Notices and announcements
Upcoming changes regarding specialty medications
These changes became effective Jan. 1, 2010:
30-day supply limit for specialty medications
Coverage for specialty medications will be limited to a 30-day supply. Members with claims history for specialty medications are being notified of this change by mail.
Members obtaining specialty medications through PrimeMail
Specialty medications will no longer be available through PrimeMail, as coverage will no longer be available for an extended supply. A communication is now being included with medication shipments to notify these members. This notice also provides members instructions for transitioning their medication to the Triessent® specialty pharmacy program. This change applies only for specialty medications.
Walmart behavioral health benefit announcement
Effective Jan. 1, 2010, Walmart has chosen New Directions as their behavioral health vendor. Walmart members will continue to use Blue Cross and Blue Shield of Texas (BCBSTX) behavioral health physicians, behavioral health professional providers and behavioral health facilities.
Preauthorization will be required from New Directions for behavioral health services rendered in facilities for both ambulatory and inpatient services. In addition, behavioral health office visits will need preauthorization upon the ninth visit per benefit year (which is the calendar year). You can contact New Directions online at www.ndbh.com or by phone at 877-709-6822.
AIM ProviderPortal enhancement
An AIM enhancement of their ProviderPortalSM on Oct. 5, 2009 provided script bundling when a user attempts to add a multiple-exam type of abdomen CT and pelvis CT. The system now verifies this as a valid combination. Users will need to confirm indication is the same as the previous request and autopopulate clinical data into the second exam. Abdomen CT and pelvis CT are the only valid combinations as of the October release.
Are you billing for services performed on yourself or a family member?
Please be advised that any services rendered or supplies provided by a person who is related to the patient by blood or marriage will be considered a benefit exclusion and will not be covered. Services rendered or supplies provided by a provider on him/herself are also excluded and will not be covered.
New HRA benefit for Kohler employees
Effective Jan. 1, 2010, Kohler Company, a national account administered by Blue Cross and Blue Shield of Alabama (BCBSAL) with a plant located in Brownwood, Texas, will add the Provider Paid Health Reimbursement Arrangement (PPHRA) benefit to their employees' coverage. The difference between a PPHRA and an HRA is that a PPHRA reimburses the provider.
Member identification (ID) cards for Kohler will have a member contract number that begins with KHB. The cards will include Provider Paid HRA logos in the lower right-hand corners to indicate the benefit is included in their coverage. If you have questions about any of these members’ benefits, call BlueCard® Eligibility at 800-676-BLUE (2583).
Here is a summary of the benefits BCBSAL’s PPHRA will offer providers:
- PPHRA funds and payments from the medical plan will both be included in your remittance advice as medical plan payments.
- Since reimbursement is based on your contractual allowances, you don’t have to collect any money differences between what you collected and the actual payment.
- Once the PPHRA funds are exhausted for each member, you can collect the remaining copays, deductible and coinsurance amounts.
Step Therapy and Prior Authorization programs
Step Therapy and Prior Authorization at Blue Cross and Blue Shield of Texas (BCBSTX) are clinical programs that apply to certain prescription medications. These programs are designed to encourage appropriate use of medication and help manage the rising cost of prescription drugs.
Effective for the 2010 renewal of BCBSTX Fully Insured groups, Step Therapy for Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis) and Prior Authorization for Growth Hormone have been included as standard provisions for Fully Insured pharmacy benefits.
Individuals currently on a biologic immunomodulator or growth hormone, under a BCBSTX Fully Insured group health plan in 2010, will be “grandfathered” to continue that medication. This will assure no disruption in their current therapy.
Physician fax forms are available to download at http://www.bcbstx.com/provider/pa_step_therapy.htm.
Medical policy disclosure
New or revised medical policies, when approved, will be posted on our Provider Portal on the first or the 15th day of each month. Those policies requiring disclosure will become effective 90 days from the posting date. Policies that do not require disclosure will become effective 15 days after the posting date. The specific effective date will be noted for each policy that is posted.
To view pending policies, go to the General Reimbursement section at www.bcbstx.com/provider and click on Medical Policies. After reading the disclaimer, click on I Agree to advance to the medical policy page. The policies can be accessed by clicking the View Pending Policies tab.
Draft medical policy review
In an effort to streamline the medical policy review process, you can view draft medical policies on our Provider Portal and provide your feedback online. The documents will be made available for your review around the first and the 15th of each month with a review period of approximately two weeks.
To view draft policies, go to the General Reimbursement Information section of our Provider Portal at www.bcbstx.com/provider and click on Draft Medical Policies. After reading the disclaimer, click on I Agree to advance to the Medical Policy page.
Urgent versus standard predeterminations
At times, a predetermination for services may need to be handled as priority.
Urgent predetermination requests include, but are not limited to:
- Procedures and/or drugs needed to relieve pain.
- Acute medical conditions.
- Continuities of care in a chronic condition.
- Treatments that need to be given within one week of the date the request is received.
Cosmetic procedures and bariatric surgery would not be considered urgent.
In order for a predetermination request to be processed as priority, please check the box marked “URGENT” located at the top of the completed predetermination form and indicate the anticipated date of service. Urgentpredetermination requests only should be faxed to 888-579-7935.
Please note that photographs will not be accepted via fax.They should be placed in a sealed envelope with the words “Request for Predetermination — Original Photos — Do Not Bend” written on both sides and sent to the appropriate address found on the form.
Remember, all predetermination requests are considered standard and should be mailed to the appropriate address found on the form if treatment is to be given later than one week.
No additional medical records needed
Physicians and professional providers who have received an approved predetermination (which establishes medical necessity of a service) or have obtained a radiology quality initiative (RQI) number from American Imaging Management (AIM) need not submit additional medical records to Blue Cross and Blue Shield of Texas (BCBSTX). In the event that additional medical records are needed to process a claim on file, BCBSTX will request additional medical records at that time.
Importance of obtaining preauthorizations for initial stay and add-on days
Preauthorization is required for certain types of care and services. It is the responsibility of the insured person to confirm that their provider obtains preauthorizations for services requiring preauthorization. Preauthorization must be obtained for any initial stay in a facility and any additional days or services added on.
If an insured person does not obtain preauthorization for initial facility care or services, or additional days or services added on, the benefit for covered expenses may be reduced.
Preauthorization does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, application of the exclusions and limitations, and other provisions of the policy at the time services are rendered.
Avoidance of delay in claims pending COB information
Blue Cross and Blue Shield of Texas receives thousands of claims each month that require unnecessary review for coordination of benefits (COB). What that means to our providers is a possible delay, or even denial of services, pending receipt of the required information from the member.
Here are some tips to help prevent claims processing delays when there is only one insurance carrier:
- CMS-1500, box 11-d – if there is no secondary insurance carrier, mark the “No” box.
- Do not place anything in box 9, a thru d – this area is reserved for member information for a secondary insurance payer.
It is critical that no information appears in box 11-d or in box 9 a- d if there is only one insurance payer.
Nonliability and hold harmless reminders: billing for non-covered services
As a reminder, contracted providers may collect payment from subscribers for supplemental charges, copayments, coinsurance and deductible amounts. The provider may not charge the subscriber more than the patient share shown on their provider claim summary (PCS) or electronic remittance advice (ERA).
In the event that Blue Cross and Blue Shield of Texas (BCBSTX) determines that a proposed service is not a covered service, the provider must inform the subscriber in writing in advance. This will allow the provider to bill the subscriber for the non-covered service rendered.
In no event shall a contracted provider collect payment from the subscriber for identified hospital acquired conditions and/or never events.
QVT (quantity versus time) limits
To help minimize health risks and to improve the quality of pharmaceutical care, QVT limits have been placed on select prescription medications. The limits are based upon the FDA (Federal Drug Administration) and medical guidelines as well as the drug manufacturer’s package insert.
The Blue Cross and Blue Shield of Texas Clinical Pharmacy Department is currently working on updating the QVT list for 2010. Please visit www.bcbstx.com for an update and detailed list under the Pharmacy section.
Preferred drug list
Throughout the year, the Blue Cross and Blue Shield of Texas Clinical Pharmacy Department team frequently reviews the preferred drug list. Tier placement decisions for each drug on the list follow a precise process, with several committees reviewing efficacy, safety and cost of each drug.
The 2010 drug guide updates are posted at www.bcbstx.com under the Pharmacy section.
PrimeMail utilizers for specialty medications (all groups)
Effective Jan. 1, 2010, specialty medications will no longer be available through PrimeMail. After Jan. 1, these medications will be delivered through the Triessent specialty pharmacy program. PrimeMail will no longer be filling prescriptions for specialty medications. Triessent staff will assist members with their transfer from PrimeMail to Triessent when they call 888-216-6710. To see a complete list of specialty drugs, go to www.bcbstx.com/member/pdf/specialty_druglist.pdf.
A notice will also be sent to members utilizing specialty medications informing them that effective Jan. 1, 2010, a 90-day supply of these specialty medications will no longer be available. Specialty medications will be limited to a one-month supply at a time.