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BEHAVIORAL HEALTH |
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Behavioral Health Consultations During Medical Hospitalization Can Improve Outcomes
We encourage hospital staff/attending providers to discuss behavioral health with our members during a hospital stay, and to consider consultations and follow-up care coordination when appropriate.
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CLAIMS & ELIGIBILITY |
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Claim Processing Enhancements for ERS Effective Sept. 1, 2024
Review the changes coming to claim processing for Employee Retirement System of Texas participants, including Cotiviti, and multi-plan out-of-area or out-of-network rate negotiations.
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Electronic Claim Review and Ensuring the Correct Use of our Claim Review Form
Beginning Aug. 1, incomplete Claim Review Forms will be returned (without claim review). To prevent this from happening, please review helpful tips for submitting the form.
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ClaimsXtenTM Quarterly Update Effective Aug. 19, 2024
We will implement our third quarter code updates for the ClaimsXten auditing tool on or after Aug. 19. Code updates may include additions, deletions and revisions to:
- Current Procedural Terminology codes
- Healthcare Common Procedure Coding System codes
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Access MCG Care Guidelines Clinical Criteria via Availity®
We use some clinical criteria from MCG Care Guidelines when reviewing requests to determine medical necessity. As a helpful resource, you can now access MCG guidelines through your Availity Essentials login.
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Fee Schedule Updates
Reimbursement changes and updates for commercial HMO and PPO providers are posted under the Standards and Requirements / General Reimbursement Information / Reimbursement Schedules and Related Information section on our provider website.
Changes resulting in a decrease do not become effective until at least 90 days from the posting date. The specific effective date is noted for each change that is posted. To view this information, visit the General Reimbursement Information section on our provider website. The Drug CPT®/HCPCS Fee Schedule is updated quarterly on March 1, June 1, Sept. 1 and Dec. 1 each year. The NDC Fee Schedule is updated monthly.
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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:
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Reminder
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CLINICAL RESOURCES |
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PeriPAN Perinatal Mental Health Toolkit for Obstetric Clinicians
We’re providing a toolkit to help providers monitor perinatal mood and anxiety conditions. |
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EDUCATION & REFERENCE |
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Helping Our Members Manage Diabetes
Because you play an important role in supporting our members living with diabetes, we’re providing you resources, recommendations and tips to close gaps in diabetes care. |
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Reminder: Sanitas Medical Center Name Changes to Innovista Medical Center
We value your partnership in patient care and want to remind you of a change that has occurred at all Sanitas Medical Center locations in Texas. As of April 1, 2024, all clinics are now rebranded as Innovista Medical Center. |
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HEALTH & WELLNESS |
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BCBSTX 2023 Marketplace Member Satisfaction with Providers Results
The QHP Enrollee Experience Survey is a measurement tool that assesses service gaps and develops improvement strategies. As such, review the key findings, key drivers and measures of improvement results from last year’s survey. |
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The Need for Better, Improved Continuity and Coordination of Care
Review the results from our Provider Satisfaction Survey, which includes PCP satisfaction with inpatient hospital discharge summaries and emergency department visit summaries. |
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MEDICARE ADVANTAGE PLANS |
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Closing Gaps in Care for Group Medicare Advantage (PPO) Members
You may receive medical record requests from us for Blue Cross Group Medicare Advantage (PPO)SM members, which includes members with BCBSTX coverage, as well as Group MA PPO members enrolled in other BCBS plans (who live in Texas). If we need medical records for Group MA PPO members, you will receive requests only from us or our vendor, Advantmed.
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Preventive Services Reminder: Zero Copay for Blue Cross Medicare AdvantageSM
We want to remind you that there are no copays for preventive services for Blue Cross Medicare Advantage (PPO) or Blue Cross Medicare Advantage (HMO)SM. Blue Cross Medicare Advantage covers a full range of preventive services to help patients stay healthy, detect problems early and determine when treatment is necessary. Please let members know which of these services is right for them and encourage them to set appointments for preventive services.
Access the Centers for Medicare & Medicaid Services Medicare Learning Network’s Medicare Preventive Services for more detailed information.
Additionally, you should check eligibility and benefits electronically through Availity, or your preferred web vendor.
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MEDICAID |
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Access all 2023 and 2024 news and updates for BCBSTX Medicaid (STAR), STAR Kids and CHIP providers.
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Reminder
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PHARMACY |
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Pharmacy Program Quarterly Update Changes Effective July 1, 2024 – Part 1
Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes. |
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STANDARDS & REQUIREMENTS |
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Physician Performance Insights Coming Soon from PEAQSM
In July, physicians eligible for our Physician Efficiency, Appropriateness, and Quality Program can view their Physician Performance Insights in Availity Essentials. PPI reports show how physicians compare to their peers and include information on improving performance. |
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UTILIZATION MANAGEMENT |
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Changing ‘Prior Authorization’ to ‘Recommended Clinical Review’ Effective Sept. 1 for TRS Participants
This article details which outpatient services will move from PA to RCR, which services Carelon will manage and RCR key points. |
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Utilization Management Update Including Change to Recommended Clinical Review Effective Sept. 1, 2024, for ERS Plans
Review the changers we’re making to Employee Retirement System of Texas medical plans, including HealthSelect of Texas® and Consumer Directed HealthSelectSM.
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Utilization Management Decisions
We’re dedicated to serving our customers through the provision of health care coverage and related benefit services. Utilization Management 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
- 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 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. Please call the Customer Service or Health Advocate number on the back of the member’s ID card.
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Reminder
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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 articles .
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 PDF of the non‑Medicaid information in this newsletter.
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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. You can download other tools and learn more about accessibility at adobe.com  .
By clicking this link, you will go to a website/app (“site”). The site may be offered by a vendor or an independent third party. The site may also contain non-Medicare related information. Some sites may require you to agree to their terms of use and privacy policy.
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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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1001 E. Lookout Drive, Richardson, TX 75082
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