July 2022

Monthly News for Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR), STAR Kids and CHIP Providers

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 on our News and Updates page.

Provider Satisfaction Survey 2022

Each year, we survey a random sample of providers to measure satisfaction with us and to identify areas where we can improve. SPH Analytics (SPH) will administer this year’s survey between June and August. If selected to participate, SPH will contact you via email, mail or phone.

PEAQ^SM Provider Performance Insights Available in August 2022

In August 2022, PEAQ Provider Performance Insights (PPI) PDF reports will be available to qualifying physicians. The PEAQ program evaluates physician performance in a transparent and multidimensional way. Materials have been developed for providers to get acquainted with PEAQ and to understand the upcoming PPIs.

Importance of a Great Discharge Summary

Discharge summaries are an invaluable resource that can improve patient outcomes by providing continuity and coordination of care, and a safe transition to other care settings and providers. Results from our 2021 provider satisfaction survey indicated a decrease in overall satisfaction with continuity of care and the timeliness of receiving hospital discharge summaries. To improve the discharge process, the CMS implemented the Interoperability and Patient Access Rule.

Upcoming CMS Risk Adjustment Data Validation Medical Records Request

Because of the Affordable Care Act Risk Adjustment program, our IVA team will soon be requesting medical records from providers for select members. We understand this is a busy time and appreciate your compliance with CMS requirements and timely delivery of the requested medical record(s).

New Online Option to Confirm Medical Record Receipt Status

There’s a new application in our BCBSTX-branded Payer Spaces section on Availity^® Essentials to confirm receipt of medical records for claims processing. This new functionality is the first iteration of more enhancements to come.

Pricing Information to Display Starting in July

The Transparency in Coverage Final Rule requires health insurers and some employers to publicly display certain health care price information via machine-readable files on their websites beginning July 1, 2022. What this means for you:

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.

To support quality care, we provide information to providers and members to encourage discussions on health topics. Watch for more on health care quality in our website’s News and Updates section and on our Wellness Can’t Wait web page.

Catch Up on Routine Vaccines and Well-Child Visits

According to the CDC, the pandemic is still disrupting routine childhood immunizations and well-child visits. Therefore, they recommend that doctors and health care professionals encourage families to schedule vaccines and well-visits to get children caught up and close gaps in care. To help you, we’ve created wellness guidelines, vaccination information and tips to encourage families into action.

In-Home Test Kits for Colorectal Cancer Screening

This summer, Everlywell is sending Fecal Immunochemical Test (FIT) kits to certain BCBSTX Blue Advantage HMO^SM and MyBlue Health^SM members at no charge. As their trusted provider, please encourage your patients to take advantage of this opportunity. Review how home testing works and how you can encourage patients to participate.

Flex and Open Access for Medicare Patients and Providers

If you’re a Medicare provider, you may treat Blue Cross Medicare Advantage Flex (PPO)^SM and Blue Cross Group Medicare Advantage Open Access (PPO)^SM members, regardless of your contract or network status with us. That means you don’t need to participate in our Medicare Advantage networks or in any other BCBSTX networks to see our members. The only requirement is that you accept Medicare assignment and submit the claims to us.

Reminder: Help Close Gaps in Care for Group Medicare Advantage Members

If we need medical records for Blue Cross Group Medicare Advantage (PPO) members, you’ll receive requests only from BCBSTX or our vendor, Change Healthcare. This is part of the Blue Cross and Blue Shield (BCBS) National Coordination of Care program so that you won’t receive requests from multiple BCBS plans or their vendors. Please respond quickly to our requests, including those related to risk adjustment gaps and Healthcare Effectiveness Data and Information Set (HEDIS^®) measures.

Clinical Record Submission Update for Online Prior Authorization Requests

Effective June 18, Availity Authorization & Referrals will not allow providers to submit clinical in scenarios where it’s not needed for a determination. This article details submission tips and how to access and efficiently use Availity’s Authorization & Referrals online.

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:

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 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. You can call the Customer Service or Health Advocate number on the back of the member’s ID card.

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