Tag: Claims
CMS Instructs MACs to Lift Claims Hold
Special edition – courtesy of Novitas Solutions
Claims Hold Update
CMS instructed all Medicare Administrative Contractors (MACs) to lift the claims hold and process claims with dates of service of October 1, 2025, and later for certain services impacted by select expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025 (Pub. L. 119-4, Mar. 15, 2025). This includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center (FQHC) claims. This includes telehealth claims that CMS can confirm are definitively for behavioral and mental health services. CMS has directed all MACs to continue to temporarily hold claims for other telehealth services (i.e. those that CMS cannot confirm are definitively for behavioral and mental health services) and for acute Hospital Care at Home claims.
Beginning October 1, 2025, for services that are not behavioral health services, many of the statutory limitations on payment for Medicare telehealth services that were, in response to the COVID-19 Public Health Emergency, lifted, and subsequently extended, through legislation again took effect. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are currently not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.
CMS notes that the Bipartisan Budget Act of 2018 (Pub. L. 115-123, Feb. 9, 2018), which added section 1899(l) to the Social Security Act, allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restrictions and in the beneficiary’s home. Separate from requirements to participate in the Medicare Shared Savings Program, there is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers to offer these covered telehealth services. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For clinicians in applicable ACOs, telehealth claims that CMS can confirm are definitively for behavioral and mental health services will be paid. At this time, claims for some telehealth services will continue to be held. For more information, including information on to which ACOs these flexibilities apply: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf.
HealthSpring Rollout
■ Important Updates for Physician Offices-New Plans Coming in 2026
New benefit plans under the HealthSpring name will roll out January 2026. For now, you can find articles about these changes on: MedicareProviders.Cigna.com …and in the Provider Newsroom.
■ Claims Contact Information
Jim Denman will no longer handle claims.
For more information, please call POET
■ Goodbye HSConnect – Hello Availity Essentials
Cigna MA has partnered with Availity Essentials for enhanced online tools. HSConnect and Cigna for HCP are no longer needed.
■ Verify eligibility & benefits
■ Verify primary care provider
■ View customer ID cards
■ View maximum-out-of-pocket amounts
■ Submit professional & institutional claims
■ Check claim status
■ View remittance advice
■ Access Cigna MA links (including prior authorizations & resources) via the Payer Space page
Superior HealthPlan Billing Changes
Important Provider Update
Effective September 1, 2025
The Texas Health and Human Services Commission (HHSC) will transition Medicaid-only services for dually eligible clients (eligible for both Medicare and Medicaid) from Fee-for-Service (FFS) to a Managed Care service delivery system.
Superior HealthPlan will be responsible for adjudicating these claims.
Provider Responsibilities
Submit claims for Medicaid-only services for dual eligible clients directly to the Managed Care Organization (MCO).
If a Claim is Sent to TMHP in Error:
TMHP will forward the claim to the correct MCO.
The TMHP response will only confirm forwarding – no ER&S report will be issued.
Claims with dates of service on or after Sept. 1, 2025 will not be adjudicated by TMHP.
Provider Action Steps
✅ Submit Medicaid-only service claims directly to the MCO.
✅ Contact the MCO for claim status and adjudication questions.
✅ Review the Rider 32 Procedure Code List (PDF) for impacted services.
✅ Reach out to your Provider Representative via the Find My Provider Representative webpage.
Need Help?
Contact your dedicated Provider Representative
UHC Claims their new API makes work easier.
UnitedHealthCare’s Application Program Interface (API) is a free digital solution that automates everyday work.
Benefits of using API
- Reduces phone calls and paper
- Automates transactions on your timetable
- Distributes data faster to where you need it
- Get real‑time information
- Supports standard formats and compatible with new technology
- Maximizes efficiency and productivity through workflow integration
Why add API to your practice?
- Flexibility: Allows you to choose the data and API that fit your needs.
- Automation: Incorporates seamlessly into your workflow.
- Security: Ensures data is accessed and transferred securely
Check Your BCBS Flu Test Claims
BCBSTX explained in correspondence with TMA’s Physician Payment Resource Center (PPRC) – which reached out for clarification earlier this month on the payer’s new flu testing policy – that some claims for certain labs, including those offering flu testing, were unintentionally denied due to a vendor error.
TMA’s Director of Physician Payment Services Carra Benson says physicians do not need to take action to receive payment. However, she recommends physicians review flu testing claims filed between Jan. 1 and Feb. 13 to ensure correct reprocessing.
Aetna OfficeLink Updates 12/1/2024
Claim and Code Review Program (CCRP) Update
Aetna states in their newsletter
“We might have new claim edits for our commercial members.
Beginning March 1, 2025, you may see new claim edits. These are part of our CCRP. These edits support our continuing effort to process claims accurately for our commercial members. You can view these edits on our provider portal on Availity.*
For coding changes, go to Aetna Payer Space > Resources > Expanded Claim Edits
You’ll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to our provider portal on Availity. You’ll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools.
We may request medical records for certain claims, such as high-dollar claims, implant claims, anesthesia claims, and bundled services claims, to help confirm coding accuracy.”
Digital Claim Correspondence for Cigna
Beginning today, registered users with the Claim Search entitlement have access to digital claim correspondence via the Messaging Center on CignaforHCP.com.
Virtual Vigilance
“The Change outage was disruptive to the business of my practice, but most importantly it was disruptive to my patients,” Dr. Bruggeman testified. “Every minute my staff spent trying to reconcile [electronic remittance advice] with received payments, assessing which patients received incorrect bills, [and] resubmitting prior authorizations is time taken away from patient care.”
Robust Cybersecurity Can Safeguard Practices
By Alisa Pierce Texas Medicine June 2024
Data held hostage
. . . cautions that ransomware attacks can be delivered via multiple platforms, such as in email attachments or links within an email. Malicious attachments can include documents, zip files, and executable applications, and suspicious email links can bring users directly to websites that are used to place malware on a system.
Similarly, “phishing” email scams can give hackers access to internal business systems that could reveal confidential information like credit card numbers, personal identity data, and passwords. Often these emails appear to come from real companies or trusted individuals.
From there, hackers steal electronic patient data, even encrypted information; block the practice from accessing it; and demand a ransom for its return, much like “a hostage situation,” according to Shannon Vogel, TMA’s associate vice president of health information technology.
If that data aren’t backed up, practices don’t have much leeway. At that point, they can either hope the data can be retrieved by law enforcement or move forward without patient records.
“It’s vital that practices talk to their [electronic health record] and other vendors about redundant systems so that all is not lost,” Ms. Vogel said. “Otherwise, it would be like starting from scratch.”
Cigna and Zelis
If you have accidently signed up to receive virtual credit card (VCC) payments, and would like to change back to Automated Clearinghouse (ACH), please call Zelis.
Zelis Customer Service:(877) 828-8770
If you have questions regarding claim payments, please contact Cigna Healthcare Provider Service Line (800) 882-4462.
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