April 2023

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

•	End of Continuous Medicaid Coverage Ends March 31, 2023
•	Provider Enrollment Revalidation Ends May 11, 2023
•	Reinstatement of CHIP Co-Pays for Medical Office Visits Begins May 12
•	Primary Care Physicians Appointment Accessibility Standard Availability
•	Reporting Potential Quality of Care Concerns
•	Case Management for Children and Pregnant Women Resource Tool
•	Missed Opportunities to Increase Adolescent Well-Care Visits
•	Register Now for BCBSTX Claims Billing Provider Webinar

AIM Specialty Health^® Changes Its Name to Carelon Medical Benefits Management

As a result of AIM Specialty Health becoming Carelon, we’re updating our website with the new name, including our Utilization Management page and other related resources.

Medical Necessity Review of Observation Services

As a reminder, it is our policy to provide coverage for observation services when it is medically necessary based on the medical criteria and guidelines outlined in the MCG Care Guidelines. Claims for observation services are subject to post-service review, and we might request medical records for the determination of medical necessity.

Hospitals, and Routine Services and Supplies

Providers usually include routine services and supplies in charges related to other procedures or services. As such, those services/supplies are considered non-billable for separate reimbursement. The following guidelines identify items, supplies and services that are not separately billable. (Note: This is not an all-inclusive list.)

Supporting Behavioral Health Quality Care

We track quality measures related to behavioral health to monitor and improve our members’ care. Below is information about the measures and tips for closing gaps in care.

Technical and Professional Components

Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical components 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 services 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 policies were added or updated:

Earn Continuing Education Credit through Webinar on Opioids

Join us on April 24 or April 26 for a Zoom webinar about opioids where the discussion will focus on:

To support quality care, we provide information to providers and members to encourage discussions on health topics. Watch for more on health care quality on our website’s News and Updates section and on our Delivering Quality Care web page.

Blue Cross Medicare Advantage (PPO)^SM and Blue Cross Medicare Advantage (HMO)^SM Annual Health Assessment Incentive FAQs – 2023

Check out FAQs for answers to questions about the Annual Health Assessment incentive including who is eligible, how it works, when payments are made and more.

Pharmacy Program Quarterly Update, Part 2: Changes Effective Jan. 1, 2023

Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes.

New for 2023: Specialty Pharmacies Added In-Network

See how we have expanded our specialty pharmacy network, which includes new dispensing options for specialty medications covered under the pharmacy benefit.

Pharmacy Benefits

As a participating practitioner, you are given a list of drugs that we review and update throughout the year. For certain drugs, we 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.

For more information, visit the Pharmacy Program section on our provider website. For Federal Employee Program^® members, information can be found at fepblue.org/pharmacy. We encourage you to check our provider website regularly and watch for updates in this newsletter.

The following information is available on our website: 

bcbstx.com/provider

File is in portable document format (PDF). To view this file, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe^® Reader^® which has a built-in screen reader. Other Adobe accessibility tools and information can be downloaded at https://www.adobe.com.

You are leaving this website/app (“site”). This new site may be offered by a vendor or an independent third party. The site may also contain non‑Medicare related information. In addition, some sites may require you to agree to their terms of use and privacy policy.

1001 E. Lookout Drive, Richardson, TX 75082

© Copyright 2023 Health Care Service Corporation. All Rights Reserved.

Legal and Privacy  |  Unsubscribe  |  view in Web Browser