You may occasionally receive requests for medical records. The records may be used for a variety of reasons including audits and medical necessity reviews. Due to the potential of financial impact, these requested items must be submitted and handled as a priority. Failure to do so may result in payment being denied or recovered.
Also, as a reminder, you will not be reimbursed for the submission of these records.
The Bureau of TennCare requires any provider and/or facility rendering care to TennCare enrollees to obtain and have on file a Tennessee Medicaid number before claims can be processed for payment.
The requirement to obtain and have on file a Tennessee Medicaid number applies to any in-state or out-of-state provider who provides services to a TennCare enrollee.
Providers may obtain a Tennessee Medicaid number by calling the Medicaid/TennCare Provider Enrollment Unit at 1-800-342-3145, by visiting the Provider page of the company Web site, bcbst.com, or the Bureau of TennCare's Web site at http://tennessee.gov/tenncare/pro-forms.html.
Yes. Claims for practitioners and facilities with dates of service prior to May 1, 2008, where a Tennessee Medicaid number is not on file with BlueCare will be identified on the paper remittance advice with an "NM" ex code – meaning payment is being withheld. Claims with dates of service after May 1, 2008, in the BlueCross BlueShield of Tennessee processing system will be identified on the paper remittance advice with a "WNM" code – meaning payment of this claim is pending the receipt of a Medicaid number. Payments will continue to be withheld until we have a record of the provider's Tennessee Medicaid.
Routine vision and dental services are covered for members under the age of 21. Vision services are covered for members over 21 if they are due to some illnesses or accidental injuries. BlueCare/TennCareSelect will not pay for eyeglasses, contact lenses or examinations for prescribing or fitting them for members over the age of 21 except for the first pair of cataract glasses or contact lens/lenses following cataract surgery.
Since DSM-5 is completely compatible with the HIPAA-approved ICD-9-CM coding system now in use by insurance companies, the revised criteria for mental disorders can be used immediately for diagnosing mental disorders (approval for use in the US by CMS is located here). However, the change in format from a multi-axial system in DSM-IV-TR may result in a brief delay while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes. For additional FAQs, refer to this document: Insurance Implications of DSM-5
Abortions and services associated with the abortion procedure are covered only if the pregnancy is the result of an act of rape or incest; or in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death if the abortion is not performed. A “Certification of Medical Necessity for Abortion” is required. [MCO CRAs, Sec. 2.7.8.] Certification of Medical Necessity for Abortion (English) Certification of Medical Necessity for Abortion (Spanish) (pdf, 425kb)
BlueCare Tennessee provides a fully integrated health offering including behavioral health services for our BlueCare and TennCareSelect members. Providers needing assistance for BlueCare members should call BlueCare Provider Service at 1-800-468-9736, and for assistance TennCareSelect members call TennCareSelect Provider Service at 1-800-276-1978.
When a SelectKids® member is seen at anytime by a behavioral health care provider, a copy of the medical record encounter must be sent to his or her primary care provider. Behavioral health providers may use the Medical Record Update Form, available in the forms section, to document services.
For Primary Care Providers in need of BH Referral/Consult:
Effective January 1, 2014, in an effort to help improve the coordination of care for these Medicare Medicaid enrollees, BlueCare is offering BlueCare Plus. This plan is a Medicare Advantage HMO managed by BlueCare that will only enroll dual eligible members. Also see: http:BlueCarePlus.BCBST.com
CareSmart Clinical Care Management Programs partner with providers to improve the health and quality of life for members with chronic disease and illness. The programs emphasize the importance of primary care provider collaboration and involvement.
The CaringStart Maternity Management program collaborates with providers to improve the health and birth outcomes of our pregnant members.
For more information visit our Maternity Care section
CHOICES was designed to provide streamlined, timely access to long term care (LTC) services, expand access to and utilization of cost-effective home and community based services (HCBS) alternatives to nursing facility care, serve more people with existing LTC funds, increase HCBS options, improve coordination of all Medicaid services, and rebalance LTC spending.
CHOICES was designed to provide streamlined, timely access to LTC services, expand access to and utilization of cost-effective HCBS alternatives to nursing facility care, serve more people with existing LTC funds, increase HCBS options, improve coordination of all Medicaid services, and rebalance LTC spending. CHOICES promotes quality and cost-effective coordination of care for CHOICES Members with chronic, complex, and complicated health care, social service, and custodial needs. Care coordination involves the systematic process of assessment, planning, coordinating, implementing, and the evaluation of care received through a fully integrated physical, behavioral health, and LTC/HCBS program to ensure the care needs of the Member is met.
If you have additional questions about CHOICES, please call 1-800-782-2433, Monday through Friday from 8 a.m. to 6 p.m.
Please use the Critical Incident form attached here to document all incidents regarding the following situations. Critical incidents must be reported verbally to 1-888-747-8955, and in writing within 24 hours to Fax # (615) 565-1923.
BlueCare Tennessee follows the Clinical Practice Guidelines that have been adopted by BlueCross BlueShield of Tennessee. BlueCare Tennessee may also follow modified Clinical Practice Guidelines based on conditions relevant to our member population, TennCare guidelines and/or nationally recognized standards in which there is not a supporting corporate guideline. See our Clinical Practice Guidelines page for additional information.
Federal law requires that state Medicaid programs cover emergency medical services for illegal and ineligible aliens, when these individuals otherwise meet the financial criteria for Medicaid.
The Centers for Medicare & Medicaid Services released new information regarding the Vaccines for Children (VFC) program. New CPT vaccine administration codes will be used for the VFC vaccines (90460 and 90461). Per the attached memo from the Department of Health, the instructions for reimbursing the VFC administration codes will continue to be based on a per-vaccine (per unit) basis and NOT on a per antigen or per component basis.
For non-VFC services, reimbursement will be on a per component basis.
Prior authorization may be required for CT, CTA, MRI, MRA, MR Spectroscopy, PET Scans, and Nuclear Cardiology imaging services for BlueCare members. For your convenience, you may submit the request for authorization through BlueAccess.
BlueCare members in the West Grand Region and BlueCare members in the East Grand Region, Volunteer State Health Plan will require prior authorization for select high tech imaging procedures performed in an outpatient setting. These services will not require prior authorization when a patient is receiving treatment in an emergency room or in an inpatient setting.
Procedures requiring prior authorization include, but are not limited to: CT, CTA, MRI, MRA, MR Spectroscopy, PET Scans, and Nuclear Cardiology. At this time, TennCareSelect and individuals who qualify as dually eligible for Medicare and Medicaid are not subject to this prior authorization requirement.
MedSolutions has created a toll-free phone number to be used exclusively by providers that request prior authorization for these services for BlueCare Tennessee members. Please call 877-791-4101 when requesting prior authorization for these members.
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A Hysterectomy is covered pursuant to applicable state and federal regulations, with informed consent. The “Acknowledgement of Hysterectomy Form” form is required. [MCO CRAs, Sec. 2.7.8.] Hysterectomy Acknowledgment Form (pdf, 105kb)
The PCP Rate Bump went into effect Jan. 1, 2013. Qualified PCPs, as detailed by CMS regulation, were to receive a rate change for eligible CPT codes effective until Dec. 31, 2014. This rate change is also referred to as the “PCP Bump” and the "PCP Rate Enhancement Payment". This is a reminder that the PCP Rate Bump is scheduled to end on Dec. 31, 2014. Please watch for future BlueAlert articles or continue to visit our website at bluecare.bcbst.com for more information.PCP Rate Bump Details:
In accordance with Section 1202 of the Affordable Care Act, qualified Medicaid primary care providers practicing in family medicine, general internal medicine, pediatric medicine and related subspecialties who meet specified requirements will be eligible to receive enhanced reimbursement rates. This is effective for dates of service on and after January 1, 2013 through December 31, 2014.
BlueCare Tennessee has prepared and sent notices to providers that have been identified in one of the eligible specialties/subspecialties that may qualify for the PCP enhanced rate. If you have received one of these notices, PLEASE READ IT CAREFULLY and follow any instructions that are contained therein.
If you have not received a notice from BlueCare Tennessee by May 15, 2013 and think you qualify, complete the attestation form below and return it in order to receive the enhanced rates.
Please note the following key points:
If you are board certified in an applicable specialty, please complete all related fields on the Attestation Form identifying the specific board specialty, dates and signatures. We will also notify our credentialing department accordingly.
If you are attesting based on the 60% claims threshold, please note this requirement applies to your total eligible Medicaid services, statewide, not at the individual MCO level.
If you supervise and are professionally responsible for mid-level practitioners in your office, you must complete all requested information on the Attestation Form for each in order for him/her to be eligible for the enhanced payment.
Continue to provide services to your BlueCare Tennessee members and submit your claims as you do today. You will be reimbursed at your current contractual rates.
Watch for updates published in the BlueCare Tennessee Provider Newsletter. BlueCare Tennessee will communicate the effective date as soon as it is known.
In order to receive the enhanced rates retroactive to dates of service on and after January 1, 2013, we must receive your completed attestation form by July 15, 2013. For forms received after this date, payments will be adjusted retroactively only for a date of service on or after the date the form was received by BlueCare Tennessee. Please note that if we receive incomplete forms, we will notify you; however, we cannot guarantee that you will be notified in time for you to return a completed form by the July 15, 2013 deadline.
For retroactive processing, you will not have to resubmit eligible claims. Once the implementation date is established, BlueCare Tennessee will identify the eligible claims, based on the CPT® codes noted in the regulations, and adjust payments to the greater of your contractual rates or the increased rate specified in the regulations and the CMS approved TennCare State Plan Amendment.
Continue to visit www.medicaid.gov for updated information, as well as this website. Please contact your Provider Network Manager if you have any additional questions.
Thank you for your assistance in providing the best quality care for our members.
Additional information may be found at http://www.cms.gov/apps/media/fact_sheets.asp
The Bureau of TennCare has given approval for the PCP enhanced payments to begin processing current claims with the new PCP enhanced rates beginning August 1, 2013
BlueCare Tennessee introduced its plans to consolidate lab services to Quest Diagnostics in an effort to rein in rapidly escalating lab expenditures within its TennCare business. Based on feedback from our provider community, several changes have been made to the original program design and the Exclusion List has been significantly revised; See the latest here:
Learn about the lab results and full IT offerings of Quest Diagnostics and get setup now and start with electronic lab orders and results from Quest Diagnostics.
This is the TennCareSelectSM program for certain persons with Intellectual Disabilities Members have Nurse Care Managers to assist them with getting their physical and behavioral health needs met.
The Bureau of TennCare established a TennCareSelect program for persons with Intellectual Disabilities called SelectCommunity. Beginning in April 2010, Arlington Class Members were transitioned into SelectCommunity, then the State-wide and Self Determination DIDD waiver members were phased into the Program. The West Members transitioned in August 2011, Middle late 2011, and East Members transitioned in February 2012.
All SelectCommunity members are assigned a Nurse Care Manager (NCM) who serves as the member's and the provider's primary point of contact for physical and behavioral health needs. With the use of the Electronic Visit Verification system, (EVV), Nurse Care Managers are able to monitor the initiation and provision of home health and private duty services.
If you have additional questions about SelectCommunity, please call 1-800-292-8196, Monday through Friday from 8 a.m. to 6 p.m. EST.
Covered, pursuant to applicable state and federal regulations for individuals who are at least 21 years of age, who are not institutionalized, who are mentally competent, and who give informed consent on the approved “Sterilization Consent Form” no less than 30 calendar days (or no less than 72 hours in the case of premature delivery or emergency abdominal surgery) but not more than 180 calendar days before the date of sterilization. [MCO CRAs, Sec. 2.7.8.]
Effective July 1, 2013, based on federal guidance, TennCare will no longer accept the Medicaid XIX Consent for Sterilization form with an expiration date of 12/31/2012. The Consent for Sterilization form has been revised to reflect a new expiration date of 10/31/2015. Additionally, there are slight format changes in the revised form, as well as the deletion of recording the time that the physician signs the form. The current consent form is available in both English and Spanish on the BlueCare Tennessee website at http://bluecare.bcbst.com/Providers/Provider-Education-and-Resources/Forms.html or the TennCare website at http://www.tn.gov/tenncare/pro-misc.shtml.
TENNderCare is a program for BlueCare and TennCareSelect members under the age of 21. The program provides free Early Periodic Screening, Diagnosis and Treatment (EPSDT) services. Every child under the age of 21 is eligible for TENNderCare services and should receive checkups, even if there is no apparent health problem.
Follow-up for elevated blood levels
Follow-up for elevated blood lead levels in children must be carried out in accordance with the State Medicaid Manual, Chapter 5, located at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html and the recommendations of the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention (CDC), located at http://www.cdc.gov/nceh/lead/ACCLPP/Final_Document_030712.pdf
The manual currently says that children with elevated blood lead levels should be followed according to CDC guidelines. 2012 CDC guidelines include follow up blood tests and investigations to determine the source of lead, when indicated, for blood lead levels equal to or greater than 5ug/dL. BlueCare Tennessee Care Coordination will provide any follow up service including monitoring and documenting elevated blood lead levels (EBLLs), assisting with coordination of Medically Necessary services, and coordinating the primary environmental lead investigation to determine the source of lead for children when elevated blood levels suggest a need for such investigation. This investigation, which is commonly called a "lead inspection", involves the use of X-ray fluorescence (XRF) machines in the home, which have the ability to identify lead based paint.
BlueCare Tennessee TENNderCARE comprehensive Tool Kit is designed to support practitioners' efforts in promoting childhood immunizations and TENNderCARE services.
The Tool Kit contains links to a compilation of resources and educational materials for your office staff and patients.