visit our web site - health insurance texas | blue … failure or coronary artery disease during the...

Blue ReviewNew Disease Management Pro g r a mAn innovative program for managing coronary artery disease has been launchedto help promote coronary wellness, decrease the risk of myocardial infarctionand reduce readmissions for heart failure. The Coronary Artery Disease (CAD)Management Program, in collaboration with our CAD disease management vendor,QMed, utilizes a physician-centered model.

The program is designed to help:

• Identify patients who may be at risk for coronary artery disease • Encourage patients with cardiovascular disease and heart failure to take an active

role in their own daily monitoring and self-care• Support physicians in helping to manage costs for these patients• Help improve quality of care as reflected by process measures and

clinical outcomes• Enhance coordination of patient care by

linking the physician and the health plan.

The enrollment process begins when a QMedaccount representative contacts the attendingphysician’s office staff to provide information aboutthe program and a list of members who are potentialprogram candidates. Based upon the physician feed-back, members will receive information aboutenrollment in the program. QMed will schedule avisit to the physician’s office to conduct a chartreview of those members who agree to participatein the program. The program is provided at no costto the member.

Outbound Calling Campaign for Asthma and Diabetes:Members identified as having asthma or diabetes will receive calls from an outboundcalling campaign to begin in the fourth quarter of 2004. During the call, memberswill be given educational information about these conditions and the importance ofmedication compliance and condition specific prevention screenings.

Seasonal Mailings for Asthma, Diabetes, CHF and CAD:Seasonal mailers will be sent to members identified with asthma, diabetes, congestiveheart failure or coronary artery disease during the fourth quarter of 2004. Themailings contain disease related educational info rmation and are designed to helpp romote self management techniques.

For further information regarding any of the diseasemanagement programs, please contact the Disease

Management Program Department at 1-800-462-3275.

fourthFourth Quarter 2004

Visit our Web site• Claims Submission Update

at: www. b c b s t x . c o m /p ro v i d e r / g r i / g r i . h t m

• Secondary Claim EDIRequirements

• Quick Reference Guides: ~HealthSelectSM

~UT HMO~UT SELECT

w w w. b c b s t x . c o m / p ro v i d e r

Decline in PneumoniaVaccinationsCreates HealthCare Gap Blue Cross and Blue Shield of Texas(BCBSTX) recently completed a hospitalrecord review to determine opportunitiesto improve the care of patients admitted withpneumonia. Since pneumonia is preventable,it is important to take eve ry opportunity toprotect patients from this disease.

Helpful Tips:• Implement a hospital-wide standing orders

program allowing nurses to administerthe vaccinations.

• Provide ongoing staff education regardingthe importance of vaccinations.

• Implement reminder tools such as chartreminder stickers, posters, and fact sheets.

• Learn more by accessing the BCBSTXWeb site at www.bcbstx.com, the Centersfor Medicare and Medicaid Services Website at www.cms.gov, or www.medqic.org,and the National Immunization Program,sponsored by the CDC at www.cdc.gov.

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productAll Product News

Fees Updated for the New YearThe ParPlan, BlueChoice® and HMO Blue® Texas (Independent Pro v i d e rNetwork only) maximum allowable fees for the pro c e d u re codes listed belowwill be updated effective Jan. 1, 2005 and will be posted on our Web site atw w w. b c b s t x . c o m / p ro v i d e r (see General Reimbursement section). The passwordfor the General Reimbursement section is “manual”.

A0435 A0436 A4641 A4646 A9300 A9511

A9512 A9699 J8499 S1001 43272 78099

80299 86586 87299 87799 87899 89342

89343 89344 89346 90399 90889 92589

97039 97139

In addition, maximum allowable fees for pro c e d u re codes that are new codesin 2005 will be loaded effective January 1, 2005 and will be posted on our website at www. b c b s t x . c o m / p ro v i d e r. (See General Reimbursement section). Thep a s s w o rd for the General Reimbursement section is “manual”.

Policy Change Could Affect Claims PaymentSpecial Notification on Medical Policy 501.051(Tumor Necrosis Factor (TNF) Alpha Inhibitors for Treatmentof Rheumatoid Arthritis (RA) and OtherChronic Inflammatory Diseases)

As a re m i n d e r, the claims payment pro c e d u re related to medical policy501.051 ( Tumor Necrosis Factor (TNF) Alpha Inhibitors for Tre a t m e n to f Rheumatoid Arthritis (RA) and Other Chronic Inflammatory Diseases)will change slightly effective Feb. 1, 2005. All claims associated with501.051 will be reviewed against coverage criteria detailed in the policy.Plus, medical records may be requested for review.

You can review the new changes under the pending policy folder on theBCBSTX Web site under medical policies.

Normally, 90-days notice of such a change is required. However, because ofthe impact on members and physicians, BCBSTX has decided to provide anadditional 30-days notice, making the policy effective Feb. 1, 2005.

Please check the pending policy section of the BCBSTX medical policyWeb site frequently for updates. On the first of each monthwe post new or revised policies that re q u i re 90-days notice. The postedrevisions include claims pro c e d u re ch a n ges that might have an adve r s eeffect on claims payment.

Blue Review 3


No Social Security Number On NewMellon Bank ID CardsEffective Jan. 1, 2005, the ID card for Mellon Bank will no longer contain the member’s socialsecurity number. The new ID card will show an alpha prefix and a six-digit number. All otherinformation on the card will remain the same. There are no benefit changes.

Rockwell Collins Members’ Health BenefitsAdministered by The Blues®

Beginning January 1, 2005, over 800 Rockwell Collins employees and retirees will have theirhealth benefits administered by Wellmark Blue Cross and Blue Shield of I owa. The Ro ck we l lCollins logo will appear on the identification (ID) card, along with one of the unique alphaprefixes listed below. The alpha prefix that appears on the card will be determined by the typeof benefit plan selected.

Rockwell Collins employees have the option of selecting a high deductible PPO plan that allowsmembers to open a Health Savings Account (HSA). Since the benefit plans vary on deductible,coinsurance, and copayment amounts, please check each patient’s benefits bycalling 800-676-2583.

The copayment amount you are to collect for office visits will be printed onthe ID card. Behavioral health and chemical dependency services will be administered byWellmark. Prescription drug cove r a ge for Ro ck well Collins members will be administered byCaremark and is separate from their health benefits.

If you have claims payment questions regarding the Rockwell Collins group,please call the Customer Service number on the back of the member’s ID card .

Alpha Prefix Type of Plan Description

RKP Rockwell Collins PPO BlueCard® PPO network with both(Preferred Provider Organization) in- and out-of-network benefits

RKE Rockwell Collins PPO with BlueCard PPO network with no out-of-network benefits no out-of-network benefits

RKL Rockwell Collins Traditional Blue participating network

RKR Medicare Primary Retirees Medicare primary

RKW Rockwell Collins Iowa PPO Blue participating network foremergency/urgent care, anddependents of Iowa membersresiding out-of-state.

Professional Claims ProcessingEnhancements UpdateAs a reminder, Blue Cross and Blue Shield of Texas has updated numerous claims processes, including the highlightslisted below with their effective date. These changes are not retroactive to claims processed prior to the effectivedate listed.

Continue to check the Blue Review newsletter every quarter for regular updates on enhancements to professionalclaims processing and claims associated with payment-audit logic.

• Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft willbe allowed with repair of nasal ve s t i bular stenosis. PPO/POS effective 8/3/04

• Ve rt ebral corp e c t o my, partial or complete, transperitoneal or re t roperitoneal a p p ro a ch with decompression ofspinal cord, cauda equine or nerve root(s), lower thoracic, lumbar, or sacral; single segment and each additionalsegment will be allowed with Arthrodesis, anterior interbody technique, including minimal diskectomy to prepareinterspace; lumbar. PPO/POS/HMO effective 8/3/04

• Intubation, endotrachael, emergency procedure will be allowed with newborn resuscitation.PPO/POS/HMO effective 8/3/04

• Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)will be allowed with Submucous resection turbinate, partial or complete, any method.PPO/POS/HMO effective 8/3/04

• Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) will be allowedwith electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion.PPO/POS/HMO effective 8/3/04

• Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/ortherapeutic intervention; each additional vessel will be allowed with Percutaneoustransluminal coronary balloon angioplasty; single vessel and Percutaneous transluminalc o ro n a ry athere c t o my, by mechanical or other method, with or without balloonangioplasty; single vessel. PPO/POS effective 8/3/04

• Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-Jtype); will be allowed with cystourethroscopy with ureteroscopy; with treatment ofureteral stricture, with treatment of ureteropelvic junction stricture, with treatmentof intrarenal pelvic lesion, and with resection of ureteral or renal pelvic tumor.PPO/POS/HMO effective 8/3/04

• Outflow tract augmentation (gusset), with or without commissurotomy orinfundibular resection will allow Assistant Surgeon benefits.PPO/POS/HMO effective 8/3/04

• Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteralcatheterization is included) will be allowed with Lithotripsy, extracorporeal shockwave. PPO/POS/HMO effective 9/14/04

• Biopsy of liver, wedge will be allowed with Laparoscopy, surgical; with guidedtranshepatic cholangiography, with/without biopsy; cholecystectomy with/withoutcholangiography; exploration of common duct; and cholecystoenterostomy.PPO/POS/HMO effective 9/14/04

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• Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacingcardioverter-defibrillator or pacemaker pulse generator will be allowed with subcutaneous removal of single ordual chamber pacing cardioverter-defibrillator pulse generator. PPO/POS/HMO effective 9/14/04

• Laryngoscopy direct, with/without tracheoscopy; with dilation, subsequent will be allowed with Tonsillectomy,primary or secondary; > age 12. PPO/POS/HMO effective 9/14/04

• Tr a n s p e t rosal appro a ch to posterior cranial fossa, cl ivus or foramen magnum, including ligation of superior petro s a lsinus and/or sigmoid sinus will be allowed with Infratemopoal pre-auricular approach to middle cranial fossa,with/without disarticulation of the mandible, including paro t i d e c t o my, craniotomy, decompression and/ormobilization of the facial nerve and/or petrous carotid artery. PPO/POS/HMO effective date 9/14/04

• Nasal sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus will beallowed with Ethmoidectomy; extranasal, total. PPO/POS/HMO effective date 9/14/04

• Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F); will beallowed with Hemoglobin fractionation and quantitation; chromatography (eg, A2, S,C, and/or F). PPO/POS/HMO effective date 9/14/04

• Injection procedure during cardiac catheterization; for pulmonary angiography will beallowed with Left heart catheterization, retrograde, from the brachial artery, axillaryartery or femoral artery; by cutdown. PPO/POS/HMO effective date 9/14/04

• Fluoroscopic guidance for needle placement and fluoroscopic guidance and localizationof needle or catheter tip for spine or paraspinous diagnostic or therapeutic injectionprocedures, including neurolytic agent destruction will be allowed with Radiologicexamination, spine, lumbosacral; two, three, four views, complete including bendingviews. PPO/POS/HMO effective date 9/14/04

• Excision of Meckel’s diverticulum (diverticulectomy) or omphalomesenteric duct willbe allowed with excision or destruction, open, intra-abdominal or retroperitonealtumors or cysts or endometriomas. PPO/POS/HMO effective date 9/14/04

• Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-Jtype) will be allowed with Cystourethroscopy (including ureteral catheterization);removal of ureteral calculus; with fragmentation or ureteral calculus; with subureteric injection ofimplant material and with manipulation, without removal of ureteral calculus.PPO/POS/HMO effective date 9/14/04

• Bone graft, any donor area; major or large, and Graft; ear cartilage, autogenous, to nose or ear will beallowed with Osteoplasty, facial bones; augmentation (Autograft, allograft, or prosthetic implant).PPO/POS/HMO effective date 9/14/04

• Destruction of vaginal lesion(s); simple will be allowed with treatment of missed abortion, complete surgically;first trimester. PPO/POS/HMO effective date 9/14/04

• Incision and drainage of vulva or perineal abscess will be allowed with Hysteroscopy, surgical; with sampling ofendometrium and/or polypectomy, with/without D&C; with lysis of intrauterine adhesions; with division orresection of intrauterine septum; with removal of leiomyomata; with removal of impacted foreign body and withendometrial ablation. PPO/POS/HMO effective date 9/14/04

• Implantation of mesh or other prosthesis for incisional or ventral hernia repair will be allowed with Breast recon-struction with free flap. PPO/POS/HMO effective date 9/14/04

• Synovectomy; intertarsal or tarsometatarsal joint, each will be allowed with Partial excision bone; talus or calca-neus. PPO/POS/HMO effective date 9/14/04

• Tracheostomy, fenestration procedure with skin flaps will be allowed with Surgical closure tracheostomy or fistula;with plastic repair. PPO/POS/HMO effective date 9/14/04

• Repair umbilical hernia, >5 yrs; reducible will be allowed with Renal allotransplantation, implantation of graft;excluding donor and recipient nephrectomy. PPO/POS/HMO effective date 9/14/04

• Excision, tumor, foot; subcutaneous tissue; deep, subfascial, intramuscular; and Radical resection of tumor, softtissue of foot will be allowed with radical resection of tumor, bone; tarsal, metatarsal, phalanx of toe.PPO/POS/HMO effective date 9/14/04

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Is Your Claim Being Unnecessarily Delayed?Did you know that Blue Cross and Blue Shield of Texas receives thousands of claims each month that requireunnecessary review? What that means to you is a possible delay or even denial of services pending receipt of therequired information.

Here are some tips to improve claims processing timelines.

1) Always include the provider number along with your tax ID number in block 24K on your claim. 2) Enter the patient’s first name in its entirety – avoid using a single initial in place of the patient’s full name.3) Verify that the patient relationship code is correct.4) Always include the appropriate alpha prefix that is located on the member’s ID card in block 1A.

These few additional steps can help eliminate additional delays or potentially reduce rejected claims for your office.

Proof of Timely FilingBlue Cross and Blue Shield of Texas considers the following as proof of timely filing of claims:• TDI Mail Log• Certified Mail Receipt (only if accompanied by TDI Mail Log)• EDI-link Blue Claim Acceptance Response Report• Documentation indicating that the claim was filed with the wrong area of Blue Cross and Blue Shield of Texas• Documentation from BCBSTX indicating claim was incomplete• Documentation from BCBSTX requesting additional information• Primary carrier’s EOB indicating claim was filed with primary carrier within the timely filing deadline.

New Injectable Drug Delivery Program AvailableBlue Cross and Blue Shield of Texas re c e n t ly contracted with McKesson Specialty Pharmaceuticals to provide aninnovative new injectable drug delivery program. Providers who participate with Blue Cross and Blue Shield of Texasplans have the option of obtaining certain high cost injectable drugs through McKesson Specialty Pharmaceuticals.The service eliminates the need to stock and bill for office administered injectable drugs, and enables you to orderinjectables one dose at a time.

When a patient needs an injectable medication, the prescription can be submitted by fax or phone. Specializedrequest forms can be obtained by calling 1-888-456-7274. McKesson will coordinate authorization with BCBSTXand ship the prescription to your office. All pack a ges are indiv i d u a l ly marked for each patient, and re f r i gerated dru g sa re shipped in insulated pack a ges with frozen gel packs. The new service also offers the additional conve n i e n c eo f e n closing all needed ancillary supplies (needles, syringes, and alcohol swabs) with the injectable medication atno charge.

McKesson Specialty Pharmaceuticals is an experienced specialty pharmacy with a proven record of high qualitycustomer service and satisfaction, currently servicing over 40 million managed care members nationwide.

For more information about this program, please visit the Blue Cross and Blue Shield of Texas Web site atwww.bcbstx.com/provider under the Pharmacy section or call McKesson at 1-800-249-3249.

Blue Review 7


Crossover Process Saves Time and MoneyMedicare Part B: Submit Supplemental ClaimsElectronicallyThe BCBSTX Defensive Strategy Medicare Part B Team recently implemented an electronic submission process thatmay impact as many as two million claims currently submitted on paper each year.

Most patients who are eligible for Medicare Part B will have their supplemental claims automatically generated viathe crossover process. When Medicare releases its payment for Part B claims, these claims will then crossover toBCBXTX/Health Care Service Corporation for processing of the supplemental benefits. This is the best way toobtain your secondary payment with the least amount of effort. By allowing the crossover process to work, we allsave time and money.

However, in some cases when patients have not updated their BCBSTX membership information, the claims will notautomatically crossover. BCBSTX is now offering an electronic alternative to obtain that supplemental paymentwhen Blue Shield (professional) claims do not crossover.

Use the timeline below to determine when crossover has not occurred or will occur. (This guideline assumes the pri-mary Medicare claim was submitted in the HIPAA compliant 837 format.) Procedures for Medicare Part Acrossovers will follow in a future newsletter.

Start with the date you receive your Explanation ofMedicare Benefits:

Day 1 - Receive payment and EOMB from Medicare indicating theclaim has been forwarded to BCBSTX for supplemental payment.

Days 4 - 19 - Re c e ive the complementary cro s s over pay m e n tf rom BCBSTX (cro s s over claims are highlighted with a messageon the PCS - the Provider Claim Summary )

Day 20 - If no payment or denial indicated on the PCS (ProviderClaim Summary) is re c e ived, file the supplemental port i o ne l e c t ro n i c a l ly to BCBSTX using the guidelines on the Web site atw w w. b c b s t x . c o m/p rov i d e r.

Notes:• For non-HIPAA compliant claims and paper submissions,

please add 14 days to this timeline.• The cro s s over process re q u i res the patient to provide BCBSTX with the HICN Number

assigned by Medicare. Wh e re claims do not cro s s over for patients or do so inconsistently,please advise them to provide BCBSTX with their HICN# by contacting Customer Serviceat the 800 number on the back of their BCBSTX Identification Card.

Web Info: Go to www.bcbstx.com/provider for the Medicare Part B Guidelines and EDI Requirements.

Blue Review8


Expecting Some ImportantChecks In the Mail?An average of 40 billion pieces of mail a year must be forwarded,re t u rned to the sender or simply thrown away due to incorre c taddresses. The Postal Service contends that undelivered as addressed( U.A.A.) mail is among the largest reasons for frequent postagerate hikes.

H ow does an incorrect address affect you? You could ex p e r i e n c ean increase in postage costs, plus delays in receiving reimbursementchecks and i m p o rtant info rmational mailouts.

At Blue Cross and Blue Shield of Texas we currently use the mostup-to-date address correction methods recommended by the PostalS e rvice. Despite the use of the address correction tech n o l o gytechniques, Blue Cross and Blue Shield of Texas still receives over6,000 pieces of U.A.A. mail each business day. Most of this mailis returned because the forwarding order expired. Simply stated, t h eletter carrier was unable to deliver the re c i p i e n t ’s mail since addresschange information was more than 18 months old. Also, returnmail is in a lower priority work-stream within the postal s e rvice, andmail can be weeks old befo re it is re t u rned to Blue Cross and BlueShield of Texas.

What can you do to help us and the Postal Service improve the delive ry of your mail wh e nyou’ve changed addresses? Visit www.bcbstx.com/provider and find the contact informationfor your are a ’s provider network office by cl i cking on “contact us”. Then fax any updates toyour provider network office, including mailing address as well as other contact information.

Ensuring we have your most current address information will help us continue to providethe best possible customer service.

The Federal Employee Program, FDAApproval and Medical NecessityIn a previous issue, we explained that FEP plans cannot deny a pro c e d u re or tre a t m e n tas experimental or inve s t i gational when it invo l ves the use of a device that is approve dfor marketing by the FDA. Howeve r, these pro c e d u res and treatments are still subject toreview for medical necessity. You can help get a review for medical necessity faster byp roviding medical re c o rds and other info rmation documenting medical necessity wh e nyou submit claims for these procedures or treatments. For more information about FEPand medical necessity, please see the latest version of the Blue Cross and Blue ShieldS e rvice Benefit Plan bro ch u re at w w w. f e p b l u e . o r g .

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How to Expedite Your UB92 Electronic Facility ClaimsTo help us get your electronically submitted claims paid faster, please review and followthe procedures below.

• Ensure the correct spelling of patient’s/insured’s name in fields 12 and 58 on theUB92 form is used. Please use full names and avoid using initials or abbreviationswhenever possible.

• Field 80 on the UB92 form should be populated with ICD9 procedure codes insteadof HCPC/CPT procedure codes.

• E-Diagnosis code (External Cause of Injury Code) should be submitted in field 77on the UB92 form.

• Ensure the claims are submitted with the appropriate alpha prefix that is locatedon the member’s ID card.

• E n s u re the appropriate UB92 Type of Bill is submitted in field 4 on the UB92form. Do not bill as a corrected/replacement claim unless a prior claim has beenp reviously billed.

Introducing BCBSTX’s Health Savings Account(HSA) Product—BlueEdgeSM HSAWe are pleased to announce the launch of BCBSTX’s BlueEdge HSAproduct beginning first quarter 2005. A Health Savings Account is at a x - exempt savings ve h i cle ava i l a ble to individuals cove red by highd e d u c t i ble health plans. Funds in the account are used to pay for qualifi e dmedical expenses. BlueEdge HSA plan designs confo rm to fe d e r a lguidelines outlining specific minimum annual deductible amounts,maximum out-of-pocket expenses, and contribution amounts. Congressauthorized tax-advantaged HSAs in December 2003 as a provision ofthe Medicare Prescription Drug Improvement and Modernization Act(Medicare Act of 2003).

M o re information on BlueEdge HSA, as well as otherc o n s u m e r-driven products, will be featured in futureeditions of Blue Review.

BCBSTX Increasing InstitutionalDetail Line Limit on UB92 ClaimsE ffe c t ive immediately, Blue Cross and Blue Shield of Texas has madeenhancements within the adjudication system to process up to 115 detail lineson Institutional claims. Claims that exceed 115 detail lines will require manualintervention, so we encourage you to limit the detail lines to 115 to expediteprocessing of your facility claims. THIN will accept up to 999 lines as required by the 837 Institutional Implementation Guide.

To ensure that you can submit claims with the additional lines, please review your system edits with your vendor. It may benecessary for your system vendor to make changes to your software to accommodate the additional detail lines.

Electronic Submission of Texas Blue Shield(Professional) Secondary ClaimsIn an effort to pay claims more quickly, we would like to remind providers that all Texas Blue Shield Secondary toC o m m e rcial Carrier claims can be submitted electro n i c a l ly. Electronic secondary pro fessional claims do notrequire the submission of the primary payer’s explanation of benefits. They only require the submission of afew additional data elements as indicated below.

If you are unsure of primary vs. secondary status for a claim or if you have questions regarding claim payment or need other claim information, please contact BCBSTX provider customer serviceat 1-800-451-0287.

If you experience problems with COB secondary claims after following the submission instructions, you mightconsider the following:• Were all of the required electronic data elements supplied on the claim?• Have you verified with your software vendor that your software accommodates the required electronic data

elements for secondary claims? • Does your or your vendor’s software have certain preset defaults preventing you from submitting a

secondary claim?

I f you have any questions rega rding electronic claims submission, please contact the EDI Helpline at 972-766-5480.

Please Note: Information on BCBSTX secondary for Institutional claims will be coming soon.

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Other Insurance IndicatorRecord CA0, field 22.0 (position 182)Must equal “1” = Yes, patient has other insurance

Primary Payer RecordRecord DA0 – sequence 01, field 04.0 (position 23)Must be equal to “I”

Primary Payer NameRecord DA0 – sequence 01, field 09.0 (positions 36 – 68)Enter the name of the Primary Insurance Carrier

Primary Payer Amount PaidRecord DA1 – sequence 01, field 14.0 (positions 149 – 155)Enter the amount paid by the Primary Insurance Carrier

Secondary Payer RecordRecord DA0 – sequence 02, field 04.0 (position 23)Must be equal to “P”

EDI Requirements for Submitting BCBSTX Electronic Secondary Blue ShieldClaims When Another Commercial Carrier is Primary.

T0301 FORMAT

ANSI 837 PROFESSIONAL FORMAT

Primary Payer NameLoop 2330B – Other Payer Name, NM103Enter the name of the Primary Insurance Carrier

Primary Payer Amount PaidLoop 2320 – Coordination of Benefits (COB) Payer PaidAmount, AMT02Enter the amount paid by the Primary Insurance Carrier

texasHMO Blue Texas News

Rights & Privacy Statements Availableon Web siteThe HMO Blue Texas Member Rights & Responsibilities Statement is ava i l a ble atw w w. b c b s t x . c o m . The statement appears on both the member and provider sites. On themember site, go to HMO Group Product; on the provider site, go to Provider Manual.

The BCBSTX Web site and the HMO Provider Manual include a summary of H C S Cp r iva cy policies. The Provider Manual is ava i l a ble under the Provider Library section atw w w. b c b s t x . c o m/p rov i d e r. To obtain a hard copy or CD of the Provider Manual, pleasecall your Provider Network Representative. The password is “manual”.

LabCorp: Exclusive Outpatient Laboratory Provider ForHMO Blue® Texas Members - UPDATEAs of Sept. 1, 2003, Quest and CPL, Inc. were no longer participating outpatient clinical reference laboratory providers forHMO Blue Texas. HMO Blue Texas contracted providers are obl i gated to use participating laboratory facilities. LaboratoryCorporation of America (LabCorp) remains the exclusive outpatient clinical reference laboratory provider for HMO BlueTexas members in specified geographic areas.

The agreement with LabCorp specifically excludes any lab services provided during emergency room visits, in-patientadmissions, skilled nursing care, home care services and out-patient surgeries (hospitals and ambulatory surgery centers).

Additionally, anatomical pathology providers may continue to provide services referred to them from any of the abovereferral sources (ambulatory surgery centers, hospitals, home health care providers and skilled nursing providers).

To find the closest LabCorp Patient Service Center, please access LabCorp’s toll-free phone system at 1-888-LabCorp ortheir Web site at www.labcorp.com. Both of these systems will prompt you for your ZIP code and provide service centersnearest the ZIP code location.

Exception: Physicians who are contracted/affiliated with a capitated IPA/Medical Groupmust contact their IPA/Medical Group for direction on where to refer their HMO Blue Texas

patients for outpatient laboratory services.

11Blue Review

Blue Review12

choiceBlueChoice News

BlueChoice PPO/POS Radiology QualityInitiative (RQI) - UpdateE ffe c t ive Oct. 1, 2004, Blue Cross and Blue Shield of Texas has contracted with American Imaging M a n a ge m e n t ,Inc. (AIM) to implement a new Radiology Quality Initiative (RQI) for outpatient diagnostic imaging servicesfor BlueChoice PPO/POS and BlueChoice Solutions subscribers. This program applies to subscribers with a Texasaddress and who receive a benefit booklet from Blue Cross and Blue Shield of Texas.

This program helps to ensure that:• the most appropriate diagnostic imaging exam is ordered for the diagnosis,• studies are performed in the proper sequence, and• services to subscribers are maximized by the efficient use of their benefit plan.

Effective for dates of service on or after Oct. 1, 2004, compliance with the Radiology Quality Initiative will berequired for the following outpatient diagnostic imaging services when performed in a physician’s office, theoutpatient department of a hospital or a freestanding imaging center – CT, MRI, MRA, Nuclear Cardiologystudies and PET scans. Ordering physicians must contact AIM to obtain an RQI number when ordering anyo f the above studies. Imaging studies perfo rmed in conjunction with emerge n cy room serv i c e s, inpatienthospitalization, outpatient surge ry (hospital and freestanding surge ry centers) or 23-hour observation areexcluded from this requirement.

The RQI process is based uponguidelines from medical organiza-tions and medical literature. Theguidelines are consistent with theclinical appropriateness criteriadeveloped by the American Collegeof Radiology (ACR).

For questions related to the RQIprogram, please contact AmericanImaging Management, Inc. at 800-859-5299 or visit AIM’s Web site atwww.americanimaging.net

Please refer to page 13 of this issue for thePhysician’s Reference Guide to the RQI Program.

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texasBlueChoice News

Physician’s GuideRadiology Quality Initiative • Effective Oct. 1, 2004

Blue Cross and Blue Shield of Texas understands the increasing importance of high-tech imaging studies for yourpatients’ care. To assist in having these critical outpatient diagnostic tests utilized in the most beneficial and costeffective manner, a Radiology Quality Initiative (RQI) program is being implemented through American ImagingManagement, Inc. (AIM) for BlueChoice PPO/POS and BlueChoice Solutions subscribers. For tests performed onor after Oct. 1, 2004, ordering physicians must obtain an RQI number for non-emergency outpatient diagnosticimaging CT, MRA, MRI, PET, and Nuclear Cardiology procedures by following the steps below.

Obtaining RQI Number

Required InformationAIM will require the following information for every request (please have the subscriber’s chart or officenotes available):• Subscriber’s name and date of birth• Insurance information, such as subscriber’s BCBSTX ID number, group number, etc.• Ordering physician’s name, address and telephone number• Name of imaging facility (where the procedure will be performed)• Type of service and/or CPT code• Reason (indication) for the imaging procedure and/or ICD-9 CM diagnosis code• Results of pertinent previous studies (labs, x-rays, etc.) and treatments, including their duration• Subscriber’s symptoms

Based on clinical criteria, AIM will either issue an RQI number or forward the case to a nurse or physician forreview. The physician reviewer may contact the ordering physician to discuss the case in greater detail within two (2)business days of receipt of the request.

O rdering physicians may also contact AIM’s physician rev i e wer at any timeduring the RQI process. AIM will provide the ordering physician with anRQI number, wh i ch will be valid for 30 days from the date issued. Th eo rdering physician must write the RQI number on the requisition for theimaging study. Issuance of an RQI number is not a guarantee of p ay m e n t .When submitted, the claim will be processed in accordance with the term so f a subscriber’s health benefit plan. Exams will be directed to the mostcost effe c t ive outpatient providers in order to maximize subscribers’insurance benefi t s .

Telephone Requests:

Call AIM toll free at 1-800-859-5299, Monday through Friday,6 a.m. to 6 p.m. CT.

Web/Internet Requests:

Access AIM’s Web site to set up alogin and passwo rd for Intern e tbased RQI requests and other helpfultools at www.americanimaging.net.

Fax Requests:

Complete the AIM re fe rr i n gphysician fax form, including allre l evant info rmation, and fax toAIM at 1-800-610-0050.


14

Employer Groups Enrolling in BCBSTX’sBlueChoice Solutions Network

We are pleased to announce increased member enrollment in our new BlueChoice Solutions benefit plan launched inJu ly 2004. Please refer to the chart below for a list of the current employer groups and their effective dates enrolledwith Blue Cross and Blue Shield of Texas as of N ovember 1, 2004 to utilize the BlueChoice Solutions netwo r k .BlueChoice Solutions has been chosen as an optional network for the employees ofBlue Cross and Blue Shield of Texas, HEB and TXU.

BlueChoice Solutions Group Accounts

Group Name Group EffectiveNumber Date

American Steel Building 35966 10-1-2004

Auto Nation 92102 01-1-2005

Blue Cross and Blue Shield of Texas Employees 191246 01-1-2005

Buckalew Chevrolet 81097 09-1-2004

Challenger Process Systems Co. 92006 11-1-2004

City of South Houston 90639 10-1-2004

DIAB LP DBA DIAB Inc. 54403 11-1-2004

HEB 90211 01-1-2005

Parent/Child, Inc. 90359 09-1-2004The Crossings 84027 11-1-2004

Tim Smoot Electric 90321 09-1-2004

TXU 90729 01-1-2005

Ypone Operations 90835 10-1-2004

A sample of the BlueChoice Solutions ID card is provided below. Each subscriber ID card includes the BlueChoiceSolutions logo for easy recognition. The network number is also specific to BlueChoice Solutions - PSNOA .

Please Note: In Texas, BlueChoice Solutionssubscribers must use BlueChoice Solutions providersfor in-network benefits.

For additional information aboutBlueChoice Solutions, pleasevisit the BCBSTX Web site atwww.bcbstx.com/provider, click on“Learn More — BlueChoice Solutions”.

Blue Review 15

LabCorp: Preferred Outpatient Laboratory Provider ForBlueChoice PPO/POS Members – UPDATE

On Sept. 1, 2003, Laboratory Corporation of America (LabCorp) became the statewide preferred outpatient clinicalreference laboratory provider for the BlueChoice PPO/POS products.

BlueChoice PPO/POS contracted providers (PCPs and SCPs) are encouraged to utilize LabCorp. However, BlueChoicePPO/POS providers can still refer both clinical and anatomical lab work to other BlueChoice PPO/POS contracted labproviders without any penalty for doing so. We ask, however, that you consider using LabCorp as your lab of choice for ourBlueChoice PPO/POS network members.

As with the HMO product, all contracted anatomical pathology providers may continue to provide services referred to themfrom ambulatory surgery centers (ASCs), hospitals and home health providers.

If you have specific questions regarding your LabCorp account or need to set up an account with LabCorp, please contactLabCorp’s Client Services Department at:

Dallas/Fort Worth/El Paso/West Texas Houston/San Antonio/Austin/South Texas800-788-9892, ext 6202 800-800-2387, ext 3999972-566-7500, ext 6202 713-856-8288, ext 3999


BlueChoice Solutions Selection Process EnhancedIn response to ongoing feedback from the physician community, we have enhanced the selection process forBlueChoice Solutions.

The Risk Adjusted Cost Index (RACI) calculation was modified to exclude episodes in which a physician orprovider did not make a significant contribution. The original RACI calculation included all episodes in which asolo physician practice, professional provider, or group practice participated. This “Significant Contributor” modelonly includes those episodes in which a solo physician practice, professional provider, or group practice contributedto more than 10 percent of the allowed cost of an episode.

A RACI of 1.00 or less by itself, does not guarantee participation in BlueChoice Solutions network. The RACImethodology does not include measures of appropriateness of utilization or coding. When physicians and otherpractitioners have exc ep t i o n a l ly high utilization, a detailed claims review is perfo rmed by experienced nurses and al i ke-specialty peer review is obtained as needed. Practitioners with utilization patterns that stand out from theirpeers are sent letters that explain the specific concerns and the “ d r ive r s ” behind them. These practitioners may notbe eligible to participate in the BlueChoice Solutions network.

Additional information about BlueChoice Solutions is available on our Web site at www.bcbstx.com/provider.

PRSRT STDU.S. POSTAGE

PA I DDallas, TexasPermit No. 6010

Blue Review Published quarterly for BlueChoice®, ParPlan and HMO Blue® Texas contractingphysicians and other health care providers. Ideas for articles and letters to the editor are welcome.

Please mail to: Corporate Communications, Blue Review Editor,Blue Cross and Blue Shield of Texas, P.O. Box 655730, Dallas, Texas 75265-5730.

© 2004 Health Care Service Corporation

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

HealthSelectSM administered by Blue Cross and Blue Shield of Texas

The information provided in Blue Review does not constitute a summary of benefits, and all benefitinformation should be confirmed or determined by referring to the appropriate benefit booklet.

8712.770-1004

Inside Blue Review

All Product News 2Information applicable to all lines of businessfor Blue Cross and Blue Shield of Texas andHMO Blue Texas

HMO Blue Texas News 11

BlueChoice News 12BlueChoice is a PPO and POS product providedor administered by Blue Cross and Blue Shieldof Texas with networks for contracting PPO andPOS providers

A Provider Publication


Partners Access FSA With New Debit CardBeginning Jan. 1, 2005, H E B ’s Pa rtners (employees) will start using a debit card to access pre-tax dollars intheir Flexible Savings Account (FSA). This debit card acts like a credit card and can be used anywhere that displaysthe MasterCard logo. (The “credit” option must be selected on the card reader.) This product is administered forHEB by Ceridian. These funds can be used to pay for RX and medical co-pays, co-insurance and deductibles.

If you are providing treatment to an HEB Partner and your office accepts MasterCard, please make sure you calcu-late any co-insurance amount based on the BCBSTX contracted rate, not the billed charges.

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