2012

1. Medicaid Managed Care Program (STAR) and Children’s Health Insurance Program (CHIP) OB/GYN Provider Training 2012 Rev 020612

2. 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

3. Customer Service

4. 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 • Web Support at: www.availity.com 4

5. Member Enrollment and Eligibility

6. 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

7. 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

8. Member Identification Cards Continued • Examples of BCBSTX identification cards

9. Member Benefits and Services

10. 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.

11. 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.

12. 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

13. 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 co-payment maximum reached • An identification card will be re-issued to show that co-payments do not apply

14. 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)

15. 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: • Bothprograms 800-357-9577 • Prior authorization requests will be addressed within 24 business hours • The Benefit Identification Number (BIN), or plan identification number, is 003858

16. 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

17. Claims and Billing

18. 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

19. 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

20. Billing Maternity Claims (Cont’d) • 17P (Alpha HydroxyprogesteroneCaproate) 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

21. 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

22. 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

23. Pregnancy Notification Report (PNR) and Notification of Delivery

24. 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

25. SamplePregnancy Notification Report

26. 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

27. 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

28. SampleNewborn Notification Report

29. 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)

30. Sample HHSCReport of Pregnancy Form

31. Sample HHSCReport of Pregnancy Form

32. Medical Case Management

33. 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.

34. 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

35. 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)

36. Value Added Services (VAS)

37. 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.

38. 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

39. 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 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.

40. Sample Infant Safety Car Seat Form

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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.

48. 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

49. BCBSTX Additional Information

50. 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)