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Blue Review - Blue Cross and Blue Shield of Texas

January 10, 2014

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.

Have You Updated Your Provider Information?
Visit the Blue Cross and Blue Shield of Texas (BCBSTX) provider website, bcbstx.com/forms/provider/update_info.html, to update any changes to your address, telephone number, group affiliation, and/or any other material facts via the Provider Information Change Form. Also, update your information with Texas Medicaid & Healthcare Partnership (TMHP) via their Provider Information Change Form at www.tmhp.com.


Contracted Hospitals and Ambulatory Surgery Centers

The following general acute care hospitals and ambulatory surgery centers are contracted with the BCBSTX Medicaid network:

Initial Health Assessment
Primary Care Providers (PCPs) or other professional providers should perform an Initial Health Assessment (IHA) with new members within 90 days of enrollment in BCBSTX. The IHA consists of:
  • A history and physical examination.
  • A developmental assessment.
An IHA is not necessary if the member is an existing patient of the PCP group (but new to the BCBSTX plan). Follow-up is not required if there is an established medical record that shows a baseline health status. This record must include sufficient information for the PCP to understand the member's health history and to provide treatment recommendations as needed. Transferred medical records can meet the requirements for an IHA if a completed history is included.


Referrals to Specialist

Utilization Management is available to assist providers in identifying a network specialist and/or arranging for specialist care. Here are some other items to keep in mind when referring members.

  • Authorization from Utilization Management is not required if referring a member to an in-network specialist for consultation or a nonsurgical course of treatment.
  • Authorization from Utilization Management is required when referring to an out-of-network specialist.
All providers are responsible for documenting referrals in the member's chart and requesting that the specialist provide updates as to the diagnosis and treatment plan.

For additional information on referral billing and claim submission refer to, Claims Billing Requirements for PCP's and Specialist, http://www.bcbstx.com/pdf/claims_pcps.pdf.


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.


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 • January 10, 2014 • www.bcbstx.com