Transcript Slide 1

Medicaid Managed Care Program (STAR) and
Children’s Health Insurance Program (CHIP)
OB/GYN Provider Training
2012
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Rev 020612
Introduction
Welcome
Customer Service
Member Enrollment and Eligibility
Member Benefits and Services
Claims and Billing
Pregnancy Notification and Notice of Delivery Reports
Medical Case Management
Value Added Services
BCBSTX Additional Information
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Customer Service
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Customer Care Center
Committed to providing excellent service to
members and providers
Telephone support
 Provider: 888-292-4487
 Member: 888-292-4480
 TTY: 888-292-4485
 Monday to Friday
 7 a.m. to 6 p.m. CT
Inquiries
Web
Portal
Customer
Care
Center
Eligibility Verification
Claims Inquiries
Benefit Verification
Web Support at: www.availity.com
Primary Care Physician
Assistance
Interpreter/Hearing
Impaired Services
4
Member Enrollment and Eligibility
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Eligibility Verification
Providers should verify eligibility before each service
Ways to verify STAR and CHIP member eligibility
 Register with Availity at www.availity.com
- Use the State’s Automated Inquiry System (AIS)- for STAR (not CHIP)
• 800-925-9126
 Call the BCBSTX Customer Care Center:
• Provider’s may call
• Provider: 888-292-4487
– Live person
– Interactive Voice Response automated telephone response
system
 Call the 24/7 Nurse Line after-hours to verify member eligibility
• 877-351-8392
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Member Identification Cards
STAR members receive two identification cards upon enrollment:
 State issued Medicaid identification card (Your Texas Medicaid Benefit Card); this
is a permanent card and may be replaced if lost
 Blue Cross and Blue Shield of Texas member identification card
CHIP members only receive a Blue Cross and Blue Shield of Texas member
identification card, they do not receive a State issued CHIP identification card
Identification cards will be re-issued to the member
 If the member changes their address
 If the member changes their Primary Care Physician (PCP)
• The member may change their PCP at any time and the change is effective the day of
request
 Upon member request
 At membership renewal
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Member Identification Cards Continued
Examples of BCBSTX identification cards
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Member Benefits and Services
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
STAR Covered Benefits
Some of the benefits include:
 Well-child exams and preventive health services, and screening for
behavioral health problems and mental health disorders
 Physician office visits, inpatient and outpatient services
 Durable Medical Equipment and Supplies
 Chiropractic Services
 Emergency Services
 Family Planning Services (any Medicaid provider in or out of network)
 Transplants
 Vision Plan by Davis Vision
 Behavioral Health by Magellan Health Services
 Pharmacy benefits administered by Express Scripts, Inc.
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CHIP Covered Benefits
Some of the benefits include:
 Well-child exams and preventive health services, and screening for
behavioral health problems and mental health disorders
 Physician office visits, inpatient and outpatient services
 Durable Medical Equipment (not covered for CHIP Perinate)
 Transplants (not covered for CHIP Perinate)
 Chiropractic Services (not covered for CHIP Perinate)
 Vision Plan by Davis Vision (not covered for CHIP Perinate)
 Behavioral Health by Magellan (not covered for CHIP Perinate)
 Pharmacy benefits administered by Express Scripts, Inc.
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CHIP Perinate Covered Benefits
For Mothers that do not qualify for Medicaid, their unborn baby may
qualify for perinatal care as a CHIP Perinate member
Some of the benefits include:
 Prenatal care through delivery
 Medically necessary physician office visits
 Some inpatient and outpatient services
 Prenatal vitamins
 Laboratory, x-rays and ultrasounds
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CHIP Cost Sharing
Co-payments apply from $0 to $100 depending on Federal
Poverty Levels (FPL) and type of service
Co-payment amount is found on the member’s identification card
Once cost-sharing limit is reached the member must call the
enrollment broker, Maximus, to report that they met their max
BCBSTX will receive updated files from Maximus reflecting copayment maximum reached
 An identification card will be re-issued to show that co-payments do
not apply
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Self Referrals
STAR and CHIP members may self-refer for the following services:
 Diagnosis and treatment of sexually transmitted diseases
 Testing for the Human Immunodeficiency Virus (HIV)
 Family planning services to prevent or delay pregnancy (STAR
Only)
 Annual Well Woman exam (in-network only)
 Prenatal services/obstetric care (in-network only)
 Behavioral Health Services (Magellan Network)
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Pharmacy Services
Pharmacy benefits are administered by Express Scripts, Inc. (ESI)
 Provider Customer Service:
• STAR 866-294-1562
• CHIP 866-323-2088
– Call for 72 hour emergency supplies while waiting for prior authorization approval
 Prior authorization:
• STAR 866-533-7008
• CHIP 866-472-2095
 Prior authorization fax:
• Both programs 800-357-9577
• Prior authorization requests will be addressed within 24 business hours
The Benefit Identification Number (BIN), or plan identification number,
is 003858
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Pharmacy Services Cont’d
STAR members have no copay; CHIP members’ copay depends on
the family’s Federal Poverty Level
 CHIP Perinate unborn children will have prescription coverage with no
copay
 CHIP Perinate newborns will have prescription coverage with no copay
BlueCross BlueShield of Texas offers e-prescribing abilities through
Surescripts for providers to:
 Verify client eligibility
 Review medication history
 Review formulary information
For additional information visit the website www.txvendordrug.com
The Formulary is also available for Smart Phones on
www.epocrates.com
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Claims and Billing
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Billing Maternity Claims
Delivery charges should be billed with the appropriate CPT codes
 59409 = Vaginal Delivery (Without Postpartum)*
 59410 = Vaginal Delivery (Including Postpartum Care)*
 59514 = C-Section (Without Postpartum)*
 59515 = C-Section (Including Postpartum Care)*
 59430-TH = Postpartum Care after discharge*
Use appropriate CPT/HCPCS and diagnosis codes when billing
 “Evaluation and Management” codes 99201 – 99215*
*Providers must bill the most appropriate new or established patient prenatal or postnatal visit procedure code
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Billing Maternity Claims (Cont’d)
The following modifiers must be included for all deliveries
 U1-Medically necessary delivery prior to 39 weeks of gestation*
 U2-Delivery at 39 weeks of gestation or later*
 U3-Non-medically necessary delivery prior to 39 weeks of
gestation*
Payments made for non-medically-indicated Cesarean
section, labor induction, or any delivery following labor
induction that fail to meet these criteria, will be subject to
recoupment. Recoupment may apply to both physician
services and hospital fees.
*TMHP Bulletin: http://www.tmhp.com/News_Items/2011/08-Aug/08-09-11%20Update%20to%20OB%20Claims.pdf
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Billing Maternity Claims (Cont’d)
17P (Alpha Hydroxyprogesterone Caproate) is a Texas
Medicaid Benefit for pregnant clients who have a history of
preterm delivery before 37 weeks of gestation.*
Prior Authorization is required for both the compounded and the
trademarked drug
When submitting claims for the compounded drug, use the
following code:
 J1725-TH along with diagnosis code V2341 and the NDC
When submitting claims for the trademarked drug (Makena),
use the following code:
 J1725-U1 along with diagnosis code V2341 and the NDC
*TMHP Provider Manual 8.2.39.4
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Billing Newborn Claims
Routine Newborn Care - STAR:
 Initial care should be billed under the Mother’s Medicaid Patient
Control Number (PCN), or identification number, for the first 90
calendar days
Routine Newborn Care - CHIP:
 Newborns are not automatically eligible
 Mother must apply for baby’s coverage
Routine Newborn Care - CHIP Perinate:
 Newborns are automatically eligible
 Issued their own PCN or identification number
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Billing Newborn Claims
(STAR Member Only)
CMS-1500 billing for newborn care with Mother’s Medicaid Patient
Control Number (PCN), or Identification Number:
 Box 1a Mother’s Medicaid PCN or identification number
 Box 2
Newborn’s name
 Box 3
Newborn’s date of birth
 Box 4
Mother’s complete name
 Box 6
Patient’s relationship to insured
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Pregnancy Notification Report (PNR) and
Notification of Delivery
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Purpose of the PNR
Enrollment into the Future Mom’s Program
Increased awareness of high risk pregnancies
Enrollment into Care Management Programs (if
needed)
Increase rate of pregnancy notification
submissions and compliance
Create overall efficiency in pregnancy data
collection
Enrollment into Educational Programs
Participation in Value Added Service Programs
Sample
Pregnancy
Notification
Report
Purpose of the NOD
Report the birth of a child to a mother who is
a BCBSTX Medicaid member
Assist with discharge planning
Assist with coordination of follow-up care for
both mother and baby
Ensure the best possible outcome for our
members
Enrollment into Care Management
Programs (if needed)
Enrollment into Educational Programs
Participation in Value Added Service
Programs
Notification of Newborn Delivery (NOD)
BCBSTX requests, but does not require, that we receive
notification of all newborn deliveries within three days of
delivery
 Use the Newborn Enrollment Notification Report found on the
BCBSTX website www.bcbstx.com/provider/network/medicaid.html
 Failure to notify us will not result in denial of newborn claims
Routine vaginal or cesarean deliveries do not require
medical necessity review/prior authorization
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Sample
Newborn
Notification
Report
Online Access
Notification of Pregnancy and Delivery Forms available online at:
http://www.bcbstx.com/provider/network/medicaid.html
(located under Medicaid (STAR) and CHIP Forms)
Sample
HHSC
Report of
Pregnancy
Form
Sample
HHSC
Report of
Pregnancy
Form
Medical Case Management
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Post Delivery Call
(Call #1)
Opportunities exist for increased identification of members who meet criteria to be
screened within 4 days of delivery for postpartum maternal and baby complications
resulting in eligibility to enroll in care management programs.
Calls will be focused upon:
*Post delivery discharge complication identification - Mom
*Post delivery discharge complication identification - Baby
*Confirm postpartum visit scheduled within 21-56 days following delivery
*Confirm well child visit scheduled within 4 days of delivery
Members will be identified for this call based upon Notification of Delivery forms
received.
All members identified with positive responses for Case Management triggers will be
referred to Case Management for intensive post discharge management which may
include a skilled nursing home visit to assess the needs and assist with management.
Post Notification of Delivery Call
(Call #2)
Members will be called 14 days following the completion of the call logic for Call #1 with
a focus upon ensuring the mom and baby have scheduled and attended their postpartum
and well baby visits.
For members who were unable to be reached for call #1, opportunities exist to increase
the identification of members who meet criteria to be screened for postpartum maternal
and baby complications when the second outreach call is made.
Calls will focus on:
Re-screening for potential post delivery complications (e.g. postpartum depression)
If Unable to Reach for Call #1: evaluate for Post delivery discharge complication identification - Mom
If Unable to Reach for Call #1: evaluate for Post delivery discharge complication identification - Baby
Confirm postpartum visit was attended or scheduled within 21-56 days following delivery
Confirm well child visits were attended and scheduled
Referrals to Case Management-High
Risk OB
Providers, nurses, social workers and members, or their
representative, may refer members to Case Management in
one of two ways:
 Call 1-855-879-7178
 Fax a completed Case Management Referral Form to
1-866-333-4827
• A Case Manager will respond to the requestor within three business
days
The Case Management Referral Form is located at
www.bcbstx.com/provider/network/medicaid.html (under Medicaid (STAR) and CHIP Forms)
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Value Added Services (VAS)
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
What OB/GYN providers should know about
our Value Added Services (VAS)
Many are directed at improving health of pregnant women through
increasing access to preventive services
Important for OB/GYN providers to be aware of services and how you
can request or refer you clients for services.
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Value Added Services (VAS) Overview
effective 9/1/2012*
Infant Safety Car Seats
Free Pregnancy Classes*
Home Wellness Visits (for mom and baby post delivery)*
Free Breast Pump and Breast Feeding Coaching *
Austin Farmers Market Vouchers (fresh fruit and vegetables)*
Dental Services for Pregnant Adult Members*
Non Emergency Medical Transportation (NEMT)
Lodging and Food Coverage (for out of area NEMT Travel)*
Sports and Camp Physicals
Enhanced Eyewear Frames
24/7 Nurse Line
* Services to be available 9/1/2012
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Free Infant Safety Car Seat
BCBSTX STAR and CHIP moms qualify for a free baby safety car seat when they earn
points for prenatal actions.
Moms must finish a mixture of actions listed below to earn 4 points to quality for their car
seat.
The BCBSTX Car Seat form must be filled out by the OB/GYN or PCP provider and sent
into the CRC staff who will order the car seat to be shipped to the member.
Action
Point Value
Member received their first prenatal visit during
the first 12 weeks of their pregnancy or within the
first month of enrollment in the plan
2 Points
Member completes at least 4 prenatal visits.
1 Point
Member completes at least 6 prenatal visits.
2 Points
Member completes at least 8 prenatal visits.
3 Points
Member participates in Future Mom’s Prenatal
Program.
1 Point
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Sample
Infant Safety
Car Seat
Form
Pregnancy Classes*
BCBSTX will offer free classes to all pregnant STAR and CHIP members
through Seton.
Classes will be offered at various times and days during each trimester
 First Trimester Classes: phases of Labor, when to go and what to bring to
the Hospital, Lamaze Coaching Techniques of Breathing and Relaxation
 Second Trimester Classes : include member education on Pain Relief
Options, Variations in Labor, Early Recovery Expectations, Cesarean
Section Experience, and Brief Labor Rehearsal.
 Third Trimester Classes : include member education on Newborn
Behaviors and Appearance. The Newborn Classes include Newborn
Genital Care, Diapering, Dressing and Umbilical Cord Care and Newborn
Health and Safety Basics.
 A 1 day overview class will be offered for members who join late in their
pregnancy or prefer to get all materials in 1 day.
*Effective 09/01/12
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Pregnancy Classes (Cont’d)*
Some classes will be offered in Spanish on a separate schedule
Members can attend 1-3 sessions.
Have members call our Customer Service or CRC staff to get
registered for the classes.
Customer Service: 1-888-292-4480
CRC: 1-800-618-3084
*Effective 09/01/12
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Home Wellness Visits*
(Breast Feeding Coaching and Breast Pumps)
Home visits will be conducted by a licensed RNs within 5 days of delivery.
This is strictly a VAS with no bill back for these services.
Physician referral is not required for a Home Wellness Visit
There is no criteria needed to obtain services. This can be for first time moms
to moms with high risk pregnancies.
Home Health RNs with experience in OB/GYN/Peds will visit the home to
assess mom, baby and the home environment.
Any identified issues will be referred out as appropriate to include:
Calls/Referrals to OB/GYN, PCP, Pediatrician, BCBSTX CM staff
Breast feeding coaching will be conducted during the home visit for members
requesting this service.
 The free breast pump will also be provided to the member once they
complete the coaching.
*Effective 09/01/12
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Farmers Market Vouchers*
(Fresh Fruits and Vegetables)
BCBSTX Pregnant STAR and CHIP members can get free Farmers
Market Vouchers during their pregnancy
Vouchers are redeemable for free produce and fruits at the following
Sustainable Food Center (SFC) Locations:




Downtown (4th and Guadalupe)
Sunset Valley (3200 Jones Rd./Toney Burger Center)
The Triangle (46th and Lamar)
East (51st and 183/YMCA)
Women can get 10-$2 vouchers up to 2 times during their pregnancy.
(total of $40 worth of vouchers)
*Effective 09/01/12
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Farmers Market Vouchers* (Cont’d)
(Fresh Fruits and Vegetables)
Vouchers can be combined with other Market Programs to double their
free produce
• (Note: this service is provided by SFC for the East location WIC recipients only.
This service is not administered by BCBSTX and is subject to SFC funds
availability).
Pregnant Members can call Customer Call Center or CRC staff to
obtain their vouchers.
Customer Service: 1-888-292-4480
CRC: 1-800-618-3084
*Effective 09/01/12
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Dental Services*
(for Adult Pregnant Members)
BCBSTX will offer free dental services through Liberty Dental for
pregnant adult women enrolled in our STAR and CHIP Perinate
programs
Services are available for members greater than age 20
Members must see a participating dental provider in the network
Services include oral exam, x-rays, cleaning, fillings, sealants, scaling
and planing, and extractions up to a max amount per schedule of
benefits.
*Effective 09/01/12
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NEMT Review
Non-Emergency Medical Transportation is a VAS that is offered to all CHIP members and STAR
members (who are not able to use the HHSC MTP).
NEMT can be used for provider appointments, health classes, to pick up prescriptions or DME
products.
Provided by cars or Taxis working with BCBSTX
STAR members have Medical Transportation Program benefits and would be able to use the VAS
NEMT when they are not able to use the MTP.
Members will call or be routed to the CRC staff to set up the ride with preferable 2 days advance
notice. Call the CRC at 800-618-3084
BCBSTX recognizes some appointments are scheduled same day and we will attempt to
accommodate those requests. The CRC verifies the member appointment/class with the provider
and arranges for the ride.
A parent or guardian may go with a child member.
Refer your clients to BCBSTX customer service or the CRC staff to request assistance with
transportation.
Lodging and meals can be provided when out of area medical appointments/treatment has been
approved for the members.
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24/7 Nurse Line
NurseLine is a 24-hour, 7 day a week, toll-free phone line that gives
important information on health concerns, and neighborhood health
services, and more than 300 health topics.
NurseLine staff can refer members to the on call UM nurse for 72 hour
emergency medicine supply issues or DME issues.
NurseLine uses interpreter services to meet the needs of non-English
speaking members.
Qualified members may use the NurseLine at any time with no limits.
24/7 NurseLine: 1-877-351-8392
48
BCBSTX Additional Information
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Importance of Correct Demographic
Information
Accurate provider demographic information is necessary for accurate provider
directories, online provider information, and to ensure clean claim payments
Providers are required to provide notice of any changes to their address,
telephone number, group affiliation, and/or any other material facts, to the following
entities:



BCBSTX- via the Provider Information Change Form coming soon to
www.bcbstx.com/provider/network/medicaid.html
Health and Human Services Commission’s administrative services contractor
Texas Medicaid and HealthCare Partnership (TMHP)- via the Provider Information Change
Form available at www.tmhp.com
Claims payment will be delayed if the following information is incorrect:



Demographics- billing/mailing address (for STAR and CHIP)
Attestation of TIN/rendering and billing numbers for acute care (for STAR)
Attestation of TIN/rendering and billing numbers for Texas Health Steps (for STAR)
50
Provider Training Tools
Provider Manual will have




Search capability
Links between subjects
Links to forms
Available on-line soon
Internet Site
 www.bcbstx.com/provider/network/medicaid.html
51
Magellan Care Management Center
Behavioral Health Member and provider hotline
1-800-327-7390
52
Questions?
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Thank you for your time!
We look forward to working with you!
Please complete and fax the training
evaluation form.*
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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association