Blue Choice PPO Quick Reference Guide - Blue Cross and ...

1 blue Choice PPOSM Quick Reference Guide Major Characteristics Benefits, Eligibility, Claim Reviews, All Preauthorization, Online Laboratory and Radiology Behavioral Health Services Claims Status or Correspondence Approval of Benefits for Services (Mental Health and Chemical Verification Selected Outpatient Services Dependency). and Inpatient Admissions blue Choice PPO physicians and Eligibility and benefit information Claim Reviews/ Access the iExchange Web Laboratory Services Important: Not all plans include professional providers may only bill for may be obtained through Correspondence should application through the BCBSTX Quest Diagnostics, Inc. is the Behavioral Health benefits copayments, cost share (coinsurance) or a web vendor of be sent to: website at http:// preferred statewide outpatient your Choice or call BCBSTX blue Cross and blue Shield of and deductibles, where applicable. clinical Reference laboratory.

2 Texas (BCBSTX) manages all Provider Customer Service : BCBSTX To schedule a Patient Service Center behavioral health services (mental 800-451-0287* Box 660044 (PSC) appointment, log onto To receive Network benefits, blue Current listings of providers health and chemical dependency). Dallas, TX or call Choice PPO subscribers must receive Claim Status may be obtained and their NPI numbers are Subscribers are responsible for through the Availity Claim 75266-0044 888-277-8772. medical care from blue Choice PPO available online through the requesting preauthorization, although Research tool or a web vendor of To locate other participating labs in physicians and professional providers. The Claim Review iExchange Web application or the blue Choice PPO network, visit behavioral health professionals and your Choice . physicians or a family member may No referrals are required. form with instructions is Provider Finder.

3 The Online Provider Directory To adjust a claim, call BCBSTX located on the BCBSTX. request preauthorization on behalf of To receive Network benefits, Provider Customer Service: For questions or problems, (Provider Finder). the subscriber. All services must be website: medically necessary. Preauthorization referrals to out-of-network physicians 800-451-0287* call the iExchange Support Radiology Services is required from BCBSTX for all and professional providers must be Desk at 800-746-4614. Verification does not apply to Ordering physicians and inpatient, partial hospitalization and authorized by the Medical Care administrative services only For case management or to professional providers (PCPs and outpatient behavioral health services. Management (UM) Dept. (ASO) plans. click on the Education contact the Medical Care Mgmt specialists) must contact AIM To obtain preauthorization, call: and Reference tab, then All claims should be Dept.

4 , call 855-896-2701. Specialty Health ' (AIM) to obtain a Some services may be self- submitted electronically. click on Forms Radiology Quality Initiative (RQI) for BCBSTX. referred to a blue Choice PPO BCBSTX Electronic Payor ID: For approval of select the following services when performed 800-528-7264. physician or professional provider ( 84980 outpatient services and in a physician's or professional Preauthorization must be obtained annual well woman exam, annual inpatient admissions, refer to provider's office, outpatient prior to the delivery of behavioral If the physician or professional health services. routine eye exam) as indicated by the the iExchange webpage at department of a hospital or a provider must file a paper claim, subscriber's benefit plan. freestanding imaging center: Refer to the online blue Choice mail claim to: provider/ - CT/CTA scans PPO Physicians, Professional Provider, BCBSTX - MRI/MRA scans Facility and Ancillary Provider Manual Box 660044 Refer to the Preauthorization / - SPECT/Nuclear Cardiology (Section I).

5 Dallas, TX Notification/Referral studies 75266-0044 All claims should be submitted Requirements List under Clinical - PET scans electronically. BCBSTX Electronic blue Choice PPO claims must Resources on To obtain a RQI, contact AIM as Payor ID: 84980. be submitted within 365 days of the provider to determine the follows: If the provider must file a paper date of service. Claims that are not services that require Call Center: 800-859-5299. submitted within 365 days from the claim, mail claim to: preauthoriation or referrals or Internet: BCBSTX. date of service are not eligible for reimbursement. Physicians and call the iExchange interactive Fax: 800-610-0050 Box 660044. professional providers must submit Voice Response (IVR) at Dallas, TX 75266-0044. Note: Fax option is available only a complete claim for any services 877-774-8592. for physicians or professional For claims status inquiries, contact provided to a member.

6 blue Choice PPO physicians or Effective 8/1/17 eviCore will providers who are submitting your electronic connectivity vendor, professional providers may not manage preauthorization for clinical information for existing Availity or other electronic requests. connectivity vendor or call Provider seek payment from the member for certain specialized clinical Customer Service: claims submitted after the 365 day services. Refer to the For routine radiology services not part of the RQI, refer to the blue 800-451-0287*. filing deadline. Preauthorization/ Notification/. Choice PPO Physicians, Professional *Interactive Voice Response (IVR) system. * Interactive Voice Response (IVR). system. To access, you must have full Referral Requirements List Provider, Facility and Ancillary To access, you must have full subscriber's subscriber's information, under Clinical Resources on Provider Manual (Section B) information, subscriber's ID, patient date subscriber's ID, patient date of birth, etc.

7 For eviCore of birth, etc.). ** To adjust a claim, you must have a document control number (claim number). preauthorization requirements. To authorize eviCore services contact the eviCore Healthcare Web Portal at https://. or call 855-252-1117. This Guide is intended to be used for Quick Reference and may not contain all of the necessary information. For detailed information, refer to the blue Choice PPO Physician and Professional Provider Provider Manual online at Updated June 5, 2017 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the blue Cross and blue Shield Association page 1 of 3. Additional Information Page Claims Submission: All claims should be submitted electronically. The Electronic Payor ID for BCBSTX is 84980. For support relating to claims that are being sent to the Availity platform, submitters should contact Availity Client Services at 800-AVAILITY (282-4546).

8 For support relating to claims and/or other transactions available on the Availity portal or other Availity platforms, submitters should contact Availity Client Services at 800-AVAILITY (282-4546). For information on electronic filing, access the Availity website at Paper claims must be submitted on the Standard CMS-1500 (02/12) or UB04 claim form. All claims must be filed with the insured's complete unique ID number including any letter or 3-digit alpha prefix. Duplicate claims may not be submitted prior to the applicable 30-day (electronic) or 45-day (paper) claims payment period. If services are rendered directly by the physician or professional provider, the services may be billed by the physician or professional provider. However, if the physician or professional provider does not directly perform the service and the service is rendered by another provider, only the rendering provider can bill for those services.

9 Note: This does not apply to services provided by an employee of a physician and professional provider, Physician Assistant, Surgical Assistant, Advanced Practice Nurse, Clinical Nurse Specialist, Certified Nurse Midwife and Registered Nurse First Assistant, who is under the direct supervision of the billing physician or professional provider. ParPlan is a blue Cross and blue Shield of Texas (BCBSTX) payment plan under which health care professionals agree to: File all claims electronically for BCBSTX patients;. Accept the BCBSTX allowable amount;. Bill subscribers only for deductibles, cost-share (coinsurance) and medically necessary services which are limited or not covered; either at the time of service or after BCBSTX has reimbursed the provider;. Not bill BCBSTX for experimental, investigative or otherwise unproven or excluded services; and Not bill either BCBSTX or subscribers for covered services which are not medically necessary.

10 For All blue Choice PPO Products, BCBSTX encourages the provider's office to: Ask for the subscriber's ID card at the time of a visit;. Copy both sides of the subscriber ID card and keep the copy with the patient's file;. Eligibility, benefits, and/or verification requests, contact your or a web vendor of your Choice or call the toll-free Provider Customer Service number indicated on the subscriber's ID card. Claim Status may be obtained through the Availity Claim Research tool or a web vendor of your Choice . For Claim Adjustments, call BCBSTX Provider Customer Service at 800-451-0287*. Utilize the iExchange Web application at to obtain: approval of benefits for select outpatient services and inpatient admissions, maternity notifications, or for notification within 48 hours of an emergency hospital admission. For case management, call the Medical Care Management Department at 855-896-2701. Provider Record ID and Network Effective Dates: A minimum of 30 days advance notice is required when making changes affecting the provider's BCBSTX status, especially in the following areas: (1) Physical address (primary, secondary, tertiary); (2) Billing address; (3) NPI and Provider Record ID changes; (4) Moving from Group to Solo practice; (5) Moving from Solo to Group practice.