Update to Prior Authorizations | view in Web Browser
A newsletter for physician, professional, facility, ancillary and Medicaid providers |
November 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:
Notices & Announcements
COVID-19 Provider Preparedness Updates
As the COVID-19 crisis evolves, we’re continuing to make updates on our COVID-19 Preparedness and our COVID-19 Related News pages. Be sure to check these pages frequently for updates including COVID-19: Texas Provider FAQ
and COVID-19: FAQs for Medicare Providers.
Blue High Performance NetworkSM (Blue HPN)SM to Launch in January 2021
Beginning Jan. 1, 2021, we are launching Blue HPN, a new national high-performance network for large Administrative Services Only (ASO) employer groups. It will provide additional access to quality and affordable health care nationwide in 55 major markets. Review the table of counties in and near Austin, Dallas-Fort Worth, Houston and San Antonio.
| Read More |
Provider Finder® Gets an Upgrade
If you need help finding a specialist or facility for a consultation or procedure for a BCBSTX patient, then check out our enhanced online Provider Finder which makes finding care for our members a lot easier.
| Read More |
Behavioral Health
TRS Behavioral Health Prior Authorization Forms
Effective Oct. 16, 2020, providers now need to use new designated prior authorization forms for behavioral health services for Teacher Retirement System of Texas (TRS) participants. The new forms contain a bar code for TRS participants that is needed to forward the forms to the appropriate area for review. Failure to submit the correct forms could delay processing the forms. Links to the designated forms are located on our provider website’s Forms page under Behavioral Health Forms for TRS Participants.
Claims & Eligibility
Itemized Bills Required for BlueCard® Facility Claims Over $100K
Beginning Jan. 1, 2021, we will require facilities to submit an itemized bill for inpatient care billed for $100,000 or more. An itemized bill helps ensure an accurate claim payment and reduces the need to submit more information after a claim is paid.
| Read More |
Availity® Claim Status Tool Available for All Members
Last year, we launched the Availity Claim Status Tool for providers to verify detailed claim status online for Medicare Advantage and Texas Medicaid members. Now this tool includes claim status for commercial, Federal Employee Program® and marketplace health plan members. This improvement will increase your administrative efficiencies by offering a single tool to check claim status online for all your BCBSTX patients.
| Read More |
Submitting Predetermination of Benefits Update
On July 30, we implemented an electronic predetermination of benefits submission process via Availity’s Attachment Tool. Recently, the tool was updated to better help you with submitting requests online to us.
| Read More |
Clinical Payment and Coding Policy Updates
The Clinical Payment and Coding Policies describe payment rules and methodologies for CPT®, HCPCS and ICD-10 coding for claims submitted as covered services. This information is 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 have been recently added or updated:
- Multiple Surgical Procedures – Professional Provider Services – Effective 11/10/2020
- Chiropractic Services – Effective 10/15/2020
- Co-Surgeon/Team Surgeon Modifiers – Effective 10/15/2020
- Coordinated Home Care /Private Duty Nursing Policy Guideline – Effective 10/15/2020
- Drug Testing Clinical Payment and Coding Policy – Effective 12/28/2020
- Evaluation and Management (E/M) Coding – Professional Provider – Effective 01/01/2021
- Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) (Revision) – Effective 12/1/2020
- Preventive Services Policy – Effective 10/01/2020
- Pneumatic Compression Devices – Outpatient Use – Effective 10/01/2020
- Wasted/Discarded Drugs and Biologicals Guideline – Effective 01/10/2021
- Telemedicine and Telehealth Services – Effective 01/01/2021
Clinical Resources
New HEDIS 2020-21 Tip Sheets
New tip sheets are available to help you satisfy Healthcare Effectiveness Data and Information Set (HEDIS) measures and code appropriately. They include measurement requirements, medical record best practices and billing codes. Compliance with HEDIS measures reduces the need for you to send medical records later for review.
| Read More |
Clinical Practice and Preventive Care Guidelines Updated for 2020-2021
Review our updated 2020-2021 Clinical Practice and Preventive Care Guidelines. They are built on evidence-based standards of care to direct our quality and health management programs. They can help guide your decision-making as you care for our members.
| Read More |
Are You Using Shared Decision-Making Aids?
We’re providing resources to help you involve your patients in shared decision-making. The evidence-based aids provide information about treatment options, lifestyle changes and outcomes. They’re meant to help facilitate conversations with your patients.
| Read More |
Medicare Advantage Plans
New Prior Authorization Lists for Blue Cross Medicare AdvantageSM
Updates to our Prior Authorization Lists for patients enrolled in the Medicare Advantage plans will be effective Jan 1. These updates are the result of new, replaced or removed codes implemented by the American Medical Association.
| Read More |
Prior Authorization Information
Prior Authorization Expansion to AIM®
Effective Jan. 1, 2021, AIM Specialty Health® (AIM) will be the utilization management vendor for certain outpatient prior authorizations for some members. Learn what is – and is not – changing.
| Read More |
Update to Prior Authorization Services
Effective Jan. 1, 2021, we will update the Procedure Code List for services that require prior authorization. A link is included to view the revised list of codes.
| Read More |
Standards & Requirements
2020 Annual HEDIS / Quality Rating System Reports
We have a Quality Improvement Program to better serve you. Its purpose is to monitor and improve the care and service our members receive. Review our most recent results.
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