Revision to Prior Authorization Codes for Commercial Members | view in Web Browser
A newsletter for physician, professional, facility, ancillary and Medicaid providers |
December 2021
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
Check for continuing updates to our COVID-19 Preparedness, COVID-19 Provider Information for ERS Participants and COVID-19 Related News pages.
Fighting Fraud, Waste and Abuse
Analysts and investigators review claim data, industry trends and investigative results to identify potential areas of fraud, waste and abuse. When billing issues are identified, providers receive letters explaining the concerns. The most recent letters focused on potential billing abuse around COVID-19 testing and vaccinations.
| Read More |
Provider Directory Information Verification
The Consolidated Appropriations Act requires provider directory information to be verified every 90 days. Both providers and insurers have roles in fulfilling this requirement to maintain an accurate directory.
| Read More |
BEHAVIORAL HEALTH
The Magellan® Connection: Partnering with PCPs
Learn about the various resources and services Magellan offers that can assist you with improving medical and behavioral outcomes for your patients in the following HMO networks: Blue Advantage HMOSM, Blue Cross Medicare Advantage HMOSM, Blue Cross Medicare Advantage Dual Care (HMO SNP)SM and MyBlue HealthSM.
| Read More |
Magellan’s Webinar Series: Improve Patient Outcomes with These Quality Measures
Magellan offers a series of webinars that provide recommendations and guidance on crucial Healthcare Effectiveness Data and Information Set (HEDIS) measures.
| Read More |
CLAIMS & ELIGIBILITY
New Information on Member ID Cards
The Consolidated Appropriations Act requires member ID cards include deductible information and out-of-pocket maximums. We will provide all members with updated electronic ID cards that includes this information.
| Read More |
Single Sign-On Access to AIM Specialty Health® via Availity®
Checking patient eligibility and benefits is an imperative first step to confirm coverage and prior authorization requirements before rendering services. If the requested service(s) require prior authorization through AIM Specialty Health, providers can now utilize a new single sign-on access to AIM from the Availity portal.
| Read More |
View Withdrawn Claim Descriptions via the Availity Claim Status Tool
There may be instances when you receive a “claim withdrawn” notification by mail. But you can also use the Availity Claim Status Tool to determine why a claim was withdrawn. Claim status responses include original, duplicate, adjusted, replacement and withdrawn claims. Refer to the Custom Status Description field on the Results page to determine why a claim was withdrawn. After addressing the reason, the claim may be resubmitted electronically for processing. For assistance with verifying claim status online, refer to the Claim Status User Guide
Note: This information is not applicable to Medicare Advantage or Texas Medicaid claims.
Clinical Payment and Coding Policy Updates
The Clinical Payment and Coding Policies on our website 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:
| • | CPCP017 Wasted/Discarded Drugs and Biologicals Policy – Effective 11/8/2021 |
| • | CPCP020 Drug Testing Clinical Payment and Coding Policy – Retired 12/31/2021 |
| • | CPCP037 Lab Management Program – Effective date changed to 01/01/2022 |
| • | CPCP036 Paravertebral Facet Injection Procedure Coding and Billing Policy – Effective 02/24/2021 |
Reminder:
| • | Claim Editing Enhancements Coming Jan. 10, 2022 |
CLINICAL RESOURCES
Annual HEDIS/Quality Rating System Reports
We have a Quality Improvement Program to monitor and improve the care and service our members receive. Please review some key measures, interventions and accomplishments of the program.
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Health Benefits of Collaborating with Eye Care Professionals
This article pertains to the care and services provided to our Federal Employee Program® (FEP®) members and encourages continuity and coordination of care. It includes a screening recommendation summary from the American Diabetes Association and additional information to assist you when providing annual eye exams to our diabetic FEP members.
| Read More |
Hospital Discharge Summaries Empower Members and Inform Providers
As a reminder, PCPs need to know the details about their patients’ care during inpatient hospital stays. The hospital discharge summary is the key source for this information. Please review the information that should be included in all discharge summaries.
| Read More |
Encourage Early and Timely Intervention for Pre- and Post-Partum Care
Communication between members and their health care professionals during the pre-pregnancy, pregnancy and postpartum medical journey is important. When providing this type of care, certain documentation is important to record in the patient’s chart to help ensure effective coordination and continuity of care.
| Read More |
Continuity of Care Changes: Requirement of the Consolidated Appropriations Act
Most of our group and fully insured plans include a period of time for continuity of care at in-network reimbursement rates after a provider leaves our networks. Review new legislation requirements and what this means for you.
| Read More |
EDUCATION & REFERENCE
Surprise Billing Provisions of No Surprises Act
The No Surprises Act (NSA) is part of the Consolidated Appropriations Act. Under NSA, most out-of-network providers will no longer be allowed to balance bill patients for:
| • | Emergency services |
| • | Out-of-network care during a visit to an in-network facility |
| • | Out-of-network air ambulance services if the patient’s benefit plan covers in-network air ambulance services |
| Read More |
HEALTH & WELLNESS
To support quality care, we are providing information to providers and members to encourage discussions on health topics. Watch for more on health care quality in News and Updates and our Wellness Can’t Wait web page.
MEDICARE ADVANTAGE PLANS
2022 Blue Cross Medicare AdvantageSM Expansion Service Areas
Effective Jan. 1, 2022, Blue Cross Medicare Advantage HMO and PPO networks are expanding service areas across Texas. The expansion builds on strong networks already in place and is part of our commitment to providing members with access to affordable health care.
| Read More |
NETWORK PARTICIPATION
Reminder:
| • | MyBlue HealthSM Network Expansion |
PRIOR AUTHORIZATION
Revision to Prior Authorization Codes for Commercial Members
We will be updating our lists of procedure codes requiring prior authorization to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association. Review the changes that will be effective Jan.1, 2022.
| Read More |
Coordinated Home Care and Home Infusion Therapy Prior Authorization Reminders
As a reminder, when checking if a service requires prior authorization for our members, always use our preferred vendor, Availity. Review reminders and best practices related to submitting prior authorization for coordinated home care, home infusion therapy and other services.
| Read More |
STANDARDS & REQUIREMENTS
Machine-Readable Files
Beginning in 2022, health insurers will be required to publicly display certain health care price information via machine-readable files on their websites. These machine-readable files will include negotiated rates with in-network providers, allowed amounts for out-of-network providers, and may include prescription drug pricing.
| Read More |
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