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Providers
November 2024
In This Issue
► November news: Executive summary
► Fee schedules now available via Availity Essentials portal
► Prefix replacements for 2025
► 2025 Provider Operating Guide preview starts December 2
► More biosimilars get preferred status for 2025
► Quarterly fee schedule updates effective January 1
Preview the 2025 Provider Operating Guide
You can preview the 2025 AZ Blue Provider Operating Guide (Guide) starting Monday, December 2. The Guide serves as part of your AZ Blue network contract and includes helpful tips for your teams. Please share this update with them.
2025 changes
For the full list of edits, see the 2025 Appendix of Changes. We’ve highlighted several key updates in the table below.
2025 AZ Blue Provider Operating Guide Changes (partial list)
Section 2025 Updates
01 Definitions Updated definitions related to adverse determinations and medical necessity to reflect requirements and language in Arizona HB 2599 (we made similar changes across all sections of the Guide for relevant content)
02 Contact Information and Provider Communication Updated contact information to make it current for 2025 and replaced the Provider Assistance phone numbers with a new direct-dial number: 1-844-995-2583
03 Electronic Resources Removed references to the Medicare Advantage provider portal (we have moved resources to the Availity Essentials™ portal and our Medicare Advantage Plans webpage)
04 Contracting and Credentialing
Added information about various types of provider terminations, including relocation, retirement, resigning from a contract, and ending an affiliation with a tax ID
Added the requirement for providers to submit a signed attestation form before including a third party in contract negotiations, billing, claim submission, and/or claim disputes
08 Networks and Products
Updated the TriWest network information to include both the Community Care Network and the TRICARE Network for active-duty military
Updated the network/product/prefix table to add the Alliance and PimaConnect networks as options for BlueSignatureSM Prosano plans
Updated the Federal Employee Program® (FEP®) information to include the new Postal Service Health Benefits Program enrollment codes and new benefit plan names:
• Standard Option = FEP Blue Standard
• Basic Option = FEP Blue Basic
Updated the Medicare Advantage (MA) network and plan information: The BlueJourney PPO network will be used only to service members with out-of-area MA PPO plans issued by other Blue Plans, as AZ Blue is not offering a 2025 MA PPO option
10 Member ID Cards Added information about prefix replacements and why it’s important to use the correct prefix for eligibility searches, claim submission, and online remits
11 Medical Policies and Prior Authorization
Updated the information about our Gold Card Prior Authorization Program
Updated the medical policy and prior authorization quick guides for 2025
14 Eligibility and Benefits Updated the information about how to identify members and validate eligibility
17 Billing Members: Restrictions and Exceptions Modified the content about collecting cost-share amounts: If a provider collects more than is specified by the member’s plan and there is no agreement with the member for a credit, the provider must refund the excess amount no later than 30 days from the AZ Blue remittance date
18 Claim Coding Added to the coding compliance content: Claims that don’t meet coding requirements will be denied or returned to the provider
19 Claim Submission
Added a note about ensuring your claims have the member ID prefix that is valid for the service date
When submitting a claim for a patient who is also the insured/subscriber, both name fields must match and be written exactly as the name appears on the member ID card, including a middle initial if there is one
20 Claim Pricing
Noted the change in effective date for the annual update for major fee schedule changes (from April 1 to July 1)
Updated the online fee schedule access information: Fee schedules are now available via the Availity Essentials provider portal
Clarified the content about billing and reimbursement for transfers within/across a hospital system
21 Claim Remittance
Noted that new EFT enrollments and changes must now be requested via the Availity Essentials portal
Updated the online remit content to say that starting with payments made on or after July 8, 2024, providers can access remits via the Availity Essentials remittance viewer and that earlier remits can be accessed through our Remit History app via the Availity Essentials payer space
Noted that the previous $34.99 minimum threshold no longer applies for overpayment recoveries
22 Provider Disputes and Complaints Updated the list of grievable issues to align with Arizona HB 2599: Providers must use the commercial member appeals process to challenge a decision involving how AZ Blue applied clinical criteria to determine medical necessity and appropriateness, or whether a service is considered experimental or investigational
24 Pharmacy Benefits
Added content about the “Price Edge” discount program for the best available price on certain generic drugs
Updated the Medication Therapy Management Program information with the new requirements effective January 1, 2025
Removed the coverage gap stage from the Part D drug coverage stage information
Added information about the new Medicare Prescription Payment Plan required by the Inflation Reduction Act
26 Dental Networks, Products, and Benefits Removed the reference to Change Healthcare for electronic claim attachments
How to access the Guide
You can view or download the Guide via the AZ Blue provider portal at “Provider Resources > Guidelines > Provider Operating Guide.”
Questions?
If you have questions, feel free to call us at 1-844-995-2583 or reach out to your Provider Relations Contact.
In This Issue
► November news: Executive summary
► Fee schedules now available via Availity Essentials portal
► Prefix replacements for 2025
► 2025 Provider Operating Guide preview starts December 2
► More biosimilars get preferred status for 2025
► Quarterly fee schedule updates effective January 1
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