January 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:

• COVID-19 News and Updates
• HEDIS^® MY2020 Texas Medicaid Measures and Key Dates
• Obtain BCBSTX Patient ID Numbers Online via Availity^® — Now Available for Texas Medicaid

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 FAQs and COVID-19: FAQs for Medicare Providers.

COVID-19 Fee Schedule/Reimbursement Update

Effective April 1, 2021, unless otherwise specified in the provider’s agreement, we will align 87426, 0224U and 0226U codes with the Centers for Medicare & Medicaid Services and local Medicare Intermediary reimbursement levels.

Tiered Payment Rate Modifiers for ABA Effective April 1, 2021

Review updates to how reimbursements will be applied using modifiers for Applied Behavioral Analysis Therapy (ABA) services effective April 1, 2021.

Billing Information on Free Bamlanivimab

Providers receiving bamlanivimab for free should not bill for the product.

Prior Authorization Has a New Home: Utilization Management

Prior authorizations are now under Utilization Management on our website. Watch for additional changes this month when Utilization Management will move under the Claims and Eligibility menu for easier flow of information related to submitting claims.

Financial Liability for Experimental, Investigational and Unproven Services

As a reminder, BCBSTX-contracted providers are not permitted to bill members for services that are considered experimental, investigational or unproven unless the member acknowledges in writing that the service(s) will not be covered by their plan and agrees to accept liability for payment prior to the services being rendered. If you have any questions, please contact your Network Management Office.

New HEDIS Tip Sheets — Behavioral Health HEDIS Measures: APM and UOP

Two new behavioral health tip sheets have been created to help you satisfy Healthcare Effectiveness Data and Information Set (HEDIS) measures and code claims appropriately.

1. Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
2. Use of Opioids from Multiple Providers (UOP)

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:

• Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) – Effective 01/01/2021
• Preventive Services – Effective 01/01/2021
• Evaluation and Management (E/M) Coding – Professional Provider  – Effective 01/01/2021
• Emergency Department Services Evaluation and Management (E/M) Services Coding – Facility Services  – Effective 02/25/2021
• Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)  – Effective 03/01/2021
• Applied Behavior Analysis  – Effective 03/03/2021
• Inpatient/Outpatient Unbundling Policy - Facility  – Effective 03/18/2021

Reminders:

• Check Multiple Patients’ Eligibility and Benefits via Availity
• View BCBSTX Member ID Cards via Availity

Benefits of Collaborating with Eye Care Providers

Despite COVID-19, annual eye exams are still recommended for patients with diabetes. Review a screening recommendations summary from the American Diabetes Association which aims to improve patient outcomes.

New: Obtain BCBSTX Patient ID Numbers for Government Program Members via Availity

You can now use the Patient ID Finder to obtain the insurance ID and group numbers for Blue Cross Medicare Advantage^SM and Texas Medicaid members.

Office Based Professional Providers — Credentialing

We require physicians and other professional providers to register with the Council for Affordable Quality Healthcare’s (CAQH^®) ProView for initial credentialing and recredentialing within 45 days of being rostered with CAQH. CAQH ProView is a free online service that allows providers to fill out one application to meet the credentialing data needs of multiple organizations.

Reminders:

• Requests for Medical Records
• Blue High Performance Network^SM (Blue HPN^SM) to Launch in January 2021

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2021 – Parts 1 & 2

These pharmacy updates include network changes, drug list revisions/exclusions/updates, dispensing limit change, Utilization Management Program changes and other Pharmacy Program updates/reminders.

1. Part 1

2. Part 2

Update to Prior Authorization Codes for Commercial Members

We are updating our lists of procedure codes that require prior authorization for some commercial members to reflect new, replaced or removed codes. These lists are posted to our provider website.

Use AIM^® ProviderPortal^SM for Pre & Post-Service Reviews

As a reminder, providers need to use the AIM Specialty Health (AIM) ProviderPortal to request prior authorizations and respond to post-service review requests required by AIM.

Reminders:

• Updates on our Prior Authorization Expansion to AIM
• Update to Prior Authorizations — Jan. 1, 2021

bcbstx.com/provider

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