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Issue 2, 2012 (Electronic distribution date: February 2, 2012) With this issue, Blue Review rings in the year with a new look! We hope you enjoy the redesigned masthead as we strive to continue providing you news and updates important to your practice. Code auditing update In accordance with Texas law and regulation, Blue Cross and Blue Shield of Texas (BCBSTX) hereby gives notice that changes will be made to the claims processing system that affect our bundling logic. We will be updating the current McKesson ClaimsXten™ v4.1 to include the 2012 CPT® and HCPCS code changes and the associated bundling logic, effective on or after May 7, 2012, for all lines of business. Due to our licensing agreement with McKesson, mass lists or spreadsheets of bundling combinations cannot be distributed. BCBSTX will continue with the modifier 59 exempt program through ClaimsXten. This program is based on CMS National Correct Coding Initiative (NCCI). NCCI guidelines state: "Each NCCI edit has an assigned modifier indicator. A modifier indicator of "0" indicates that NCCI associated modifiers cannot be used to bypass the edit." BCBSTX will continue to use ClaimCheck as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimCheck database will NOT be added. On a quarterly basis, BCBSTX reviews new and revised AMA CPT and HCPCS codes, which are added or deleted periodically by McKesson to the ClaimsXten software without changing the software version. Going forward, BCBSTX will load this additional data to the BCBSTX claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date of such load on the BCBSTX provider website, bcbstx.com/provider. Advance notification of updates to the ClaimsXten software version (i.e. change from ClaimsXten v.4.1 to v4.4) will continue to be posted on the BCBSTX provider website in accordance with Texas law and regulation. For further information about current bundling methodologies, or to request specific code-to-code bundling, you may access this information via the online tool, Clear Claim Connection™. Clear Claim Connection™ (CCC), a web-based code auditing reference tool, is available to all contracted BCBSTX providers. It is available at Clear Claim Connection 1 Filing BlueCard® ancillary claims Generally, claims should be filed to the local Blue Cross and Blue Shield Plan. However, there are unique circumstances when claim filing directions will differ based on the type of provider and service. The local Blue Plan as defined for ancillary services is as follows: Independent Clinical Laboratory (Lab): The Plan in whose state* the specimen was drawn. Durable/Home Medical Equipment and Supplies (DME): The Plan in whose state* the equipment was shipped to or purchased at a retail store. Specialty Pharmacy: The Plan in whose state* the ordering physician is located. The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue Plan where the claim is filed. Providers are encouraged to verify member eligibility and benefits by contacting the phone number on the back of the member ID card or call 800-676-BLUE, prior to providing any ancillary service. Providers that utilize outside vendors to provide services (e.g., sending a blood specimen for special analysis that cannot be performed by the lab where the specimen was drawn) should utilize in-network participating ancillary providers to reduce the possibility of additional member liability for covered benefits. A list of in-network participating providers may be obtained by using the Provider Finder® at bcbstx.com. Members are financially liable for ancillary services not covered under their benefit plan. It is the provider’s responsibility to request payment directly from the member for noncovered services. If you have any questions about where to file your claim, please contact Blue Cross and Blue Shield of Texas (BCBSTX) provider Customer Service at 800-451-0287. * If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim with either Plan. Provider Type Independent Clinical Laboratory (any type of non hospital based laboratory) Types of Service include, but are not limited to: blood, urine, samples, analysis, etc. Durable/Home How to file (required fields) Referring Provider: - Field 17B on CMS 1500 Health Insurance Claim Form or - Loop 2310A (claim level) on the 837 Professional Electronic Patient’s Address: Where to file File the claim to the Plan in whose state the specimen was drawn* * Where the specimen was drawn will be determined by which state the referring provider is located. File the claim to the 2 Example Blood is drawn* in lab or office setting located in Texas. Blood analysis is done in California. File to: Texas. *Claims for the analysis of a lab must be filed to the Plan in whose state the specimen was drawn. Wheelchair is Provider Type Medical Equipment and Supplies (D/HME) Types of Service include, but are not limited to: hospital beds, oxygen tanks, crutches, etc. How to file (required fields) - Field 5 on CMS 1500 Health Insurance Claim Form or, - Loop 2010CA on the 837 Professional Electronic Submission. Where to file Plan in whose state the equipment was shipped to or purchased in a retail store. Ordering Provider: - Field 17B on CMS 1500 Health Insurance Claim Form or, - Loop 2420E (line level) on the 837 Professional Electronic Submission. Example purchased at a retail store in Texas. File to: Texas Wheelchair is purchased on the internet from an online retail supplier in Ohio and shipped to Texas. File to: Texas Wheelchair is purchased at a retail store in Texas and shipped to Arizona. File to: Arizona Place of Service: - Field 24B on the CMS 1500 Health Insurance Claim Form or, - Loop 2300, CLM05-1 on the 837 Professional Electronic Submissions. Service Facility Location Information: - Field 32 on CMS 1500 Health Insurance Form or - Loop 2310C (claim level) on the 837 Professional Electronic Submission. Specialty Pharmacy Types of Service: Non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit as defined by the member’s Plan’s Specialty Pharmacy formulary. Includes, but are not limited to: injectable, infusion therapies, etc. Referring Provider: - Field 17B on CMS 1500 Health Insurance Claim Form or - Loop 2310A (claim level) on the 837 Professional Electronic Submission. File the claim to the Plan whose state the Ordering Physician is located. Patient is seen by a physician in Texas who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Colorado where the member lives for 6 months of the year. File to: Texas Bath salts: The new over-the-counter drug and its increasing epidemic abuse What comes to mind when you hear the word “bath salts*?” Unfortunately, the term has taken on a darker and considerably more dangerous connotation. “Bath salts” is slang for a new over-the-counter drug of abuse that is making headlines throughout the country. Although the name may appear harmless, this new drug is anything but. Bath 3 salts are now a leading cause of emergency room visits, hospital admissions and calls to poison control centers. Bath salts are a new designer stimulant containing substituted cathinones such as 3, 4methylenedioxypyrovalerone (MDPV) or 4-methylmethcathinone (mephedrone). Both of these chemicals are related to an organic stimulant, khat, found in East African and Arabic countries. These drugs come in powder and crystal form and are packaged similarly to bath salts although they have no legitimate use for bathing. The powder can be used rectally, smoked, injected, snorted or ingested. Bath salts have been marketed in the United States under a variety of harmless sounding names such as: “Cloud 9,” “Blizzard,” “Ivory Wave,” “White Lightning” and “Vanilla Sky”. These drugs, although now illegal, have been commonly found in gas stations, smoke shops, convenience stores and on the Internet. Both mephedrone and MDPV are central nervous stimulants and produce effects similar to those of amphetamines, cocaine and ecstasy (e.g. enhances state of alertness, euphoria and intense stimulation, etc.). However, along with this pleasurable “high” comes troubling sympathetic hyper-stimulation and psychiatric effects. The sympathetic effects include hyperthermia, tachycardia, hypertension and seizures. The psychiatric effects present as visual hallucinations, paranoia, agitation, psychosis and homicidal or suicidal thoughts. These substances have an onset of about 20 minutes when ingested orally and can last from two to four hours. When this drug is snorted or inhaled, the onset and peak occur much earlier. The effects from these substances can last up to 10 days and are extremely dangerous. Unfortunately, there is currently no antidote for bath salt overdose and the best available treatment is supportive care. The treatment is dependent upon the patient’s presentation but typically involves fluids, benzodiazepines and physical restraints. In addition, the patient’s blood pressure, body temperature, heart rate, CPK and potassium should be closely monitored. Psychiatric monitoring is recommended until mental status returns to normal as hallucinations can last for days. The U.S. Drug Enforcement Agency (DEA) has worked diligently to limit the epidemic abuse of bath salts. As of Sept. 8, 2011, the DEA utilized its emergency scheduling authority to temporarily control the common substances found in bath salts – methylenedioxypyrovalerone, mephedrone and methylone. Any product containing these substances will be illegal for at least one year until the DEA and the U.S. Department of Health and Human Services determine whether or not the substances should be permanently controlled. Although bath salts are currently illegal in the United States, it is by no means certain that people will stop abusing these substances. Therefore, it is important for clinicians to be aware of the dangers associated with the misuse of these chemicals. In patients who present with sympathomimetic overdose symptoms, bath salts (mephedrone or MDPV) should be considered. The substances are undetectable by routine drug screens and the clinical presentation can be indistinguishable from other stimulant overdoses. 4 References: 1. Ross EA, Watson M, Goldberger B. “Bath Salts” Intoxication. N Engl J Med 2011; 365(10):967-8. 2. “Bath salts” abuse. Pharmacist’s Letter/Prescriber’s Letter 2011; 27(3):270312. 3. Melton S. Bath Salts: An ‘Ivory Wave’ Epidemic? Aug. 26, 2011. Internet: medscape.com/viewarticle/748344. 4. Lowry F. DEA Moves to Make ‘Bath Salts’ Illegal as Overdoses Rise. Sept. 7, 2011. Internet: medscape.com/viewarticle/749304. 5. Goodnough A. and Zezima K. An Alarming New Stimulant, Legal in Many States. The New York Times. July 16, 2011. Internet: nytimes.com/2011/07/17/us/17salts.html?pagewanted=all. * The bath salts discussed in this article contain different ingredients than the bath salts found in retail stores across America. Understanding the Federal Employee Program and OBRA Part A The Federal Employee Program (FEP) is unique in many ways. The federal government writes the policy that is administered and federal laws apply to the program’s contracts. While many of these federal laws are not written specifically in the provider contract, they must be complied with. One such law is the Omnibus Reconciliation Act of 1990 (OBRA ’90), which initially included only the Part A component of OBRA. The Act was amended in 1993, adding OBRA ’93 Part B. OBRA affects patients who are 65 or over who do not have Medicare coverage and are on the plan as a policyholder, annuitant, former spouse or as a covered family member of an annuitant or former spouse. In addition, it limits plan benefits to those to which the patient would have been entitled if they had Medicare coverage. The provider’s contracting status with Medicare and with the plan determines the maximum amount for which the patient can be billed. How Part A and Part B Work OBRA ’90 Part A only applies to inpatient services. The OBRA ’90 pricing allowance is calculated based upon Medicare DRG pricing. If the patient has no Medicare and is not employed by an entity that confers with an FEP benefit plan, plan benefits will apply, and the claim will be paid according to the Medicare allowance for the stay. If the patient has Part B coverage, claims for ancillary services will still need to be submitted to Medicare for payment. The Explanation of Medicare Benefits (EOMB) will also need to be included with the claim. The plan will consider the payment that Medicare made on the claim. For OBRA ’93 Part B, the allowed amount will apply if there is an equivalent Medicare allowable for your services. If there is no Medicare equivalent, the plan allowance will apply. Some services, such as laboratory, ambulance, and durable medical equipment, are not subject to OBRA ’93 pricing. If a patient is over 65 and actively working, OBRA ’90 and OBRA ’93 do not apply. You may consult the plan for a further explanation of how both the Part A and Part B claims are processed. 5 Use the Claim Research Tool for expanded results Do you, your staff or your billing agent (billing service or clearinghouse) need an easy-touse administrative solution that provides more information, in less time, at no charge, with printable results? Blue Cross and Blue Shield of Texas (BCBSTX) invites you to consider using the Availity®’ Claim Research Tool (CRT) for expanded claim status information that can help expedite your patient account reconciliation process. This secure, online self-service tool allows Availity-registered users to obtain detailed, line-level claim status information, including reason codes and descriptions. You can use the CRT to conduct an unlimited number of basic or detailed claim status inquiries when it’s most convenient for you, without taking time away from your patients. Is it really easy to use? Yes! Here is a brief overview to assist you with accessing and navigating the CRT: 1. Log on to the Availity portal Go to availity.com and enter your user ID and password, then click on Login Select “Claims Management,” and then select “Claim Research Tool” Select the appropriate payer, then click on Next 2. Set your search parameters For a Member ID Search: Enter the Provider Billing NPI, Member ID, Group Number and service period Click Search to go to the Search Results page Select the Claim Number for the claim you wish to view to go to the Claim Details page For a Claim Number Search: Enter the alpha-numeric claim number in the Claim # (DCN) field Click on Search to go directly to the Claim Details page 3. View Claim Details Your search will allow you to view overall claim status and line item details You can choose to export or print the information, or conduct a new search For additional information, refer to the CRT Tip Sheet in the Education and Reference/Provider Tools section of the BCBSTX provider website at bcbstx.com/provider. To learn more about other electronic options available to independently contracted providers, contact your Provider Network Representative. You must be registered with Availity to utilize the CRT. For registration information and to learn more about Availity’s online resources and services, visit availity.com. Or, contact Availity Client Services at 800-AVAILITY (800-282-4548). Availity is a registered trademark of Availity, L.L.C. Availity is a third-party vendor, and BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by this vendor. Availity is solely responsible for the products and services it offers. If you have any questions regarding the products or services offered by Availity, you should contact them directly. 6 Notices and Announcements Molecular Pathology Procedure test codes Beginning Jan. 1, 2012, the American Medical Association has established additional Molecular Pathology Procedure test codes. Each of these new Molecular Pathology Procedure test codes represents a test that is currently being used and that may be billed with existing Current Procedural Terminology (CPT) codes. For example, a provider performs a genetic test that is generally billed as follows in order to represent the performance of the entire test: 83891 (one time) + 83898 (multiple times) + 83904 (multiple times) + 83909 (multiple times) + 83912 (one time) In the new CPT test coding structure, the provider can bill with the new, single CPT test code that corresponds to the test represented by the codes in the example above rather than billing each component of the test separately. BCBSTX requests that providers bill using the separate components or “stacked” codes rather than using the new, single Molecular Pathology Procedure test codes. Fee schedule information is posted at bcbstx.com/provider. Some procedures may be considered Experimental and Investigational by BCBSTX. Please refer to Medical Policy posted on the BCBSTX website. The table below lists the new 2012 Molecular Pathology Procedure test codes: 81200 81209 81214 81221 81226 81241 81250 81260 81265 81275 81291 81296 81301 81315 81330 81342 81372 81377 81382 81403 81205 81210 81215 81222 81227 81242 81251 81261 81266 81280 81292 81297 81302 81316 81331 81350 81373 81378 81383 81404 81206 81211 81216 81223 81228 81243 81255 81262 81267 81281 81293 81298 81303 81317 81332 81355 81374 81379 81400 81405 81408 7 81207 81212 81217 81224 81229 81244 81256 81263 81268 81282 81294 81299 81304 81318 81340 81370 81375 81380 81401 81406 81208 81213 81220 81225 81240 81245 81257 81264 81270 81290 81295 81300 81310 81319 81341 81371 81376 81381 81402 81407 Reminder: Bilateral procedures – Modifier 50 Modifier 50 should be submitted only on those procedures that can be performed bilaterally. Bilateral procedures that are performed at the same operative session should be identified by adding a modifier 50 to the appropriate 5-digit CPT code. Modifier 50 denotes a bilateral procedure (diagnostic, radiological or surgical) performed on both sides at the same operative session. Modifier 50 should not be used with procedures identified by their terminology as either "bilateral" or "unilateral or bilateral." Please report one unit, do not use modifiers RT and LT, and do not submit two line items. To view information on Blue Cross and Blue Shield of Texas’ (BCBSTX) Multiple Surgery Pricing, go to bcbstx.com/provider, under Standards & Requirements, go to General Reimbursement Information, All Product News, Multiple Surgery — Prof. Please Note: Beginning April 1, 2012, recovery will be pursued on claims paid based on Modifier 50 inappropriate billing as described above. In Every Issue Medical record requests: Include our letter as your cover sheet When you receive a letter from Blue Cross and Blue Shield of Texas (BCBSTX) requesting additional information such as medical records or certificates of medical necessity, please utilize the letter as a cover sheet when sending the requested information to us. This letter contains a barcode in the upper right corner of the page to help ensure that the information you send is matched directly to the appropriate file and/or claim. Do not submit a Claim Review Form in addition to the letter, as this could delay the review process. Thank you for your cooperation! Technical and professional components Modifiers 26 and TC: Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical component for lab and radiological services. These modifiers should be used in conjunction with the appropriate lab and radiological procedures only. Note: When a physician or other professional provider performs both the technical and professional service for a lab or radiological procedure, he/she must submit the total service, not each service individually. Surgical procedures performed in the physician's office When performing surgical procedures in a non-facility setting, the physician and other professional provider reimbursement is all-inclusive. Our payment covers all of the services, supplies and equipment needed to perform the surgical procedure when a member receives these services in the physician's or other 8 professional provider’s office. Please note the physician and other professional provider’s reimbursement includes surgical equipment that may be owned or supplied by an outside surgical equipment or Durable Medical Equipment (DME) vendor. Claims from the surgical equipment or DME vendor will be denied based on the fact that the global physician reimbursement includes staff, supplies and equipment. AIM RQI reminder Physicians and professional providers must contact American Imaging Management®’ (AIM) first to obtain an RQI number when ordering or scheduling the following outpatient, non-emergency diagnostic imaging services when performed in a physician’s office, a professional provider’s office, the outpatient department of a hospital or a freestanding imaging center: CT/CTA MRI/MRA SPECT/nuclear cardiology study PET scan To obtain a PPO RQI number, log in to AIM’s provider portal at americanimaging.net and complete the online questionnaire that identifies the reasons for requesting the exam. If criteria are met, you will receive an RQI number. If criteria are not met or if additional information is needed, the case will automatically be transferred for further clinical evaluation and an AIM nurse will follow up with your office. AIM’s provider portal uses the term “Order” rather than “Preauth” or “RQI.” Note: Facilities cannot obtain an RQI number from AIM on behalf of the ordering physician. Also, the RQI program does not apply to Medicare enrollees with BCBSTX Medicare supplement coverage. Medicare enrollees with BCBSTX commercial PPO/POS coverage are included in the program. Quest Diagnostics, Inc., is the exclusive HMO and preferred statewide PPO/POS clinical reference lab provider Quest Diagnostics, Inc., is the exclusive outpatient clinical reference laboratory provider for HMO Blue® Texas members* and the preferred statewide outpatient clinical reference laboratory provider for BCBSTX BlueChoice (PPO/POS) members. This arrangement excludes lab services provided during emergency room visits, inpatient admissions and outpatient day surgeries (hospital and free-standing ambulatory surgery centers). Quest Diagnostics Offers: On-line scheduling for Quest Diagnostics' Patient Service Center (PSC) locations. To schedule a patient PSC appointment, log onto QuestDiagnostics.com/patient or call 888-277-8772. Convenient patient access to more than 220 patient service locations. 24/7 access to electronic lab orders, results, and other office solutions through Care360®’’ Labs and Meds. 9 For more information about Quest Diagnostics lab testing solutions or to establish an account, contact your Quest Diagnostics Physician Representative or call 866-MYQUEST (866-697-8378). For physicians and other professional providers located in the HMO capitated lab counties, only the lab services/tests indicated on the Reimbursable Lab Services list will be reimbursed on a fee-for-service basis if performed in the physician’s or other professional provider’s office for HMO Blue Texas members. Please note all other lab services/tests performed in the physician’s or other professional provider’s office will not be reimbursed. You can access the county listing and the Reimbursable Lab Services list at bcbstx.com/provider under the General Reimbursement Information section located under the Standards and Requirements tab. * Note: Physicians & other professional providers who are contracted/affiliated with a capitated IPA/medical group and physicians & professional providers who are not part of a capitated IPA/medical group but who provide services to a member whose PCP is a member of a capitated IPA/medical group must contact the applicable IPA/medical group for instructions regarding outpatient laboratory services. Fee schedule updates Reimbursement changes and updates for BlueChoice and HMO Blue Texas (Independent Provider Network only) practitioners will be posted under Standards and Requirements / General Reimbursement Information / Reimbursement Schedules and Related Information / Professional Schedules section on the BCBSTX provider website at bcbstx.com/provider. The changes will not become effective until at least 90 days from the posting date. The specific effective date will be noted for each change that is posted. To view this information, visit the General Reimbursement Information section on the provider website. Also, the Drug/Injectable Fee Schedule will be updated on the following dates: March 1, 2012; and June 1, 2012. Improvements to the medical records process for BlueCard® claims BCBSTX is now able to send medical records electronically to all Blue Cross and/or Blue Shield Plans. This method significantly reduces the time it takes to transmit supporting documentation for BlueCard claims and eliminates lost or misrouted records. As always, we will request that you submit your medical records to BCBSTX if needed for claims processing. Requests for medical records from other Blues Plans before rendering services, as part of the preauthorization process, should be submitted directly to the requesting Plan. Pass-through billing BCBSTX does not permit pass-through billing. Pass-through billing occurs when the ordering physician or other professional provider requests and bills for a service, but the service is not performed by the ordering physician or other professional provider. 10 The performing physician or other professional provider should bill for these services unless otherwise approved by BCBSTX. BCBSTX does not consider the following scenarios to be pass-through billing: The service of the performing physician or other professional provider is performed at the place of service of the ordering provider and is billed by the ordering physician or other professional provider. The service is provided by an employee of a physician or other professional provider (physician assistant, surgical assistant, advanced nurse practitioner, clinical nurse specialist, certified nurse midwife or registered first assistant who is under the direct supervision of the ordering physician or other professional provider) and the service is billed by the ordering physician or other professional provider. The following modifiers should be used by the supervising physician when he/she is billing for services rendered by a Physician Assistant (PA), Advanced Practice Nurse (APN) or Certified Registered Nurse First Assistant (CRNFA): • AS modifier: A physician should use this modifier when billing on behalf of a PA, APN or CRNFA for services provided when the aforementioned providers are acting as an assistant during surgery. (Modifier AS to be used ONLY if they assist at surgery.) • SA modifier: A supervising physician should use this modifier when billing on behalf of a PA, APN or CRNFA for non-surgical services. (Modifier SA is used when the PA, APN, or CRNFA is assisting with any other procedure that DOES NOT include surgery.) Contracted physicians and other professional providers must file claims As a reminder, physicians and other professional providers must file claims for any covered services rendered to a patient enrolled in a BCBSTX health plan. You may collect the full amounts of any deductible, coinsurance or copayment due and then file the claim with BCBSTX. Arrangements to offer cash discounts to an enrollee in lieu of filing claims with BCBSTX violate the requirements of your physician and other professional provider contract with BCBSTX. Notwithstanding the foregoing, a provision of the American Recovery and Reinvestment Act changed HIPAA to add a requirement that if a patient self pays for a service in full and directs a physician or other professional provider to not file a claim with the patient's insurer, the physician or other professional provider must comply with that directive and may not file the claim in question. In such an event, you must comply with HIPAA and not file the claim to BCBSTX. Medical policy disclosure New or revised medical policies, when approved, will be posted on our provider website portal on the 1st or 15th day of each month. Those policies requiring disclosure will become effective 90 days from the posting date. Policies that do not require disclosure will become effective 15 days after the posting date. The specific effective date will be noted for each policy that is posted. 11 To view active and pending policies go to bcbstx.com/provider, click on the Policies link toward the bottom of the page and then click on the Medical Policies link. After reading and agreeing to the disclaimer, you will have access to active and pending medical policies. Draft medical policy review In an effort to streamline the medical policy review process, you can view draft medical policies on our provider portal and provide your feedback online. The documents will be made available for your review around the 1st and the 15th of each month with a review period of approximately two weeks. To view draft policies go to bcbstx.com/provider, click on the Policies link toward the bottom of the page and then click on the Draft Medical Policies link. . No additional medical records needed Physicians and other professional providers who have received an approved predetermination (which establishes medical necessity of a service) or have obtained a radiology quality initiative (RQI) number from American Imaging Management need not submit additional medical records to BCBSTX. In the event that additional medical records are needed to process a claim on file, BCBSTX will request additional medical records at that time. Importance of obtaining preauthorizations for initial stay and add-on days Preauthorization is required for certain types of care and services. Although BCBSTX participating physicians and other professional providers are required to obtain the preauthorization, it is the responsibility of the insured person to confirm that their physician or other professional provider obtains preauthorizations for services requiring preauthorization. Preauthorization must be obtained for any initial stay in a facility and any additional days or services added on. If an insured person does not obtain preauthorization for initial facility care or services, or additional days or services added on, the benefit for covered expenses may be reduced. Preauthorization does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, application of the exclusions and limitations, and other provisions of the policy at the time services are rendered. Avoidance of delay in claims pending COB information BCBSTX receives thousands of claims each month that require unnecessary review for coordination of benefits (COB). What that means to our physicians and other professional providers is a possible delay, or even denial of services, pending receipt of the required information from the member. Here are some tips to help prevent claims processing delays when there is only one insurance carrier: 12 CMS-1500, box 11-d – if there is no secondary insurance carrier, mark the “No” box. Do not place anything in box 9, a through d – this area is reserved for member information for a secondary insurance payer. It is critical that no information appears in box 11-d or in box 9 a- d if there is only one insurance payer. Billing for non-covered services As a reminder, contracted physicians and other professional providers may collect payment from subscribers for copayments, co-insurance and deductible amounts. The physician or other professional provider may not charge the subscriber more than the patient share shown on their provider claim summary (PCS) or electronic remittance advice (ERA). In the event that BCBSTX determines that a proposed service is not a covered service, the physician or other professional provider must inform the subscriber in writing in advance. This will allow the physician or other professional provider to bill the subscriber for the non-covered service rendered. In no event shall a contracted physician or other professional provider collect payment from the subscriber for identified hospital acquired conditions and/or never events. QVT (quantity versus time) limits To help minimize health risks and to improve the quality of pharmaceutical care, QVT limits have been placed on select prescription medications. The limits are based upon the U.S. Federal Drug Administration and medical guidelines as well as the drug manufacturer’s package insert. Visit bcbstx.com/provider/pharmacy/index.html to access the 2012 QVT list. Preferred drug list Throughout the year, the BCBSTX Clinical Pharmacy Department team frequently reviews the preferred drug list. Tier placement decisions for each drug on the list follow a precise process, with several committees reviewing efficacy, safety and cost of each drug. For the 2012 drug updates, visit the BCBSTX provider website under the Pharmacy Program tab, or follow this link: bcbstx.com/provider/pharmacy/index.html. Are utilization management decisions financially influenced? BCBSTX is dedicated to serving its customers through the provision of health care coverage and related benefit services. Our mission calls for us to respond to our customers with promptness, sensitivity, respect and dignity. In support of this mission, BCBSTX encourages appropriate utilization decisions; it does not allow or encourage decisions based on inappropriate compensation. Physicians, 13 other professional providers or BCBSTX staff do not receive compensation or anything of value based on the amount of adverse determinations, reductions or limitations of length of stay, benefits, services or charges. Any person(s) making utilization decisions must be especially aware of possible underutilization of services and the associated risks. This topic has been addressed in the Blue Review provider newsletter and in previous BCBSTX employee communications as a requirement of our Utilization Review Accreditation Commission accreditation. This serves as a reminder for all physicians and other professional providers in the BCBSTX provider network. Contact us Click here for a quick directory of contacts at BCBSTX. Update your contact information online To update your contact information, go to bcbstx.com/provider, click on the Network Participation tab and follow the directions under Update Your Contact Information. This process allows you to electronically submit a change to your name, office or payee address, email address, telephone number, tax ID or other information. You should submit all changes at least 30 days in advance of the effective date of the change. If your specialty, practice information/status or board certification is not correct on Blue Cross and Blue Shield of Texas Provider Finder®, or if you would like to have a subspecialty added, you can enter the information in the “Other” field or contact your local Professional Provider Network office. Blue Review is published for BlueChoice®, ParPlan and HMO Blue® Texas contracting physicians and other health care providers. Ideas for articles and letters to the editor are welcome; email [email protected]. The information provided in Blue Review does not constitute a summary of benefits, and all benefit information should be confirmed or determined by calling the customer service telephone number listed on the back of the member ID card. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by independent, third-party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services they offer. If you have questions regarding any of the products or services mentioned in this periodical, please contact the vendor directly. © 2011 14