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Blue Review - Blue Cross and Blue Shield of Texas

May 3, 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.

Update: Change in Services Requiring Prior Authorization, Effective Aug. 1, 2013
Services Requiring Prior Authorization
Effective Aug. 1, 2013, Blue Cross and Blue Shield of Texas (BCBSTX) is updating the list of codes related to services that require prior authorization (PA) before they can be provided to our members enrolled in Medicaid (STAR) and CHIP. The following service categories are affected by this update:

  • High tech radiology
  • Pain management injections and procedures
  • Prosthetic/orthotic devices
  • Sleep studies
  • Tonsillectomy and adenoidectomy

A more comprehensive list of services requiring PA will be available at bcbstx.com/provider/network/medicaid.html on July 1 by the following steps:

  1. Scroll down and select the Prior Authorization Requirements tab.
  2. Select the Services Requiring Prior Authorization document.

This information is NOT to be relied upon as an all inclusive prior-authorization list for health care services and is NOT a guarantee of payment.

Reminder: Verifying Eligibility and Benefits Reduces Denied Claims
As a reminder, providers are responsible for verifying eligibility and benefits before providing services to BCBSTX members. Except for an emergency, failure to obtain prior authorization for these services may result in a denial for reimbursement. To verify member eligibility and benefits, please call our Customer Care Center at 888-292-4487.

In addition, please remember that BCBSTX will review all non-urgent prior authorization requests within three business days. Prior authorization decisions for urgent requests will be made within 72 hours from receipt of the request. BCBSTX does not require authorization for treatment of emergency medical conditions; however, providers are required to contact BCBSTX within 24 hours of the admission.

To verify specific prior-authorization code requirements for a particular member, call 888-292-4487.

Where to Find our Medical Policies and Clinical UM Guidelines
To learn more about medical policies and clinical Utilization Management guidelines, please visit our website at bcbstx.com/provider/network/medicaid.html and scroll down to select Medical Policies.

For Prior Authorization or More Information
To request prior authorization, report a medical admission or ask questions regarding prior authorization, please contact the BCBSTX Utilization Management department at 855-879-7178. You also may fax prior authorization requests to 855-879-7180.


Texas Health Steps Continuing Education Courses

Texas Health Steps offers a variety of continuing education courses for providers and clinical staff. The courses are arranged by topic. Some of the topics covered are:

  • Acute and medical conditions
  • Adolescent health
  • Genetic screening
  • Pediatric referral guidelines
  • and more...

All Texas Health Steps Online Provider Education courses are accredited by the following organizations:

  • American Nurses Credentialing Center
  • National Commission for Health Education Credentialing
  • Texas Medical Association
  • Texas State Board of Social Workers Examiners
  • Texas Department of State Health Services Promotor (a)/Community Health Worker Training and Certification Program

For more information on Texas Health Steps Continuing Education Courses, visit http://www.txhealthsteps.com/cms/?q=catalog.


Attestation Form Now Available for Qualified Primary Care Providers to Receive ACA Rate Increase

To qualify for the Affordable Care Act of 2010 (ACA) rate increase for primary care services, a physician must have a specialty designated of general internal medicine, family practice, or pediatrics and must attest to one of the following:

  • The provider has a certification recognized by the American Board of Medicine Specialties (ABMS), American Board of Physician Services (AMPS) or American Osteopathic Association (AOA) and meets the requirements as required by federal and state regulation to receive the increased payment.
  • The provider does not have a certification recognized by the ABMS, AMPS, or AOA, but at least 60 percent of the provider's Medicaid billings for the previous calendar year (or for the previous calendar month if the provider has been enrolled in Medicaid for less than one year) were for evaluation and management (E/M) and vaccine administration procedure codes as published in the final federal and state regulations and provider meets the requirements to receive payment.

Note: New providers with no history of Medicaid billings can attest that 60 percent of their Medicaid billing will be for primary care services.

Providers can attest using the Texas Medicaid Attestation for ACA Primary Care Rate Increases form.

The form must be completed by individual providers. The form must be completed, signed and returned by fax to 512-302-5068 or by mail to:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
P. O. Box 200795
Austin, TX 78720-0795

Providers will not immediately see the rate increase payment on their Remittance and Status (R&S) reports. The increased rates will be applied retroactively. The state is working with the Centers for Medicare & Medicaid Services (CMS) to get federal approval for the state's plan to increase primary care rates. Health & Human Services Commission (HHSC) will continue to keep providers informed of the process and timeline as information becomes available.

Group providers may not submit the form using their group Texas Provider Identifier (TPI). Each member of the group must complete the form using their performing provider TPI to attest that they are eligible to receive increase reimbursement.

Facility providers may not submit the form using their facility TPI. Eligible providers who are employed by the facility must complete the form using their individual TPI to attest that they are eligible to receive increase reimbursement.

Providers that have been issued a TPI with multiple suffixes must submit a separate form for each eligible suffix in order to receive the increased reimbursement for each enrolled practice location, Tax Identification Number, etc.

Important: By signing the form, providers attest that they qualify for the rate increase, and that the increase will be applied to paid claims for primary care services on or after the effective date. Payment of the rate increase may be subject to retrospective review and recoupment if it is determined at a later time that the provider did not qualify for the ACA primary care rate increase. Federal regulations require states to conduct an annual audit of provider attestations.

Non-physician Practitioners
Non-physician practitioners who are under the supervision of a provider who has self-attested, are not required to submit a separate provider attestation form. Increased payments may be available to the supervising physician when the following conditions are met:

  • The non-physician practitioner renders services under the personal supervision of a provider who has self-attested to meeting the requirements.
  • Services are billed under the qualifying provider's provider identification number.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.


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 Member Outreach at 800-618-3084.


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 • May 3, 2013 • www.bcbstx.com