September 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
• Update to COVID-19 Testing Billing Procedure Code 87637 with QW Modifier
• Catch Up Now on Child and Adolescent Vaccinations
• Unannounced Electronic Visit Verification Home Visit Policy Repealed for STAR Kids
• Pharmacy Members Have A New Mail Order Pharmacy Choice
• Pharmacy Members Have A New Specialty Pharmacy Choice
• Removal of Alpha Prefix from all Medicaid Insurance Cards
• Key Reminders: Texas Health Steps Quick Reference Guide
• Indices Help You Stay in Compliance with Texas Health Steps and Healthcare Effectiveness Data and Information Set Measures

Effective Sept. 1, 2021:

• Lung Cancer Screening Benefits Changes
• Non-Risk Based Payment for Amondys 45
• Subcutaneous Internal Cardiac Defibrillator to Become a Texas Medicaid Benefit
• Diabetic Equipment and Supplies Benefits Changes

COVID-19 Provider Preparedness Updates

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

Earn CME/CEU Credit at Free Webinar on Comorbid Conditions

Attend a one-hour webinar on comorbid behavioral health and physical health conditions. You’ll get a high-level overview of the epidemiology of comorbid medical and mental health conditions and how they impact each other. The free webinar is on Wednesday, Oct. 27, at 8 a.m. CT. Attendees will earn one continuing medical education (CME) credit or continuing education unit (CEU).

HealthSelect of Texas^® Prior Authorization Procedure Code Update

As of Sept. 1, certain procedure codes were removed from the list of services that require prior authorization for HealthSelect of Texas and Consumer Directed HealthSelect^SM participants. You can review a list of the code removals here. We are currently working on system updates to reflect this change.

Important Information About Participants Transitioning to HealthSelect of Texas

Effective Sept. 1, HMO plans will no longer be an enrollment option under the Texas Group Benefits program. All current subscribers and dependents enrolled in one of the HMO plans will be automatically enrolled in HealthSelect of Texas administered by BCBSTX, unless they elect otherwise during their summer enrollment period. Visit our Participants Transitioning to HealthSelect of Texas page to learn more about:

• Selecting a primary care provider
• Referrals and prior authorizations
• Transition of care
• In-patient hospital stays

Documenting and Coding Obesity and Morbid Obesity

Accurate and complete documentation and coding of obesity/morbid obesity diagnoses can help identify and address related comorbidities that may impact your patients’ health status. Insights and examples of documentation and coding are included.

Availity^® Claim Status Response Enhancement for Blue Cross Medicare Advantage^SM Claims

We’re happy to announce that the Availity Claim Status response now provides additional action(s) for specific ineligible reason codes on finalized Blue Cross Medicare Advantage claim denials. This information provides the same instruction as our Customer Advocates and will help you understand what further step(s) should be taken for certain denial scenarios. Training and a guide are available.

Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPO^SM and Blue Advantage HMO^SM (for Blue Advantage Plus^SM)

It is essential that Blue Choice PPO and Blue Advantage Plus^SM enrollees fully understand the financial impact of an out-of-network referral to a health care provider that does not participate in their network. Although they have out-of-network benefits and may use out-of-network providers, they will be responsible for an increased cost-share under their out-of-network benefits.

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:

• Observation Services Policy  – Effective 11/4/21
• Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Guideline  – Effective 11/10/2021
• Laboratory Panel Billing Guideline  – Effective 11/10/2021
• CPCP034 Unbundling Policy-Professional Providers – Effective 11/12/2021

Updates to Clinical Practice and Preventive Care Guidelines

Review our updated Clinical Practice Guidelines and Preventive Care Guidelines, which help direct our quality and health management programs and help improve member care.

Reminder:

• Colorectal Cancer Screening for Members Age 45 to 75

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:

• Adhere to HPV and Shingles Vaccine Guidelines

Blue Cross Medicare Advantage PPO Network Sharing

Applies to: Blue Cross Medicare Advantage (PPO)^SM (BC MA PPO)

All Blue Cross Medicare Advantage^SM plans participate in reciprocal network sharing. This allows all BC MA PPO members to obtain in-network benefits when traveling or living in the service area of any other BC MA PPO plan if the member sees a contracted BC MA PPO provider. For detailed information on BC MA PPO network sharing, refer to the Blue Cross Medicare Advantage (PPO) Provider Manual Supplement, which can also be located under the Standards and Requirements tab/Manuals on our provider website. If you have any questions regarding the BCBS MA PPO program or products, contact Blue Cross Medicare Advantage (PPO) Customer Service at 1-877-774-8592.

Preventive Services Reminder: Zero Copay for Blue Cross Medicare Advantage^SM

A gentle reminder that there are no copays for preventive services for Blue Cross Medicare Advantage (PPO) or Blue Cross Medicare Advantage (HMO)^SM members.

Reminder:

• Update to Prior Authorization Codes for Medicare Members

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Oct. 1, 2021 – Part 1

Review changes to the following: drug list, dispensing limits and the Utilization Management program. Also, review a reminder about that Split-Fill program, a change in benefit coverage for select high-cost products and updates to bowel preparation coverage.

New Specialty Pharmacy for Pharmacy Members as of Aug. 1

As of Aug. 1, BCBSTX members whose pharmacy benefits were administrated through Prime^® are now administered through Accredo^® – a full-service specialty pharmacy. This vendor change applies to BCBSTX commercial group and retail plan members.

Pharmacy Members Have a New Mail Order Pharmacy as of Aug. 1

Also, as of Aug. 1, BCBSTX members whose mail order pharmacy services were administrated through Prime are now administered through Express Scripts^® Pharmacy. This vendor change applies to BCBSTX commercial group and retail plan members.

Reminder:

• Select Medication List to be Updated Nov. 1

Additional Update to Prior Authorization Codes for Commercial Members

On Aug. 2, an update was made to the 10/1/2021 Update to Prior Authorization Codes for Commercial Members notice and the Prior Authorization Lists for Fully Insured and Administrative Services Only Plans to include some new AMA codes recently received from the American Medical Association. Refer to the updated lists for details on the changes. As always, refer to Availity or your preferred vendor to check Eligibility and Benefits and identify if a service requires prior authorization for our members.

Reminder:

• Prior Authorization Update - Medical Oncology

bcbstx.com/provider

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