October 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
• Removal of Alpha Prefix will Impact Prior Authorizations
• Roll-Out Schedule for Provider Enrollment and Management System
• Availity^® Claim Status Response Enhancement for Government Programs Claims
• Initiating and Engaging Patients in Treatment for Alcohol and Drug Dependence: A Key Quality Measure
• Reminder: Removal of Texas Provider Identifiers Number from Prior Authorization Forms, Claims Forms and Instructions Effective Sept. 1, 2021

Effective Oct. 1, 2021:

• Prostate Procedures for Benign Prostatic Hyperplasia Benefit Changes

COVID-19 Provider Preparedness Updates

Check for continuing updates to our COVID-19 Preparedness and COVID-19 Related News pages.

Replacement for CHANTIX^® Smoking Cessation Product Recall

Pfizer^® has voluntarily recalled its CHANTIX smoking cessation product. To alleviate a shortage of these products, we’re temporarily covering Apo-Varenicline (varenicline tartrate) 0.5 mg and 1 mg tablets for our commercial plans.

Learn about Medical Oncology Prior Authorization via AIM^®

As a reminder, starting Oct. 11, AIM Specialty Health^® (AIM) will review oncology drug prior authorization requests when they’re supported by an oncology diagnosis (for some commercial members). Online training is available to learn about key implementation dates and how to submit prior authorizations for the Medical Oncology program.

MyBlue Health^SM Network Expansion

Beginning Jan. 1, we will expand the MyBlue Health network to include Bexar, Travis and Williamson counties. MyBlue Health members access care through providers contracted in this network.

New Laboratory Program Coming Jan. 1

Effective Jan. 1, we will implement new policies and program for certain outpatient laboratory services (provided to fully insured commercial members). Our new Laboratory Management program via Avalon will help our members get the right care at the right time and in the right setting.

ClaimsXten^TM 4th Quarter 2021 Update

We will implement our 2021 fourth quarter code updates to the ClaimsXten auditing tool on or after Dec. 13. These updates aren’t considered changes to the software and may include additions, deletions and revisions to CPT^® and Healthcare Common Procedure Coding System codes.

CPCP020 Drug Testing Policy Retirement

The CPCP020 Drug Testing Clinical Payment and Coding Policy (CPCP) will become inactive on Nov. 30. Medical Policy MED209.070 is replacing it for dates of service on Dec. 1 and after.

Cancer and Cancer-Related Treatments Coding

Wholly and accurately coding and documenting cancer and cancer-related treatments may improve member outcomes and continuity of care. As such, please review information for outpatient and professional services from the ICD-10-CM Official Guidelines for Coding and Reporting.

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:

• CPCP037 Laboratory Management – Effective 12/1/2021
• CPCP019 Home Infusion – Effective 12/20/20201
• CPCP026 Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding – Effective 12/20/2021

Shared Decision-Making Aids

Shared decision-making is a way for providers and patients to make informed health care decisions that align with what matters most to the patient. We’re providing evidence-based aids from Mayo Clinic^® about treatment options, lifestyle changes and outcomes. When patients help make decisions about their health care, it can improve their health journey, and yield better results and quality of life.

Initiating and Engaging Patients in Treatment for Alcohol and Drug Dependence: A Key Quality Measure

You can help patients diagnosed with alcohol or drug dependence (AOD) achieve positive treatment results when you improve their care coordination or plan and manage their treatment. Please review our recommendations on what you should do after a patient is diagnosed with AOD.

Delivering Quality Care – Managing Diabetes

More than 34 million Americans have diabetes, according to the CDC. Because symptoms can develop slowly, 1 in 5 don’t know they have it. Please review “closing care gaps” recommendations and tips to consider when managing members with diabetes.

Delivering Quality Care – Breast Cancer Screening

According to the CDC, about 1 in 8 women will be diagnosed with breast cancer at some point in her life. Because screening is the best way to find cancer early, we’re providing resources to help you discuss risk factors and the importance of screenings with your patients. Please review “closing care gaps” recommendations and tips to consider when screening members for breast cancer.

Reminder:

• Earn CME/CEU Credit at Free Webinar on Comorbid Conditions

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.

Reminder:

• Update to Prior Authorization Codes for Medicare Members

Facility-Based Provider Onboarding Process

To get assigned a provider record ID and join our networks, new facility-based providers must complete an onboarding form to prevent a delay in processing the request.

Utilization Management Decisions

We are dedicated to serving our customers through health care coverage and 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 appropriateness of care and service and existence of coverage. We prohibit decisions based on financial incentives, nor do we 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.

bcbstx.com/provider

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an Independent Licensee of the Blue Cross and Blue Shield Association

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