Chapter 5- Member EligibilityCHAPTER 5 MEMBER ELIGIBILITY |91 Member Name: PCP: MARY LAMB ...
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88 | CHAPTER 5 MEMBER ELIGIBILITY APPENDIX A ELIGIBILITY VERIFICATION Member Eligibility The Texas Health and Human Services Commission (HHSC) determine eligibility and Maximus, the enrollment broker, facilitates enrollment into health plans for STAR and CHIP members. Following notification from the HHSC or contracted eligibility agents, BCBSTX electronically updates member eligibility each day. Confirm Member Identity To prevent fraud and abuse, providers should confirm the identity of the person presenting the ID card. Providers must verify the member’s eligibility before services are provided. Claims submitted for services rendered to non-eligible members will not be eligible for payment.
Transcript of Chapter 5- Member EligibilityCHAPTER 5 MEMBER ELIGIBILITY |91 Member Name: PCP: MARY LAMB ...
88|CHAPTER 5 MEMBER ELIGIBILITY
APPENDIX A
ELIGIBILITYV E R I F I C A T I O N
Member Eligibility
The Texas Health and Human Services Commission (HHSC) determine eligibility and Maximus, the enrollment broker, facilitates enrollment into health plans for STAR and CHIP members. Following notification from the HHSC or contracted eligibility agents, BCBSTX electronically updates member eligibility each day.
Confirm Member Identity To prevent fraud and abuse, providers should confirm the identity of the person presenting the ID card. Providers must verify the member’s eligibility before services are provided. Claims submitted for services rendered to non-eligible members will not be eligible for payment.
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STAR – HOW TO VERIFY MEMBER ELIGIBILITYAt each member visit, before rendering services, providers must ask to see the member’s BCBSTX and state identification (ID) cards to verify health plan eligibility.
State of Texas Access Reform (STAR) members should provide their state eligibility card, the Texas Benefits Medicaid Card, the card is part of an online system providers can use to verify a member’s Medicaid eligibility and access their Medicaid health history. This ID system also offers a secure provider portal, www.yourtexasbenefitscard.com, where providers can get up-to-date member’s eligibility information.
Each person approved for Medicaid benefits gets a ‘Your Texas Benefits Medicaid Card’. However, having a card does not always mean the patient has current Medicaid coverage. Providers should verify the patient’s eligibility for the date of service prior to services being rendered. There are several ways to do this: • Availity website: Log on to the Availity website, an online tool for providers, by going online to www.availity.com.
Registration is required to use this site.• Call BCBSTX Provider Services at 877-560-8055.• Swipe the patient’s Your Texas Benefits Medicaid Card through a standard magnetic card reader, if your office uses
that technology• Use TexMedConnect on the TMHP website at www.tmhp.com• Call the Your Texas Benefits provider helpline at 1-855-827-3747• Call Provider Services at the patient’s medical or dental plan
Important: Do not send patients who forgot or lost their State-issued Medicaid cards to an HHSC benefits office for a paper form. They can request a new card by calling 1-855-827-3748. Medicaid members can also go online to order new cards or print temporary cards.
STAR SAMPLE STATE-ISSUED AND BCBSTX MEMBERID CARDSFollowing enrollment in the Medicaid managed care STAR program, each STAR Member receives two member identification (ID) cards that he or she must present at each visit to a provider: One card is from the State of Texas, and the other is from BCBSTX.
The State-issued ID card is called Your Texas Benefits Medicaid Card and contains: • Member name and Medicaid ID number (i.e., patient control number – PCN)• Managed care program name, if applicable• Date the card was issued• Billing information for pharmacies• Health plan names and contact information• Pharmacy and physician information for those in the Medicaid Limited program• Toll-free number for general inquiries
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Member Name: PCP: GEORGESHANE TEST CURIOUSAlpha Prefix: XYZ 877-800-5555Subscriber ID: 987654321
Medicaid ID Number:123456789
PCP Effective Date: 01/01/2017Rx Group No.: TXS1Rx BIN: 001122Rx PCN: TXCAIDPBM: PRIME
Sample Your Texas Benefits Medicaid Card
Sample BCBSTX Medicaid (STAR) ID Card BCBSTX’s Member ID card contains the following information:
• Member name, ID number, group number, patient control number (PCN)• Name of assigned primary care provider (PCP), effective date and phone number• Phone number for Customer Service, the 24-Hour Nurse Advice Line, behavioral health benefits, pharmacy benefits and
behavioral health services
CHIP MEMBER ELIGIBILITYA CHIP Perinate (unborn child) who lives in a family with an income at or below 186% of the Federal Poverty Level (FPL) will be deemed eligible for Medicaid and moved to Medicaid for 12 months of continuous coverage (effective on the date of birth) after the birth is reported to HHSC’s enrollment broker. A CHIP Perinate mother in a family with an income at or below 186% of the FPL may be eligible to have the cost of the birth covered through Emergency Medicaid. Clients under 186% of the FPL will receive a Form H3038 with their enrollment confirmation. Form H3038 must be filled out by the doctor at the time of birth and returned to HHSC’s enrollment broker.
Your Texas BenefitsHealth and Human Services Commission
billing assistance. No medical plan card?
1-888-657-6061
1-844-971-8906
1-888-657-6061711
1-800-327-73901-800-735-2988
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Member Name: PCP: MARY LAMB<F_NAME M_INIT L_NAME> 877-800-5555Alpha Prefix: ZGCSubscriber ID: <SBSB_ID>CHIP ID No: Office Visit/123456789 Visitas al consultorio: $20
Non-Emergency ER/No emergencias en la ER: $75
PCP Effective Date: 03/01/2017 Hospital per admit/por hospital admiten: $75
Rx Group No.: TXJ1 Emergency Room/com/MedicaidRx BIN: 010101 Emergencia en la ER: $0
Pharmacy (Brand)/CarRxe/APCtencióN:n al Cliente TXCAID farmacia (marca): $35rPBescripM:tion Drug/Vision): PRIME Pharmacy (Generic)/days a week 1-888-657-6061 farmacia (generico): $10
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A CHIP Perinate will continue to receive coverage through the CHIP Program as a CHIP Perinate Newborn if born to a family with an income above 186% to 201% FPL and the birth is reported to HHSC’s enrollment broker. A CHIP Perinate Newborn is eligible for 12 months continuous CHIP enrollment, beginning with the month of enrollment as a CHIP Perinate (month of enrollment as an unborn child plus 11 months). A CHIP Perinate Newborn will maintain coverage in the CHIP Perinatal health plan.
Determination of eligibility is made by HHSC or Maximus, the Administrative Service Contractor.
CHIP – HOW TO VERIFY MEMBER ELIGIBILITYProviders can verify CHIP member eligibility in one of the following ways: • Availity website: Log on to the Availity website, an online tool for providers, at www.availity.com. Registration is
required to use this site.• Call BCBSTX Provider Services at 877-560-8055.
CHIP SAMPLE MEMBER ID CARDSFollowing enrollment in our CHIP program, each member receives a member identification card that must be presented to providers at each visit. Members in CHIP do not have a Medicaid identification card from the state. BCBSTX’s member ID card contains the following information: • Member name, ID number, group number, patient control number (PCN)• Name of assigned primary care provider (PCP), effective date and phone number• Copayments (CHIP Perinate, Native American and Alaskan Native members do not have copayments/cost sharing)• Phone number for Customer Service, the 24-Hour Nurse Advice Line, behavioral health services, pharmacy benefits and
behavioral health services• Instructions for obtaining care in an emergency
Sample BCBSTX ID Card – CHIP Mail claims for all services to:
Blue Cross and Blue Shield of Texas Attn: Claims PO Box 51422 Amarillo, TX 79159-1422
Show this BCBS card to your health care providereach time you get covered services. Some servicesmay need preapproval. Directions for what to do in
bcbstx.
Customer(Medical/P24 hours/7
an emergency: In case of emergency call 911 or go to TTY:the closest emergency room. After treatment, call your 24-Hour Nurse Line/líneachild’s PCP within 24 hours or as soon as possible.This card is for member ID only and does not proveeligibility.Muestre la tarjeta BCBS a su proveedor de atención
de ayuda de enfermeríadisponible las 24 horas:TTY:Prescription Drug/
1-844-971-8906711
médica cada vez que reciba servicios cubiertos. Puede Medicamentos Recetados: 1-888-657-6061que algunos servicios necesiten aprobación previa. TTY: 711Instrucciones en caso de emergencia. En caso deemergencia, llame al 911 o vaya a la sala de
Behavioral Health Services Hotline/Behavioral Health Línea Directade Servicios:
emergencia mas cercana. Despues de recibirtratamiento, llame al PCP de su hijo dentro de 24horas o tan pronto como sea possible. Esta tarjeta essolo para identificación de los miembros y no es
24 hours/7 days a weekTTY:
1-800-327-73901-800-735-2988
comprobante de elegibilidad.
Claims: PO Box 51422Amarillo, TX 79159-1422
For emergency care received outside of Texas:Hospital and physicians should file claims to thelocal BCBS Plan.
Card Issued <DT>
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Perinate
Member Name: PCP: N/ATY O TEST7 N/AAlpha Prefix: ZYXSubscriber ID: 987654321CHIP ID No:123456789
Effective Date: 01/01/2017Rx Group No.: ABC3Rx BIN: 001122Rx PCN: TXCAIDPBM: PRIME
Perinate
Member Name: PCP: N/A<F_NAME M_INIT L_NAME> N/AAlpha Prefix: ZGESubscriber ID: <SBSB_ID>CHIP ID No:<CHIP ID No.>
Effective Date: <EFF DT>Rx Group No.: <Rx Group>Rx BIN: 011552Rx PCN: TXCAIDPBM: PRIME
Sample ID Card - CHIP Perinate ID OVER 198% Federal Poverty Level (FPL) For hospital, facility and professional services billing, mail claims to:
Blue Cross and Blue Shield of Texas Attn: Claims PO Box 51422 Amarillo, TX 79159-1422
bcbstx.com/Medicaid
Show this BCBS card to your health care providereach time you get covered services. Some services
Customer Care/Atención al Cliente(Medical/Prescription Drug/Vision):
may need preapproval. Directions for what to do in 24 hours/7 days a week 1-888-657-6061an emergency: In case of emergency call 911 or go to TTY: 711the closest emergency room. This card is for memberID only and does not prove eligibility.Muestre la tarjeta BCBS a su proveedor de atención
24-Hour Nurse Line/líneade ayuda de enfermeríadisponible las 24 horas: 1-844-971-8906
médica cada vez que reciba servicios cubiertos. Puede TTY: 711que algunos servicios necesiten aprobación previa.Instrucciones en caso de emergencia. En caso deemergencia, llame al 911 o vaya a la sala de
Prescription Drug/Medicamentos Recetados:TTY:
1-888-657-6061711
emergencia mas cercana. Despues de recibirtratamiento, llame al PCP de su hijo dentro de 24
Behavioral Health Services Hotline/Behavioral Health Línea Directade Servicios:
horas o tan pronto como sea possible. Esta tarjeta essolo para identificación de los miembros y no es
24 hours/7 days a weekTTY:
1-800-327-73901-800-735-2988
comprobante de elegibilidad.
For emergency care received outside of Texas:
For Hospital Facility and Professional ServicesBilling:BCBSTXP.O. Box 51422
Hospital and physicians should file claims to the local Amarillo, TX 79159-1422BCBS plan. Card Issued <DT>
Sample ID Card – CHIP Perinate ID under 198% Federal Poverty Level (FPL) For hospital and facility billing, mail claims to:
Texas Medicaid & Health Care Partnership (TMHP) P.O. Box 200555 Austin, TX 78720-0555
bcbstx.com/Medicaid
Show this BCBS card to your health care providereach time you get covered services. Some services
Customer Care/Atención al Cliente(Medical/Prescription Drug/Vision):
may need preapproval. Directions for what to do in 24 hours/7 days a week 1-888-657-6061an emergency: In case of emergency call 911 or go to TTY: 711the closest emergency room. This card is for memberID only and does not prove eligibility.Muestre la tarjeta BCBS a su proveedor de atención
24-Hour Nurse Line/líneade ayuda de enfermeríadisponible las 24 horas: 1-844-971-8906
médica cada vez que reciba servicios cubiertos. Puede TTY: 711que algunos servicios necesiten aprobación previa.Instrucciones en caso de emergencia. En caso deemergencia, llame al 911 o vaya a la sala de
Prescription Drug/Medicamentos Recetados:TTY:
1-888-657-6061711
emergencia mas cercana. Despues de recibirtratamiento, llame al PCP de su hijo dentro de 24
Behavioral Health Services Hotline/Behavioral Health Línea Directade Servicios:
horas o tan pronto como sea possible. Esta tarjeta essolo para identificación de los miembros y no es
24 hours/7 days a weekTTY:
1-800-327-73901-800-735-2988
comprobante de elegibilidad.
For emergency care received outside of Texas:Hospital and physicians should file claims to the localBCBS plan.
Hospital Facility Billing: Professional/OtherTMHP Services Billing:P.O. Box 200555 BCBSTXAustin, TX 78720-0555 P.O. Box 51422
Amarillo, TX 79159-1422Card Issued <DT>
For professional and other services billing, mail claims to:
Blue Cross and Blue Shield of Texas Attn: Claims PO Box 51422 Amarillo, TX 79159-1422
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Perinate NBMember Name: PCP: <PCP_NAME><F_NAME M_INIT L_NAME> <PCP_PHONE>Alpha Prefix: ZGESubscriber ID: <SBSB_ID>CHIP ID No:<CHIP ID No.> For CHIP Perinate newborns
no co-payment or cost-sharingfor covered services
PCP Effective Date: <EFF DT>Rx Group No.: <Rx Group>Rx BIN: 011552Rx PCN: TXCAIDPBM: PRIME
Sample ID Card – CHIP Perinate Newborn There is no copayment or cost sharing for covered services for CHIP Perinate or CHIP Perinate Newborns. Mail claims for all services to:
Blue Cross and Blue Shield of Texas Attn: Claims PO Box 51422 Amarillo, TX 79159-1422
bcbstx.com/Medicaid
Show this BCBS card to your health care providereach time you get covered services. Some services
Customer Care/Atención al Cliente(Medical/Prescription Drug/Vision):
may need preapproval. Directions for what to do in 24 hours/7 days a week 1-888-657-6061an emergency: In case of emergency call 911 or go to TTY:the closest emergency room. After treatment, call your 24-Hour Nurse Line/línea
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child’s PCP within 24 hours or as soon as possible.This card is for member ID only and does not proveeligibility.Muestre la tarjeta BCBS a su proveedor de atención
de ayuda de enfermeríadisponible las 24 horas:TTY:Prescription Drug/
1-844-971-8906711
médica cada vez que reciba servicios cubiertos. Puede Medicamentos Recetados: 1-888-657-6061que algunos servicios necesiten aprobación previa. TTY: 711Instrucciones en caso de emergencia. En caso deemergencia, llame al 911 o vaya a la sala de
Behavioral Health Services Hotline/Behavioral Health Línea Directade Servicios:
emergencia mas cercana. Despues de recibirtratamiento, llame al PCP de su hijo dentro de 24horas o tan pronto como sea possible. Esta tarjeta essolo para identificación de los miembros y no es
24 hours/7 days a weekTTY:
1-800-327-73901-800-735-2988
comprobante de elegibilidad.
Claims: PO Box 51422Amarillo, TX 79159-1422
For emergency care received outside of Texas:Hospital and physicians should file claims to thelocal BCBS Plan.
Card Issued <DT>
Pharmacy Electronic Member Eligibility (STAR and CHIP) Pharmacists and other pharmacy staff may call or use a secure online network to confirm eligibility. Each member has a sturdy, plastic Your Texas Benefits Medicaid Card issued by HHSC. Pharmacists and other pharmacy staff will use one of the existing vendor drug eligibility verification tools to obtain out-patient pharmacy eligibility and prescription benefits data for any client.
BCBSTX Provider Services at 877-560-8055 can also assist with determining member eligibility or pharmacies. You can call the Prime Pharmacy Customer Service Help Desk at the numbers on Page 17.
