Did You Know? Authorizations and Referrals

September 7, 2018

Did You Know?

The following is information that Blue Cross and Blue Shield of Texas (BCBSTX) is required to provide in all published

correspondence with physicians, professional providers, and facility and ancillary providers. It includes a collection of

articles to assist provider offices in servicing BCBSTX patients. For the latest updates, visit the

News and Updates

area of the BCBSTX provider website.

Topics:

• Authorizations and Referrals

• Benefits and Eligibility

• Claims

• Clinical Resources

• CMS Guidance Notifications

• Education & Reference

• Electronic Options

• eviCore

• Pharmacy

• Provider General Information

• Rights and Responsibility

-----------------------------------------------------------------------------

Authorizations and Referrals

Importance of Obtaining a Preauthorization/Referral

A preauthorization/referral is required for certain types of care and services. Although Blue Cross and Blue Shield of

Texas(BCBSTX) participating physicians, professional providers and facility and ancillary providers are required to

obtain preauthorizations/referrals, it is also the responsibility of the member/subscriber to confirm that this action has

been taken for services that require a preauthorization/referral.

To determine if a service requires a referral or preauthorization, refer to the

Preauthorizations/Notifications/Referral

Requirements Lists under Clinical Resources on bcbstx.com.

Preauthorizations/referrals must be obtained for any services provided by someone other than the member's primary

care physician/provider (PCP) (i.e., specialist, ambulatory surgery centers, ancillary, etc.). A preauthorization/referral

is also needed for an initial stay in a facility and any additional days or services added on.

Preauthorizations are required to allow for medical necessity review. If a member/subscriber does not obtain a

preauthorization/referral for initial facility care or services, or additional days or services added on, the benefit for

covered expenses may be reduced. Retrospective reviews for medical necessity will not be performed for any HMO

plans except in limited special circumstances.

A preauthorization/referral does not guarantee payment. All payments are subject to determination of the

member/subscriber'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.

BCBSTX has implemented fax notifications of benefit preauthorization and predeterminations to the requesting

provider. This enhancement provides real-time information and eliminates the need for providers to check the status

of preauthorization or predetermination requests while waiting on the mailed notification letters. The faxed notification

will be in addition to the notification letter sent via mail to the address we have on file.

Notifications are faxed to the number either on file or listed on the utilization management or clinical request. You can

also check the status of your submitted request via iExchange

. As a reminder, because we are sending confidential

protected health information (PHI) to your fax machine, it should be in a secure location that is not accessible to those

who do not have the authority to review member/patient PHI.

If a preauthorization/referral request is received from an out-of-network (OON) provider and the member/subscriber

does not have an OON benefit, BCBSTX will contact the ordering provider to discuss network options. However, if a

member/subscriber has an OON benefit, OON benefits will apply, which could result in a higher cost sharing.

If you need any additional information on the preauthorization process or do not wish to receive faxed notifications,

please contact your BCBSTX Network Management Representative.

Checking eligibility, benefit information and/or if a service has been preauthorized is not a guarantee of payment. Benefits will be determined once

a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage

applicable on the date services were rendered. If you have any questions, please call the number on the back of the member’s ID card.

iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and

providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third-party vendors such

as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

-----------------------------------------------------------------------------

Reminder: Utilization Management Review

The Medical Management team, which includes physicians and nurses, evaluate hospital admissions (anticipated or

unanticipated) and continued stays, as well as outpatient services. The team utilizes a variety of resources, including

MCG criteria and BCBSTX medical policy to inform benefit determinations regarding the level of care, transition of

care and the management of home care needs.

Medical management does not make determinations about whether services are medically appropriate, only if the

services meet the definition of medically necessary under the terms of the applicable benefit plan. If a service does

not meet the definition of medically necessary, initially the case is referred to a medical director for a review of the

medical necessity determination. Board certified physicians are available to review referred cases, make medical

necessity determinations and resolve appeals.

See the provider manual f

or guidance on provider requirements when requesting services. The final determination

about what treatment or services should be received is between the patient and their health care provider.

-----------------------------------------------------------------------------

Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPO

and Blue Advantage

HMO

(for Blue Advantage Plus)

Prior to referring a Blue Choice PPO or Blue Advantage HMO (for Blue Advantage Plus point-of- service benefit plan)

member to an out-of-network provider for non-emergency services – if such services are also available through an in-

network provider – the referring participating network provider must complete the appropriate Out-of-Network Care –

Enrollee Notification form below.

• Out-of-Network Care - Enrollee Notification Form for Regulated Business

(Use this form if "TDI" is on the

member's ID card.)

• Out-of-Network Care - Enrollee Notification Form for Non-Regulated Business (Use this form if "TDI" is not on

the member's ID card.)

The referring network physician must provide a copy of the completed form to the enrollee and retain a copy in the

enrollee’s medical record files.

It is essential that Blue Choice PPO and Blue Advantage Plus enrollees fully understand the financial impact of an

out-of-network referral to a physician, professional provider, hospital, ambulatory surgery center or other facility that

does not participate in their Blue Cross and Blue Shield of Texas provider network. Blue Choice PPO and Blue

Advantage Plus enrollees have out-of-network benefits and may choose to use out-of- network providers, however

they will be responsible for an increased cost-share under their out-of-network benefits.

For additional information, refer to the Provider Manual

section D Referral Notification Program on the

bcbstx.com/provider website.

-----------------------------------------------------------------------------

AIM RQI Reminder

Note: Be sure to review the Preauthorizations/Notifications/Referral Requirements Lists

under Clinical Resources

on the BCBSTX website for changes effective Jan. 1, 2018, to some self-insured Blue Choice PPO

plan

requirements for Advanced Radiology Imaging.

Physicians, professional providers, and facility and ancillary providers must contact AIM Specialty Health (AIM) first to

obtain a Radiology Quality Initiative (RQI) for most Blue Choice PPO

members. Refer to the

Preauthorizations/Notifications/Referral Requirements Lists

for applicable members when ordering or scheduling the

following outpatient, non-emergency diagnostic imaging services when performed in a physician’s, professional

provider’s or facility or ancillary provider’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 Blue Choice PPO RQI, log into AIM’s provider portal at aimspecialtyhealth.com,

and complete the online

questionnaire that identifies the reasons for requesting the exam. If criteria are met, you will receive an RQI. 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

“RQI.”

Notes:

• Facilities cannot obtain a RQI from AIM on behalf of the ordering physician, professional provider, facility or

ancillary provider.

• The RQI program does not apply to Medicare enrollees with Blue Cross and Blue Shield of Texas (BCBSTX)

Medicare supplement coverage. Medicare enrollees with BCBSTX PPO coverage are included in the

program.

AIM Specialty Health (AIM) is an operating subsidiary of Anthem, Inc.

-----------------------------------------------------------------------------

Are Utilization Management Decisions Financially Influenced?

Blue Cross and Blue Shield of Texas (BCBSTX) is dedicated to serving our customers through the provision of health

care coverage and related benefit services. BCBSTX prohibits decisions based on financial incentives – utilization

management decisions are based on appropriateness of care and service and existence of coverage.

BCBSTX does not specifically reward practitioners or clinicians for issuing denials of coverage, nor is there

compensation based on the number or frequency of telephone calls or other contacts that occur with health care

providers, members or subscribers. Financial incentives for utilization management decision makers do not

encourage decisions that result in underutilization.

-----------------------------------------------------------------------------

Benefits and Eligibility

BCBS Medicare Advantage PPO Network Sharing

Applies to: Blue Cross Medicare Advantage (PPO)

What is Blue Cross and Blue Shield (BCBS) Medicare Advantage (MA) PPO network sharing?

All BCBS MA PPO Plans participate in reciprocal network sharing. This network sharing will allow all BCBS MA PPO

members to obtain in-network benefits when traveling or living in the service area of any other BCBS MA PPO Plan if

the member sees a contracted BCBS MA PPO provider.

What does the BCBS MA PPO network-sharing mean to me?

If you are a contracted BCBS MA PPO provider with Blue Cross and Blue Shield of Texas (BCBSTX) and you see

BCBS MA PPO members from other BCBS Plans, these BCBS MA PPO members will be extended the same

contractual access to care and will be reimbursed in accordance with your negotiated rate with your Blue Cross and

Blue Shield of Texas contract. These BCBS MA PPO members will receive in-network benefits in accordance with

their member contract.

If you are not a contracted BCBS MA PPO provider with BCBSTX and you provide services for any BCBS MA PPO

members, you will receive the Medicare allowed amount for covered services. For urgent or emergency care, you will

be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network

benefit level.

How do I recognize an out-of-area BCBS MA PPO member from one of these Plans participating in the BCBS

MA PPO network sharing?

You can recognize a BCBS MA PPO member when their Blue Cross and Blue Shield Member ID card has the

following logo:

The “MA” in the suitcase indicates a member who is covered under the BCBS MA PPO network sharing program.

BCBS MA PPO members have been asked not to show their standard Medicare ID card when receiving services;

instead, members should provide their Blue Cross and/or Blue Shield member ID card.

Do I have to provide services to BCBS MA PPO members from these other BCBS Plans?

If you are a contracted BCBS MA PPO provider with BCBSTX, you should provide the same access to care for BCBS

MA members from other BCBS Plans as you do for BCBSTX MA PPO members. You can expect to receive the same

contracted rates for such services.

If you are not a BCBS MA PPO contracted provider, you may see BCBS MA PPO members from other BCBS Plans,

but you are not required to do so. Should you decide to provide services to BCBS MA PPO members, you will be

reimbursed for covered services at the Medicare allowed amount based on where the services were rendered and

under the member’s out-of-network benefits. For urgent or emergency care, you will be reimbursed at the in-network

benefit level.

What if my practice is closed to new local BCBS MA PPO members?

If your practice is closed to new local BCBS MA PPO members, you do not have to provide care for BCBS MA PPO

out-of-area members. The same contractual arrangements apply to these out-of-area network sharing members as

your local BCBS MA PPO members.

How do I verify benefits and eligibility?

Call BlueCard

Eligibility at 800-676-BLUE (800-676-2583) and provide the BCBS MA PPO member’s alpha prefix

located on the member’s ID card. You may also submit electronic eligibility requests for BCBS MA PPO members.

Follow these three easy steps:

• Log in to the Availity Provider Portal

or your preferred vendor

• Enter required data elements

• Submit your request

Where do I submit the claim?

You should submit the claim to BCBSTX under your current billing practices. Do not bill Medicare directly for any

services rendered to a BCBS MA PPO member.

What will I be paid for providing services to these out-of-area BCBS MA PPO network sharing members?

If you are a BCBS MA PPO contracted provider with BCBSTX, benefits will be based on your contracted BCBS MA

PPO rate for providing covered services to BCBS MA PPO members from any BCBS MA PPO Plan. Once you submit

the BCBS MA PPO claim, BCBSTX will work with the other Plan to determine benefits and send you the payment.

What will I be paid for providing services to other BCBS MA out-of-area members not participating in the

BCBS MA PPO network sharing?

When you provide covered services to other BCBS MA PPO out-of-area members not participating in network

sharing, benefits will be based on the Medicare allowed amount. Once you submit the BCBS MA PPO claim,

BCBSTX will send you the payment. However, these services will be paid under the BCBS MA member’s

out-of-network benefits unless for urgent or emergency care.

What is the BCBS MA PPO member cost sharing level and co-payments?

A BCBS MA PPO member cost sharing level and co-payment is based on the BCBS MA PPO member’s health plan.

You may collect the co-payment amounts from the BCBS MA PPO member at the time of service. To determine the

cost sharing and/or co-payment amounts, you should call the Eligibility Line at 800- 676-BLUE (800-676-2583).

May I balance bill the BCBS MA PPO member the difference in my charge and the allowance?

No, you may not balance bill the BCBS MA PPO member for this difference. Members may be balance billed for any

deductibles, co-insurance, and/or co-pays.

What if I disagree with the reimbursement amount I received?

If there is a question concerning the reimbursement amount, contact Blue Cross Medicare Advantage (PPO)

Customer Service at 877-774-8592.

Who do I contact if I have a question about BCBS MA PPO network sharing?

If you have any questions regarding the BCBS MA PPO program or products, contact Blue Cross Medicare

Advantage (PPO) Customer Service at 877-774-8592.

-----------------------------------------------------------------------------

Claims

HMO Plans – PCP Selection and Referral Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) HMO plans are:

• Blue Advantage HMO

• Blue Advantage Plus

• Blue Essentials

• Blue Essentials Access

• Blue Premier

• Blue Premier Access

Blue Essentials Access and Blue Premier Access are considered “open access” HMO plans where no Primary Care

Provider (PCP) selection or referrals are required when the member uses participating providers in their network.

For Blue Advantage HMO, Blue Essentials and Blue Premier where referrals are required, it must be initiated by the

member's designated PCP and must be made to a participating physician or professional provider in the same

provider network.

The table below defines when a PCP selection and referrals to specialists (except OB-GYN) are required and when

they are not required. (Note: Members can self-refer to in-network OB/GYNs – no referrals are required.) If an in-

network physician, professional provider, ambulatory surgery center, hospital or other facility is not available in the

member's applicable provider network, preauthorization is required for services by an out- of-network physician,

professional provider, ambulatory surgery center, hospital or other facility, through either iExchange

or by calling the

preauthorization number on the back of the member ID card.

Additional services for all HMO plans may require preauthorization. A complete list of services that require

preauthorization or a referral for in and out of network benefits is available on the BCBSTX provider website under

Preauthorization/Notification/Referral Requirements

HMO Plan

Designated PCP

Required

Referrals Required for In-

Network Providers

Out-Of-Network

Benefits Available with

Higher Member Cost

Blue Advantage HMO

Yes

Blue Advantage Plus HMO

Yes

Blue Essentials

Yes

Blue Essentials Access

Blue Premier

Yes

Blue Premier Access

*Prior to referring a Blue Advantage Plus member to an out-of-network provider for non-emergency services, please

refer to Section D Referral Notification Program, of the Blue Essentials, Blue Advantage HMO and Blue Premier

provider manual for more detail including when to utilize the Out-of-Network Enrollee Notification forms for

Regulated

Business and Non-Regulated Business.

Sample HMO ID cards

and other benefit plan ID cards are available on the BCBSTX provider website.

Reminders:

• The Blue Essentials, Blue Advantage HMO and Blue Premier physician, professional provider, facility or

ancillary providers are required to admit a patient to a participating facility, except in emergencies.

• Blue Advantage Plus is a benefit plan that allows members to use out-of-network providers. However,

members must understand the financial impact of receiving services from an out-of-network physician,

professional provider, ambulatory surgery center, hospital or other facility.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for

benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the

member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered. If you have questions,

contact the number on the member's ID card.

iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and

providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third-party vendors such

as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

--------------------------------------------------------------------------------------------------------------------------

EFT and ERA Information Available Online

Refer to the Blue Cross and Blue Shield of Texas (BCBSTX) Electronic Funds Transfer (EFT)/Electronic Remittance

Advice (ERA) page on BCBSTX’s provider website for electronic transactions that may increase administrative

efficiencies for your office, while also making it easier for you to conduct business with BCBSTX.

The EFT/ERA

page includes resources to help you learn more about EFT and ERA such as EFT and ERA Online

Enrollment Tip Sheets, EFT and ERA 835 Companion Guides and other pertinent information.

Providers are encouraged to enroll for EFT and ERA through the Availity

Provider Portal, which also allows users to

make any necessary set-up changes online. Once you are enrolled for ERA, providers and billing services have

access to the

Availity Remittance Viewer. This tool allows users to search, view, save and print remittance

information, even if the ERA is delivered to a vendor and/or clearinghouse other than Availity. To register for Availity,

simply go to

availity.com and sign up today. There is no cost to register to become an Availity user.

Visit the EFT/ERA page in the Claims and Eligibility section of our provider website

for additional information on

electronic options. For assistance with EFT and ERA enrollment through Availity, or to learn more about how to use

the remittance viewer tool, contact a BCBSTX Provider Education Consultant at

ECommerceHotline@bcbsil.com or

800-746-4614.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange

services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or

warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions about the products or

services offered by such vendors, you should contact the vendor(s) directly.

-----------------------------------------------------------------------------

Billing and Documentation Information and Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) has implemented changes to clarify existing policies related to billing

and documentation requirements for the BlueChoice

PPO, Blue Advantage HMO

, Blue Essentials

, Blue

Premier

, Blue Cross Medicare Advantage (PPO)

and Blue Cross Medicare Advantage (HMO)

plans effective

Sept. 15, 2017, as reflected in the Blue Choice PPO Provider Manual and the Blue Essentials, Blue Advantage HMO

and Blue Premier Provider Manual in Section F Filing Claims posted on bcbstx.com/provider under

Standards and

Requirements/Manuals. Below are the updates to be posted:

Billing & Documentation Information & Requirements Permissible Billing

BCBSTX does not permit pass-through billing, splitting all-inclusive bills, under-arrangement billing, and any billing

practices where a provider or entity submits claims by or for another provider not otherwise provided for in the

provider’s agreement or in this policy.

Pass-through Billing

Pass-through billing occurs when the ordering physician, professional provider, facility, or ancillary provider requests

and bills for a service, but the service is not performed by the ordering physician, professional provider, facility, or

ancillary provider.

The performing physician, professional provider, facility, or ancillary provider is required to bill for the services they

render unless otherwise approved by BCBSTX. BCBSTX does not consider the following scenarios to be pass-

through billing:

• the service of the performing physician, professional provider, facility, or ancillary provider is performed at the

place of service of the ordering physician or professional provider and billed by the ordering physician or

professional provider;

• the service is provided by an employee of a physician, professional provider, facility, or ancillary provider (i.e.,

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

professional provider); and

• the service is billed by the ordering physician or 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 the AS modifier when billing on behalf of a PA, APN or CRNFA, including that

providers National Provider Identifier (NPI), for services provided when the PA, APN, or CRNFA is acting as an

assistant during surgery. Modifier AS is to be used ONLY if the PA, APN, or CRNFA assists at surgery.

SA modifier: A supervising physician should use the SA modifier when billing on behalf of a PA, APN, or CRNFA for

non-surgical services. Modifier SA is to be used when the PA, APN, or CRNFA is assisting with any other procedure

that DOES NOT include surgery.

Under Arrangement Billing

"Under-arrangement" billing and other similar billing or service arrangements are not permitted by BCBSTX. "Under-

arrangement" billing refers to situations where services are performed by a physician, facility, or ancillary provider but

the services are billed under the contract of another physician, facility or ancillary provider, rather than under the

contract of the physician, facility, or ancillary provider that performed the services.

All Inclusive Billing

Any testing performed on patients treated by a physician, professional provider, facility, or ancillary provider that is

compensated on an all-inclusive rate should not be billed separately by the facility or any other provider. The testing is

a part of the per diem or outpatient rates paid to a facility for such services. The Physician, professional provider,

facility, or ancillary provider may, at their discretion, use other providers to provide services included in their all-

inclusive rate, but remain responsible for costs and liabilities of those services, which shall be paid by the facility and

not billed directly to BCBSTX.

For all-inclusive billing, all testing and services that share the same date of service for a patient must be billed on one

claim. Split billing is a violation of network participating provider agreements.

Other Requirements and Monitoring CLIA Certification Requirement

Facilities and private providers who perform laboratory testing on human specimens for health assessment or the

diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments

of 1988 (CLIA). Therefore, any provider who performs laboratory testing, including urine drug tests, must possess a

valid a CLIA certificate for the type of testing performed.

Review of Codes

BCBSTX may monitor the way test codes are billed, including frequency of testing. Abusive billing, insufficient or lack

of documentation to support the billing, including a lack of appropriate orders, may result in action taken against the

provider's network participation and/or 100 percent review of medical records for such claims submitted.

Limitations and Conditions

Reimbursement is subject to:

• Medical record documentation, including appropriately documented orders

• Correct CPT/HCPCS coding

• Member Benefit and Eligibility

• Applicable BCBS Medical Policy(-ies)

Obligation to notify BCBSTX of Certain Changes

Physicians, facilities, and ancillary providers are required to notify BCBSTX of material changes that impact their

contract with BCBSTX including the following:

• Change in ownership

• Acquisitions

• Change of billing address

• Change in billing information

• Divestitures

Assignment

As a reminder, no part of the contract with BCBSTX may be assigned or delegated by a physician, facility or ancillary

provider without the express written consent of both BCBSTX and the contracted provider. If you have any questions

or if you need additional information, please contact your BCBSTX Network Management Representative

--------------------------------------------------------------------------------------------------------------------------

Benefit Categories Contained in IVR Phone System

Below is a list of common benefit categories contained within the Blue Cross and Blue Shield of Texas (BCBSTX)

Interactive Voice Response (IVR) phone system.

The IVR quotes the same level of eligibility and benefit information that a Customer Advocate provides. Our Customer

Advocates are available for more complex benefit quotes.

As a reminder, this information is continually reviewed and may vary across different BCBSTX networks, products

and/or group policies. The current contained benefit category lists are shown below.

Contained Benefit Categories

• Allergy Colonoscopy Consultations Coordinated Home Care

• Electrocardiogram (EKG) Extended Care Facility Hospital

• Inhalation Therapy Laboratory Mammogram Office Services

Office Visit Pap Smear Physical Exam Preventive Care

• Private Duty Nursing Ultrasound

• X-ray

• 23-hour Observation Air Ambulance Anesthesia Assistant

Surgeon CAT Scan Dialysis

• Ground Ambulance Hospice

• Medical Supplies MRI

• Pathology PET Scan Prosthetics

• Prostate-specific Antigen (PSA) Sterilization

FEP IVR

Contained Benefit Categories

Accidental Injury

Maternity

Allergy

Office Visit

Chiropractic Services

Outpatient Physical, Occupational

and Speech Therapy

Diagnostic – Lab, X-ray, Outpatient

Diagnostic

Vision

Inpatient Benefits – Inpatient

Hospital, Inpatient Surgery

Note: The above listings are not applicable to Blue Cross Medicare Advantage (PPO)

or Blue Cross Medicare

Advantage (HMO)

government program member policies. For eligibility and benefits for these government

programs via phone, refer to the number on the member’s BCBSTX identification card.

As a reminder, checking eligibility and benefits electronically through Availity

or your preferred web vendor is the

quickest way to access BCBSTX member information. To learn more about online solutions, see the

Provider Tools

section of the BCBSTX provider website.

Checking eligibility, benefit information and/or if a service has been preauthorized is not a guarantee of payment.

Benefits will be determined once a claim is received and will be based upon, among other things, the member’s

eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you

have any questions, please call the number on the back of the member’s ID card.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information

exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement,

representations or warranties regarding any products or services offered by third-party vendors such as Availity. If you have any questions about

the products or services offered by such vendors, you should contact the vendor(s) directly.

-----------------------------------------------------------------------------

Clinical Payment and Coding Policies Now Online

BCBSTX is now publishing Clinical Payment and Coding Policies

on our website. These payment and coding policies

describe BCBSTX’s application of payment rules and methodologies for Current Procedural Terminology (CPT

HCPCS and ICD-10 coding as applied to claims submitted for covered services. This information is offered as a

helpful general resource regarding BCBSTX payment polices and is not intended to address all reimbursement

related issues. New policies have been posted and existing policies will be added over time. We regularly adjust

clinical payment and coding policy positions as part of our ongoing policy review processes. Check

this newsletter

and the News and Updates section on our website for newly adapted or revised policies.

-----------------------------------------------------------------------------

Update to After-hours and Weekend Care Codes Payment Policy

Blue Cross and Blue Shield of Texas (BCBSTX) will be updating its payment policy regarding after-hours and

weekend care codes.

After-hours or weekend care is reimbursable, within limitations, for services provided by an individual physician or

other health care professional who is required to provide office-based services outside of regular posted office hours

to treat a patient's urgent illness or condition.

Effective Jan. 1, 2017, BCBSTX will no longer reimburse facility-based or non-office-based providers for CPT Codes

99053, 99056 and 99060. These codes will be considered inclusive of the primary procedure. Please contact your

BCBSTX Network Management Representative i

f you have any questions or if you need additional information.f you

have any questions or if you need additional information.

-----------------------------------------------------------------------------

ClaimsXten

Quarterly Updates

New and revised Current Procedural Terminology (CPT

) and HCPCS codes are periodically added to or deleted

from the ClaimsXten code auditing tool software by the software vendor on a quarterly basis and are not considered

changes to the software version.

Blue Cross and Blue Shield of Texas (BCBSTX) will normally load this additional data to the BCBSTX claim

processing system within 60 to 90 days after receipt from the software vendor and will confirm the effective date via

the News and Updates

section of the BCBSTX provider website. Advance notification of updates to the ClaimsXten

software version (i.e., change from ClaimsXten version 4.1 to 4.4) also will be posted on the BCBSTX provider

website.

To help determine how coding combinations on a claim may be evaluated during the claim adjudication process, you

may continue to utilize Clear Claim Connection

(C3). C3 is a free, online reference tool that mirrors the logic behind

BCBSTX’s code-auditing software. Refer to our website at bcbstx.com/provider f

or additional information on gaining

access to C3.

For more details regarding ClaimsXten, including answers to frequently asked questions, refer to the C3 page

Claims Filing Tips under Claims and Eligibility on the BCBSTX website. Additional information may also be included

in upcoming issues of Blue Review.

Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be

based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services

were rendered.

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third-party vendor that is solely

trademark of the AMA.

-----------------------------------------------------------------------------

Additional Code-Auditing Software

Blue Cross and Blue Shield of Texas (BCBSTX) implemented additional code-auditing software, Verscend

ConVergence Point

BCBSTX implemented this code- auditing software in June 2017*.

This software further enhances the auditing of professional and outpatient facility claims for correct coding according

to the Healthcare Common Procedure Coding System (HCPSC), Current Procedural Terminology (CPT

) and the

Centers for Medicare and Medicaid Services guidelines. Providers may use the Claim Inquiry Resolution Tool, which

is available on the Availity Provider Portal to research specific claim edits.

*The above notice does not apply to government program claims.

ConVergence Point is a trademark of Verscend Technologies, Inc., an independent third-party vendor that is solely responsible for its products and

services.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange

services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or

warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions about the products or

services offered by such vendors, you should contact the vendor(s) directly.

-----------------------------------------------------------------------------

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 professional provider and facility or ancillary 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 professional provider reimbursement

covers the services, equipment and some of the supplies needed to perform the surgical procedure when a

member/subscriber receives these services in the physician's or professional provider’s office.

Reimbursement will be allowed for some supplies billed in conjunction with a surgical procedure performed in a

physician's or professional provider’s office. To help determine how coding combinations on a claim may be

evaluated during the claim adjudication process, you may continue to utilize Clear Claim Connection

(C3). C3 is a

free, online reference tool that mirrors the logic behind Blue Cross and Blue Shield of Texas’(BCBSTX) code-auditing

software. Refer to the BCBSTX provider website at bcbstx.com/provider for additional information on gaining access

to C3.

Please note the physician's and professional provider’s reimbursement includes surgical equipment that maybe

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 since the global physician’s or professional provider’s

reimbursement includes staff and equipment.

-----------------------------------------------------------------------------

Improvements to the Medical Records Process for BlueCard

Claims

Blue Cross and Blue Shield of Texas (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 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.

-----------------------------------------------------------------------------

Contracted Providers Must File Claims

As a reminder, physicians, facilities, professional providers and ancillary providers must file claims for any covered

services rendered to a patient enrolled in a Blue Cross and Blue Shield of Texas (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 provider contract with BCBSTX.

Notwithstanding the foregoing, a provision of the American Recovery and Reinvestment Act changed HIPAA (Health

Insurance Portability and Accountability Act of 1996) to add a requirement that if a patient self pays for a service in full

and directs a provider to not file a claim with the patient's insurer, the 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.

-----------------------------------------------------------------------------

Billing for Non-Covered Services

As a reminder, contracted physicians, professional providers, facility and ancillary providers may collect payment from

members/subscribers for copayments, co-insurance and deductible amounts. The physician, professional provider,

facility or ancillary provider may not charge the member/subscriber more than the patient share shown on their

provider claim summary (PCS) or electronic remittance advice (ERA).

If Blue Cross and Blue Shield of Texas (BCBSTX) determines that a proposed service is not a covered service, the

physician, professional provider, facility or ancillary provider must inform the member/subscriber in writing in advance.

This will allow the physician, professional, facility or ancillary provider to bill the member/subscriber for the non-

covered service rendered.

In no event, shall a contracted physician, professional provider, facility or ancillary provider collect payment from the

subscriber for identified hospital acquired conditions and/or serious reportable events.

-----------------------------------------------------------------------------

Avoidance of Delay in Claims Pending COB Information

Blue Cross and Blue Shield of Texas (BCBSTX) receives thousands of claims each month that require unnecessary

review for coordination of benefits (COB). What that means to our physicians, professional providers, facility and

ancillary providers is a possible delay, or even denial of services, pending receipt of the required information from the

member/subscriber.

Here are some tips to help prevent claims processing delays when there is only one insurance carrier:

• 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.

-----------------------------------------------------------------------------

Hospitals, and Routine Services and Supplies

Routine services and supplies are generally already included by the provider in charges related to other procedures

or services. As such, these items are considered non-billable for separate reimbursement. The following guidelines

may assist hospital personnel in identifying items, supplies, and services that are not separately billable (this is not an

all-inclusive list):

• Any supplies, items and services that are necessary or otherwise integral to the provision of a specific service

and/or the delivery of services in a specific location are considered routine services and not separately

billable in the inpatient and outpatient environments.

• All items and supplies that may be purchased over-the-counter are not separately billable.

• All reusable items, supplies and equipment that are provided to all patients during an inpatient or outpatient

admission are not separately billable.

• All reusable items, supplies and equipment that are provided to all patients admitted to a given treatment area

or units are not separately billable.

• All reusable items, supplies and equipment that are provided to all patients receiving the same service are not

separately billable.

-----------------------------------------------------------------------------

Clinical Resources

BCBSTX Lab Guidelines

Quest Diagnostics, Inc., is the exclusive outpatient clinical reference laboratory provider for Blue Essentials

, Blue

Premier and Blue Advantage HMO

members* and the preferred statewide outpatient clinical reference laboratory

provider for Blue Cross and Blue Shield of Texas (BCBSTX) Blue Choice PPO

subscribers. 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:

• Online 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 195 patient service locations.

• 24/7 access to electronic lab orders, results and other office solutions through Care360

labs and meds.

For more information about Quest Diagnostics lab testing solutions or to establish an account, contact your Quest

Diagnostics Physician Representative or call 866-MY-QUEST (866-697-8378).

For physicians, professional providers or facility and ancillary providers located in the HMO Reimbursable 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, professional provider’s office for Blue Essentials members. All other lab

services must be sent to Quest. You can access the county listing and the Reimbursable Lab Services list in the

General Reimbursement Information

section located under the Standards and Requirements tab.

*Note: Physicians, professional providers or facility and ancillary providers who are contracted/affiliated with a

capitated IPA/medical group and physicians, professional providers or facility or ancillary providers who are not part of

a capitated IPA/medical group but who provide services to a member/subscriber whose PCP is a member of a

capitated IPA/medical group must contact the applicable IPA/medical group for instructions regarding outpatient

laboratory services.

-----------------------------------------------------------------------------

Blue Cross Medicare Advantage (PPO)

Lab Guidelines

Quest Diagnostics, Inc., Clinical Pathology Laboratory (CPL) and LabCorp, Inc. are the preferred outpatient clinical

reference laboratory providers for Blue Cross Medicare Advantage (PPO) members.

Note: This arrangement excludes lab services provided during emergency room visits, inpatient admissions and

outpatient day surgeries (hospital and free-standing ambulatory surgery centers).

For locations or questions contact:

• Quest Diagnostics at 888-277-8772 or questdiagnostics.com/patient

• Clinical Pathology Laboratory at 800-595-1275 or cpllabs.com

• LabCorp at 800-845-6167 or labcorp.com

As previously indicated, if lab services are performed at the participating physician’s or other professional provider’s

office, the physician or professional provider may bill for the lab services. However, if the physician’s or other

professional provider’s office sends the lab specimens to a contracted lab for completion, only the contracted lab can

bill Blue Cross Medicare Advantage (PPO) for the lab services.

-----------------------------------------------------------------------------

Medical Necessity Review of Observation Services

As a reminder, it is the policy of Blue Cross and Blue Shield of Texas (BCBSTX) to provide coverage for observation

services when it is determined to be medically necessary based on the medical criteria and guidelines as outlined in

the Milliman Care Guidelines

. Claims for observation services are subject to post- service review, and BCBSTX may

request medical records for the determination of medical necessity.

When medical records are requested, documentation should include the following information:

• The attending physician’s order for observation care with clock time (or clock time can be noted in the nurse’s

observation admission note)

• The physician’s admission and progress notes confirming the need for observation care

• The supporting diagnostic and/or ancillary testing reports

• The admission progress notes (with the clock time) outlining the patient’s condition and treatment

• The discharge notes (with clock time) with discharge order and nurse’s notes

• Itemized bill

-----------------------------------------------------------------------------

Coordination of Care Between Medical and Behavioral Health Providers

Blue Cross and Blue Shield of Texas (BCBSTX) continually strives to promote coordination of member care between

medical and behavioral health providers. We understand that communication between providers and their patients

regarding the treatment and coordination of care can pose challenges. Here are few resources available to you

through BCBSTX:

The Coordination of Care Form Available Online

To provide assistance when coordinating care, BCBSTX has created a Coordination of Care form

that is available

online. This new form may help in communicating patient information, such as:

• To provide member treatment information to another treating provider

• To request member treatment information from another treating provider. It is important to note that a written

release to share clinical information with members’ medical providers must be obtained prior to the use of this

form. BCBSTX recommends obtaining a written release prior to the onset of treatment.

If you are requesting member treatment information from another provider, it is recommended that the Patient

Information and Referring Provider sections of the form be completed to expedite the care coordination process for

the receiving provider.

If You Need Help Finding Behavioral Health Providers for Your Patients

Call the number on the back of members’ BCBSTX ID cards to receive assistance in finding outpatient providers or

behavioral health facilities.

Behavioral Health or Medical Case Management Services

If you believe a patient has complex health needs and could benefit from additional support and resources from a

clinician, you can make a referral to one of the BCBSTX Case Management programs by calling the number on the

back of the member’s BCBSTX ID card. Case Management can also provide you and the member with information

about additional resources provided by their insurance plan.

-----------------------------------------------------------------------------

CMS Guidance Notifications

CMS Notifications for Blue Cross Medicare Advantage (PPO)

and Blue Cross Medicare Advantage (HMO)

The Centers for Medicare and Medicaid Services (CMS) routinely publishes notifications that provide CMS guidance

to all Medicare physicians, providers and suppliers, including those serving beneficiaries enrolled in Original Medicare

and one of the Blue Cross Medicare Advantage (PPO) or Blue Cross Medicare Advantage (HMO) plans. These CMS

notifications are located in the Medicare Learning Network (MLN Matters) on CMS.gov and in the BCBSTX

News and

Updates section of the provider website under CMS Notifications Medicare Advantage Plans and may include

informational regulatory updates and reminders, as well as required actions or changes by the provider rendering

services. As such, it is important for providers to review these notifications and ensure your staff are aware of them.

-----------------------------------------------------------------------------

Education & Reference

Provider Manual Update

Blue Cross and Blue Shield of Texas (BCBSTX) makes periodic updates and clarifications related to operational

changes and regulatory mandates to the provider manual, as well as the processes, policies and procedures that you

comply with as a network provider. It is important that you stay up-to-date, so we share these changes in our monthly

Blue Review newsletter, in the News and Updates and/or the Standards & Requirements/Disclosures sections

of the

BCBSTX provider website. These changes may also be communicated via mail. We encourage you to review both

resources as you provide care to your patients. As a provider, it is your responsibility to review and comply with these

changes.

-----------------------------------------------------------------------------

Electronic Options

Multiple Online Enrollment Options Available in Availity

Blue Cross and Blue Shield of Texas (BCBSTX) offers you multiple enrollment opportunities for electronic options

through the Availity Provider Portal. This is in addition to other electronic transactions available to you through Availity

or your preferred web vendor portal. Instead of faxing or mailing paper enrollment forms, you can complete the online

enrollment options listed below through Availity at no cost. Availity also provides single sign-on access to several

online tools that offer greater convenience and security, without the need for another user ID and password.

Online Enrollment for EFT and ERA

BCBSTX contracted providers can enroll online for Electronic Fund Transfer (EFT) and Electronic Remittance Advice

(ERA) and make any necessary set-up changes in Availity. The online enrollment process can be completed in near

real-time.

Providers will receive a confirmation letter acknowledging the enrollment effective date and related information. Once

enrolled for ERA, providers and billing services also gain access to the Availity Remittance Viewer. This online tool

permits users to search, view, save and print remittance information, even if the ERA is delivered to a different

clearinghouse or vendor.

Single Sign-On Access

Benefit Preauthorization Via iExchange

Once you are registered as an Availity user, you may enroll through the Availity Provider Portal for iExchange. This

tool supports online submission and electronic approval of benefits for inpatient admissions, as well as select

outpatient and clinical pharmacy services. iExchange also offers you an alternative to calling to request the status of

most benefit preauthorization requests. Additionally, iExchange accepts electronic medical record documentation for

predetermination of benefits requests. As a reminder, always check eligibility and benefits first to find out if benefit

preauthorization is required for a member.

Please note that for behavioral health services, you should continue to use the current fax and telephone benefit

preauthorization methods.

Electronic Refund Management (eRM)

Registered Availity users can also gain access to eRM, an online tool that helps simplify the overpayment

reconciliation process. You will receive electronic notification of overpayments with the option to deduct from a future

payment or pay by check. eRM also gives access to the Claim Inquiry Resolution (CIR) tool. CIR offers online

assistance that helps save your staff time by reducing the number of calls and specific written inquiries on finalized

claims.

Please note that the eRM and CIR tools are not available for government programs claims.

Learn More

To learn more about these and other electronic tools and resources, visit the Provider Tools section

of our website.

Also, see the Provider Training page for dates, times and registration for online training sessions on a variety of

topics.

For assistance or customized training, contact a BCBSTX Provider Education Consultant at PECS@tx.com.

Visit availity.com

to complete the online application today. If you need registration assistance, contact Availity Client

Services at 800-AVAILITY (800-282-4548).

Checking eligibility, benefit information and/or the fact that a service has been preauthorized is not a guarantee of payment. Benefits will be

determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate

of coverage applicable on the date services were rendered. If you have any questions, please call the number on the back of the member’s ID

card. *This excludes atypical providers who have not acquired a National Provider Identifier (NPI).

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange

services to medical professionals. Availity provides administrative services to BCBSTX. iExchange is a trademark of Medecision, Inc., a separate

company that offers collaborative healthcare management solutions for payers and providers. BCBSTX makes no endorsement, representations or

warranties regarding any products or services offered by third party vendors such as Availity or Medecision. If you have any questions about the

products or services offered by such vendors, you should contact the vendor(s) directly.

-----------------------------------------------------------------------------

Online Portal Applications Help Expedite Administrative Workflows

Does your office or organization ever ask: “Is this patient eligible for Blue Cross and Blue Shield Texas (BCBSTX)

benefits? Does this service require preauthorization? or How did my claim process?” If so, these questions and so

many more can be answered in a matter of seconds with a few key strokes using an online portal application, such as

Availity

Electronic options deliver real-time resolutions, avoiding disapproved services and optimizing your payment. You can

confirm patient coverage, preauthorize services and post payments with a few simple clicks.

Not only can you conduct Health Insurance Portability and Accountability Act-compliant transactions online, using

Availity you can also:

• Submit pre- and post-exam transactions

• Conduct pre-service requests

• Complete post-service reconciliations

• Update provider demographics

• Enroll for electronic remittance and fund transfers

If you have not registered and would like to learn more about Availity, and our online referral and preauthorization tool

iExchange

, register for a Back to Basics: Availity 101 webinars.

Additionally, for more advanced training of online tools, email a Provider Education Consultant at PECS@bcbstx.com.

-----------------------------------------------------------------------------

Corrected Claim Request Change

As a reminder, corrected claim requests for previously adjudicated claims must be submitted as electronic

replacement claims, or on the appropriate professional (CMS-1500) or institutional (UB-04) paper claim and Claim

Review form.

Electronic Submission

Electronic replacement claims should be submitted with the appropriate claim frequency code. Frequency code 7 will

result in Blue Cross and Blue Shield of Texas (BCBSTX) adjudicating the original claim number (sometimes referred

to as a Document Control Number, or DCN) with the corrections. The replacement claim will be issued a new

BCBSTX claim number and subsequently deny based on the re-adjudication of the original claim.

Note: Claim corrections submitted without the appropriate frequency code will deny as a duplicate and the original

BCBSTX claim number will not be adjudicated. See below for additional information on claim frequency codes and

guidelines to assist you with when and how to use them for making corrections to electronic claims submitted to

BCBSTX.

Claim Frequency Codes

Code

Description

Filing Guidelines

Action

5 Late Charge(s)

Use to submit additional

charges for the same

date(s) of service as a

previous claim.

File electronically, as

usual. Include only the

additional late charges

that were not included on

the original claim.

BCBSTX will add the

late charges to the

previously processed

claim.

7 Replacement of Prior

Claim

Use to replace an entire

claim (all but identity

information).

File electronically,

usual. File the claim in its

entirety, including all

services for which you are

requesting

reconsideration.

BCBSTX will

replace the

original claim with

corrections and the

replacement claim will

be denied. Refer to the

original claim for

adjudication.

8 Void/Cancel of Prior

Claim

Use to eliminate a

previously

submitted claim

for a specific provider,

patient, insured and

"statement covers period."

File electronically, as

usual. Include all charges

that were on the original

claim.

BCBSTX will void th

original claim from

records, based on

request.

Paper Submission

More than 98 percent of the claims BCBSTX receives from providers are submitted electronically. BCBSTX

encourages all providers to use electronic options as the primary method for claim submission. There are several

multi-payer web vendors available to providers. If you are a registered Availity

Provider Portal user, you have access

to submit direct data entry replacement claims electronically, at no additional cost.

As of July 11, 2016, any changes to a claim that are specified only on the Claim Review form (or via a letter) will be

returned with a notice advising resubmission on the appropriate CMS-1500 or UB-04 paper claim form. Paper claim

submitters are required to indicate “corrected claim” on the paper claim form and the accompanying Claim Review

form.

-----------------------------------------------------------------------------

eviCore

eviCore Preauthorization Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) contracts with eviCore healthcare (eviCore), an independent

specialty medical benefits management company, to administer preauthorization requirements for certain specialized

services and products for BCBSTX members.

To determine which specialized clinical services and the effective dates of those services which require

preauthorization/prior authorization through eviCore, refer to the Preauthorization/Referral/Notification Requirements

found on the BCBSTX provider web site.

Be sure to review the Preauthorization/Referral/Notification Requirements Lists

carefully as the services and effective

dates vary by product as well as whether the member’s group is self-insured or fully insured (identified by TDI on ID

card).

For a detailed list of the services that require authorization through eviCore, refer to the eviCore implementation site

Services performed without authorization may be denied for payment and you may not seek reimbursement from

members/subscribers.

eviCore authorizations can be obtained using one of the following methods:

• Use the eviCore healthcare web portal,

which is available 24/7. After a one-time registration, you can initiate

a case, check status, review guidelines, view authorizations and eligibility, and more. The web portal is the

quickest, most efficient way to obtain information.

• Call eviCore at 855-252-1117 toll-free between 6 a.m. - 6 p.m. CT, Monday through Friday, and 9 a.m. - noon

CT, Saturday, Sunday and legal holidays.

For all other services that require a referral and/or authorization as noted on the Preauthorization/Referral

Requirements Lists or the Prior Authorization/Referral List for ERS, continue to use iExchange

. iExchange is

accessible to all physicians, professional providers and facilities.

Learn more about iExchange or set up a new

account on BCBSTX’s provider website.

Watch for additional information and training opportunities for eviCore in future editions of this newsletter

, on the

BCBSTX provider website or on the eviCore implementation site.

If you have any questions, please contact your BCBSTX Network Management Representative

As a reminder, it is important to check eligibility and benefits prior to rendering services. This step will help you

determine if a member requires benefit preauthorization or prior authorization. For additional information, such as

definitions and links to helpful resources, refer to the Eligibility and Benefits section

on BCBSTX’s provider website.

Checking eligibility, benefit information and/or if a service has been preauthorized or prior authorized is not a guarantee of payment. Benefits will be

determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate

of coverage applicable on the date services were rendered. If you have any questions, please call the number on the back of the member’s ID

card.

eviCore is a trademark of eviCore health care, LLC, formerly known as CareCore, an independent company that provides utilization review for

select health care services on behalf of BCBSTX.

iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and

providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third-party vendors such

as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

-----------------------------------------------------------------------------

Pharmacy

Pharmacy Benefit Tips

For Blue Cross and Blue Shield of Texas (BCBSTX) members with prescription drug benefits administered by Prime

Therapeutics

, BCBSTX employs many industry-standard management strategies to ensure appropriate utilization of

prescription drugs. These strategies can include drug list management, benefit design modeling, specialty pharmacy

benefits, clinical programs, among others. BCBSTX providers can assist in this effort by:

1. Prescribing drugs listed on the drug list

BCBSTX drug lists are provided as a guide to help in the selection of cost-effective drug therapy. Every major

drug class is covered, although many of the drug lists cover most generics and fewer brand name drugs. The lists

also provide members with criteria for how drugs are selected, coverage considerations and dispensing limits.

While these drug lists are a tool to help members maximize their prescription drug benefits, the final decision

about what medications should be prescribed is between the health care provider and the patient.

BCBSTX drug lists are regularly updated and can be found on the Pharmacy Program page on the

BCBSTX

provider website.

Note: For members with Medicare Part D or Medicaid coverage, the drug lists can be found on the plan’s

website:

• Blue Cross MedicareRx (PDP)

: getbluetx.com/pdp/druglist

• Blue Cross Medicare Advantage

: getbluetx.com/mapd/druglist

• Blue Cross Medicare Advantage Dual Care (HMO SNP)

: getbluetx.com/dsnp/druglist

• Texas STAR: bcbstx.com/star/prescription-drugs/drug-coverage

• Texas CHIP: bcbstx.com/chip/prescription-drugs/drug-coverage

• Texas STAR KIDS: bcbstx.com/starkids/plan-details/drug-coverage.html

2. Reminding patients of covered preventive medications

Many BCBSTX health plans include coverage at no cost to the member for certain prescription drugs, women’s

contraceptive products and over-the-counter medicines used for preventive care services.*

• ACA $0 Preventive Drug List

• Women’s Contraceptive Coverage List

3. Submitting necessary prior authorization requests

For some medications, the member’s plan may require certain criteria to be met before prescription drug

coverage may be approved. You will need to complete the necessary prior authorization request and submit it to

BCBSTX. More information about these requirements can be found on the Pharmacy Program

page on

the BCBSTX provider website.

4. Assisting members with drug list exceptions

If the medication you wish to prescribe is not on your patient’s drug list or the preventive care lists, a drug list

exception can be requested. You can call the customer service number on the member’s ID card to start the

process or complete the online form

Visit the Pharmacy Program

page for more information.

*Not available for all plans. Members should call the customer service number on their ID card to help determine what benefits may be available,

including any requirements, limitations or exclusions that apply. Please refer to the member’s certificate of coverage and prescription drug list as

there may be coverage for additional products beyond these lists.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSTX contracts with Prime to provide pharmacy benefit management

and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician.

Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of

coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits.

Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final

decision about any medication is between the member and their health care provider.

-----------------------------------------------------------------------------

Dispensing QVT (Quantity Versus Time) Limits

To help minimize health risks and to improve the quality of pharmaceutical care, dispensing 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. For current Drug List Dispensing Limits, visit

Pharmacy Program/Dispensing Limits

on the BCBSTX provider website.

-----------------------------------------------------------------------------

Prescription Drug Lists

Throughout the year, the Blue Cross and Blue Shield of Texas (BCBSTX) Clinical Pharmacy department frequently

reviews the prescription drug lists. 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 current drug updates, visit Pharmacy Program/Prescription Drug List and Prescribing Guidelines

on the BCBSTX

provider website.

-----------------------------------------------------------------------------

Provider General Information

Fee Schedule Updates

Reimbursement changes and updates for Blue Choice PPO, Blue Essentials (Independent Provider Network only),

Blue Advantage HMO and Blue Premier practitioners will be posted under Standards and Requirements/General

Reimbursement Information/Reimbursement Schedules and Related Information/Professional Schedules section on

the Blue Cross and Blue Shield of Texas (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 BCBSTX provider website. The CPT/HCPCS Drug/Injectable codes Fee Schedule will be updated quarterly on

March 1, June 1, Sept. 1 and Dec. 1 each year. The NDC fee schedule will be updated monthly.

-----------------------------------------------------------------------------

Employees Retirement System of Texas (ERS)

BCBSTX was awarded the six- year

contract for the ERS account, effective Sept. 1, 2017.

ERS participants covered under HealthSelect

of Texas and Consumer Directed HealthSelect

benefit

plans

will access care through the Blue EssentialsSM provider network in all 254 counties in Texas.

ERS participants can be identified through their BCBSTX ID card:

•

The plan names HealthSelect of Texas and Consumer Directed HealthSelect will be printed

directly

on the ID card.

•

ERS Participants will have a unique Blue Essentials network ID labeled HME.

Providers can refer to ERS Tools on the provider website under the Education and Reference

section for additional

information.

-----------------------------------------------------------------------------

Provider Training

BCBSTX is proud to offer complimentary educational webinar sessions. These online training sessions give you the

flexibility to attend live sessions. Provider billers, utilization areas and administrative departments will benefit from

these webinars. Please visit Educational Webinar/Workshop Sessions on the bcbstx.com/provider

website to view

what is available and sign up for training sessions.

-----------------------------------------------------------------------------

After-hours Access Is Required

Blue Cross and Blue Shield of Texas (BCBSTX) requires that primary care physicians/providers,

Specialty care physicians, professional providers, and facility and ancillary providers provide urgent care, and

emergency care or coverage for care 24 hours a day, seven days a week. Providers must have a verifiable

mechanism in place, for immediate response, for directing patients to alternative after-hours care based on the

urgency of the patient's need.

Acceptable after-hours access mechanisms may include:

• An answering service that offers to call or page the physician/provider or on-call physician/provider;

• a recorded message that directs the patient to call the answering service and the phone number is provided;

• a recorded message that directs the patient to call or page the physician/provider or on-call

physician/provider and the phone number is provided.

For more detail, please refer to the provider manuals f

or Blue Choice PPO

Physician, Professional Provider and

Facility and Ancillary Provider Manual (Section B) and Blue, Blue Premier Physician, Professional Provider, Facility

and Ancillary Provider Manual (Section B) available in the Education & Reference section of our provider website.

Click on the “Manual” link (note, a password is required).

-----------------------------------------------------------------------------

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 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!

-----------------------------------------------------------------------------

Medical Policy Disclosure

New or revised medical policies, when approved, will be posted on the Blue Cross and Blue Shield of Texas

(BCBSTX) provider website on the 1st or 15th day of each month. Those medical policies requiring disclosure will

become effective 90 days from the posting date. Medical policies that do not require disclosure will become effective

15 days after the posting date. The specific effective date will be noted for each medical policy that is posted.

To view active and pending medical policies go to bcbstx.com/provider

and click on the Standards & Requirements

tab, then click on the Medical Policies offering. After reading and agreeing to the disclaimer, you will then have access

to active and pending medical policies.

-----------------------------------------------------------------------------

Draft Medical Policy Review

To streamline the medical policy review process, you can view draft medical policies on the Blue Cross and Blue

Shield of Texas (BCBSTX) provider website and provide your feedback online. If there are any draft medical policies

to review, these 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.

View draft medical policies

. After reading and agreeing to the disclaimer, you will then have access to view any draft

medical policies, if available.

-----------------------------------------------------------------------------

Annual Rights and Responsibilities Notification

Thank you for choosing to be a participating practitioner with Blue Cross and Blue Shield of Texas

(BCBSTX).

Please review the information below for the latest information that could affect your practice.

Your Rights

As a participating practitioner of our network, you have the right to review information submitted to support your

credentialing application and receive the status of your credentialing (or recredentialing) application, upon request.

Providers have the responsibility to work directly with the reporting entity(ies) to correct erroneous information and/or

conflicting information within 30 calendar days. All corrections must be submitted in

writing to our Enterprise

Credentialing Department, your assigned Network Management Consultant or a Medical Director to avoid future

delays in processing your information for consideration in BCBSTX

networks.

Mail:

1001 E. Lookout Drive

Richardson,

Texas 75082

Fax:

972-766-2137

Email: CredentialingCommittee@bcbstx.com

Please Note: Credentialing decisions will not be made until the applicant has responded or if the response has

exceeded the 30 calendar days allocated.

Applicants who only see patients in an office setting and do not have hospital admitting privileges at a

network

hospital may attest to having coverage for hospital admissions by submitting a signed Hospital

Coverage letter. You

can find a copy of this letter by visiting the Forms section under Education and

Reference on the BCBSTX provider

website.

Care Management Programs: Case Management and Disease Management

BCBSTX Case Management (CM) and Disease Management (DM) staff work with enrolled members to

increase

their knowledge about their condition and help them better manage crisis events when they

occur. CM and DM staff

support the member and practitioner relationship, and aid communication

between them. Members are encouraged

to discuss issues and questions with their practitioner, develop

a “shared decision making” partnership with their

practitioner and take an active role in managing their

own health.

Member compliance with physician treatment plans is monitored, including keeping appointments,

compliance with

medications and completing ordered tests. Program interventions are designed to

coordinate with the activities of a

member’s treating practitioners, specifically their primary care physician

and/or appropriate specialist.

As a practitioner, you may refer a member for these care management programs at any time by calling

the number

on the back of the member’s identification (ID) card. A clinician will collaborate with you to

provide our members

with available resources and additional support.

Member Rights and Responsibilities

As a BCBSTX practitioner, it is important that you are aware of our members’ Rights and Responsibilities.

Our

health plan members can find their Rights and Responsibilities in their benefit booklet or on our

website.

Member Rights and Responsibilities include:

•

A right to receive information about BCBSTX, our services, our providers and facilities, and

member

rights and responsibilities.

•

A right to be treated with respect and recognition of the member’s dignity and right to privacy.

•

A right to participate with providers in making decisions about the member’s health care.

•

A right to have a candid discussion of appropriate or medically necessary treatment options for

the

member’s condition, regardless of cost or benefit coverage.

•

A right to voice complaints or appeals about BCBSTX or the care we provide.

•

A right to make recommendations regarding our members’ Rights and Responsibilities policy.

•

A responsibility to provide, to the extent possible, information that BCBSTX and the provider and

facility

need to provide care.

•

A responsibility to follow the plans and instructions for care that the member has agreed to with

their

provider.

•

A responsibility to understand their health problems and participate in the development of

mutually

agreed upon treatment goals, to the degree possible.

Utilization Management Decisions

BCBSTX is dedicated to serving our customers through the provision of health care coverage and related

benefit

services. Utilization Management (UM) determinations are made by licensed clinical personnel

based on the:

•

benefits policy (coverage) of a member’s health plan,

•

evidence-based medical policies and medical necessity criteria, and the

•

medical necessity of care and service.

All UM decisions are based on appropriateness of care and service, and existence of coverage. BCBSTX

prohibits

decisions based on financial incentives, nor does BCBSTX specifically reward practitioners or

clinicians for issuing

denials of coverage. Financial incentives for UM decision makers do not encourage

decisions that result in

underutilization.

The criteria used for UM determinations are available upon request. Please call the Customer Service or

Health

Advocate number on the back of the member’s ID card.

Pharmacy Benefits

As a participating practitioner, you are given a list of drugs that are reviewed and updated throughout the

year.

For certain drugs, we have quantity limits and/or may require prior authorization before we approve any

benefits for

the drug. Prior approval and quantity limits are in place to ensure we are following current

medically appropriate drug

guidelines.

For more information regarding our Pharmacy programs, visit the Pharmacy Program section on the

BCBSTX

provider website. For Federal Employee Program (FEP) members, information can be found at

fepblue.org/pharmacy. We encourage you to check the website regularly and watch for updates in this

newsletter.

You can find the following information on our website:

•

Formulary lists, including restrictions and preferences

•

How to use our pharmacy procedures

•

An explanation of limits or quotas

•

How you can provide information to support an exception request

•

The process for generic drug substitutions, therapeutic interchange and step-therapy protocols

BCBSTX distributes the Roles and Responsibilities Notification to our practitioners annually to keep you

informed

about important topics that impact you and your practice.

------------------------------------------------------------------------------------------------------------------------------

View our quick directory of contacts

for BCBSTX.

-----------------------------------------------------------------------------

Update Your Information

Do you need to update your location, phone number, email or other important details on file with BCBSTX? Use our

online forms to request information changes.

Are you receiving a copy of the Blue Review by email? If not, contact

your local BCBSTX Network Management Representative to have up to 10 of your office email addresses added.

bcbstx.com/provider

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee

of the Blue Cross and Blue Shield Association