Reimbursement Change for Inpatient DRG Claims
A newsletter for physician, professional, facility, ancillary and Medicaid providers |
September 2023
MEDICAID
Access all 2023 news and updates for Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR), STAR Kids and CHIP Providers. Highlights include:
NOTICES & ANNOUNCEMENTS
Future Blue Cross Blue Shield Association (BCBSA) Provider Performance Program
The BCBSA has created a Provider Performance Program that will evaluate providers against their peers regarding efficiency, appropriateness and quality. Each Blue plan will have access to this information and members may be able to see physician-performance summaries.
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Reimbursement Change for Inpatient DRG Claims When Patients Are Transferred Early
Effective Nov. 20, we will use the CMS’ transfer policy when the original facility is reimbursed based on an inpatient DRG rate and the patient is transferred early to another acute or post-acute facility.
| Read More |
Claim Editing Changes for Emergency Department Services Coming Nov. 1, 2023
We’ve made changes to our claims editing and review process (with Cotiviti) for emergency department evaluation and management for some of our commercial members. These changes will help ensure accurate billing and proper reimbursement.
| Read More |
BEHAVIORAL HEALTH
See New Enhancements for Behavioral Health Prior Authorizations
Review the enhancements that are coming Nov. 1 to our Behavioral Health prior authorization review process, which includes using the Interactive Voice Response System to complete real-time reviews.
| Read More |
CLAIMS & ELIGIBILITY
BlueCard® Program Reminder
BlueCard enables our members to obtain health care services while traveling or living in the BCBSTX service area. It’s important to check eligibility and benefits on BlueCard members to determine if you’re eligible to treat them.
| Read More |
Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPOSM and Blue Advantage HMOSM (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.
| Read More |
Submitting Claims for Infertility Services
When completing claims for infertility services rendered to a surrogate or from a donor, you must indicate the recipient on the claim form because coverage for surrogates and donors vary by plan.
| Read More |
Reporting On-Demand via Availity® Essentials is Now Named Provider Claim Summary
On Aug. 2, we changed the name of our long-standing Reporting On-Demand tool to Provider Claim Summary. The tool remains the same, only the name has changed.
| Read More |
CLINICAL RESOURCES
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 policies were added or updated:
| • | Revised CPCP003 and New CPCP042 for Emergency Department Evaluation and Management Services Coding for Facility and Professional Services, Effective 10/25/2023 |
HEALTH & WELLNESS
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.
Shared Decision-Making Aids Can Help Guide Care Choices
Shared decision making is a way for providers and patients to make informed health care decisions that align with what matters most to patients. This article includes resources to help you involve your patients in these conversations.
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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 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. In addition, you may receive requests from EXL Health for select inpatient, diagnosis-related group claims for any out-of-area Blue Cross Medicare AdvantageSM members.
Reminder:
| • | Update to Prior Authorization Codes for Medicare Members, Effective Oct. 1, 2023 |
PHARMACY
Pharmacy Program Quarterly Update, Part 1: Changes Effective Oct. 1, 2023
Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes.
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Removal of Select Medication List
Effective Dec. 1, 2023, the Select Medication List will be removed from our provider website. The intent of this list was to show specific medications that may have a higher reimbursement rate versus other medications within the same drug class. Reimbursement rates for these and all other specialty medications will continue to be updated monthly, as applicable. You can find more information about reimbursements on our provider website.
PRIOR AUTHORIZATION
Designating Prior Authorization (PA) Requests as ‘Urgent’
As a reminder, you must submit PA requests with the appropriate documentation and level of urgency. When non-urgent requests are marked urgent, they burden the review process by taking precedence over standard requests, which creates a backlog, and potentially delays responses for legitimate urgent requests.
| Read More |
Reminder:
| • | Update to Prior Authorization Codes for Commercial Members, Effective Oct. 1, 2023 |
UTILIZATION MANAGEMENT
Utilization Management (UM) Decisions
We’re dedicated to serving our customers through the provision of health care coverage and related benefit services. UM determinations are made by licensed clinical personnel based on the:
| • | benefits policy (coverage) of a member’s health plan, |
| • | evidence-based medical policies and medical necessity criteria, and the |
| • | medical necessity of care and service. |
All UM decisions are based on appropriateness of care and service, and existence of coverage. We prohibit decisions based on financial incentives, and we do not 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. Please call the Customer Service or Health Advocate number on the back of the member’s ID card.
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