January 2020

Medicaid

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

Read this month’s Medicaid news to learn about:

• HEDIS^® 2020
• Eight Steps Toward Health Equity in Diabetes
• Eight Steps Toward Health Equity in Hypertension

Physician Efficiency, Appropriateness and Quality (PEAQ) Program Measuring and Maximization

Driving quality of care: Learn about BCBSTX’s PEAQ program that will evaluate physician performances in a transparent and multidimensional way for all BCBSTX networks, including Medicaid and Medicare.

New Blue Cross Medicare Group Plan Names and ID Cards

To-do list: Review a list of new group plan names. Why? Since Jan. 1, 2020, there are new Blue Cross Medicare and Medicare Supplement group plan names and ID cards. Blue Cross Medicare Advantage^SM plan names for Individuals remain the same. 

ACO Savings Go Back to Employers and Providers

The big picture: ACOs are a win-win for employer groups, physicians and members. To date, ACOs have had almost $86.9 million in total savings, which are given back to employer groups and physicians. Why it matters: ACO savings can be reinvested to improve the quality of care for members, save on health care costs and shift care from treating symptoms to preventing illnesses.

Medicare Outpatient Observation Notice Required – Annual Reminder

Reminder: Hospitals and critical access hospitals must give the standardized Medicare Outpatient Observation Notice (MOON) to people who receive Medicare and are observed as outpatients for more than 24 hours. 

Reminder

• Provider Manual Updates

Reminder Medicare Advantage Program 30-Day Readmission Facility

What you should know: Beginning March 1, 2020, BCBSTX will perform a clinical review of acute care facility readmissions that occur within 30 days of discharge from the same facility. Payment may be denied for related readmissions. This change supports quality of care improvements by linking payment to the quality of facility care. 

Reminder

• Critical Details to Include in Hospital Discharge Summary

Magellan^® Connection 2019: Partnering with PCPs to Manage Behavioral Health Care Needs

Primary care providers should take advantage of a variety of resources and services offered by Magellan that improve medical and behavioral health outcomes for members.

Magellan’s New Webinar Series: HEDIS Measures and a Focus on Coordination of Care

The bottom line: When behavioral health care is coordinated appropriately across all lines of care, members see better overall results. To improve coordination of care amongst all providers, Magellan is providing a series of webinars. 

Behavioral Health Measures from HEDIS

To help you satisfy Healthcare Effectiveness Data and Information Set (HEDIS) requirements, we’re providing three different tip sheets that include measurement requirements, medical record best practices and billing codes. Why it’s important: Compliance with HEDIS measures reduces the need for you to send medical records later for review. 

Reminder

• Behavioral Health Program Changes for AT&T Members

Pharmacist Healthcare Services

Based on legislation that went into effect Jan. 1, BCBSTX will reimburse a pharmacist for services within the scope of their license for fully insured members. These services include patient counseling and other services that could also be provided by a physician, advanced nurse practitioner or a physician assistant.

Reminder: Medicare Providers May Not Bill Participants in the Qualified Medicare Beneficiary Program

If you’re a Medicare provider, you may not bill individuals enrolled in the Qualified Medicare Beneficiary (QMB) program. Review your responsibility, the federal law and helpful tips to avoid billing QMB patients.

National Coordination of Care^SM Program for Group Medicare Advantage PPO Members

Due to concerns about gaps in care, BCBSTX is now participating in the BCBSA’s Coordination of Care program. This program streamlines administrative processes for providers and may encourage members to come into your practice more frequently, allowing for greater continuity of care. 

Reminder of Change to the Pre-service Appeals Process for Your Blue Cross Medicare Advantage Patients

As of Nov. 1, 2019, eviCore^® healthcare is no longer administering the appeals process for denied or partially denied Medicare Advantage prior authorization requests. BCBSTX is now managing the process.

2020 Holiday Schedule Reminders (for 835 and 837 Transactions)

Plan ahead now for all 2020 holidays, which may affect electronic claims (837) and/or claims payment and remittance (835) transactions.

Notification of Annual Benefit Updates

BCBSTX will be updating member files with annual benefit changes over the next several weeks. We encourage you to verify your patients’ coverage first, using Availity^® or your preferred vendor portal. In the event a call is necessary to BCBSTX, please recognize that hold times may be longer than normal. Customer Advocates will be available for eligibility and benefit inquiries from 7:30 a.m. to 6 p.m. CT Jan. 2, through Jan. 24, 2020, Monday through Friday. Claims Customer Advocate hours will remain the same from 8:30 a.m. to 4:30 p.m. CT.  As a reminder, you can obtain routine eligibility and benefit information, as well as claim status using Availity or the web vendor of your choice. 

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.

Reminders

• Change to Online Enrollment Process for 835 EFT & ERA through Availity
• Availity Remittance Viewer Upgrade
• Medicare Advantage: Interpreting the ‘PLB’ Segment on the 835 ERA
• Medicare Advantage: Additional Payment for Medication Reconciliation Post Discharge
• Fee Schedule Update March 1, 2020
• Texas House Bill 29 - Referrals for Physical Therapy
• Itemized Bills Required for BlueCard^® Claims Over $200k
• Time-based Measurement Standard to Follow AMA
• Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers Decision Memo from CMS

Pharmacy Program Updates: Quarterly Pharmacy Changes - Part 2

Review drug list changes, updates and revisions that went into effect Jan. 1, 2020.

Reminder

• Pharmacy Program Updates: Quarterly Pharmacy Changes – Part 1

Reminder: Out-of-Network Medicare Providers Can Treat Group Medicare Advantage Open Access (PPO) Members

Did you know: If you’re a Medicare provider, you don’t need to have a contract with BCBSTX to treat Blue Cross Group Medicare Advantage Open Access (PPO)^SM members. This plan offers members access to care from any providers nationwide who accept Medicare assignment and are willing to bill BCBSTX. 

Reminder

• 2020 Blue Cross Medicare Advantage Expansion Service Areas

Reminders

• New Prior Authorization Requirements for Blue Cross Medicare Advantage Beginning Jan. 1, 2020
• 2020 New Prior Authorization Requirements and Introduction of MyBlue Health^SM

Reminders

• Medicare Advantage: Electronic Payment Summary Now Available for 835 ERA Receivers
• Medicare Advantage: New Claim Status Tool via Availity Provider Portal

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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