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Blue Review - Blue Cross and Blue Shield of Texas

December 20, 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.

Clinical Submissions
The following is a list of some claims categories where we may routinely require submission of clinical information before or after payment of a claim. A complete list of claims categories is located in the Provider Manual, http://www.bcbstx.com/pdf/medicaid_star_chip_manual.pdf.

Claims involving precertification/prior authorization/predetermination (or some other form of utilization review) including but not limited to:

  • Claims pending for lack of precertification or prior authorization
  • Claims involving medical necessity or experimental/investigative determinations
  • Claims involving drugs administered in a physician's office requiring prior authorization
  • Claims requiring certain modifiers
  • Claims involving unlisted codes
  • Claims that we have reason to believe involve inappropriate (including fraudulent) billing
  • Claims that are subject to an audit (internal or external), including high-dollar claims

Benefit Codes
Submit claims with the appropriate benefit code for services, as required. For electronic claims, add the benefit code in SBR Loop 2000B, SBR03. For paper claims, add the benefit code in Box 11 on the CMS-1500 Claim Form. If you submit a claim without the benefit code when it is required, the claim will be returned for resubmission.

Benefit Code

Service

CCP*

Comprehensive Care Program (CCP)

CSN

Children with Special Healthcare Needs (CSHCN) Services Program Provider

DE1

Texas Health Steps Dental

DM2

Texas Medicaid Home Health DME

DM3

CSHCN Services Program Home Health DME

EC1

Early Childhood Intervention (ECI) Providers

EP1*

Texas Health Steps

FP3*

Family Planning

HA1

Hearing Aid

IM1

Immunization

MA1

Maternity

MH2

Behavioral/Mental Health Case Management

TB1

Tuberculosis (TB) Clinic

WC1

Women, Infants, and Children (WIC) Program

*Required codes for submission to BCBSTX for submitting claims; all others codes are required by Health and Human Services Commission (HHSC) when claims are sent to the state for reimbursement.


CHIP Provider Responsibility

CHIP providers are responsible for collecting any applicable copayments at the time of service, in accordance with Children's Health Insurance Program (CHIP) cost-sharing limitations.

The CHIP member's copayment is listed on their ID card.

Families that meet the enrollment period cost-sharing limit requirement must report it to Maximus, the Texas Health and Human Services Commission (HHSC) Administrative Services Contractor. Upon notification from Maximus that the cost-sharing limit has been reached, BCBSTX will issue the CHIP member a new member ID card within five days, showing that the member's cost-sharing limit has been met. No copayment may be collected from these CHIP Members for the balance of their term of coverage.

Exceptions
Immunizations, Well-Child, Well-Baby
No copayments apply, at any income level, to well-child or well-baby visits or immunizations, except for costs associated with unauthorized, non-emergency services provided by out-of-network providers for non-covered services.

Native Americans and Alaskan Natives
Federal law prohibits charging copayments, deductibles or out-of-pocket cost to CHIP and CHIP Perinate members who are Native Americans or Alaskan Natives. When a member is identified as a Native American or Alaskan Native, the member will be issued a member ID card showing the member has no cost-sharing obligations.


Synagis
RSV (respiratory syncytial virus) season is here. BCBSTX Medicaid and CHIP will be following the Texas Pediatric Society (TPS) Infectious Disease Committee RSV Task Group recommendations for administration of Synagis. The recommendations are based on more than 10 years of epidemiologic data for each of the DSHS Regions, and the 2009 AAP guidelines noted in the 2012 Redbook.

For Region 7, Austin and the Travis Service Area, the dates for administration of Synagis are Oct. 1, 2013, to March 1, 2014. AAP guidelines recommend a maximum of five doses of Synagis and note that the last dose should provide good protection for four weeks, allowing the child to be covered for the remainder of the season. TPS suggests, if possible, waiting to start prophylaxis until the arrival of RSV in the area to allow more efficient use of Synagis. The TPS information and epidemiologic updates are available on the TPS website: http://txpeds.org/rsv-data.

In summary, BCBSTX will implement the TPS recommendations with a maximum of five doses of Synagis for the highest risk infants and use the dates of Oct. 1, 2013, to March 1, 2014.


Weekly Newsletter Update

The BCBSTX Medicaid (STAR) and CHIP newsletter will no longer be issued on a bi-weekly basis. The January 2014 newsletter will be issued on Jan.10. Beginning in February, the newsletter will be issued the first Friday of every month.


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 Anselmi, angela_anselmi@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.

Blue Cross and Blue Shield of Texas (BCBSTX), a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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Blue Review Medicaid (STAR) & CHIP Update • December 20, 2013 • www.bcbstx.com