SA Modifier and Midlevel Provider Contracting Update | view in Web Browser
A newsletter for physician, professional, facility, ancillary and Medicaid providers |
June 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
- 2021 Policies Updates for Cotiviti Regarding Texas Medicaid
- Healthy Texas Women New Requirements for Provider Certification
- Well-Care Visits
Best Practices
- Texas Medicaid Encounter Issues with Present on Admission with Hospital Claims
- New Texas
Health Steps Preventive Care Screening Tools
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 FAQs and COVID-19: FAQs for Medicare Providers.
SA Modifier and Midlevel Provider Contracting Update
On Jan. 19, we posted an article about contracting and credentialing midlevel providers and the upcoming implementation of the ClaimsXtenTM edit of the SA modifier for non-payable services resulting in the SA modifier being non-reimbursable. This edit has not been implemented and there are currently no plans for future implementation of this edit.
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Update to Telemedicine Code List
Review the codes we’ve updated in the Telemedicine Code List; these codes were effective Jan. 1.
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Newsletter Readership Survey: Your Feedback Is Important
Blue Review strives to deliver important information each month to our contracted providers. To provide the content that’s most relevant, we need your feedback. You will soon receive a survey via email that will only take a few minutes to complete. As a thank you for your time, we’re providing an opportunity to win one of three, $25 Amazon.com® gift certificates. (Note: Government employees are not eligible.)
Behavioral Health
Free CME Webinar on Depression
Join our board-certified psychiatrists and behavioral health medical directors for a one-hour webinar, Depression in a Primary Care Setting. The webinar is Wednesday, June 16 at 8 a.m. CT. It is free to all providers. Those who attend will earn one continuing medical education credit (CME) or continuing education unit.
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Claims & Eligibility
Prepayment Reviews on BlueCard® Inpatient DRG Claims
Beginning July 1, the Blue Cross and Blue Shield Association will require us to review select, inpatient diagnosis-related group (DRG) claims for services rendered to any hosted BlueCard member. Hosted BlueCard members are members of any Blue Cross and Blue Shield plan outside Texas receiving health care services in Texas.
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Professional Provider Fee Schedule via Availity®
Starting May 27, participating professional providers are able to access fees for up to 20 procedure codes using the online Fee Schedule Viewer Tool via the Availity Provider Portal.
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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:
- Increased Procedural Services (Modifier 22) – Effective 08/12/2021
- Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) – Effective 08/15/2021
Reminders:
Clinical Resources
Keys to Diabetes Management
In late 2020, we asked BCBSTX providers to tell us what works best to manage diabetes. Read their responses and also learn about the programs we offer to close the gaps in care for managing diabetes.
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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.
Catch Up Now on Child and Adolescent Vaccinations
Due to COVID-19, children and adolescents have fallen behind on receiving recommended vaccines. The CDC recommends that children get caught up now with vaccinations so that they’re protected when they return to in-person learning. We’re encouraging providers to schedule catch-up vaccinations as soon as possible and prepare for COVID-19 vaccine protocols.
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Treating Substance Abuse
We encourage providers to talk with our members about the signs of substance abuse disorders and how alcohol can affect them. Learn about closing the health care gaps related to substance abuse and review tips to consider when urging a member to seek help.
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Medicare Advantage Plans
Reminder:
Pharmacy
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2021 – Part 1
This pharmacy update includes changes/updates to the drug list, dispensing limits, the Utilization Management program, benefit coverage for select high-cost claimants and HIV pre-exposure prophylaxis coverage. It also includes reminders about the Split Fill program and the HDHP/HAS Preventive Drug program.
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Prior Authorization
Reminder:
Utilization Management
New Location for Utilization Management on Provider Website
Utilization Management information, which includes Prior Authorizations, is now located under Claims and Eligibility on our provider website. This change was designed to enhance your experience for the entire claim cycle, from the moment a member walks into your office, from reviewing prior authorization requirements to processing claims for covered services you provide.
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Utilization Management Decisions
We are dedicated to serving our customers through the provision of health care coverage and related benefit services. Utilization Management (UM) determinations are made by licensed clinical personnel based on the:
- benefits policy (coverage) of a member’s health plan,
- evidence-based medical policies and medical necessity criteria, and the
- medical necessity of care and service.
All UM decisions are based on the appropriateness of care and service and the existence of coverage. We prohibit decisions based on financial incentives, nor do we specifically reward practitioners or clinicians for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. The criteria used for UM determinations are available upon request. Please call the Customer Service number on the back of the member’s ID card.
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