Exclusive Provider Organization (EPO) Quick Reference Guide

Exclusive Provider Organization (EPO)

Quick Reference Guide

MAIN CHARACTERISTICS

• Benefits vary by plan

• The Exclusive Provider Organization (EPO) utilizes the Blue Choice PPO

network. No additional contract is

necessary.

• EPO providers may only bill for copayments, cost share (coinsurance) and deductibles, where applicable

• To receive Network benefits, EPO members must receive medical care from EPO physicians and professional

providers. No referrals are required.

• To receive Network benefits, referrals to out-of-network providers must be authorized by the Blue Cross and Blue

Shield of Texas (BCBSTX) Utilization Management Department. Unless an out-of-network provider is authorized

by the Utilization Management Department., there are no benefits available for the EPO member.

• All claims should be submitted electronically. BCBSTX EPO Electronic Payor ID: 84980

• If the provider must submit a paper claim, mail claim to:

BCBSTX, P.O. Box 660044 Dallas, TX 75266-0044

• Claims must be submitted within 365 days of the date of service. Claims that are not submitted within 365 days

from the date of service are not eligible for reimbursement. Providers must submit a complete claim for any

services provided to a member. EPO providers may not seek payment from the member for claims submitted

after the 365 day filing deadline.

CLAIM SUBMISSIONS

CLAIMS STATUS AND PROCESSING

• Claim Status may be obtained through the Availity Claim Status Tool or a web vendor of your choice.

• To adjust a claim, you must have a document control number (claim number) then submit:

- Electronically via the Claim Inquiry Resolution Tool when available

- Mail the Claim Review form which is located on the BCBSTX provider website. Select Education & Reference

then select Forms.

- Call BCBSTX EPO Provider Customer Service at 1-800-451-0287.

• Claim Reviews and Correspondence should be sent to:

BCBSTX

P.O. Box 660044

Dallas, TX 75266-0044

BENEFITS AND ELIGIBILITY

• Eligibility and benefit information may be obtained through Availity® Essentials or an electronic web vendor

of your choice or call EPO Provider Customer Service at 1-800-451-0287.

Note: To access eligibility and benefits, you must have full member’s information, i.e.,. member's ID, patient date

of birth, etc.

• Verification of benefits does not apply to EPO members,

Revised: May 2023

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

Independent

Licensee

the

Blue Cross and Blue Shield Association

Page 1 of 4

UTILIZATION MANAGEMENT - Prior Authorization and Referrals

• Providers should verify through Availity® or their preferred vendor if prior authorization or referrals are required

for select outpatient or inpatient services and determine if they are managed by BCBSTX Medical Care

Management or Carelon Medical Benefit Management (Carelon).

• Some services may be subject to a Prior Authorization Exemption.

• Refer to Utilization Management on the provider website for additional information.

UTILIZATION MANAGEMENT - Prior Authorization and Referrals, cont.

• To submit referrals for specialty care and prior authorizations requests for inpatient and outpatients services

managed by:

o BCBSTX Medical Management:

(1) Submit online using Availity Authorizations & Referrals Tool

 Log in to Availity

Select Patient Registration menu option, choose Authorizations & Referrals, then Authorizations

(choose Referrals instead of Authorizations if you are submitting a referral request)

 Select Payer BCBSTX, then choose your organization

 Select Inpatient Authorization or Outpatient Authorization

 Review and submit your authorization

 For more information, refer to Availity Authorizations & Referrals under Provider Tools on the

provider website.

(2) By Phone: 1-855-896-2701

o Carelon Medical Benefit Management:

(1) Submit online using Carelon Provider Portal

(2) By Phone: 1-800-859-5299

• Current listings of providers and their NPI numbers are available online through Provider Finder®.

• For case management or to contact the Utilization Management Dept., call 1-800-441-9188.

LABORATORY AND RADIOLOGY SERVICES

Laboratory Services

• Providers should refer outpatient lab to in-network participating EPO providers. To locate participating providers

in the EPO network, visit Provider Finder.

• Lab services may require prior authorization through BCBSTX Medical Management or Carelon. See Utilization

Management - Prior Authorization and Referrals section above for more information.

Revised:

May 2023

Page 2 of 4

Radiology Services

• Providers should check using Availity or their preferred vendor if prior authorization or a Radiology Quality Intiative

(RQI) is needed for radiology services managed by Carelon.

• Refer to Utilization Management section above for services requiring prior authorization through Carelon.

• For services requiring an RQI, ordering physicians and professional providers must contact Carelon for the

• following services when performed in a physician’s or professional provider’s office, outpatient department of a

hospital or a freestanding imaging center:

- CT/CTA scans

- MRI/MRA scans

- SPECT/Nuclear Cardiology Studies

- PET Scans

• Submit Carelon services:

- Online at Carelon Provider Portal

- Phone 1-800-859-5299

- Fax 1-800-610-0050 - Note: Fax option is available only for physicians or professional providers who are

submitting clinical information for existing requests.

• For routine radiology services not requiring prior authorization or RQI, refer to the Blue Choice PPO

and Blue High

Performance Network

(BlueHPN

) - Provider Manual (Section B (d) - Outpatient Lab and Radiology).

EPO Quick Reference Guide

Important: Not all plans include Behavioral Health Benefits through BCBSTX.

• BCBSTX manages all behavioral health services (mental health and chemical dependency).

• Members are responsible for requesting prior authorization, although behavioral health professionals and physicians

or a family member may request prior authorization on behalf of the patient. All services must be medically

necessary. Prior authorization is required from BCBSTX for all inpatient, partial hospitalization and outpatient

behavioral health services.

• To obtain prior authorization, call BCBSTX: 1-800-528-7264

• Prior authorization must be obtained prior to the delivery of behavioral health services.

• Refer to the online EPO and BlueHPN - Provider Manual (Section I).

• All claims should be submitted electronically using BCBSTX Electronic Payor ID: 84980.

• If the provider must file a paper claim, mail claim to:

• Claim status may be obtained through the Availity Claim Status Tool or a web vendor of your choice or call Provider

Customer Service at 1-800-451-0287. (To access the Interactive Voice Response (IVR) system, you must have full

member’s information, i.e., member’s ID, patient date of birth, etc.)

This guide is intended to be used for quick reference and may not contain all of the necessary information. For detailed information, refer to the

EPO and Blue High Performance Network–Provider Manual online at https://www.bcbstx.com/provider/standards/standards-requirements/

manuals/bluechoice-manual.

BEHAVIORAL HEALTH (Mental Health and Chemical Dependence)

EPO

Quick Reference Guide

BCBSTX

P.O. Box 660044

Dallas, TX 75266-0044

ADDITIONAL INFORMATION

Claims Submission:

• All claims should be submitted electronically. The Electronic Payor ID for BCBSTX is 84980.

• For support relating to claims and/or other transactions available on the Availity portal or other Availity platforms, submitters should contact

Availity Client Services at 1-800-282-4548.

• For information on electronic filing, access the Availity website at availity.com.

• If you must submit paper claims, submit on the Standard CMS-1500 (02/12) or UB-04 claim form.

• All

claims must be filed with the insured’s complete unique ID number including any letter or 3-character prefix.

• Duplicate claims may not be submitted prior to the applicable 30-day (electronic) or 45-day (paper) claims payment period.

• If services are rendered directly by the physician or professional provider, the services may be billed by the physician or professional provider.

However, if the physician or professional provider does not directly perform the service and the service is rendered by another provider, only the

rendering provider can bill for those services. Note: This does not apply to services provided by an employee of a physician or professional

provider, e.g. Physician Assistant, Surgical Assistant, Advanced Practice Nurse, Clinical Nurse Specialist, Certified Nurse Midwife and Registered

Nurse First Assistant, who is

under the direct supervision

of the billing physician or professional provider.

ParPlan is a Blue Cross and Blue Shield of Texas (BCBSTX) payment plan under which health care professionals agree to:

 File all claims electronically for BCBSTX patients;

 Accept the BCBSTX allowable amount;

 Bill members only for deductibles, cost-share (coinsurance) and medically necessary services which are limited or not covered; either at the time of

service or after BCBSTX has reimbursed the provider;

 Not bill BCBSTX for experimental, investigative or otherwise unproven or excluded services; and

 Not bill either BCBSTX or members for covered services which are not medically necessary.

For all EPO plans, BCBSTX encourages the provider’s office to:

 Ask for the member’s ID card at the time of a visit;

 Copy both sides of the member ID card and keep the copy with the patient’s file;

 Eligibility, benefits, and/or verification requests, contact availity.com or web vendor of your choice or call the toll-free Provider Customer Service

number indicated on the

member’s ID card.

 Claim Status may be obtained through the Availity Claim Status tool or a web vendor of your choice.

 For Claim Adjustments, call BCBSTX Provider Customer Service at 1-800-451-0287. To adjust a claim, you must have a document control number.

Revised:

May 2023

Page 3 of 4

ADDITIONAL INFORMATION

Provider Record and Network Effective Dates:

• The Consolidated Appropriations Act (CAA) requires name, address, phone, specialty and digital contact information in the provider directory be

verified every 90 days. Refer to Verify and Update Your Information on how to submit.

• A minimum of 30 days advance notice is required when making changes affecting the provider’s BCBSTX status, especially in the following areas:

Physical address (primary, secondary, tertiary); Billing address; NPI and Provider Record ID changes; Moving from Group to Solo practice

or vice versa; and Moving from Group to Group practice. Utilize the Demographic Change Form to submit these requests.

• New Provider Record ID effective dates will be established when the request is received in the BCBSTX corporate office. This applies to all additions,

changes and cancellations.

• BCBSTX will not add, change or cancel information related to the Provider Record ID on a retroactive basis.

• Retroactive Provider Record ID effective dates will not be issued.

• Retroactive network participation will not be issued.

• Delays in status change notifications will result in reduced benefits or non-payment of claims filed under the new Provider Record ID.

• If the provider files claims electronically and their Provider Record ID changes, the provider must contact Availity at 1-800-282-4548. to obtain a new

EDI Agreement.

• Submit a Provider Onboarding form to obtain a Provider Record ID. Review the Network Participation on our website for more information.

BlueCard® (Out-of-State Claims):

• To check benefits or eligibility, call 1-800-676-BLUE (2583)*;

• File all that include a 3-character prefix on the member’s ID card to BCBSTX (Note: The member’s unique ID number may contain alpha characters which

may or may not directly follow the 3-character prefix);

• File all other claims directly to the Home Plan’s address as it appears on the back of the member’s ID card;

• For status of claims filed to BCBSTX, contact availity.com or a web vendor of your choice or call the toll-free Provider Customer Service number indicated

on the member’s ID card.

• Refer to BlueCard Program for more information.

* Interactive Voice Response (IVR) system. To access, you must have full member’s information, i.e., member’s ID, patient date of birth, etc.)

The Affordable Care Act (ACA) includes a provision that gives Health Insurance Marketplace members who receive advanced premium tax credits (APTC)

also known as subsidies, a three-month grace period

to pay their premium.

• Grace Period Overview:

- The three-month grace period is only required for enrollees who have made one full premium payment during the benefit year and who are

receiving the APTC.

- The health plan is responsible for adjudicating claims during the first month after a member enters the grace period. The claims adjudicated are

for dates of service rendered within the first month of this grace period.

- During the second and third months of the grace period, issuers have the choice of either pending the claims or adjudicating the claims and

seeking a refund if the member doesn’t pay all outstanding premium payments.

- If a member fails to pay all outstanding premiums by the end of the three-month grace period, the health plan must terminate the member’s

coverage.

- For additional details, go to www.Healthcare.gov.

• How will

BCBSTX make providers aware?

- Eligibility and Benefits Determination will include a paid through date and be provided by:

> Electronic and/or clearinghouse compliant with the HIPAA 270/271

> Interactive Voice Response (IVR) / automated telephone system

> Provider Customer Service

- Reminders to check for grace period status will be included on correspondence related to predeterminations, prior authorizations and referrals

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.

Carelon Medical Benefits Management is an independent company that has contracted with BCBSTX to provide utilization management services for

members with coverage through BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.

Please note that verification of eligibility and benefits information, and/or the fact that any pre-service review has been conducted, is not a guarantee of

payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the

member's certificate of coverage applicable on the date services were rendered

This guide is intended to be used for quick reference and may not contain all the necessary information. For detailed information, refer to the applicable

online provider manual at https://www.bcbstx.com/provider/standards/standards-requirements/manuals

Revised: May 2023

Page 4 of 4

EPO

Quick Reference Guide