PPO product with drug plan being offered for January 1, 2013

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2 PPO product with drug plan being offered for January 1, 2013 Austin area: 8 counties Dallas/Fort Worth area: 4 counties Houston area: 3 counties

3 Austin Area Counties (8) Bastrop Burnet Caldwell Fayette Hays Lee Travis Williamson

4 Dallas/Fort Worth Area Counties (4) Collin Dallas Denton Tarrant

5 Houston Area Counties (3) Fort Bend Harris Montgomery

6 3 letter alpha prefix ZGD

7 The Customer Service number for Blue Medicare Advantage (PPO) members or providers is: (877) *Please note the phone number for Blue Medicare Advantage is different from the other BCBSTX products *Customer Service numbers can be found on the back of the Member s ID card

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9 Initiating Preauthorizations Blue Medicare Advantage Customer Service at (877) Online via iexchange through the BCBSTX website *Either process will start the preauthorization

10 Preauthorization Requirements List for Medical/Surgical All Acute Inpatient Stays All Skilled Nursing Facility Stays All Inpatient Rehab All Long Term Acute Care All Home Infusion Therapy All Home Health Care

11 Preauthorization Requirements List for Medical/Surgical, continued All DME greater than $2,500 per unit All Prosthetics/Orthotics greater than $2,500 All Organ Transplants, other than ocular & kidney All Air Ambulance All High Tech Radiology Requires RQI through AIM All Network Exceptions

12 Preauthorization Requirement List for Behavioral Health All Inpatient Hospital Stays All Electro Convulsive Therapy (ECT) All Neuropsychological Testing All Partial Hospitalization Programs (PHP) All Psychological Testing All Residential Treatment Center (RTC) All Network Exceptions

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14 High Tech Imaging Procedures CT / CTA scans MRI / MRA scans PET Scans SPECT / Nuclear Cardiology Studies

15 BCBSTX is contracted with AIM Specialty Health (AIM) to provide clinical appropriateness review and education for outpatient high-tech diagnostic imaging services. High-tech imaging studies performed in conjunction with emergency room services, inpatient hospitalization, outpatient surgery, hospitals and freestanding surgery centers, or 23-hour observation are excluded from this requirement.

16 Obtaining an Radiology Quality Initiative (RQI) Number Ordering physicians for Blue Medicare Advantage subscribers must: Contact AIM to obtain an RQI number prior to services being rendered Write the RQI number on the requisition for the imaging study Ordering physician whether a PCP or specialist is required to contact AIM

17 Hospitals and Freestanding Imaging providers cannot obtain an RQI number for exams Exception is if the Radiologist is conducting the test that was ordered and feels it is necessary to ask for an additional exam RQI number must be on the performing provider s claim form in Box 63 for UB-04 or Box 23 for CMS-1500 RQI numbers are valid for 30 days Retrospective request will not be considered

18 To obtain an RQI, contact AIM at: (M-F 6 a.m. 6 p.m. CST; Sat & Sun 9 a.m. 12 p.m. CST) Or through the internet at: aimspecialtyhealth.com *Physicians needing to submit clinical information for existing Requests can fax to:

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20 Electronic Claims: Submit claims electronically using Availity payor ID # If you must file a paper claims file to: Blue Medicare Advantage (PPO) P.O. Box Dallas, TX *Filing deadline is 180 days from date of service/discharge or as allowed by contract.

21 Medical Grievances & Appeals Medical Coverage Determinations & Appeals Should be submitted to: Blue Medicare Advantage (PPO) P.O. Box 4288 Scranton, PA 18505

22 Medicare edits and coding guidelines should be followed for Blue Medicare Advantage The claim should include the member s ID as it appears on their ID card, including the 3 letter alpha prefix ZGD

23 Payments and remittance advice for Blue Medicare Advantage (PPO) members will be paid in the same method as your existing BCBSTX business, i.e., check or Electronic Funds Transfer (EFT). ERA and RA has plan code as of September to identify products, Blue Medicare Advantage (PPO) code is PMC. The Blue Medicare Advantage (PPO) Customer Service phone number is the initial contact number for questions and inquiries into payment questions.

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25 Blue Medicare Advantage Blue Card Members Blue Cross and Blue Shield Medicare Advantage (PPO) plans from other states may access the Texas Blue Medicare Advantage network only PPO plan types Either a retiree from a waivered plan that has members in Texas and will be normal patient or a member visiting from their home state Use the phone number on the back of the member s ID card

26 There will be additional education and communication as needed or requested by providers

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