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A newsletter for physician, professional, facility, ancillary and Medicaid providers |
January 2022
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.
New Look Ahead for Provider Website
Our provider website will have a new streamlined design by early next year. We’re making changes to enhance your online experience and help you easily find the information you need. Information will be in the sections you’re used to seeing, such as Claims and Eligibility and Education and Reference. Please watch for future updates.
CLAIMS & ELIGIBILITY
Claim Editing Enhancements Coming April 1, 2022
Effective April 1, 2022, we will enhance our claims editing and review process with Cotiviti, Inc. for some of our commercial members. Learn what these changes will mean for you.
| Read More |
2022 Federal Employee Program® (FEP®) Prior Authorization and Benefit Updates
Effective Jan. 1, there will be changes to their prior authorization requirements and benefits for FEP. Review prior authorization updates and benefit changes.
| Read More |
Chiropractic & Mixed Therapy Benefits Contained in IVR Phone System as of Jan. 3, 2022
Beginning Jan. 3, the option to speak to a Customer Advocate will be removed from the chiropractic and mixed therapy benefit category within our automated Interactive Voice Response (IVR) phone system. The IVR quotes the same level of patient eligibility and benefits information that a Customer Advocate provides. Remain assured that our Customer Advocates will continue to be available for more complex benefit quotes.
| Read More |
Availity® Tools to Support Providers in 2022
As a reminder, the Availity Provider Portal helps providers and us quickly and securely share information, including information defined by the Consolidated Appropriations Act. Review the many self-service tools you can access through the Availity portal, instructional user guides and important tips.
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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:
| • | Coordinated Home Care/Private Duty Nursing Policy – Effective 12/01/2021 |
| • | Applied Behavior Analysis – Effective 03/01/2022 |
| • | Emergency Department Evaluation and Management (E/M) Services Coding – Facility Services – Effective 03/20/2022 |
CLINICAL RESOURCES
Rural Health Clinics and Federally Qualified Health Centers May Meet Quality Measure
Starting Jan. 1, 2022, Rural Health Clinics and Federally Qualified Health Centers may meet the requirements for the quality measure Follow-up After Hospitalization for Mental Illness (FUH). Review why FUH matters and the criteria for the Psychiatric Collaborative Care Model must meet to qualify.
| 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
COVID-19 Vaccine Billing for Medicare Advantage Members
Starting Jan. 1, 2022, we will cover the cost of COVID-19 vaccines and their administration for Blue Cross Medicare AdvantageSM members instead of the original Medicare program (also known as Fee-for-Service Medicare).
| Read More |
New Flexible Medicare Advantage PPO Plan
The Blue Cross Medicare Advantage Flex (PPO)SM plan is an open-access plan that allows members to see any provider accepting Medicare, including Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM contracted providers. Members can see providers inside or outside the plan service area or plan network, at no additional cost. Learn about the value to members and what this means for you.
| Read More |
Hospitals Must Provide Medicare Outpatient Observation Notice
Hospitals and Critical Access Hospitals (CAH) are required to give the standardized Medicare Outpatient Observation Notice (MOON) to our Blue Cross Medicare Advantage members who are under outpatient observation for more than 24 hours. The notice explains why the members aren’t inpatient and what their coverage and cost-sharing obligations will be. Review the steps to complete the MOON.
| Read More |
Qualified Medicare Beneficiary Program Patients Should Not Be Billed
If you participate in Blue Cross Medicare Advantage networks, you may not bill cost-sharing or out-of-pocket costs to our members enrolled in the Qualified Medicare Beneficiary (QMB) program, a federal Medicare savings program. Review tips to avoid billing QMB patients.
| Read More |
Blue Cross Medicare Advantage Prior Authorization Code Update Effective April 1, 2022
We are changing prior authorization requirements for Blue Cross Medicare Advantage members to reflect new, replaced or removed procedure codes due to updates from Utilization Management or the American Medical Association. A summary of changes is included.
| Read More |
Medicare Advantage Provider Manual Supplements Update
Be sure to check out the updated Medicare Advantage PPO and HMO Provider Manual Supplements posted on the Provider Manuals page on the BCBSTX provider website. In addition, throughout the year, keep current on changes by visiting the provider website for News and Updates and the Blue Review newsletter. You and your staff can also directly receive the newsletter by submitting your email address(es) using the Demographic Change Form. Refer to the User Guide for instructions on which fields to complete.
Reminder:
| • | 2022 Blue Cross Medicare Advantage Expansion Service Areas |
PHARMACY
Pharmacy Program Updates Effective Jan. 1, 2022
Pharmacy programs have numerous updates effective Jan. 1, 2022. Some members may have new pharmacy networks and/or changes within their current network. You can refer to our News and Updates page to review the Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2022 – Part 1 for details on the changes.
PRIOR AUTHORIZATION
Prior Authorization Code Update Effective April 1, 2022, for Commercial Members
We will be updating our lists of procedure codes requiring prior authorization for some commercial members. Review the changes effective April 1.
| Read More |
Reminder:
| • | Revision to Prior Authorization Codes for Commercial Members |
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