November 2017

Medicaid

Monthly News for Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR), STAR Kids & CHIP Providers

Read this month’s Medicaid newsletter to learn about the MCO application due date for LTSS providers, THMP enrollment to continue receiving CHIP reimbursements, an update to 835 electronic remittance advice, an eviCore^TM Web Portal enhancement and more.

In-home Colorectal Cancer Screening and Hemoglobin A1c Test Kits for Selected Members

Applies to: Blue Advantage HMO^SM, Blue Advantage Plus^SM and Federal Employee Program^® Members

Beginning in October, certain members began receiving the FIT test for colorectal cancer screening and/or the A1c test for blood sugar control for diabetes. Encourage your patients who’ve received the kits to participate in the program and help them understand why this testing is important for their health.

BCBSTX Celebrates LGBTQ Inclusion

As part of our commitment to promote the health and wellness of our members and communities, we’re offering information and resources to LGBTQ members, families and decision makers.

Reminders

• Fee Schedule Updates Effective Oct. 1
• Integration of Prime Therapeutics^® and Walgreens^® Specialty Pharmacy and Mail Order Services
• BCBSTX New Employer Group Plan - Employees Retirement System of Texas Effective Sept. 1, 2017
• Become a BCBSTX HealthSelect^SM of Texas Provider Today

Review Documentation Guidelines for Laboratory Audit and Review

To accurately and timely process claims, specific information is required on laboratory requisitions and lab result documentation.

Reimbursement Percentage Update for Modifier 52 (Reduced Services)

Beginning Feb. 1, 2018, the reimbursement percentage for Modifier 52 (Reduced Services) will be 50 percent.

Government Programs: 835 Electronic Remittance Advice (835 ERA) Update

Applies to: Blue Cross Medicare Advantage^SM, STAR, STAR Kids and CHIP

Effective Nov. 30, 2017, government program providers enrolled to receive the 835 ERA from BCBSTX may request redelivery of missing ERA files to their designated receivers issued since Jan. 1, 2017. Please note that ERA files originally issued prior to Jan. 1, 2017, cannot be reloaded.

Find BCBSTX Resources in Availity^TM Payer Spaces

Some BCBSTX tools and resources found on the Availity Web Portal have moved to the BCBSTX Payer Spaces. This section contains payer-specific in-house applications, resources and links to the BCBSTX provider website for quick access to pertinent information.

Operational Effectiveness: Better and Faster Ways to Do Business Together

Become a registered Availity user today to access resources, including the Clinical Data Exchange tool and the Provider Performance Analytics and Reporting tool. These tools help improve efficiencies, quality and cost of care.

Reminders

• National Drug Code Billing Update for Medicare Advantage Claims
• Notice of Changes to Billing and Documentation Information and Requirements
• New ClaimsXten^TM Rules Implemented Sept. 18
• New EFT and ERA Information Available Online

Use New Applied Behavior Analysis (ABA) Service Request Forms

There are updated forms on the BCBSTX provider website to use when requesting ABA services. BCBSTX constantly looks for ways to enhance the quality and effectiveness of provider interactions with us. This includes looking for operational and clinical efficiencies that add value while not sacrificing quality. The ABA Service Request forms were updated to capture sufficient data needed by the Clinical Reviewer and reduce additional clinical requests of the provider. Providers should begin using these forms as soon as possible. You can access the ABA forms under the Education and Reference/Forms tab on the BCBSTX provider website.

Requesting Predetermination of Benefits

When submitting predetermination requests, you should submit them electronically through iExchange^®, our online benefit preauthorization and predetermination of benefits tool. If you are unable to submit electronically, beginning Dec. 1, 2017, written predetermination requests must be submitted using the Predetermination Request Form.

Know the Requirements for Preauthorization/Prior Authorization Rules and Retrospective Reviews for Medical Necessity

Certain services require preauthorization/prior authorization and the requirements are specific to each BCBSTX network. BCBSTX posts the Preauthorization/Notifications/Referral Requirements Lists for all of its networks (e.g., Blue Advantage HMO^SM, Blue Essentials^SM, Blue Premier^SM, etc.) on the BCBSTX provider website. Preauthorization/prior authorization are required to allow for medical necessity review. Claims for services rendered without preauthorization/prior authorization for services requiring it will be denied and providers will be held responsible. Please be aware, retrospective reviews for medical necessity will not be performed for any HMO plans except in limited special circumstances.

Update: Getting Prior Authorizations and Referrals for HealthSelect of Texas Participants Online

To reduce call hold times, BCBSTX recommends using iExchange for submission of prior authorizations and referrals for HealthSelect of Texas participants.

Reminders

• Preauthorization and Referral Requirements Lists Are Changing Jan. 1, 2018
• Medicare Advantage Preauthorization List Update

BCBSTX Requires Adherence to Vaccine Guidelines

It’s important to follow vaccine guidelines set by the FDA and ACIP. BCBSTX has identified two categories of vaccines that may have been administered outside the recommended guidelines.

Provider Manual Update

Be sure to stay up to date by reviewing periodic updates and clarifications to the provider manuals. For example, section M has been added to the Blue Essentials provider manual, which is for the Employee Retirement System of Texas participants.

New Online Magazine Spotlights Emerging ‘Episodes of Care’ Payment Model

Visit our new online magazine Making the Health Care System Work^SM, which explores major health care topics in the national news and how we can all work together to improve the health care system. A recent article looks into moving away from the traditional fee-for-service model, and toward paying for all the care associated with a single procedure or condition as one product.

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