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BlueCross BlueShield of Illinois
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Blue Review

For Providers

October 2023

 

MEDICAID

Note: In November, the Medicaid section will move down in the newsletter so that it’s in alphabetical order.

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

Hepatitis C Follow-Up Information and Website Resources
Infant and Early Childhood Developmental Surveillance and Screening Components of the Texas Health Steps Checkup and Well-Checkups
Texas Health Steps and Well-Checkup Preventive Care Screening Tools
Supporting Quality Care During Breast Cancer Awareness Month
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Reminders

How to get Reimbursements for Sports/Camp Physicals
CLIA Certification Required for Claims Payment
New Form for OB/GYN Compliance Challenges with Prenatal Appointment AvailabilityAdobe Acrobat
Texas Medicaid Providers Help Ensure Our Members Don’t Lose Their CoverageAdobe Acrobat
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NOTICES & ANNOUNCEMENTS

New BlueApprovRSM Tool Expedites Prior Authorization and Recommended Clinical Review for Some Medical/Surgical Services

Effective Sept. 11, the new BlueApprovR tool (in Availity®) will streamline the Prior Authorization and Recommended Clinical Review process. It should help reduce your workload by expediting some medical and surgical services approvals.

Learn More
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CLAIMS & ELIGIBILITY

Reminder for Billing Point-Of-Use (POU) Convenience Kits

We periodically check the pricing of POU kits to manage costs. As a reminder, only the drug component of the kit is reimbursable.

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ClaimsXtenTM Quarterly Update Effective Dec. 4, 2023

We will implement our Q4 code updates for the ClaimsXten auditing tool on or after Dec. 4. Code updates may include additions, deletions and revisions to:

Current Procedural Terminology (CPT®) codes
Healthcare Common Procedure Coding System (HCPCS) codes
Learn More
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CLINICAL RESOURCES

Updates to Clinical Practice and Preventive Care Guidelines

We’ve updated our Clinical Practice Guidelines and Preventive Care Guidelines. The guidelines help direct our quality and health management programs and improve member care. They may help guide your decision-making as you care for our members. We update them no less than every two years or when new significant findings or major advancements in evidence-based care are established.


Clinical Payment and Coding Policy Updates

Our website’s Clinical Payment and Coding Policies 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 may add and modify clinical payment and coding policies. The following policy was updated:

CPCP028 Non-Reimbursable Experimental, Investigational and/or Unproven Services Update 12/01/2023
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HEALTH & WELLNESS

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


Supporting Quality Care During Breast Cancer Awareness Month

October is Breast Cancer Awareness Month, so it’s a great time to remind our members about the importance of regular screenings. Tips to reduce gaps in care are included.

Learn More
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MEDICARE ADVANTAGE PLANS

Medical Records Reminder for Out-of-Area Medicare Advantage Members

If we need medical records for Blue Cross Group Medicare Advantage (PPO)SM members, you will receive requests directly from us or our vendor, Change Healthcare, as part of the Blue Cross and Blue Shield National Coordination of Care program. Please respond quickly to our requests, including requests related to risk adjustment gaps and Healthcare Effectiveness Data and Information Set (HEDIS®) measures. Also, you may receive requests from EXL Health for select inpatient, diagnosis-related group claims for any out-of-area Blue Cross Medicare AdvantageSM members.

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NETWORK PARTICIPATION

Physician Performance Insight Reports Now Available

Physician Performance Insight reports are now in Availity for physicians who met eligibility requirements for the Physician Efficiency, Appropriateness, and QualitySM (PEAQSM) program.

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MyBlue HealthSM Network Expansion

Effective Jan. 1, 2024, members in Comal, McLennan and Rockwall counties will access care through providers contracted in the MyBlue Health network.

Learn More
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PRIOR AUTHORIZATION

Notifications for Prior Authorization Exemptions for Jan. 1 to June 30, 2023, Review Period

Effective Sept. 1, providers who met the necessary criteria for prior authorization (PA) exemptions from Jan. 1 to June 30, 2023, were issued a PA exemption.

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New Location in Availity to Access Prior Authorization Exemption Communications as of Sept. 7, 2023

Effective Sept. 7, there’s a new location on the Availity website where you can access all communications for prior authorization exemptions.

Learn More
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Regulatory & Requirements

This section includes additional items related to regulatory requirements and operational processes to assist provider offices with servicing our members. Access this month’s articlesAdobe Acrobat.

We are required to provide certain notices in all published correspondence with health care providers. For the latest updates, visit the News and Updates section on the BCBSTX provider website.

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Printable PDF

View a printable PDFAdobe Acrobat of the non‑Medicaid information in this newsletter.

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Contact Us

View our quick directory of contacts for BCBSTX.

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Verify and Update Your Information

Verify your directory information every 90 days. Use the Provider Data Management feature on Availity® or our Demographic Change Form. You can also use this form to submit email addresses for you and your staff to receive the Blue Review each month.

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