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Blue Review - Blue Cross and Blue Shield of Texas

September 13, 2013

For Travis Service-Area Medicaid (STAR) & CHIP Providers

Welcome to the Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR) & CHIP newsletter. Thank you for participating in BCBSTX Medicaid (STAR) & CHIP programs.

Pertussis Health Alert
As of Aug. 27, 2013, Texas has reported 1,935 pertussis cases to the Centers for Disease Control and Prevention. If cases continue to be diagnosed and reported at the current rate, Texas will report the highest number of pertussis cases it has had in more than 50 years. Biweekly updates on pertussis in Texas are available at http://www.dshs.state.tx.us/idcu/disease/pertussis/.

Early recognition of cases, effective treatment and prophylaxis, and appropriate vaccination are vital to limiting the spread of pertussis. Pertussis can cause serious and potentially life-threatening complications in infants and young children who are not fully vaccinated. More than half of infants younger than 12 months of age who get pertussis require hospitalization.

Prior Authorization Required on Claims: Submission of Medical Records Not Accepted in Place of Prior Authorization

This is an update about information in the Blue Cross and Blue Shield of Texas (BCBSTX) Provider Manual. For access to the latest Provider Manual, go online to bcbstx.com/provider/medicaid/education_reference.html.

  • Prior authorization codes vs. medical records on submitted claims
    To streamline the claims process and ensure that eligible claims are processed in a timely manner, BCBSTX no longer accepts and reviews medical records attached to claims in place of required prior authorization (PA). This change was effective May 15, 2013. If a claim for a service requiring PA is received with medical records attached in place of the required PA, that claim will be denied due to lack of prior authorization.

Note: BCBSTX will review claims with medical records attached only if that review relates to an appeal request on a claim previously denied for no PA. Administrative denial on such claims will be upheld through appeal, regardless of attached medical records, unless the services are deemed to be a true emergency.

  • Prior authorization is required for certain services
    Providers are reminded that certain services require prior authorization (PA) from our Utilization Management (UM) department. A list of the services affected by this requirement is located online at bcbstx.com/provider/medicaid/forms.html.

  • Listing PA approval number on claim speeds processing
    Once you have received a PA, please remember to include the PA approval number on the claim form you submit to BCBSTX for reimbursement of services. Dependent upon the type of claim, this is done as follows:
    • If using CMS1500 professional claim , enter PA number in Box 23
    • If using CMS1450 (UB04) institutional claim form, enter PA number in Box 63

It is important that you include the PA approval number on your submitted claim. Failure to do so results in the manual processing of your claim. Manual processing slows both the approval of the claim and your payment.

Contact us for more information
If you would like to request prior authorization, please contact the UM staff at 855-879-7178. If you have general questions about PA, please contact Customer Care Center at 888-292-4487.

Prior Authorization Waiver Policy Enforced Oct. 14, 2013

This is an update about information in the BCBSTX Provider Manual. For access to the latest Provider Manual, go online to bcbstx.com/provider/medicaid/education_reference.html.

At BCBSTX, we appreciate the care you give to our members/your patients enrolled in Medicaid (STAR) and CHIP. As part of our ongoing communication efforts, we want to remind you about our policy concerning the waiver of prior authorization for emergency services rendered in an emergency room. Our policy remains in effect that providers do not need to obtain prior authorization to render emergency services in an emergency room or urgent care setting.

Please remember to obtain prior authorization on services that require a prior authorization when rendered outside of an emergency room or urgent care setting, regardless of diagnosis such as emergency DX codes. Effective Oct. 14, 2013, claims requiring a prior authorization for services performed outside the emergency room or urgent care will deny if no authorization was obtained.

To view the current list of services requiring prior authorization, access our website at bcbstx.com/provider/medicaid/forms.html.

If you have any questions about this provider bulletin, please call our Customer Care Center at 888-292-4487.

Magellan's Behavioral Health Disorders Toolkit for Primary Care Physicians
With physical and behavioral health so tightly entwined, consideration of your patient's behavioral health concerns has never been more essential for the delivery of integrated quality care. With this in mind, Magellan developed its Behavioral Health Disorders Toolkit, which contains:

  • descriptions of common behavioral health concerns
  • user-friendly screening tools for diagnosing behavioral health and substance use disorders
  • patient handouts
  • provider tip sheet
  • information materials

Organized by category, this online toolkit is designed to give medical practitioners the resources needed to identify potential behavioral health concerns and assist in making appropriate referrals.

We encourage you to use the toolkit to help address the behavioral components of patient treatment and improve overall outcomes for Magellan members in your care. Visit www.MagellanPCPtoolkit.com.

Additional resources:


Magellan PCP Toolkit Handout, http://www.bcbstx.com/pdf/toolkit_handout.pdf.

Magellan PCP Toolkit: Bridging the Gap, information, http://www.bcbstx.com/pdf/bhpcp_toolkit.pdf.

Questions about Claims
Claim status may be checked anytime by logging on to the Availity®’ website at http://www.availity.com or by calling the Customer Care Center Interactive Voice Response (IVR) system 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
Shelby Robinson, shelby_robinson@bcbstx.com, 512-349-4897
Austin County, Bell, Burleson, Milam, Williamson ( Georgetown and Round Rock)

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

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

Juanita Hill,  juanita_hill@bcbstx.com, 512-349-4896

Angela Rankin, angela_rankin@bcbstx.com, 512-349-4881
Facility/Ancillary Provider Network Representative

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
If the member is unable to reach Sonia, please contact Consuelo Izquierdo, consuelo.izquierdo@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 • September 13, 2013 • www.bcbstx.com