| December 7, 2012 For Travis Service-Area Medicaid & CHIP Providers Welcome to the Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR) & CHIP weekly newsletter. Thank you for participating in BCBSTX Medicaid (STAR) & CHIP programs.
Primary Care Provider Rate Increase Delayed
Texas will be increasing Medicaid primary care rates, including those for certain physician visits and vaccine administration, as quickly as possible. However, the state did not received final federal regulations on the rate increase until Nov.1, 2012. This was too late to allow the state to meet the Jan. 1, 2013, implementation date authorized in the Affordable Care Act.
Once the state increases primary care rates, we will make retroactive payments for the increase for providers and services that qualify under the federal regulations. The state is working with the U.S. Centers for Medicare and Medicaid Services to obtain federal approval for the state’s plan to increase primary care rates. We will continue to keep providers informed of the process and timeline.
Billing Members for Services Not Medically Necessary or Not Covered
Providers may bill a Blue Cross and Blue Shield of Texas (BCBSTX) member for a service that is not medically necessary or not a covered benefit if all of the following conditions are met:
- The patient requests a specific service or item that, in your or BCBSTX’s opinion, may not be reasonable and medically necessary;
- You must obtain and keep a written acknowledgment statement – see the sample Member Acknowledgment Statement form at http://bcbstx.com/provider/network/medicaid.html verifying that you notified the BCBSTX member of financial responsibility for services rendered; and,
- This acknowledgement must be signed and dated by the member. If the services the member requested are determined not to be medically necessary by BCBSTX, then the signed acknowledgment statement must indicate that the member has been notified of the responsibility to pay these services.
Private Pay Form Agreement
You may bill a member without a signed Member Acknowledgement Statement form if:
- The service received is not a benefit of the Medicaid program. You must inform the member that the service in question is not a benefit under BCBSTX and notify the member of financial responsibility.
- You accept the member as a private-pay patient. You must advise members that they are accepted as private-pay patients at the time of service and will be responsible for paying for all services received. In this situation, BCBSTX strongly encourages that notification be in writing with the member’s signature and date so that there is no question of whether the member has been properly notified of the private-pay status (refer to the sample Private Pay Form Agreement on our website).
| You must inform members of the costs for non-covered services prior to rendering such services and obtain a signed Member Private Pay Form Agreement from such member. Federal and state laws provide severe penalties for any provider who attempts to bill or collect any payment from a Medicaid recipient for a covered service. You are prohibited from billing or collecting any amount from a Medicaid member for health care services pursuant to your contract with BCBSTX.
Hospital Readmissions Policy
BCBSTX does not reimburse for a hospital readmission within 30 days of discharge (from a previous hospital confinement for a related condition) as a SEPARATE admission. This is in accordance with Health and Human Service Commission policy for readmissions. Claims for new admission fees will be denied.
After-Hours Appointment Accessibility Survey
BCBSTX began conducting quarterly phone surveys on designated network providers. The purpose of the survey is to monitor the length of time it takes for Members to schedule an appointment with in-network providers. Both the Texas Health and Human Services Commission (HHSC) and Texas Department of Insurance (TDI) require all managed care organizations to monitor appointment accessibility periodically, but no less than annually.
Providers should inform their staff they may receive a survey by fax and/or a phone call from a BCBSTX representative in November. The brief survey measures each provider office's ability to comply with established appointment accessibility standards. See the chart below for the standards that will be addressed in the survey: Appointment Type | Standard | Emergency Care | Provided immediately when Member presents or Member is sent to the Emergency Center if deemed necessary and appropriate by the Member’s PCP. | Urgent Care (not considered life threatening) | Care should be provided within 24 hours of the Member’s appointment request. | Routine Sick Care | Appointment must take place within three (3) days for PCP and fourteen (14) calendar days of appointment request for Specialists. | Pre-Natal Care | Appointment must take place within fourteen (14) calendar days of appointment request, except for high-risk pregnancies or newly identified pregnant Members in her third trimester, in which case must be seen within five (5) days. If an emergency situation exists, pre-natal Members must be seen immediately. | Preventive Health Care (Adults) | Appointment must be offered to Member within 90 days of request. | Preventive Health Care (Children) | Appointments must be offered in accordance with Texas Health Steps periodicity schedule and no later than 14 days after enrollment of a newborn or no later than 90 days of enrollment for Members under the age of 21. |
After-Hours Accessibility Surveys
BCBSTX began conducting quarterly phone surveys of primary care providers (PCPs) during November. The purpose of the survey is to ensure that PCPs are available to BCBSTX members 24 hours a day, seven days a week. PCPs who do not answer their office telephone after normal business hours must have an answering service, an answering machine or another provider answering calls.
Both the Texas Health and Human Services Commission (HHSC) and Texas Department of Insurance (TDI) require all managed care organizations to monitor after-hours accessibility periodically, but no less than annually. PCPs should inform their staff and answering service they may receive a phone call from a BCBSTX representative in November between the hours of 6 p.m. and 9 a.m. The brief survey measures each provider’s availability to be reached by BCBSTX members after-hours. Acceptable after-hours call coverage arrangements are:
- The office telephone is answered after normal business hours by an answering service that can contact the PCP or another designated medical practitioner. The PCP or his/her designee must be available to return calls answered by the answering service within 30 minutes.
- The office telephone is answered after normal business hours by a recording directing the member to call another number to reach the PCP or another designated medical practitioner. Someone must be available to answer the designated provider’s telephone. Another recording/answering machine is not acceptable.
- The office telephone is transferred after normal business hours to another location where a live person answers the phone and can contact the PCP or another designated medical practitioner. The PCP or his/her designee must be available to return calls within 30 minutes.
| The following are considered unacceptable after-hours call coverage arrangements:
- The office telephone is not answered after normal business hours.
- The office telephone is answered after normal business hours by a machine which instructs members to leave a message.
- The office telephone is answered after normal business hours by a machine that instructs patients to go to the emergency room.
- Messages or pages are not returned within 30 minutes.
| Archiving Newsletters
BCBSTX began archiving the weekly Medicaid (STAR) and CHIP newsletters on our provider website. The first archived newsletter is Oct. 5, 2012. The newsletters will be available on the website for three months. The newsletters will be located on the left hand side of the website under News & Updates.
http://bcbstx.com/provider/network/medicaid.html
News and Updates Section Added to Provider Website
We have added a new feature to our provider website titled: News & Updates. This new section is located on our provider website on the left hand side of the page. Check the News & Updates section for the latest information relating to the BCBSTX Medicaid (STAR) and CHIP Program.
http://bcbstx.com/provider/network/medicaid.html
Link to BCBSTX Medicaid Website
On this website, you will find links to the Provider Manual, Quick Reference Guide, Services Requiring Prior Authorization, webinars/trainings and other useful information.
http://bcbstx.com/provider/network/medicaid.html
Contact Us
Provider Customer Service: 888-292-4487, 7 a.m. to 6 p.m. CT, Monday through Friday
For general questions and concerns:
Jamye Rushing, jamye_rushing@bcbstx.com, 512-349-4876; Fax: 512-349-4848 Network Provider Representatives
Juanita Hill, juanita_hill@bcbstx.com, 512-349-4896
Burnet, Williamson, Blanco, Lampasas, Llano, San Saba Shelby Robinson, shelby_robinson@bcbstx.com, 512-349-4897
Lee, Austin County, Bell, Burleson, Milam, Washington Britton Thibodeaux, britton_thibodeaux@bcbstx.com, 512-349-4898
Bastrop, Caldwell, Fayette, Hays, Colorado, Comal, Gonzales, Guadalupe, Lavaca Dee Culver, deanna_culver@bcbstx.com, 512-349-4899
Travis Clinical Outreach & Education, Quality/Compliance
Kathy Clark, kathy.clark@wellpoint.com, 512-349-4480 For Member Outreach inquiries, BCBSTX Medicaid (STAR) and CHIP members may contact
Sonia Saenz, Senior Outreach Specialist/Member Advocate, sonia.saenz@wellpoint.com, 512-349-4883 Senior Outreach Specialist/Member Advocate
Sonia Saenz, sonia.saenz@wellpoint.com, 512-349-4883
If unable to reach Sonia, please contact Lupe Yanez at guadalupe.yanez@wellpoint.com, 512-349-4887 | 