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Blue Review - Blue Cross and Blue Shield of Texas

May 2014

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.


Upcoming Provider Training
Topic: Provider Training – A Comprehensive Overview of Claims, Billing, Authorization
Presenter: Deneice Pryor, RN, BSN; provider representative for Texas Health Steps
Date:  May 23, 2014
Place:  Marie Callender's, 9503 Research Blvd, #400, Austin, TX 78759
Time:  Noon to 2 p.m.
RSVP:  May 22 by noon
RSVP to juanita_hill@bcbstx.com

Topic: Migrant Health
Date:  May 28, 2014
Place:  Joe’s Crab Shack, 600 E. Riverside Dr., Austin, TX 78704
Time:  Noon to 2 p.m.
RSVP:  May 27 by noon
RSVP to juanita_hill@bcbstx.com


HEDIS Quality Improvement Study and Project

The Healthcare Effectiveness Data and Information Sets (HEDIS) is a core set of performance measures that gauges the effectiveness of Blue Cross and Blue Shield of Texas (BCBSTX) and its providers. BCBSTX measures the effectiveness of our care and service through HEDIS measures. We submit the results of HEDIS annually to the Texas Health and Human Services Commission.  Providers are asked to support and contribute to our efforts to improve HEDIS measure rates. 


Access to Medical Records for HEDIS Audits

BCBSTX will contact the provider's office to arrange a review or to copy any medical records required for quality improvement studies. Office staff must give access to medical records for reviewing and copying. 


Services Requiring Prior Authorization

Providers are responsible for verifying eligibility and authorization for non-emergent services prior to rendering services to a BCBSTX member. For benefits to be paid, the member must be eligible on the date of service and the service must be a covered benefit.  Except in an emergency, failure to obtain prior authorization for the designated services may result in a denial for reimbursement.   Providers may access the Request for Prior Authorization form and the Services Requiring Prior Authorization toolkit at bcbstx.com/provider/Medicaid. Click on the Education and Reference tab and then Forms.

Here are some tips for getting the fastest response to your authorization request:

  • Access forms online when you need one, rather than pre-printing and storing them.  We revise forms periodically and outdated forms can delay your request.
  • Print out and complete forms fully before faxing. Unanswered questions typically result in delays.


Formulary and Prior Authorization (PA)

Prior Authorization (PA) is required for all non-formulary medications that appear on the Texas Medicaid Formulary. PA is not available for drugs that are not covered or not included in this benefit. PA may be obtained by phone or by fax.

CHIP Prior Authorization: 866-472-2095
Prior Authorization fax: 800-357-9577

STAR Prior Authorization: 866-533-7008
Prior Authorization fax: 800-357-9577

Emergency Prescription Supply
A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and a prior authorization (PA) is not available. This applies to all drugs requiring a prior authorization (PA), such as those that 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 formulary 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 72-hour emergency supply is not applicable if the three-prescription limit has been met.


Value-Added Services
  • Free rides to non-emergency doctor visits, pharmacies, covered services and health education classes
  • 24-Hour Nurse Line
  • Free baby car seats for infants and youth booster car seats for children ages 2 to 12
  • Safety helmets to help keep kids stay safe on bikes or skateboards and in other outdoor activities
  • Free sports and camp physicals for kids who want to go to camp or play sports
  • Upgraded eye glass frames for children to get stylish frames if they wear glasses
  • Pregnancy, childbirth and newborn care classes for pregnant members
  • An in-home wellness visit and breastfeeding support with a free breast pump after the baby is born
  • Dental care for adult pregnant STAR members age 21 and older, and CHIP Perinate members age 19 and older
  • Coupons for pregnant members for the SFC Farmers' Markets in and around the Austin area to get fresh fruits and vegetables
  • A free multilingual glucometer that speaks test results in English, Spanish, French and Arabic for diabetic STAR members who need help monitoring their blood sugar.
For additional information on any of the above listed Value Added Services, contact the Customer Care Center at 888-292-4487.


2014 Immunization Schedule Now Available

The Recommended Childhood and Adolescent Immunization Schedule for 2014 is now available on http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html.


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

Becky Gdula, becky_gdula@bcbstx.com, 512-349-4840
Facility/Ancillary

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 • May 2014 • www.bcbstx.com