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Blue Review - Blue Cross and Blue Shield of Texas

March 1, 2013

For Travis Service-Area Medicaid (STAR) & 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.

Newly Revised 2013 BCBSTX Medicaid (STAR) and CHIP Provider Manual

The BCBSTX Medicaid (STAR) and CHIP Provider Manual will be available on the BCBSTX provider website, bcbstx.com/provider/network/medicaid.html, March 2013. The provider manual has been updated with program changes/updates and contains valuable resource information. We encourage all providers to utilize the provider manual. Providers can find the answer to many of their questions within the provider manual.

BCBSTX Medicaid (STAR) and CHIP Provider Availity Workshops

Please join Blue Cross and Blue Shield of Texas (BCBSTX ) and Availity®’ for an educational workshop on the tools and features of Availity. The workshop will be held at:
Blue Cross and Blue Shield of Texas
9442 Capital of Texas Highway North
Suite 500, Arboretum Plaza II
Austin, Texas 78759

Topics covered will include:
  • Verification of Medicaid member eligibility
  • Verification of Medicaid member benefits
  • Checking the status of BCBSTX Medicaid claims
  • And more.....
Training will take place on Thursday, March 21, 2013, at the times listed below:
  • 9 a.m. to 10 a.m.
  • 11 a.m. to Noon
  • 1 p.m. to 2 p.m.

Hands-on training will be provided after each workshop. Providers are encouraged to bring their Availity user ID and password and examples (claims, eligibility and benefits).

Light snacks and drinks will be provided at each session.

Please RSVP by noon March 20, 2013, via email to Juanita Hill: juanita_hill@bcbstx.com or call 512-349-4896.

Substitute Physician
Physicians may bill for the service of a substitute physician who sees clients in the billing physician’s practice under either a reciprocal or locum tenens arrangement of up to 60 days.

A reciprocal arrangement is one in which a substitute physician covers for the billing physician on an occasional basis when the billing physician is unavailable to provide services. Reciprocal arrangements do not have to be in writing.

A locum tenens arrangement is one in which a substitute physician assumes the practice of a billing physician who is absent for reasons such as illness, pregnancy, vacation, continuing medical education or active duty in the armed forces. The locum tenens arrangement may be extended for a continuous period of longer than 60 days if the billing physician’s absence is due to being called or ordered to active duty as a member of a reserve component of the armed forces. Locum tenens arrangements must be in writing.

The substitute physician is not required to enroll in Texas Medicaid. The billing provider’s name, address and national provider identifier must appear in Block 33 of the claim form. The name and office or mailing address of the substitute physician must be documented on the claim in Block 19, not Block 33.

When a physician bills for a substitute physician, modifier Q5 or Q6 must follow the procedure code in Box 24D for services provided by the substitute physician. The Q5 modifier is used to indicate a reciprocal arrangement and the Q6 modifier is used to indicate a locum tenens arrangement.

When physicians in a group practice bill substitute physician services, the performing provider identifier of the physician for whom the substitute provided services must be in Block 24J.

Physicians must familiarize themselves with these requirements and document accordingly. Those services not supported by the required documentation as detailed above will be subject to recoupment.

Medicaid (STAR) Postpartum Visit

One postpartum care procedure code may be reimbursed per pregnancy for Medicaid (STAR) members. The claim for the postpartum visit may be submitted with either procedure code 59430 or with a delivery procedure code that includes postpartum care. The reimbursement amount for the submitted procedure code covers all postpartum care per pregnancy regardless of the number of postpartum visits provided.

New Billing Requirements for CHIP Perinate Postpartum Visits

CHIP Perinate Mothers are entitled to a maximum of 2 postpartum visits. CHIP Perinate Mother’s eligibility terms at the end of the month the baby was born. If a provider calls to check benefits after the month of the baby’s birth, they will be advised the CHIP Perinate Mother is not eligible. CHIP Perinate Mothers may receive their postpartum visits after their eligibility ends (at the end of the month of the baby’s birth). In order to be reimbursed for the postpartum visits, providers must bill using the CPT delivery codes that include postpartum care. See below for a list of codes. The reimbursement amount for the below procedure codes includes both postpartum care visits.

If the provider bills any other code and the date of service is after the CHIP Perinate Mother’s eligibility has termed, the provider will not receive payment for the postpartum care.

If the claim was submitted with the incorrect code, you may re-submit the original delivery claim with the correct code within the 120-day appeal deadline.

If you have any questions, contact the Customer Care Center at 888-292-4487 or your Provider Network Representative at 512-349-4876.

CPT Delivery Code



Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum


Cesarean delivery only; including postpartum care


Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care


Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care

For More Information
If you have questions regarding proper postpartum billing or CHIP Perinate member eligibility for postpartum care, please contact the Customer Care Center at 888-292-4487 or your Provider Network Representative at 512-349-4876. *These changes only apply to CHIP Perinate Postpartum Visits. For Medicaid (STAR) postpartum billing requirements refer to the BCBSTX Medicaid (STAR) and CHIP Provider Manual.

Billing Sterilization Claims
When billing for sterilization procedures, use the CMS-1500 claim form and follow the appropriate coding guidelines. Attach a copy of the completed Sterilization Consent Form, available at www.thmhp.com/Pages/Medicaid/medicaid_forms.aspx. Failure to attach the Sterilization Consent Form will cause the entire claim to deny.

Questions about Claims

If you have questions about claims status or how to file a claim, including how to complete claims forms, please contact the Customer Care Center at 888-292-4487.

Link to BCBSTX Medicaid Website

On this website, you will find links to the Provider Manual, Quick Reference Guide, Services Requiring Prior Authorization 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
Blanco, Burnet, Lampasas, Llano, Williamson (Georgetown)

Shelby Robinson, shelby_robinson@bcbstx.com, 512-349-4897
Austin County, Bell, Burleson, Lee, Milam, San Saba, Washington, Williamson (Round Rock)

Britton Thibodeaux, britton_thibodeaux@bcbstx.com, 512-349-4898
Bastrop, Caldwell, Colorado, Comal, Fayette, Gonzales, Guadalupe, Hays, Lavaca

Dee Culver, deanna_culver@bcbstx.com, 512-349-4899
Travis, Williamson (except Georgetown, Round Rock)

Clinical Outreach & Education, Quality/Compliance
Kathy Clark, kathy.clark@wellpoint.com, 512-349-4880

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


BCBSTX makes no endorsements, representations, or warranties about any products or services offered by
independent, third-party vendors mentioned in this newsletter. The vendors are solely responsible for the products or
services offered by them. If you have any questions about the products or services mentioned in this newsletter,
contact the vendor directly.

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an Independent Licensee of the Blue Cross and Blue Shield Association.

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Blue Review Medicaid (STAR) & CHIP Update • March 1, 2013 • www.bcbstx.com