May 2023

Access all 2023 news and updates for Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR), STAR Kids and CHIP Providers.

May highlights include:

•	Texas Medicaid Providers Help Patients Get Ready for Redetermination
•	Update to Prior Authorization Codes for Medicaid Members, Effective July 1, 2023
•	Texas Health Steps Guidelines Clarified
•	The CAHPS Survey: We All Play a Role

How to Correctly Use Our Claim Review Form

We’ve revised our Claim Review Form so now is a good time to check out reminders about how to use it correctly.

Ground and Air Ambulance Overpayment Error

We have identified an overpayment error for some ground and air ambulance claims. As such, this error has been corrected, and we’ve begun requesting applicable overpayments for these claims.

Behavioral Health Consultations During Hospitalization Can Improve Outcomes

Behavioral health consultations during a hospital stay can help our members who have both physical and behavioral health conditions. Addressing behavioral health care with timely follow-ups can help reduce hospital readmissions and improve health outcomes.

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

When a network provider refers a Blue Choice PPO or Blue Advantage HMO member to an out-of-network provider for non-emergency services (when such services are available through an in-network provider), appropriate forms must be filled out and filed.

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 and does not 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:

Webinar on Coding for Chronic Kidney Disease

Join us on one of three dates for a Teams webinar about coding for chronic kidney disease. The webinar is free to providers and coding professionals, and 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.

Track Care Visits During and After Pregnancy

Since prenatal and postpartum care contributes to the long-term well-being of new mothers and their infants, we track the quality of care our members receive to assess and improve their care. So, to improve quality, we’re providing tips to close gaps in care.

New Support Program for Members with Kidney Disease

We’re working with Somatus^®, a value-based kidney care organization, to deliver a new, no-cost support program to eligible members living with kidney disease.

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

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

Update to Prior Authorization Codes for Commercial Members, Effective July 1

We will be updating our lists of codes that require prior authorization to reflect new, replaced or removed codes.

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 the appropriateness of care and service, and the existence of coverage. We prohibit decisions based on financial incentives, nor do we specifically reward practitioners or clinicians for issuing denials of coverage. In addition, financial incentives for UM decision-makers do not encourage decisions that result in underutilization. The criteria used for UM determinations are available upon request. Please call the customer service or health advocate number on the back of a member’s ID card. 

bcbstx.com/provider

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