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Administrative Policy Effective February 1, 2020

Excellus BlueCross BlueShield will implement an administrative policy entitled “Transitional Care Management” effective February 1, 2020, for Medicare and commercial lines of business. The new policy defines the coverage and billing guidelines for transitional care services billed by providers contracted to provide this service, and aligns with Centers for Medicare & Medicaid Services, Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) guidelines.

Administrative Policy 23 – Transitional Care Management (TCM):

  • The Health Plan will reimburse code 99495 when billed with a face-to-face visit rendered within 14 days post-discharge.

  • The Health Plan will reimburse code 99496 when billed with a face-to-face visit rendered within seven days post-discharge.

  • The Health Plan will not reimburse TCM services if they are billed on the same date of service as a facility discharge service.

  • The Health Plan will reimburse one TCM service rendered by one provider during the TCM service period despite any subsequent readmissions/discharges within the same TCM period.

  • If a provider performs a 10- or 90-day global surgical service that results in a TCM post-discharge, the Health Plan will not reimburse the TCM service reported by that provider.

  • The Health Plan will not reimburse the specific services if billed by the same physician or other qualified health care professional who reports codes 99495 or 99496 during the 30-day post-discharge period

  • This policy will be reviewed post-payment. Pre-payment review means claims are reviewed prior to payment. A pre-payment review results in an initial determination. Post-payment review means that claims are reviewed after adjudication. A post-payment review may result in either no change to the initial determination or a revised determination.

These services are subject to audit and policy updates at the Health Plan’s discretion. Members are held harmless for all denials resulting from this administrative policy.  You can access the individual policies on our website, ExcellusBCBS.com/Adminpol. Note: You must login with your username and password to access our administrative policies.

If you are not currently registered to view the secure section of our website, we encourage you to register today at Provider.ExcellusBCBS.com.

If you need assistance registering, contact the Web Security Help Desk at 1-800-278-1247. In addition, your Provider Relations representative is available to assist with website registration and functionality training.

Thank you for the quality of care and service that you provide to our members.

 
 
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