In Every Issue

Managing Your Patients' Questions on Their Individual Plans
In light of the open enrollment season, Blue Cross and Blue Shield of Texas (BCBSTX) providers are getting questions from patients about changes to our individual health plans. We recently sent providers an alert to help guide them through these specific changes. Please review the alert.

BCBSTX Announces New Health Insurance Options for Individuals and Small Businesses
Individual Network Options
In anticipation of the upcoming open enrollment season, BCBSTX has introduced 2016 individual and small group health insurance coverage. Texas residents now can choose from coverage options that best fit their varying needs.

BCBSTX will again offer its Blue Advantage (BAV) HMO^SM to individual members both on and off the Health Insurance Marketplace. Individual members are those who buy their own insurance that is not provided by an employer or through a government program (Medicare, Medicaid or CHIP). We will also offer the new Blue Advantage Plus^SM HMO plan with added Point of Service (POS) benefits to individual members both on and off the Health Insurance Marketplace.

Get the details and get started today.

Enrollee Notification Form Required for Out-of-network Care for Blue Choice PPO^SM and Blue Advantage HMO^SM (for Blue Advantage Plus)
Effective Jan. 1, an out-of-network care form is required to be completed by the referring network physician for enrollees of Blue Choice PPO and Blue Advantage HMO (for Blue Advantage Pluspoint-of-service benefit plan only), prior to referring or directing an enrollee to an out-of-network physician, professional provider, hospital, ambulatory surgery center or other facility, for non-emergency services, if such services are available through an in-network provider.

It is essential that Blue Choice PPO and Blue Advantage Plus enrollees fully understand the financial impact of an out-of-network referral to a physician, professional provider, hospital, ambulatory surgery center or other facility that does not participate in their BCBSTX provider network. Blue Choice PPO and Blue Advantage Plus enrollees 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.

Prior to referring or directing a Blue Choice PPO or Blue Advantage Plus enrollee to an out-of-network provider for non-emergency services, referring network physicians must complete this form if such services are also available through an in-network provider. The referring network physician must provide a copy of the completed form to the enrollee and retain a copy in his or her medical record files.

Use of this form is subject to periodic audit to determine compliance with this administrative requirement outlined in the provider manuals.

Effective Jan. 1, 2016, the following range of codes will allow only one unit on a single date of service: 80300, 80301, 80303, 80320-80328 and 80345-80377. Services should be provided in the most cost effective manner and in the least costly setting required for the appropriate treatment of the member.

Beginning Feb. 1, Two Additional Drug Codes to Allow Only One Unit for Single Date of Service
BCBSTX periodically reviews claims submitted by providers to help ensure that benefits provided are for services that are included in our member’s/subscriber’s benefit plan and meet BCBSTX’s guidelines. Some providers are submitting claims with more than one unit count for drug test codes 80337 and 80338, which should be a single date of service.

Effective Feb. 1, 2016, the following two codes will allow only one unit on a single date of service: 80337 and 80338. Services should be provided in the most cost-effective manner and in the least costly setting required for the appropriate treatment of the member.

Hospitals and Routine Services and Supplies
Routine services and supplies are generally already included by the provider in charges related to other procedures or services. As such, these items are considered non-billable for separate reimbursement. The following guidelines may assist hospital personnel in identifying items, supplies, and services that are not separately billable. This is not an all-inclusive list.

• Any supplies, items and services that are necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine services and not separately billable in the inpatient and outpatient environments.
• All items and supplies that may be purchased over-the-counter are not separately billable.
• All reusable items, supplies and equipment that are provided to all patients during an inpatient or outpatient admission are not separately billable.
• All reusable items, supplies and equipment that are provided to all patients admitted to a given treatment area or units are not separately billable.
• All reusable items, supplies and equipment that are provided to all patients receiving the same service are not separately billable.

Two New Products for 2016: Blue Premier and Blue Premier Access
In 2016, BCBSTX will offer two new HMO products to our employer groups under the names of Blue Premier^SM and Blue Premier Access^SM. We will continue to offer our HMO Blue Texas^SM product as well. These two new product offerings reflect our commitment to offer more choices and to increase access to affordable and quality health care services for our members.

Below is a look at our rollout process for Blue Premier and Blue Premier Access effective Jan. 1, 2016:

Blue Premier
Blue Premier offers its members access to a select set of hospitals and providers within the county coverage area listed in the grid above. With this product, members must select a primary care physician (PCP), and referrals are required to see a specialist.

This product has a geographic restriction where the member has to live or work within the network coverage area (listed in the grid above) to enroll into the Blue Premier product.

Blue Premier Access
Blue Premier Access provides the same county coverage (listed in the grid above) as Blue Premier, but gives its members the freedom to choose their care without having to select a PCP or get a referral when seeing an in-network provider.

Like the Blue Premier product, Blue Premier Access has a geographic restriction where the member has to live or work within the network coverage area (listed in the grid above) to enroll in the Blue Premier Access product.

Blue Premier and Blue Premier Access will appear on our Provider Finder^® under their respective product names. There is a geographic restriction with this product, so a member must live or work within the network coverage area to enroll in this product.

How to Identify Blue Premier and Blue Premier Access Members
We understand and recognize that this is a new product for you and our members. Here are some tips to assist your staff when scheduling appointments for these members:

• Ask for the name of the product
  The product name, Blue Premier or Blue Premier Access, appears on the front of the ID card in the lower left corner. You are considered an in-network provider for this patient if you are contracted with Blue Premier (HMH).
• Ask for the three-letter network code
  This code is in red in the lower left on the front of the ID card. The network code for Blue Premier is HMH
• Alpha prefix code
  Blue Premier – ZGW
  Blue Premier Access – VCE

Patient eligibility and benefits should be verified prior to every scheduled appointment. Eligibility and benefit quotes include membership verification, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It’s strongly recommended that providers ask to see the member’s ID card for current information and photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

Our growing portfolio of product offerings is part of BCBSTX’s efforts to meet its goal of increasing access and affordability of health care products to our members and the community that we serve. Making it easier for you and your staff to conduct business with us is equally important. We appreciate your patience, cooperation and support as we all work to adapt to new product options.

If you have questions about Blue Premier in the defined member counties listed above, please call your network representative in those counties at the applicable number below:

BCBSTX Implements Changes in Maximum Allowable Fee Schedule
BCBSTX implemented changes in the maximum allowable fee schedule used for Blue Choice PPO^SM, HMO Blue Texas^SM, Blue Advantage HMO^SM (Independent Provider Network and THE Limited Network only), and ParPlan effective Nov. 1, 2015.

The changes to the maximum allowable fee schedules used for the Blue Cross Medicare Advantage PPO^SM and Blue Cross Medicare Advantage HMO^SM effective Jan. 1, 2016.

• The methodology used to develop the maximum allowable fee schedule for Blue Choice PPO, HMO Blue Texas and Blue Advantage HMO  will be based on 2015 CMS values posted on the CMS website as of Jan. 16, 2015, for those services for which the BCBSTX reimbursement is based on CMS values.
• Geographic Practice Cost Indices (GPCIs) will not be applied to the relative values so the relative values will not differ by Medicare locality.
• Blue Choice PPO, HMO Blue Texas, Blue Advantage HMO and ParPlan relative values will consider the site of service where the service is performed (facility or non-facility).
• The CPT/HCPCS Fee Schedule will be updated quarterly on March 1, June 1, Sept. 1 and Dec. 1 each year.
• The NDC Fee Schedule will continue to be updated monthly.

BCBSTX provides general reimbursement information policies, request forms for allowable fees and fee schedule information. To view this information, visit the General Reimbursement Information section on the BCBSTX provider website. If you would like to request a sample of maximum allowable fees or if you have any other questions, please contact your Network Management office.

Reimbursement changes will be posted under "Reimbursement Changes and Updates" in the Reimbursement Schedules section on the BCBSTX provider website. 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 that is posted.

Blue Choice PPO^SM Subscriber(s) / Blue Advantage HMO^SM Member Rights and Responsibilities
As a provider for BCBSTX, you are obligated to be aware of subscribers'/members’ rights and informed of subscribers' responsibilities. Our health plan subscribers/members  may refer to their benefit booklet for a listing of their rights and responsibilities, which are also included below; you can also access these documents on our website at bcbstx.com.

Rights                                                    Responsibilities

HMO Blue Texas Member Rights & Responsibilities
Member Rights – You Have the Right to:

• Receive information about the organization, its services, its practitioners and providers and members’ rights and responsibilities.
• Make recommendations regarding the organization's members’ rights and responsibilities policy.
• Participate with practitioners in making decisions about your health care.
• Be treated with respect and recognition of your dignity and your right to privacy.
• A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
• Voice complaints or appeals about the organization or the care it provides.

Member Rights – You Have the Responsibility to:

• Meet all eligibility requirements of your employer and the Health Maintenance Organization (HMO).
• Identify yourself as an HMO member by presenting your ID card and pay the copayment at the time of service for network benefits.
• Establish a physician/patient relationship with your primary care physician (PCP) and seek your PCP’s medical advice/referral for network services prior to receiving medical care, unless it is an emergency situation or services are performed by your HMO participating OBGyn.
• Provide, to the extent possible, information that the HMO and practitioner/providers need, in order to care for you. Including changes in your family status, address and phone numbers within 31 days of the change.
• Understand the medications you are taking and receive proper instructions on how to take them.
• Notify your primary care physician or HMO plan within 48 hours or as soon as reasonably possible after receiving emergency care services.
• Communicate complete and accurate medical information to health care providers.
• Call in advance to schedule appointments with your network provider and notify them prior to canceling or rescheduling appointments.
• Read your coverage documents for information about benefits, limitations, and exclusions.
• Ask questions and follow instructions and guidelines given by your provider to achieve and maintain good health.
• Understand your health problems and participate to the degree possible in the development of treatment goals mutually agreed upon between you and your provider.

Fee Schedule Updates
Reimbursement changes and updates for Blue Choice PPO, HMO Blue Texas (Independent Provider Network only) and Blue Advantage HMO practitioners will be posted under Standards and Requirements / General Reimbursement Information / Reimbursement Schedules and Related Information / Professional Schedules section on the BCBSTX provider website at 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 that is posted. To view this information, visit the General Reimbursement Information section on the BCBSTX provider website. The CPT/HCPCS Fee Schedule will be updated quarterly on March 1, June 1, Sept. 1 and Dec. 1 each year. The NDC Fee Schedule will be updated monthly.

After-hours Access Is Required
BCBSTX requires that primary care physicians, specialty care physicians and professional providers provide urgent care and emergency care or coverage for care 24 hours a day, seven days a week. They must have a verifiable mechanism in place, for immediate response, for directing patients to alternative after-hours care based on the urgency of the patient's need.

Acceptable after-hours access mechanisms may include:

• An answering service that offers to call or page the physician or on-call physician; 
• A recorded message that directs the patient to call the answering service and the phone number is provided; or
• A recorded message that directs the patient to call or page the physician or on-call physician and the phone number is provided.

For more detail, please refer to the provider manuals for Blue Choice PPO^SM Physician and Professional Provider (Section B) and HMO Blue Texas^SM / Blue Advantage HMO^SM / Blue Premier Physician, Professional Provider, Facility and Ancillary Provider Manual (Section B) available in the Education & Reference section of our provider website (note, a password is required).

BCBS Medicare Advantage PPO Network Sharing
What is Blue Cross and Blue Shield (BCBS) Medicare Advantage (MA) PPOSM network sharing?

All BCBS MA PPO Plans participate in reciprocal network sharing. This network sharing will allow 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 as long as the member sees a contracted BCBS MA PPO provider.

What does the BCBS MA PPO network sharing mean to me?
If you are a contracted BCBS MA PPO provider with Blue Cross and Blue Shield of Texas (BCBSTX) and you see BCBS MA PPO members from other BCBS Plans, these BCBS MA PPO members will be extended the same contractual access to care and will be reimbursed in accordance with your negotiated rate with your Blue Cross and Blue Shield of Texas contract. These BCBS MA PPO members will receive in-network benefits in accordance with their member contract.

If you are not a contracted BCBS MA PPO provider with BCBSTX and you provide services for any BCBS MA PPO members, you will receive the Medicare allowed amount for covered services. For urgent or emergency care, you will be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network benefit level.

How do I recognize an out-of-area BCBS MA PPO member from one of these Plans participating in the BCBS MA PPO network sharing?
You can recognize a BCBS MA PPO member when their Blue Cross Blue Shield Member ID card has the following logo:



The “MA” in the suitcase indicates a member who is covered under the BCBS MA PPO network sharing program. BCBS MA PPO members have been asked not to show their standard Medicare ID card when receiving services; instead, members should provide their Blue Cross and/or Blue Shield member ID card.

Do I have to provide services to BCBS MA PPO members from these other BCBS Plans?
If you are a contracted BCBS MA PPO provider with BCBSTX, you should provide the same access to care for BCBS MA members from other BCBS Plans as you do for BCBSTX MA PPO members. You can expect to receive the same contracted rates for such services.

If you are not a BCBS MA PPO contracted provider, you may see BCBS MA PPO members from other BCBS Plans, but you are not required to do so. Should you decide to provide services to BCBS MA PPO members, you will be reimbursed for covered services at the Medicare allowed amount based on where the services were rendered and under the member’s out-of-network benefits. For urgent or emergency care, you will be reimbursed at the in-network benefit level.

What if my practice is closed to new local BCBS MA PPO members?
If your practice is closed to new local BCBS MA PPO members, you do not have to provide care for BCBS MA PPO out-of-area members. The same contractual arrangements apply to these out-of-area network sharing members as your local BCBS MA PPO members.

How do I verify benefits and eligibility?
Call BlueCard^® Eligibility at 800-676-BLUE (800-676-2583) and provide the BCBS MA PPO member’s alpha prefix located on the member’s ID card.

You may also submit electronic eligibility requests for BCBS MA PPO members. Follow these three easy steps:

• Log in to the Availity Portal, the Availity Revenue Cycle Management Portal or your preferred vendor

• Enter required data elements 

• Submit your request

Where do I submit the claim?
You should submit the claim to BCBSTX under your current billing practices. Do not bill Medicare directly for any services rendered to a BCBS MA PPO member.

What will I be paid for providing services to these out-of-area BCBS MA PPO network sharing members?
If you are a BCBS MA PPO contracted provider with BCBSTX, benefits will be based on your contracted BCBS MA PPO rate for providing covered services to BCBS MA PPO members fromany BCBS MA PPO Plan. Once you submit the BCBS MA PPO claim, BCBSTX will work with the other Plan to determine benefits and send you the payment.

What will I be paid for providing services to other BCBS MA out-of-area members not participating in the BCBS MA PPO Network Sharing?
When you provide covered services to other BCBS MA PPO out-of-area members not participating in network sharing, benefits will be based on the Medicare allowed amount. Once you submit the BCBS MA PPO claim, BCBSTX will send you the payment. However, these services will be paid under the BCBS MA member’s out-of-network benefits unless for urgent or emergency care.

What is the BCBS MA PPO member cost sharing level and co-payments?
A BCBS MA PPO member cost sharing level and co-payment is based on the BCBS MA PPO member’s health plan. You may collect the co-payment amounts from the BCBS MA PPO member at the time of service. To determine the cost sharing and/or co-payment amounts, you should call the Eligibility Line at 800-676-BLUE (800-676-2583).

May I balance bill the BCBS MA PPO member the difference in my charge and the allowance?
No, you may not balance bill the BCBS MA PPO member for this difference. Members may be balance billed for any deductibles, co-insurance, and/or co-pays.

What if I disagree with the reimbursement amount I received?
If there is a question concerning the reimbursement amount, contact Blue Cross Medicare Advantage (PPO) Customer Service at 877-774-8592.

Who do I contact if I have a question about BCBS MA PPO network sharing?
If you have any questions regarding the BCBS MA PPO program or products, contact Blue Cross Medicare Advantage (PPO) Customer Service at 877-774-8592.

Medical Record Requests: Include Our Letter as Your Cover Sheet
When you receive a letter from BCBSTX requesting additional information, such as medical records or certificates of medical necessity, please utilize the letter as a cover sheet when sending the requested information to us.

This letter contains a barcode in the upper right corner to help ensure that the information you send is matched directly to the appropriate file and/or claim. Do not submit a Claim Review form in addition to the letter, as this could delay the review process.

Thank you for your cooperation!

Technical and Professional Components
Modifiers 26 and TC: Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical component for lab and radiological services. These modifiers should be used in conjunction with the appropriate lab and radiological procedures only.

Note: When a physician or professional provider performs both the technical and professional service for a lab or radiological procedure, he/she must submit the total service, not each service individually.

Surgical Procedures Performed in the Physician's Office
When performing surgical procedures in a non-facility setting, the physician and professional provider reimbursement covers the services, equipment, and some of the supplies needed to perform the surgical procedure when a member receives these services in the physician's or professional provider’s office.

Reimbursement will be allowed for some supplies billed in conjunction with a surgical procedure performed in the physician's or professional provider’s office. To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim Connection^TM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSTX’s code-auditing software. Refer to the BCBSTX provider website at bcbstx.com/provider for additional information on gaining access to C3.

Please note the physician and professional provider’s reimbursement includes surgical equipment that may be owned or supplied by an outside surgical equipment or Durable Medical Equipment (DME) vendor. Claims from the surgical equipment or DME vendor will be denied based on the fact that the global physician reimbursement includes staff and equipment.

AIM RQI Reminder
Physicians and professional providers must contact AIM Specialty Health^® (AIM) first to obtain a Radiology Quality Initiative (RQI) for Blue Choice PPO^SM subscribers 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 Blue Choice PPO RQI, log into AIM’s provider portal at aimspecialtyhealth.com, and complete the online questionnaire that identifies the reasons for requesting the exam. If criteria are met, you will receive a RQI. 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 ProviderPortal^SM uses the term “Order” rather than “RQI.”

Notes:
1) Facilities cannot obtain a RQI from AIM on behalf of the ordering physician.
2) The RQI program does not apply to Medicare enrollees with BCBSTX Medicare supplement coverage. Medicare enrollees with BCBSTX PPO coverage are included in the program.

AIM Specialty Health (AIM) is an operating subsidiary of Anthem, Inc.

Quest Diagnostics, Inc., Is the Exclusive HMO and Preferred Statewide PPO Clinical Reference Lab Provider
Quest Diagnostics, Inc., is the exclusive outpatient clinical reference laboratory provider for HMO Blue Texas^SM members and Blue Advantage HMO^SM subscribers,* and the preferred statewide outpatient clinical reference laboratory provider for BCBSTX Blue Choice PPO^SM subscribers. This arrangement excludes lab services provided during emergency room visits, inpatient admissions and outpatient day surgeries (hospital and free-standing ambulatory surgery centers).

Quest Diagnostics Offers:

• On-line scheduling for Quest Diagnostics' Patient Service Center (PSC) locations. To schedule a patient PSC appointment, log onto QuestDiagnostics.com/patient or call 888-277-8772.

• Convenient patient access to more than 195 patient service locations.

• 24/7 access to electronic lab orders, results and other office solutions through Care360^® Labs and Meds.

For more information about Quest Diagnostics lab testing solutions or to establish an account, contact your Quest Diagnostics Physician Representative or call 866-MY-QUEST (866-697-8378).

For physicians and professional providers located in the HMO capitated lab 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 or professional provider’s office for HMO Blue Texas members. Please note all other lab services/tests performed in the physician’s or professional provider’s office will not be reimbursed. You can access the county listing and the Reimbursable Lab Services list in the General Reimbursement Information section located under the Standards and Requirements tab.

*Note: Physicians and professional providers who are contracted/affiliated with a capitated IPA/medical group and physicians and professional providers 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.

Improvements to the Medical Records Process for BlueCard^® Claims
BCBSTX 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 BCBSTX if needed for claims processing.

Requests for medical records from other Blues Plans before rendering services, as part of the preauthorization process, should be submitted directly to the requesting Plan.

Pass-through Billing
BCBSTX does not permit pass-through billing. Pass-through billing occurs when the ordering physician or professional provider requests and bills for a service, but the service is not performed by the ordering physician or professional provider.

The performing physician, professional provider or facility and ancillary provider should bill for these services unless otherwise approved by BCBSTX. BCBSTX does not consider the following scenarios to be pass-through billing:

• The service of the performing physician or professional provider or facility and ancillary provider is performed at the place of service of the ordering provider and is billed by the ordering physician or professional provider.

• The service is provided by an employee of a physician or professional provider or facility and ancillary 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 physician or professional provider) and the service is billed by the ordering physician or professional provider.

The following modifiers should be used by the supervising physician when he/she is billing for services rendered by a Physician Assistant (PA), Advanced Practice Nurse (APN) or Certified Registered Nurse First Assistant (CRNFA):

• AS modifier: A physician should use this modifier when billing on behalf of a PA, APN or CRNFA for services provided when the aforementioned providers are acting as an assistant during surgery. (Modifier AS is to be used ONLY if they assist at surgery.)
• SA modifier: A supervising physician should use this modifier when billing on behalf of a PA, APN or CRNFA for non-surgical services. (Modifier SA is used when the PA, APN, or CRNFA is assisting with any other procedure that DOES NOT include surgery.)

Contracted Providers Must File Claims
As a reminder, physicians, facilities, professional providers and ancillary providers must file claims for any covered services rendered to a patient enrolled in a 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.

Notwithstanding the foregoing, a provision of the American Recovery and Reinvestment Act changed HIPAA to add a requirement that if a patient self pays for a service in full and directs a provider to not file a claim with the patient's insurer, the provider must comply with that directive and may not file the claim in question. In such an event, you must comply with HIPAA and not file the claim to BCBSTX.

Medical Policy Disclosure
New or revised medical policies, when approved, will be posted on the BCBSTX provider website on the 1st or 15th day 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 view active and pending medical policies go to bcbstx.com/provider and click on the Standards & Requirements tab, then click on the Medical Policies offering. After reading and agreeing to the disclaimer, you will then have access to active and pending medical policies.

Draft Medical Policy Review
In an effort to streamline the medical policy review process, you can view draft medical policies on the BCBSTX provider website and provide your feedback online. If there are any draft medical policies to review, these documents will be made available for your review around the 1st and the 15th of each month with a review period of approximately two weeks.

To view draft medical policies go to our provider website and click on the Standards & Requirements tab, then click on the Medical Policies offering. After reading and agreeing to the disclaimer, you will then have access to view any draft medical policies, if available.

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) from AIM Specialty Health need not submit additional medical records to 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.

Predetermination 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.

Importance of Obtaining a Preauthorization/Referral
A preauthorization/referral is required for certain types of care and services. Although BCBSTX participating physicians and professional providers are required to obtain preauthorizations/referrals, it is also the responsibility of the member/subscriber to confirm that this action has been taken for services that require a preauthorization/referral.

Preauthorizations/referrals must be obtained for any services provided by someone other than the member's primary care physician (PCP) i.e., specialist, ambulatory surgery centers, ancillary, etc. A preauthorization/referral is also needed for an initial stay in a facility and any additional days or services added on.

If a member/subscriber does not obtain a preauthorization/referral for initial facility care or services, or additional days or services added on, the benefit for covered expenses may be reduced.

A preauthorization/referral does not guarantee payment. All payments are subject to determination of the member/subscriber'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.

If a preauthorization/referral request is received from an out-of-network (OON) provider and the member/subscriber does not have an OON benefit, BCBSTX will contact the ordering provider to discuss network options. However, if a member/subscriber has an OON benefit, OON benefits will apply, which could result in a higher cost sharing.

Avoidance of Delay in Claims Pending COB Information
BCBSTX receives thousands of claims each month that require unnecessary review for coordination of benefits (COB). What that means to our physicians, professional providers, facility and ancillary providers is a possible delay, or even denial of services, pending receipt of the required information from the member/subscriber.

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 through 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.

Billing for Non-covered Services
As a reminder, contracted physicians, professional providers, facility and ancillary providers may collect payment from members/subscribers for copayments, co-insurance and deductible amounts. The physician, professional provider, facility or ancillary provider may not charge the member/subscriber more than the patient share shown on their provider claim summary (PCS) or electronic remittance advice (ERA).

In the event that BCBSTX determines that a proposed service is not a covered service, the physician, professional provider, facility or ancillary provider must inform the member/subscriber in writing in advance. This will allow the physician, professional, facility or ancillary provider to bill the member/subscriber for the non-covered service rendered.

In no event shall a contracted physician, professional provider, facility or ancillary provider collect payment from the subscriber for identified hospital acquired conditions and/or serious reportable events.

Dispensing QVT (Quantity Versus Time) Limits
To help minimize health risks and to improve the quality of pharmaceutical care, dispensing QVT limits have been placed on select prescription medications. The limits are based upon the U.S. Federal Drug Administration and medical guidelines as well as the drug manufacturer’s package insert.

Access the 2015 Standard Drug List Dispensing Limits and 2015 Generics Plus Drug List Dispensing Limits documents online.

Prescription Drug Lists
Throughout the year, the BCBSTX Clinical Pharmacy Department team frequently reviews the prescription drug lists. Tier placement decisions for each drug on the list follow a precise process, with several committees reviewing efficacy, safety and cost of each drug.

For the 2015 drug updates, visit the BCBSTX provider website under the Pharmacy Program tab, or follow this link: bcbstx.com/provider/pharmacy/index.html and click on the Rx List/Prescribing Guides offering in the left-side navigation list.

Are Utilization Management Decisions Financially Influenced?
BCBSTX is dedicated to serving our customers through the provision of health care coverage and related benefit services. BCBSTX prohibits decisions based on financial incentives – utilization management decisions are based on appropriateness of care and service and existence of coverage.

BCBSTX does not specifically reward practitioners or clinicians for issuing denials of coverage, nor is there compensation based on the number or frequency of telephone calls or other contacts that occur with health care providers, members or subscribers. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization.