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Blue Review - Blue Cross and Blue Shield of Texas

April 12, 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.

Interpreter Services are Available
As a reminder, providers should discourage BCBSTX members from using friends and family members, especially children, as interpreters. Multilingual staff should self-assess their non-English language speaking and comprehension skills prior to interpreting on the job. Using a bilingual skill set is not the same as interpreting, and office staff should not serve as interpreters unless they have been tested for use of those skills. This can be a particular problem with medical terminology.

You will find the current recommended employee language skills self-assessment tool on the BCBSTX provider website, Provider Cultural and Linguistic Program, http://bcbstx.com/provider/network/medicaid.html.

Office staff using bilingual skills set to communicate with members should complete the self-assessment tool.  The tool should be faxed to BCBSTX so that the languages available in the provider's office can be maintained and available to assist members in selecting providers. Please fax the completed form to BCBSTX Network Management at 512-349-4860. The original should be maintained in the provider office for review during facility site audits.

For those instances when you cannot communicate with a member because of a language barrier, interpreter services are available at no cost to the provider or the member. Face-to-face interpreters for members needing language assistance, including American Sign Language, are available by placing a request at least 72 hours in advance by calling the Customer Care Center at 888-292-4487. A 24-hour cancellation notice is required.

Out of Network Referrals
BCBSTX recognizes there may be instances when an out-of-network referral is justified. Case Management will work with the medical director and the primary care provider to determine medical necessity of out-of-network referrals. Out-of-network referrals will be authorized on a limited basis. Case Management may be contacted at 855-879-7178 for questions regarding referrals to out-of-network providers.

Preventive Healthcare Guidelines
Good health begins with good lifestyle habits and regular exams. Preventive healthcare guidelines help physicians and other professional providers keep members on track with necessary screenings and exams based on age and gender.

Several national organizations produce tools that physicians and other professional providers can use to improve the health of our members, such as educational materials, health management programs ad preventive healthcare guidelines. These guidelines are posted under the Preventive Health Care Guidelines tab on our provider website at http://bcbstx.com/provider/network/medicaid.html. Providers will also find educational Member Handouts on Preventive Health Care Guidelines available in English and Spanish.

These guidelines recommendations are not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined by the list of covered services.

Clinical Healthcare Guidelines

BCBSTX supports physicians in following nationally accepted clinical practice guidelines to improve the health of our Members. Several national organizations produce guidelines for the following conditions:
  • Asthma
  • Attention deficit hyperactivity disorder (ADHD)
  • Bipolar
  • Chlamydia/HPV
  • Chronic obstructive pulmonary disease (COPD)
  • Coronary artery disease (CAD) (General Population and in Women)
  • Depression
  • Diabetes
  • Heart failure
  • Maternity/Perinatal
  • Post partum depression (PPD) and Post partum psychosis (PPP)
  • Substance Abuse
  • Vascular at risk - Hyperlipidemia
  • Vascular at risk - Hypertension
Providers can access these recommended guidelines at http://bcbstx.com/pdf/clinical_guidelines.pdf.

These guideline recommendations are not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined by the list of covered services.

Mailback Form

A claim that is returned to the provider for correction or additional information is called a "mailback." Providers have 21 calendar days from the date on the mailback to submit the corrected claim information to BCBSTX. The provider then has 120 days from the date of the first denial to appeal the claim.

Questions about Claims

ac 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 • April 12, 2013 • www.bcbstx.com