They are targeting an October 1, 2016 effective date and will notify the provider community of any changes to this effective date.

Changes to anticipate:

  • New member identification cards, ID numbers and prefixes
    • The prefix for Medicaid Managed Care will be WNH
    • The prefix for Child Health Plus will be WNB
  • Claims submission process
  • Online provider website/portal
  • Preauthorization information and look-up tool
  • EFT and ERA capability
  • Provider service contact info
  • Medicaid and CHP-specific provider manual
  • HealtheNet will no longer be used to verify eligibility and benefits after 10/1/16 for MMC and CHP members only

Additional information is forthcoming from Blue Cross with detailed information about this transition.

For Billing questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.co


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