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Blue Review - Blue Cross and Blue Shield of Texas

June 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: Medicaid (STAR) and CHIP Provider Comprehensive Overview (includes Billing, Coding, Authorizations, and more)
Date:   June 20, 2014
Place:  Joe's Crab Shack, 600 E. Riverside Dr. Austin, TX 78704
Time:   Noon to 2 p.m.
RSVP: June 19 by noon

Topic:  Migrant Farmworkers Presentation
Presenter: Richardo Garary
Date:   June 25, 2014 
Place:  Red Lobster, 3815 S. Lamar Blvd, Austin, TX 78704
Time:   Noon to 2 p.m.
RSVP:  June 24 by noon

RSVP to Juanita Hill at Juanita_Hill@bcbstx.com.

Claim Payment Appeal Procedure

Claim Payment  Appeal is the process by which a provider may challenge the disposition of a claim that has already been adjudicated. Claim payment appeals may also include retrospective medical necessity reviews. Requests for claim payment appeals must be submitted in writing to BCBSTX within 120 days of a claim disposition. Claim payment appeal requests are resolved within 30 days of receipt of written request.

When BCBSTX changes a previous claim disposition, the provider will be notified of the final disposition through a remittance advice that indicates the additional payment due to the provider. When BCBSTX upholds a previous claim disposition, a resolution letter with the details of our decision is sent to the provider. 

Complete the Provider Dispute Resolution Request Form for claim payment appeals.

Note:  Claim payment appeals are sent to a different address than first time claims submissions.

Provider Appeals
Blue Cross and Blue Shield of Texas
Attn: Complaints and Appeals
P.O. Box 684249
Austin, TX 78768

Additional Administrative Issues Contact Information

Submit paper claims to (for first submission of claims):
Blue Cross and Blue Shield of Texas
Attn:  Claims
P.O. Box 684787
Austin, TX 78768-4787

Provider Complaints
Blue Cross and Blue Shield of Texas
Attn: Complaints and Appeals Department
P.O. Box 684249
Austin, TX 78768

External Review
The provider may request an external review from a non-network provider of the same or related specialty.
Blue Cross and Blue Shield of Texas
Attn: Complaints and Appeals Department
P.O. Box 684249
Austin, TX 78768

Claim Filing with the Wrong Plan
If you file a claim with the wrong insurance carrier and provide documentation verifying the initial timely claims filing within 95 days of the date of the other carrier's denial letter or RA form, BCBSTX processes your claim without denying it for failure to file within the filing time limits.

Claim Status and Follow-up
Checking Claim Status
Providers should receive a response from BCBSTX within 30 business days of receipt of claim.  If the claim contains all required information, BCBSTX enters the claim into the BCBSTX 's claim system for processing and sends the provider a Remittance Advice (RA) or Claims Disposition Notice (CDN) at the time the claim is finalized.

Checking Status Online

Providers can confirm BCBSTX's receipt of your claim through the AvailityTM online tool at www.availity.com. Using Availity, providers can also view claim status and payment information.

IVR Claim Status

Providers can confirm that BCBSTX received your claim through our Interactive Voice Response (IVR) by calling the BCBSTX Customer Care Center (CCC) at 888-292-4487. 

Representative hours are Monday - Friday, 7 a.m. to 6 p.m. (CT), except holidays.

Interpreter Services

Telephone interpreters
During business hours, call the BCBSTX Customer Care Center at 888-292-4487. After business hours, call NurseLine 24/7 at 877-351-8392.

1. Give the customer care represnetative the member's ID number.
2. Explain the need for an interpreter and state the language.
3. Wait on the line while the connection is made.
4. Once connected to the interpreter, introduce the BCBSTX member, expain the reason for the call, and begin the dialogue.

Face-to-face interpreters including sign language.
Call the BCBSTX Customer Care Center at 888-292-4487 to schedule during business hours. We require three business days to schedule, and one business day to cancel.

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

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.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.

1001 E. Lookout Drive, Richardson, TX 75082

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Blue Review Medicaid (STAR) & CHIP UPDATE • June 2014 • www.bcbstx.com