|November 16, 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.
After-Hours Accessibility Surveys
Blue Cross and Blue Shield of Texas (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 following are considered unacceptable after-hours call coverage arrangements:
- 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 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.
Cesarean Section Deliveries
Texas Medicaid restricts any Cesarean section, labor induction, or any delivery following labor induction to one of the following additional criteria:
Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to 39 weeks of gestation are not considered medically necessary and will be denied.
- Gestational age of the fetus should be determined to be at least 39 weeks or fetal lung maturity must be established before delivery.
- When the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery.
Records will be subject to retrospective review. Payments made for any non-medically indicated Cesarean section, labor induction, or any delivery following labor induction that fail to meet these criteria (as determined by review of medical documentation), will be subject to recoupment. Recoupment may apply to all services related to the delivery, including additional physician fees and hospital fees.
Obstetric Delivery Guidelines
- BCBSTX reimburses only one delivery or cesarean section procedure per Member in a seven-month period. Reimbursement includes multiple births.
- Delivering physicians who perform regional anesthesia or nerve block may not receive additional reimbursement because these charges are included in the reimbursement for the delivery.
- BCBSTX reimburses anesthesia services and delivery at full allowance when provided by the delivering obstetrician.
- BCBSTX will reimburse antepartum care, deliveries, including cesarean performed by physicians, and postpartum care. (Codes 59410, 59515, 59614, and 59622 are deliveries that include the postpartum visit.)
- When billing BCBSTX, you must itemize each service individually and submit claims as the services are rendered. The filing deadline will be applied to each individual date of service submitted to BCBSTX.
- Laboratory (including pregnancy test) and radiology services provided during pregnancy must be billed separately and be received by BCBSTX within 95 days from the date of service.
Obstetric Global Codes
BCBSTX requires itemization of maternity services when submitting claims for reimbursement. Global codes cannot be used when billing BCBSTX. If BCBSTX receives a claim with global coding, it will be returned to you with a mailback form asking you to re-bill using itemized codes. You have 21 calendar days from the date of our request letter to submit the corrected claim. The provider then has 120 days from the date of the first denial to appeal.
Billing for Circumcisions
All circumcisions performed on members more than 30 days after birth will require authorization from BCBSTX’s Utilization Management department and will be subject to medical necessity. Circumcision charges should be billed with the appropriate CPT codes:
- 54150 - Circumcision, Using Claim or Other Device – Newborn
- 54152 - Circumcision, Using Clamp or Other Device – Except Newborn
- 54160 - Circumcision, Surgical Excision Other than Clamp, Device or Dorsal
Split – Newborn
- 54161 - Circumcision, Surgical Excision Other than Clamp, Device or Dorsal
Split – Except Newborn
Claim Tip of the Week
Question: What are BCBSTX Medicaid (STAR) and CHIP Obstetric Ultrasound Requirements?
Answer: An authorization is not required for obstetric ultrasounds performed by in-network providers. All obstetric ultrasounds performed by out of network physicians required authorization. Contact utilization management by calling 855-879-7178 or fax the Prior Authorization form, located at the below link, to 855-879-7180.
A Message from the Texas Health and Human Services Commission (HHSC)
Texas Women's Health Program Offers Continuity of Care
The Texas Women's Health Program is looking for doctors and physicians with a specialty in family practice, gynecology, OB/GYN, internal medicine or pediatrics who want to help low-income women take control of their futures. You can make a dramatic difference in the lives of women who need the expertise and health services you offer.
"The comments we received from physician groups helped shape the development of the new state program," said Texas Health and Human Services Executive Commissioner Kyle Janek, M.D. "I encourage physicians to join the Texas Women's Health Program. It's a great way to provide excellent services to low-income Texas women and to your communities."
The women who benefit from this fee-for-service, state-funded program are between 18 and 44 years old. They don't qualify for Medicaid or have health insurance. The Texas Women's Health Program provides them with an annual family planning exam, health screens for things such as diabetes and breast and cervical cancer, treatment for certain sexually transmitted diseases and family planning services such as birth control.
The program offers an opportunity for providers to continue caring for patients whose Medicaid coverage expires after giving birth. Continuity of care is an important aspect of the program for participating doctors, as well as women who want consistency in their family planning and health care.
Any Medicaid provider that offers services covered by the program and complies with the new program rules can enroll as a Texas Women's Health Program provider.
Learn more about enrolling in Medicaid or certifying as a Texas Women's Health Program provider at www.TMHP.com. Click the providers navigation link:
- To enroll as a Medicaid provider, click Enroll Today in the web page banner.
- To certify as a Women's Health Program provider, click the Texas WHP tab under the banner.
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.
Provider Customer Service: 888-292-4487, 7 a.m. to 6 p.m. CT, Monday through Friday
For general questions and concerns:
Jamye Rushing, firstname.lastname@example.org, 512-349-4876; Fax: 512-349-4848
Network Provider Representatives
Juanita Hill, email@example.com, 512-349-4896
Burnet, Williamson, Blanco, Lampasas, Llano, San Saba
Shelby Robinson, firstname.lastname@example.org, 512-349-4897
Lee, Austin County, Bell, Burleson, Milam, Washington
Britton Thibodeaux, email@example.com, 512-349-4898
Bastrop, Caldwell, Fayette, Hays, Colorado, Comal, Gonzales, Guadalupe, Lavaca
Dee Culver, firstname.lastname@example.org, 512-349-4899
Clinical Outreach & Education, Quality/Compliance
Kathy Clark, email@example.com, 512-349-4480
For Member Outreach inquiries, BCBSTX Medicaid (STAR) and CHIP members may contact
Sonia Saenz, Senior Outreach Specialist/Member Advocate, firstname.lastname@example.org, 512-349-4883
Senior Outreach Specialist/Member Advocate
Sonia Saenz, email@example.com, 512-349-4883
If unable to reach Sonia, please contact Lupe Yanez at firstname.lastname@example.org, 512-349-4887