Here’s some news you can use from Blue Cross and Blue Shield of Texas (BCBSTX).
Submitting requested documentation: When sending in documents such as medical records in response to a letter from BCBSTX, always attach a copy of the letter as a cover sheet to your submission. A barcode in the upper right corner of the letter helps match your information directly to the appropriate file and/or claim. For more helpful claims tips from BCBSTX, visit Avoid Claim Delays and Claim Filing Tips on the payer’s website.
Treating relatives or yourself: Standard BCBSTX benefit plans exclude coverage for services a physician renders to any plan member who’s related, either by blood or marriage. Certain plans also exclude coverage for self-administered services. Read more about the risks of treating family and friends in the Texas Medicine article, “Treating Your Own.”
Understanding rejections, denials: Confused about the difference between the two? BCBSTX has created a one-pager to help you remember. The upshot is:
- Claim rejections occur at multiple steps within the electronic claim submission process, before adjudication.
- Claim denials occur during the claim adjudication process.
Obtaining a preauthorization/referral: To determine if a service requires a referral or preauthorization, refer to the lists on the BCBSTX Preauthorizations/Notifications/Referral Requirements webpage. Also, note that preauthorizations/referrals are needed for:
- Any services provided by someone other than the patient’s primary care physician/provider, e.g., a specialist, ambulatory surgery center, ancillary provider; and
- An initial stay in a facility and any additional days or services added on.
Although BCBSTX participating physicians and providers are required to obtain preauthorizations/referrals, it is also the patient’s responsibility to confirm this has been done.
Preauthorizations allow for medical necessity review. If the patient doesn’t obtain a preauthorization/referral as needed, the benefit for covered expenses may be reduced. BCBSTX will not perform retrospective reviews for medical necessity for any HMO plans except in limited special circumstances.
Remember that a preauthorization/referral does not guarantee payment.
Source: BCBSTX Blue Review
The Texas Medical Association’s payment specialists continuously review health care payment plans’ newsletters and updates for items important to Texas physicians. Texas Medicine Today periodically publishes key excerpts from those newsletters that you might have missed.
If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.