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Blue Review - Blue Cross and Blue Shield of Texas

April 5, 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.

Ancillary Training
BCBSTX Medicaid (STAR) and CHIP is hosting an ancillary training. The training will focus on claims and billing, medical management, the authorization process and more.

All ancillary providers are encouraged to attend, including:
  • Physical therapy, occupational therapy and speech therapy
  • Early childhood intervention providers
  • Freestanding and hospital-based ambulatory surgery centers
  • Home health agencies
  • Comprehensive outpatient rehabilitation facilities
  • and all others
Date: Friday, April 12, 2013
Time: Noon to 2 p.m.
Location: Marie Callender's, 9503 Research Blvd #400, Austin, TX 78759
Lunch will be provided
RSVP Deadline: Thursday, April 11, 2013, at noon, email Juanita Hill at juanita_hill@bcbstx.com or call 512-349-4896

Texas Health Steps Third-Party Resource (TPR) Requirements

Texas Health Steps medical and dental providers are not required to bill other insurance before billing BCBSTX. If the provider is aware of other insurance, however, the provider must choose whether or not to bill the other insurance. The provider has the following options:
  • If the provider chooses to bill the other insurance, the provider must submit the claim to the client's other insurance before submitting the claim to BCBSTX.
  • If the provider chooses to bill BCBSTX and not the client's other insurance, the provider is indicating acceptance of the BCBSTX payment as payment in full. BCBSTX then has the right to recovery from the other insurance. The provider does not have the right to recovery and cannot seek reimbursement from the other insurance after BCBSTX has made payment.

Early Childhood Intervention Referrals
Early Childhood Intervention (ECI) is a statewide program for families with children, age 0 to 3 years, with disabilities or developmental delays. ECI supports families to help children reach their developmental potential. Providers are required to identify and refer any member birth through 35 months of age suspected of having a developmental disability or delay, or who is at risk of delay, to a participating ECI program for screening and assessment within two business days from the day the provider identifies the member.

Referrals can be based on professional judgment or a family's concern. A medical diagnosis or a confirmed developmental delay is not required for referrals. To refer families for services, providers can call their local ECI program, or they can call the Department of Assistive and Rehabilitative Services (DARS) Inquiry Line at 800-628-5115.

For additional information, providers can visit the DARS website at: http://www.dars.state.tx.us/ecis
TDD/TYY 866-581-9328

Medicaid (STAR) members may initiate ECI services (initial evaluation) without referral by their PCP. The initial evaluation does not require prior-authorization or referral by the PCP, however subsequent services do require prior-authorization per the BCBSTX Prior Authorization guidelines, http://bcbstx.com/provider/pdf/services_prior_auth.pdf.

ECI Case Management and specialized skills training are carved-out of Medicaid managed care and must be billed to TMHP for payment consideration. Carved-out services are those that are rendered to Medicaid managed care clients but are administered by TMHP and not the client's MCO. ECI therapies, physical therapy (PT), occupational therapy (OT), and speech therapy (ST) are not carved out and must be submitted to the Managed Care Organization that administers the client's managed care benefits.

Medical Records Standards

Providers are required to maintain medical records in a manner that permits effective and confidential member care and quality review. BCBSTX performs, by appointment, medical record reviews as part of its quality improvement program on a periodic basis to help ensure that providers are in compliance with record keeping standards and Texas Health Steps requirements.

For more information on BCBSTX Medical Records Standards, refer to the BCBSTX Medicaid (STAR) and CHIP Provider Manual, http://bcbstx.com/pdf/medicaid_star_chip_manual.pdf, or contact Kathy Clark, R.N.. Contact Information for Kathy Clark is located under the Contact Us section at the end of the newsletter.


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 • April 5, 2013 • www.bcbstx.com