What is the lawsuit about?

In the class action In re: Blue Cross Blue Shield Antitrust Litigation, the Plaintiffs (Provider Class Representatives, or group of providers and facilities bringing the suit) claim that the Settling Defendants (Individual Blue Plans and the Blue Cross Blue Shield Association) violated antitrust laws by illegally dividing the United States into "Service Areas" and agreed not to compete in those areas.  They also claim that the Settling Defendants fixed prices for services provided.

Why is there a Settlement?

The Court did not decide in favor of the Plaintiffs or Settling Defendants.  Instead, both sides have agreed to the Settlement.

Who is included in the Settlement Classes?

The Settlement Class includes all Providers in the U.S. (except Excluded Providers) who currently provide or provided healthcare services, equipment or supplies to any patient who was insured by, or was a member of or a beneficiary of any plan administered by any settling individual Blue Plan from July 24, 2008 to October 4, 2024.

Starting October 1, 2024, the Centers for Medicare and Medicaid Services incorrectly returned certain Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) claims with reason code W7072:

• Type of bill: 017X (RHC) and 077X (FQHC)
• HCPCS code 93010 (electrocardiogram, EKG or ECG)

RHCs and FQHCs should resubmit these claims that were returned in error.

Humana Military's claim processor will switch from Wisconsin Physicians Service (WPS) to PGBA LLC, effective January 1, 2025.

Key Changes:

EDI Claims:

• The 2025 TRICARE East Payer ID is 99727

Claims and Document Submissions:

• Starting January 1, 2025, use XPressClaims via provider self-service

Clearinghouse Requirements:

• New submitters must file a Trading Partner Agreement and Enrollment Form to obtain a          mailbox/submitter ID
• Confirm Payer ID 99727 is enabled if your clearinghouse already files claims to PGBA
• If your clearinghouse does not submit to PGBA, files can be uploaded directly if they meet ANSI     X12 standards.
• Batch claims processing is available through the EDI Gateway mailbox system.
• Complete a PGBA EDI Provider Agreement to submit claims electronically

Claims with 2024 Dates of Service (DOS)

• WPS will process claims with 2024 DOS until April 30, 2025
• After April 30, 2025, submit 2024 claims via XPressClaims or the clearinghouse.
• Ensure all documentation and disputes are submitted promptly before April 30, 2025.

ERA/EFT Enrollment:

• Re-enroll in ERA/EFT by January 1, 2025 even if currently enrolled. (click 'I am staying in East Region'). 
• Note: T17 EFT/ERA applications will no longer be accepted after this date.

Source: Tricare EFT Changes Coming in 2025

"A picture is worth a thousand words." 

Does your practice accept Cigna insurance? We have learned of an important policy change:

You play a crucial role in testing, treating and vaccinating uninsured individuals, or those with limited health care coverage.