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CLAIMS & ELIGIBILITY |
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Additional Claim Processing Enhancements for ERS Plans Effective Oct. 21
In addition to post-pay audits already in place for ERS, pre-payment reviews will be implemented on Oct. 21. This may help avoid refund requests handled post-pay.
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Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPOSM and Blue Advantage HMOSM (for Blue Advantage Plus HMOSM)
Before referring a Blue Choice PPO or Blue Advantage HMO (for the Blue Advantage Plus point-of- service benefit plan) member to an out-of-network provider for non-emergency services, when such services are available through an in-network provider, you must complete the appropriate Out-of-Network Care – Enrollee Notification form for Regulated Business (used when “TDI” is on the member’s ID card) or Non-Regulated Business (used when “TDI” is not on the member’s ID card). These are located under Forms on our provider website.
Requirements: The referring network physician must provide a copy of the completed form to the enrollee and retain a copy in the enrollee’s medical record files.
Why? It’s essential that Blue Choice PPO and Blue Advantage Plus enrollees fully understand the financial impact of an out-of-network referral to a health care provider that does not participate in their BCBSTX provider network. They have out-of-network benefits and may choose to use out-of-network providers, however they will be responsible for an increased cost-share under their out-of-network benefits.
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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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EDUCATION & REFERENCE |
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Medical Necessity Review of Observation Services
As a reminder, it’s our policy to provide coverage for observation services when medically necessary based on the medical criteria 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. |
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Language Line Supporting Cultural Competence
The use of telephonic or video interpretation can improve the quality of care for patients whose primary language is not English. As such, we encourage your office to use the language line that’s available through your local state or county agencies. |
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HEALTH & WELLNESS |
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Cancer Prevention Vaccine? The Earlier the Better
Because cervical cancer is the fourth most common cancer in women, it’s imperative that health care professionals educate parents about the human papillomavirus and how to protect their children with the HPV vaccine.
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Shared Decision-Making Aids Can Help Guide Care Choices
Our members may have better patient experiences and outcomes when they participate in their care. Learn about evidence-based aids that can involve your patients. |
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Speaking Out About the ‘Silent Killer’
This article provides best practices to help close gaps in care regarding blood pressure control. |
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Reminder
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MEDICARE ADVANTAGE PLANS |
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Encourage Medicare Advantage Members to Respond to Health Outcomes Survey
The Centers for Medicare & Medicaid Services is sending a survey to a sample of our members asking them to rate their provider care. Learn about the survey topics our members may discuss with you.
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Prior Authorization Code Updates for Medicare Advantage Members, Effective Oct. 1
We’re changing prior authorization requirements for Blue Cross Medicare AdvantageSM members to reflect the addition of lab codes to be reviewed by EviCore by Evernorth®. |
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BCBS Medicare Advantage PPO Network Sharing
Applies to: Blue Cross Medicare Advantage (PPO)SM
All Blue Cross Medicare Advantage plans participate in reciprocal network sharing, which allows all BCBS MA PPO members to obtain in-network benefits when traveling or living in the service area of any other BCBS MA PPO plan if the member sees a contracted BCBS MA PPO provider.
For more information, refer to this Blue Cross Medicare Advantage PPO Supplement .
If you have questions regarding the BCBS MA PPO program or products, contact Blue Cross Medicare Advantage (PPO) Customer Service at 1-877-774-8592. |
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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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Reminders
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NETWORK PARTICIPATION |
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Reminders
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PHARMACY |
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Pharmacy Program Quarterly Update Changes Effective Oct. 1, 2024 – Part 1
Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes. |
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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 page 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:
- Formulary lists, including restrictions and preferences
- How to use our pharmacy procedures
- An explanation of limits and quotas
- How you can provide information to support an exception request
- The process for generic drug substitutions, therapeutic interchange and step-therapy protocols
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UTILIZATION MANAGEMENT |
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Medical Policy Updates
When policies are posted: New or revised medical policies, when approved, may be posted on our provider website (under Standards and Requirements) on the 1st or 15th of each month. Those medical policies requiring disclosure will become effective 90 days from the posting date. Medical policies that do not require disclosure will become effective 15 days after the posting date. The specific effective date will be noted for each medical policy that is posted. To streamline the review process, you can view medical policy drafts and provide your feedback online. If there are any draft medical policies to review, they will be made available around the 1st and 15th of each month with a review period of approximately two weeks.
Related information: Refer to the Recommended Clinical Review Option page for information on submitting a request for review of your services before rendering the service. Also, other policies and information regarding payment can be found on the Clinical Payment and Coding Policies page.
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Recommended Clinical Review Services and Code List Changes for Certain Members
Periodically, as often as monthly, we update our lists of services and procedure codes that are available for Recommended Clinical Review (for some commercial members) to reflect new, replaced or removed codes. These changes are based on updates from our Utilization Management team’s prior authorization assessment, Current Procedural Terminology code changes released by the American Medical Association, or Healthcare Common Procedure Coding System changes from the Centers for Medicare & Medicaid Services.
Accessing RCR lists: To avoid post-service medical necessity reviews and minimize delays in claim processing, providers should refer to the RCR inpatient services and outpatient code lists on our Recommended Clinical Review Option webpage prior to rendering services. If services are performed that do not meet medical necessity criteria, they may be denied for payment and the rendering provider may not seek reimbursement from the member.
Check eligibility and benefits: Providers should check eligibility and benefits through Availity® Essentials or their preferred vendor. The site may also indicate if a service requires prior authorization or an RCR.
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Reminders
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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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