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Blue Review - Blue Cross and Blue Shield of Texas

May 17, 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.

Emergency Prescription Supply

A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring PA, either because they are non-preferred drugs on the Preferred Drug List (PDL) or because they are subject to clinical edits.

The 72-hour emergency supply should be dispensed any time a PA cannot be resolved within 24 hours for a medication on the Vendor Drug Program PDL that is appropriate for the member's medical condition. If the prescribing provider cannot be reached or is unable to request a PA, the pharmacy should submit an emergency 72-hour prescription.

The PDL is available online at http://www.txvendordrug.com/pdl.

PA may be obtained by phone or fax:
Medicaid (STAR) phone: 866-533-7088
Medicaid (STAR) fax: 800-357-9577
CHIP phone: 866-472-2095
CHIP fax: 800-357-9577

Providers may call the Medicaid (STAR) Help Desk at 866-294-1562 or CHIP/CHIP Perinate Help Desk at 866-323-2088 for more information about the 72-hour emergency prescription supply.

Texas Health Steps Quick Reference Guide

The Texas Health Steps Quick Reference Guide has been updated. Under the column titled "Immunizations Administered," vaccine procedure code 90644 has been added as a new vaccine to this section.

The Texas Health Steps Quick Reference Guide is located at http://www.tmhp.com.

McKesson ClaimsXten

For BCBSTX Medicaid (STAR) and CHIP programs, BCBSTX uses claims editing software from McKesson called ClaimsXten. ClaimsXten incorporates the McKesson editing rules that determine whether a claim should be paid, rejected or requires manual processing.

These editing rules assess Current Procedural Terminology (CPT®’) and Healthcare Common Procedure Coding System (HCPCS) codes on the CMS-1500 form. A claim auditing action then determines how the procedure codes and code combinations will be adjudicated. The auditing action recognizes historical claims related to current submissions and may result in adjustments to previously processed claims. You can find descriptions of specific reimbursement policies in the BCBSTX Medicaid (STAR) and CHIP Provider Manual at http://bcbstx.com/pdf/medicaid_star_chip_manual.pdf.

For the latest information and current ClaimsXten rules, click http://bcbstx.com/pdf/cxten_rules.pdf.

Provider Disputes

To request a claim appeal, send the request in writing to:
Blue Cross and Blue Shield of Texas
Attn: Claims
P. O. Box 684787
Austin, TX 78768

Provider Dispute Resolution Form (http://bcbstx.com/provider/pdf/provider_dispute.pdf)

Providers have 120 calendar days from the receipt of BCBSTX Remittance Advice (RA) or notice of action for a claim appeal. If BCBSTX requires additional information, the provider must return the information to BCBSTX within 21 calendar days from the date of the request by BCBSTX. If the information is not received within the 21 calendar days, BCBSTX may close the case. If the appeal deadline falls on a weekend or holiday, the deadline is extended to the next business day.

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.
Read more

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 17, 2013 • www.bcbstx.com