Download Issue 2, 2012

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
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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
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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.
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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:
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

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,
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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
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