Blue Cross Blue Shield HMO Blue Texas

UT System Members, Dependents & Retirees

2004-2005

HMO Blue Overview•• Eligibility VerificationEligibility Verification

•• CoCo--pays and Benefit Limitationspays and Benefit Limitations

•• Preauthorization/Notification/Referral RequirementPreauthorization/Notification/Referral Requirement–– http://http://www.bcbstx.com/provider/index.htmwww.bcbstx.com/provider/index.htm

•• PCP Referral ProcessPCP Referral Process

•• Blue Link AccessBlue Link Access

•• Claim SubmissionClaim Submission

http://www.bcbstx.com/provider/index.htm

HMO Blue Overview•• Pharmacy Pharmacy

•• Lab Services Lab Services

•• Outpatient Diagnostic Imaging Outpatient Diagnostic Imaging

•• Behavioral Health ServicesBehavioral Health Services

•• UTMB Plan CodesUTMB Plan Codes

HMO Blue Overview

•• HMO Blue Provider ManualHMO Blue Provider Manual

•• http://www.bcbstx.com/http://www.bcbstx.com/•• Password is Password is ““manualmanual””

•• HMO Blue Quick reference GuideHMO Blue Quick reference Guide

•• http://www.bcbstx.com/provider/pdf/hmoblue_qrg.pdfhttp://www.bcbstx.com/provider/pdf/hmoblue_qrg.pdf

•• Glossary Of Terms Glossary Of Terms

http://www.bcbstx.com/http://www.bcbstx.com/provider/pdf/hmoblue_qrg.pdf

Eligibility Verification

•• Verification of member eligibility and covered benefits must Verification of member eligibility and covered benefits must be done prior to delivering services. Available options:be done prior to delivering services. Available options:

BCBS benefits & eligibility phone number BCBS benefits & eligibility phone number (888) 322(888) 322--23792379

THIN Online THIN Online http://http://bcbstx.com/provider/claim_status.htmbcbstx.com/provider/claim_status.htm

Co-pays and Benefit Limitations

•• PCP Office VisitsPCP Office Visits $25$25•• Specialist Office Visits Specialist Office Visits -- Includes OB/GYNIncludes OB/GYN $30$30•• ERER $100$100•• Outpatient SurgeriesOutpatient Surgeries $200$200•• Hospital AdmissionsHospital Admissions $100 per day $100 per day --

$500 max per $500 max per occurrenceoccurrence

•• Urgent Care Urgent Care $25$25

CoCo--pays are to be collected at every encounter. Any employee pays are to be collected at every encounter. Any employee going to Urgent Care who has a nongoing to Urgent Care who has a non--UTMB PCP will be required UTMB PCP will be required to pay for services in full. For more details on coto pay for services in full. For more details on co--pays (page 51):pays (page 51):

http://www.utsystem.edu/egi/pubs/2004HMOBluePlanBooklet.pdfhttp://www.utsystem.edu/egi/pubs/2004HMOBluePlanBooklet.pdf

http://www.utsystem.edu/egi/pubs/2004HMOBluePlanBooklet.pdf

Preauthorization/Notification/Referral Requirements

Verification of member eligibility and covered benefits must Verification of member eligibility and covered benefits must be done prior to delivering services. Available options:be done prior to delivering services. Available options:

•• BCBS benefits & eligibility phone number BCBS benefits & eligibility phone number (888) 322(888) 322--23792379

•• THIN OnlineTHIN Online

Preauthorization/Notification/Referral Requirements

Available options:Available options:

•• BCBS phone: (800) 413BCBS phone: (800) 413--08690869

•• Blue Link: Blue Link: https://www.bcbstxbluelink.com/security/https://www.bcbstxbluelink.com/security/

For more details: For more details: http://www.bcbstx.com/provider/index.htmhttp://www.bcbstx.com/provider/index.htm

https://www.bcbstxbluelink.com/security/http://www.bcbstx.com/provider/index.htm

PCP Referral Process

•• PCP referral process options:PCP referral process options:

Phone: (800) 413Phone: (800) 413--08690869

Blue Link: Blue Link: https://https://www.bcbstxbluelink.comwww.bcbstxbluelink.com/security//security/

•• Referrals to specialists (SCP), except OB/GYN and Referrals to specialists (SCP), except OB/GYN and behavioral health providers, must be initiated by the PCPbehavioral health providers, must be initiated by the PCP

•• SCP cannot refer to other SCP SCP cannot refer to other SCP

https://www.bcbstxbluelink.com/security/

Blue Link Access•• You must go to You must go to www.bcbstxbluelink.com/security/login.aspwww.bcbstxbluelink.com/security/login.asp

•• Each person will need their own User name and password Each person will need their own User name and password

•• Any Blue Link Online ID (numbers assigned to UTMB providers) Any Blue Link Online ID (numbers assigned to UTMB providers) can be used to begin the processcan be used to begin the process

•• Use your UTMB address and phone number when completing the Use your UTMB address and phone number when completing the processprocess

•• Special Note: UTMB providers are not immediately inSpecial Note: UTMB providers are not immediately in––network network until HMO Blue issues a BC provider numberuntil HMO Blue issues a BC provider number

•• Effective Sept 1, 2004 UTMBEffective Sept 1, 2004 UTMB’’S Provider Enrollment Department S Provider Enrollment Department will provide Blue Link numbers (Link to be announced)will provide Blue Link numbers (Link to be announced)

http://www.bcbstxbluelink.com/security/login.asp

Blue Link Access•• You should receive the password confirmation within 2 You should receive the password confirmation within 2

business daysbusiness days

•• If you do not receive a phone call from a Blue Link If you do not receive a phone call from a Blue Link representative after 2 business days, please contact 1representative after 2 business days, please contact 1--800800--441441--9188 option #4 and you can get your ID and password 9188 option #4 and you can get your ID and password over the phoneover the phone

•• You MUST save your You MUST save your ““application for accessapplication for access”” page as your page as your confirmationconfirmation

Claim Submission

•• Claims must be filed within 95 days of date of service or Claims must be filed within 95 days of date of service or dischargedischarge

•• Claim filing is subject to TDI clean claim rules Claim filing is subject to TDI clean claim rules

•• Claim bundling details: Claim bundling details: http://www.bcbstx.com/provider/gri/index_bundling.htmhttp://www.bcbstx.com/provider/gri/index_bundling.htm

•• Mail Claims to: Mail Claims to: PO BOX 660044PO BOX 660044Dallas, TXDallas, TX--7526675266--00440044

•• Electronic Filing Electronic Filing

http://www.bcbstx.com/provider/gri/index_bundling.htm

Pharmacy Benefits

•• CoCo--pays for 30 day supply:pays for 30 day supply:

•• GenericGeneric $10$10•• FormularyFormulary $25$25•• Non formularyNon formulary $40$40

•• A $50/person/year deductible will be collected A $50/person/year deductible will be collected with the first RXwith the first RX

•• UTMB Pharmacy is inUTMB Pharmacy is in--network for HMO Bluenetwork for HMO Blue

LAB SERVICES UTMB Lab is inUTMB Lab is in--networknetwork

Outpatient Diagnostic Imaging

•• Imaging must be preauthorized by American Imaging for Imaging must be preauthorized by American Imaging for the following outpatient diagnostic imaging services:the following outpatient diagnostic imaging services:

–– CT scansCT scans–– MRI scansMRI scans–– MRA scansMRA scans–– Nuclear Cardiology studiesNuclear Cardiology studies–– PET scans PET scans

•• PhonePhone(800) 859(800) 859--52995299

•• FaxFax(800) 610(800) 610--66506650

•• website: website: www.americanimaging.netwww.americanimaging.net

http://www.americanimaging.net/

Behavioral Health Services

•• Magellan Behavioral Health Providers of Texas, Inc. (pending) Magellan Behavioral Health Providers of Texas, Inc. (pending)

•• Member can self refer to behavioral health providersMember can self refer to behavioral health providers

•• Preauthorization for covered services is requiredPreauthorization for covered services is required(800) 729(800) 729--24222422

•• Mail Claims to: Magellan Behavioral HealthMail Claims to: Magellan Behavioral HealthP.O. Box 1659P.O. Box 1659Maryland Heights, MO 63043 Maryland Heights, MO 63043

•• Magellan Behavioral Health Provider Handbook and Facility Magellan Behavioral Health Provider Handbook and Facility Supplement: Supplement: ((www.magellanprovider.comwww.magellanprovider.com))

https://https://www.magellanprovider.com/MagellanProvider/do/Load/Homewww.magellanprovider.com/MagellanProvider/do/Load/Home

http://www.magellanprovider.com/MagellanProvider/do/Load/Home

Plan Codes

Member Classification

Financial Class

UTMB Plan Code

Invision Plan Code

Signature Plan Code

UTMB Employee O 415UT 415 415

UT Systems Employee G 416BL 416 416

Glossary Of Terms

•• Eligibility verification Eligibility verification

To confirm eligibility and benefits, the HMO Blue Texas To confirm eligibility and benefits, the HMO Blue Texas participating physician/provider may contact HMO Blue participating physician/provider may contact HMO Blue TexasTexas

•• Verification of benefitsVerification of benefits

Under the Texas prompt pay rules, providers of service Under the Texas prompt pay rules, providers of service have the right to request verification that a particular have the right to request verification that a particular service will be paid by the insurance carrierservice will be paid by the insurance carrier

Glossary Of Terms•• Covered ServicesCovered Services

Health services specified and defined as covered Health services specified and defined as covered services in the Schedule of Benefits For details: services in the Schedule of Benefits For details: http://www/utsystem.edu/egi/pubs/2004HMOBluePlanhttp://www/utsystem.edu/egi/pubs/2004HMOBluePlanBooklet.pdfBooklet.pdf

•• ReferralReferral

The referral process is a mechanism by which a The referral process is a mechanism by which a primary care physician can refer his or her members primary care physician can refer his or her members for services to specialty care physiciansfor services to specialty care physicians

http://www/utsystem.edu/egi/pubs/2004HMOBluePlanBooklet.pdfhttp://www/utsystem.edu/egi/pubs/2004HMOBluePlanBooklet.pdf

Glossary Of Terms•• Preauthorization Preauthorization

Determines whether medical services are:Determines whether medical services are:

•• Medically necessaryMedically necessary•• Provided in the appropriate setting or at the appropriate Provided in the appropriate setting or at the appropriate

level of care generally accepted by the medical level of care generally accepted by the medical communitycommunity

Blue Cross Blue Shield HMO Blue TexasUT System Members, Dependents & Retirees2004-2005HMO Blue OverviewHMO Blue OverviewHMO Blue OverviewEligibility VerificationCo-pays and Benefit LimitationsPreauthorization/Notification/Referral RequirementsPreauthorization/Notification/Referral RequirementsPCP Referral ProcessBlue Link AccessBlue Link AccessClaim SubmissionPharmacy BenefitsLAB SERVICESOutpatient Diagnostic ImagingBehavioral Health ServicesPlan CodesGlossary Of TermsGlossary Of TermsGlossary Of Terms