Update to Prior Authorization Codes for Medicaid Members | view in Web Browser
A newsletter for physician, professional, facility, ancillary and Medicaid providers |
August 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:
NOTICES & ANNOUNCEMENTS
COVID-19 Provider Preparedness Updates
Check for continuing updates to our COVID-19 Preparedness and COVID-19 Related News pages.
Update Your Information
If you’ve changed your address, phone number, email or other important details, please notify us promptly using our online Demographic Change form.
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BEHAVIORAL HEALTH
Antidepressant Medication Management
Major depressive disorder is one of the most common mental disorders in the U.S. We encourage you to talk with your patients about getting help if needed. To help with these conversations, we’re providing a depression screening tool, tips and resources.
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CLAIMS & ELIGIBILITY
Technical and Professional Components
Modifiers 26 and TC: Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes the technical component for lab and radiological services. These modifiers should be used in conjunction with the appropriate lab and radiological procedures only. Note: When a health care provider performs both the technical and professional service for a lab or radiological procedure, they must submit the total service, not each service individually.
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:
- CPCP028 Non-Reimbursable Experimental, Investigational and/or Unproven Services - Revision – Effective 8/15/2021
- Hernia Repair – Effective 10/1/2021
- Preventive Services Policy – Effective 7/1/2021
Reminder:
CLINICAL RESOURCES
Colorectal Cancer Screening for Members Age 45 to 75
In line with new U.S. Preventive Services Task Force recommendations, we recommend that colorectal cancer screening for our members begin at age 45 rather than 50. We are updating our Preventive Care Guidelines and our claims processing to reflect this change. Review why screening is important and how to check member eligibility and benefits.
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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.
Adhere to HPV and Shingles Vaccine Guidelines
Upon reviewing claims, we found that HPV and shingles vaccines are often administered outside of FDA and ACIP recommendations. If vaccines are administered outside of the recommendations, we will:
- Consider the services to be experimental, investigational or unproven, which are not covered benefits for BCBSTX members; and
- Recover reimbursements per the claim payment recovery process outlined in our participating provider contracts.
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Reminder:
MEDICARE ADVANTAGE PLANS
Update to Prior Authorization Codes for Medicare Members
We are changing prior authorization requirements for Medicare members to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association. Review a summary of the changes.
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PHARMACY
Select Medication List to be Updated Nov. 1
Review the viscosupplement products on the Select Medication List that will be updated effective Nov. 1, 2021.
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Pharmacy Benefits
As a reminder, certain drugs have quantity limits and/or may require prior authorization before we approve any benefits for the drug. Prior approval and quantity limits are in place to ensure we are following current medically appropriate drug guidelines.
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PRIOR AUTHORIZATION
Prior Authorization Update - Medical Oncology
Starting Oct. 11, AIM Specialty Health® will begin managing prior authorization and post-service medical necessity review requests for drugs in the ”Medical Oncology” care category for certain BCBSTX commercial members
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