Provider Roster Updated 09/15/2020
Roster was updated to reflect UHC All Products effective 9/15/2020. Click to review.
Aetna OfficeLink Updates, Published 9/1/2020
- Changes to the National Pre-Certification List
- Third Party Claim and Code Review Program
- And many interesting topics
AIM Specialty Health (AIM) to Perform Utilization Management for:
Participants with three-character prefixes of T2U and T2S (Group #3850X -last digit varies by plan) who are under 65 years of age and are active employees.
This is referring to TRS ActiveCare Patients.
To log in to “AIM” click the blue text.
To review the “AIM” training slide deck, click here.
UPCOMING Provider/Portal Training Dates
- Advanced Imaging & Cardiology: Tuesday, Sept. 15 (10 AM-11 AM)
- Sleep Medicine: Wednesday, Sept. 16 (12 PM-1 PM)
- Joint and Spine Surgery:Thursday, Sept. 17 (12 PM-1PM)
- Pain Management: Tuesday, Sept. 15 (9 AM-10 AM)
- Radiation Therapy: Thursday, Sept. 17 (3 PM-4PM)
- Genetic Testing Services: Tuesday, Sept. 15 (12 PM -1 PM)
Welcome to Blue Cross and Blue Shield of Texas (BCBSTX) Provider Orientation Information
On May 13, we announced we were awarded the contract to administer medical and behavioral health benefits for the Teacher Retirement System of Texas (TRS), effective Sept. 1, 2020. TRS-ActiveCare participants will be offered health plans that use either the nationwide Blue Choice PPOSM or statewide Blue EssentialsSM provider networks.
TRS-ActiveCare Plans
Statewide Blue Essentials network – providers who are contracted under the Blue Essential network can see participants on these plans:
- TRS-ActiveCare Primary and TRS-ActiveCare Primary+
- Copays for doctor visits before meeting deductibles.
- Primary care provider (PCP) selection and referrals to specialists are required.
- No out-of-network coverage, except for true emergencies.
Nationwide Blue Choice PPO network plans – providers who are contracted under the Blue Choice PPO network can see participants on these plans:
- TRS-ActiveCare HD
- High deductible plan which may include a health savings account (HSA) to pay for medical care.
- Does not require PCP selection or referrals.
- Deductibles must be met before the plan pays for diagnostic care.
- Includes out-of-network coverage. Participants have a lower cost share when using in-network providers.
- TRS-ActiveCare 2
- Copays for doctor visits before meeting deductibles.
- Does not require PCP selection or referrals.
- Includes out-of-network coverage. Participants have a lower cost share when using in-network providers.
Identifying TRS-ActiveCare Participants
TRS-ActiveCare participants can be identified by the following on their BCBSTX ID card:
- The TRS-ActiveCare logo will be displayed on the participants’ ID card.
- TRS-ActiveCare Primary and TRS-ActiveCare Primary+ plan holders will have ID cards with a three-character prefix of T2U.
- TRS-ActiveCare HD and TRS-ActiveCare 2 plan holders will have ID cards with a three-character prefix of T2S and a network ID of BCA.
For patients on TRS-ActiveCare Primary and TRS-ActiveCare Primary+, you must be their assigned provider to provide primary care services. Patient eligibility and benefits should be checked using Availity® or your preferred vendor before every scheduled appointment. Eligibility and benefit quotes include patients’ coverage status and other important information, such as applicable copays, coinsurance and deductibles. It’s strongly recommended that providers ask to see patients’ ID card and photo ID to guard against medical identity theft. If services may not be covered, patients should be notified that they may be billed directly.
Prior Authorization
You can check the Prior Authorization and Predeterminations page for the list of Administrative Services Only (ASO) services and procedure codes that require prior authorization for TRS participants. Refer to How to Submit a Prior Authorization or Prenotification to learn about submission processes.
Reminders
TRS will continue to use CVS Caremark as their pharmacy benefit manager. We encourage you to attend provider training sessions related to TRS-ActiveCare benefits, prior authorization requirements and ID cards. Continue to watch News and Updates and our Blue Review newsletter for more details on TRS-ActiveCare.
If you have any questions, please contact your BCBSTX Network Management Representative.
As a reminder, it is important to check eligibility and benefits before rendering services. This step will help you determine if prior authorization is required for a participant. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSTX’s provider website.
Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things the participant’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.
Click to view the training declk “AIM Provider Training for Prefixs T2U and T2S”
Click to view the training slide deck called “Introduction to TRS-ActiveCare”
TRS, Selection of PCP, Help
Below are two screenshots with notes that may help you field calls today. They are taken from the BCBS/TRS Employee Website: https://www.bcbstx.com/trsactivecare/doctors-and-hospitals
Continuity of Care
Texas Insurance Code Sec. 1301.153
(a) In this section:
(1) “Life-threatening” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(2) “Special circumstances” means a condition regarding which the treating physician or health care provider reasonably believes that discontinuing care by the treating physician or provider could cause harm to the insured. Examples of an insured who has a special circumstance include an insured with a disability, acute condition, or life-threatening illness or an insured who is past the 24th week of pregnancy.
(b) Each contract between an insurer and a physician or health care provider must provide that the termination of the physician’s or provider’s participation in a preferred provider benefit plan, except for reason of medical competence or professional behavior, does not:
(1) release the physician or health care provider from the generally recognized obligation to:
(A) treat an insured whom the physician or provider is currently treating; and
(B) cooperate in arranging for appropriate referrals; or
(2) release the insurer from the obligation to reimburse the physician or health care provider or, if applicable, the insured, at the same preferred provider rate if, at the time a physician’s or provider’s participation is terminated, an insured whom the physician or provider is currently treating has special circumstances in accordance with the dictates of medical prudence.
(c) The treating physician or health care provider shall identify a special circumstance. The treating physician or health care provider shall:
(1) request that the insured be permitted to continue treatment under the physician’s or provider’s care; and
(2) agree not to seek payment from the insured of any amount for which the insured would not be responsible if the physician or provider were still a preferred provider.
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