In every issue

AIM RQI reminder
Physicians and professional providers must contact American Imaging Management (AIM) first to obtain an RQI number when ordering or scheduling the following outpatient, non-emergency diagnostic imaging services when performed in a physician’s office, a professional provider’s office, the outpatient department of a hospital or a freestanding imaging center:

• CT/CTA
• MRI/MRA
• SPECT/nuclear cardiology study
• PET scan

To obtain a PPO RQI number, log in to AIM’s provider portal at www.americanimaging.net and complete the online questionnaire that identifies the reasons for requesting the exam. If criteria are met, you will receive an RQI number. If criteria are not met or if additional information is needed, the case will automatically be transferred for further clinical evaluation and an AIM nurse will follow up with your office. AIM’s provider portal uses the term “Order” rather than “Preauth” or “RQI.”

Note: Facilities cannot obtain an RQI number from AIM on behalf of the ordering physician. Also, the RQI program does not apply to Medicare enrollees with Blue Cross and Blue Shield of Texas (BCBSTX) Medicare supplement coverage. Medicare enrollees with BCBSTX commercial PPO/POS coverage are included in the program.

Outpatient clinical reference laboratory for HMO Blue Texas
Laboratory Corporation of America (LabCorp) is the exclusive outpatient clinical reference laboratory provider for HMO Blue Texas members (see note below for exceptions). To find the closest LabCorp Patient Service Center, call LabCorp’s automated phone system toll free at 888-LABCORP or visit their Web site at www.labcorp.com . Both systems will prompt you for your ZIP code and will provide those service centers nearest that ZIP code location.

You can find a complete list of participating providers by using the Provider Finder search tool at www.bcbstx.com/provider. For physicians located in certain counties, only the lab services/tests indicated on the Reimbursable Lab Services list will be reimbursed on a fee-for-service basis if performed in the physician’s office for HMO Blue Texas members. Please note that all other lab services/tests performed in the physician’s office will not be reimbursed.

You can access the county listing and the revised Reimbursable Lab Services list at www.bcbstx.com/provider under the General Reimbursement Information section.

Note: Physicians who are contracted/affiliated with a capitated IPA/medical group and physicians who are not part of a capitated IPA/medical group but who provide services to a member whose PCP is a member of a capitated IPA/medical group must contact the applicable IPA/medical group for instructions regarding outpatient laboratory services.

Fee schedule updates
Reimbursement changes and updates for BlueChoice^® and HMO Blue^® Texas (Independent Provider Network only) practitioners will be posted under "Reimbursement Changes/Updates" in the Professional Reimbursement Schedules section on the Blue Cross and Blue Shield of Texas Web site at www.bcbstx.com/provider.  The changes will not become effective until at least 90 days from the posting date. The specific effective date will be noted for each change posted.  

To view this information, visit the General Reimbursement Information section on this Web site.  Also, the Drug/Injectable Fee Schedule will be updated on the following dates: March 1, 2010 and June 1, 2010.

Improvements to the medical records process for BlueCard claims
Blue Cross and Blue Shield of Texas is now able to send medical records electronically to all Blue Cross and/or Blue Shield Plans. This method significantly reduces the time it takes to transmit supporting documentation for BlueCard claims and eliminates lost or misrouted records.

As always, we will request that you submit your medical records to Blue Cross and Blue Shield of Texas if needed for claims processing.

If you receive requests for medical records from other Blue Plans before rendering services, as part of the pre-authorization process, please submit them directly to the requesting Plan.

Pass-through billing
Blue Cross and Blue Shield of Texas (BCBSTX) does not permit pass-through billing. Pass-through billing occurs when the ordering provider requests and bills for a service, but the service is not performed by the ordering provider.

The performing provider should bill for these services unless otherwise approved by BCBSTX.
BCBSTX does not consider the following scenarios to be pass-through billing:

1. The service of the performing provider is performed at the place of service of the ordering provider and is billed by the ordering provider.
2. The service is provided by an employee of a physician or other professional provider (physician assistant, surgical assistant, advanced nurse practitioner, clinical nurse specialist, certified nurse midwife or registered first assistant who is under the direct supervision of the ordering provider) and the service is billed by the ordering provider.

Reminder — Contracted providers must file claims
As a reminder, providers must file claims for any covered services rendered to a patient enrolled in a Blue Cross and Blue Shield of Texas (BCBSTX) health plan. You may collect the full amounts of any deductible, coinsurance or copayment due, and then file the claim with BCBSTX. Arrangements to offer cash discounts to an enrollee in lieu of filing claims with BCBSTX violate the requirements of your provider contract with BCBSTX.

BCBSTX makes no endorsements, representations, or warranties about any products or services offered by
independent third-party vendors mentioned in this newsletter. The vendors are solely responsible for the products or
services offered by them. If you have any questions about the products or services mentioned in this newsletter,
contact the vendor directly.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Review • Issue 1, 2010 • www.bcbstx.com