New Prior Authorization Requirements for Blue Cross Medicare Advantage Begin Jan. 1  |  view in Web Browser


Blue Review

A newsletter for physician, professional, facility, ancillary and Medicaid providers

November 2019


Monthly News for Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR), STAR Kids and CHIP Providers

Read this month’s Medicaid newsletter to learn about:

  • Billing BCBSTX Medicaid as a Secondary Insurance
  • New Addresses for Submitting Payments for Refund Requests
  • Preventive Care Guidelines and Clinical Practice Guidelines Updates
  • Influenza Season 2019-2020
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Notices & Announcements

Risk Adjustment Initial Validation Audit — Important Information

Your office may have recently received requests for medical records on behalf of BCBSTX. Because the demands of fulfilling these medical record requests can be overwhelming, we’re providing best practice tips that could lessen the burden on office staff.

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Texas House Bill 29 — Referrals for Physical Therapy

HB29 expands a physical therapist’s scope of licensure to allow patients to access a physical therapist without a prescription for a limited number of visits. However, the bill did not modify the Texas Insurance Code, so members’ health plan requirements for referrals must still be followed.

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Itemized Bills Required for BlueCard® Claims Over $200k

BlueCard is a national program that enables members of one Blue Cross and Blue Shield (BCBS) Plan to obtain health care services while traveling or living in another BCBS Plan’s service area. Beginning Jan. 1, 2020, facilities will be required to submit an itemized bill for any inpatient institutional claim for BlueCard members billed at or more than $200,000. This is a change from $250,000.

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New Blue Cross Group Medicare Plan Names and ID Cards

Beginning Jan. 1, 2020, there will be new “Group” plan names on ID cards to reflect Blue Cross Group Medicare and Blue Cross Group Medicare SupplementSM members who are part of a group plan. Blue Cross Medicare AdvantageSM plan names for individuals will remain the same.

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Time-based Measurement Standard to Follow AMA

As of July 22, 2019, we changed our time measurement standard for billing physical medicine services to follow the American Medical Association’s (AMA) guidelines. Review the codes that now follow these guidelines.

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Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers Decision Memo from CMS

There are important changes to the CAR T-cell therapy for certain types of cancer considered a significant cost for contract years 2019 and 2020.

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Behavioral Health

2018 Behavioral Health QIP Evaluation Executive Summary

Based on lessons learned during 2018, which yielded an increased understanding of barriers to improvement, we’ve narrowed our focus for the 2019 Behavioral Health Quality Improvement work plan.

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Claims & Eligibility

Changes to Medicare Advantage Payment Models for Skilled Nursing Facility and Home Health Care Claims

See what changed on Oct. 1 and what will change on Jan. 1, 2020, regarding CMS’ new payment models for skilled nursing facilities and home health care.

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Clinical Payment and Coding Policy Updates

The Clinical Payment and Coding policies published on our website describe payment rules and methodologies for CPT®, HCPCS and ICD-10 coding for claims submitted as covered services. This information is offered as a resource for our payment policies; it is not intended to address all reimbursement-related issues. We regularly add and modify clinical payment and coding policy positions as part of our ongoing policy review process. The following policies have been recently added or updated:


Prior Authorization Information

New Prior Authorization Requirements for Blue Cross Medicare Advantage Beginning Jan. 1, 2020

On Jan. 1, 2020, changes to the Prior Authorization Procedure Code List will go into effect for patients enrolled in Blue Cross Medicare Advantage plans. The updated list is included.

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Clinical Resources

Collaborating to Reduce Opioid Abuse

As part of a new program, BCBSTX is now scanning pharmacy and medical claims to identify members with a combination of opioid risk factors. When these factors are found, members and their providers may be alerted.

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2019 Annual HEDIS®/QRS Reports

Review BCBSTX’s scores for preventive health and safety, and chronic condition education. Also, review key improvements BCBSTX is making in 2019 and ways you can help.

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Breast Cancer Screening — HEDIS Tip Sheet

As you know, breast cancer screening helps detect breast cancer early when it is most treatable. The NCQA has required HEDIS measures, which aren’t always intuitive, so we’ve created a HEDIS Breast Cancer Screen Tip Sheet to help.

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Comprehensive Diabetes Care — HEDIS Tip Sheets

Using the NCQA’s HEDIS measurements, it’s important you collect required data by annually testing designated members for HgbA1c, retinal eye exams, medical attention for nephropathy and controlling blood pressure. HEDIS measures aren’t always intuitive, so we’re providing the CDC’s HEDIS Tip Sheets to help.

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Congenital Syphilis Health Advisory Alert

New state legislation was enacted Sept. 1, 2019, to increase syphilis testing in pregnant women and requires testing at specific points during pregnancy.

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What You Need to Know About the 2019-2020 Flu Season

Learn what’s new this flu season and review helpful treatment and coding reminders.

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Network Participation


Education & Reference

Attend Free Provider Training Webinars

Whether new to these resources or if you need a refresher, there are many webinars available at no charge to learn about Availity, eviCore®, iExchange® and the remittance viewer.

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Health & Wellness


Health & Wellness Tips to Share

The Connect Community provides articles, blogs and videos, and visitors can ask questions and get answers. Topics include everything from improving well-being to explaining health coverage. Spanish is available.


Did You Know?

Did You Know (formerly In Every Issue) provides an ongoing collection of articles to assist provider offices with servicing BCBSTX members. Access this month’s articlesAdobe Acrobat Icon.

BCBSTX is required to provide certain notices in all published correspondence with physicians, professional providers, and facility and ancillary providers. For the latest updates, visit the News and Updates section of the BCBSTX provider website.

Printable PDF

View a printable PDFAdobe Acrobat Icon of the non-Medicaid information in this newsletter.

Contact Us

View our quick directory of contacts for BCBSTX.

Update Your Information

Do you need to update your location, phone number, email or other important details on file with BCBSTX or want to receive the Blue Review by email? Use our online form to request information changes.

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an Independent Licensee of the Blue Cross and Blue Shield Association

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