Southwest Texas HMO, Inc.

offers HMO plans and does

business as HMO Blue Texas.

® ® R E V I E WS E C O N D Q U A R T E R 2 0 0 2 A P R O V I D E R P U B L I C A T I O N

BLUE CROSS AND BLUE SHIELD OF TEXASFAMILY OF COMPANIES

Southwest Texas HMO, Inc.

HMO Blue® Texas

BlueChoice is a PPO and

POS product provided or

administered by Blue Cross

and Blue Shield of Texas with

networks for contracting

PPO and POS providers.

BlueChoice®

Information applicable to all

lines of business for Blue Cross

and Blue Shield of Texas and

HMO Blue Texas.

All Product News

As a result of the TMA carrier meetingsin April, as well as issues addressedthrough the Hassle Factor program,Blue Cross and Blue Shield of Texas(BCBSTX) recently modified somebundling concepts in an effort to streamlinethe adjudication of physician claims.

BCBSTX has implemented enhancementsto the processing of claims for thefollowing procedures. Target productiondate is June 1. This action is notretroactive to claims processed priorto June 1. Enhancements include:

• Liver biopsy codes 47000, 47001and 47100 will no longer bundleto a major abdominal procedure.

• Liver biopsy codes 47000, 47001 and47100 will continue to be consideredpart of surgical procedures performedon the liver on the same dates of service.

• Selective catheter placement codes36215-36218 and 36245-36248 will beallowed separately when submittedon the same dates of service.

• Transluminal balloon angioplastycodes 35470-35476 will be allowedseparately with intravascular stents,

codes 37205-37206, when submittedon the same dates of service.

• Therapeutic radiology port films, code77417, will be allowed separately whensubmitted with radiation oncologycodes 77261-77525.

• Transcatheter therapy, code 37202, willbe included with shoulder arthroscopycodes 29805-29807, 29824, 29900-29902and 29999 when used for intra-articularpost-operative pain management.Separate reimbursement is not allowedfor this procedure, as there are noclinical studies to show that this type ofpain therapy is equal to or better thanconventional types of post-operativepain management therapies.

• Critical care services, 99291-99292,and neonatal intensive care services,99295-99298, will be allowed separatelywhen submitted with consultationservices, 99251-99255, 99261-99263,and 99271-99275, when submitted onthe same dates of service.

Future enhancements will be announcedthrough this publication. If you haveany questions, please contact ProviderCustomer Service at 1-800-451-0287.

BLUE CROSS AND BLUE SHIELD OF TEXAS LISTENS!

The following modifiers should be used by the supervising physician when he/she isbilling for services rendered by a Physician Assistant (PA), Nurse Practitioner (ANP) orCertified Registered Nurse First Assistant (CRNFA):

AS — This modifier should be used by a physician when billing on behalf of aPA, ANP or CRNFA for services provided when the aforementioned providersare acting as an assistant during surgery.

SA — This modifier should be used by a physician when billing on behalf of aPA, ANP or CRNFA for non-surgical services.

If a PA, ANP or CRNFA bills directly to BCBSTX for his/her services, the abovemodifiers should not be used and normal billing practices would apply.

UPDATE: MODIFIERS WHEN BILLING FOR PAS,ANPS AND CRNFAS

CONTAINS REQUIRED

DISCLOSURES CONCERNING

BLUE CROSS AND

BLUE SHIELD OF TEXAS

AND HMO BLUE TEXAS

CLEAN CLAIM REQUIREMENTS

HMO Blue® TexasBlueChoice®

A L L P R O D U C T N E W S

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s The Teacher Retirement System of Texas (TRS)selected Blue Cross and Blue Shield of Texas(BCBSTX) to administer health benefits foractive public education employees (Aetna contin-ues to administer TRS-Care, the health benefitsprogram for retirees). TRS-ActiveCare, whichincludes three PPO plan options, will be offeredto over 156,000 employees and their familymembers during two enrollmentperiods. The spring enrollment period endedMay 17. The summer enrollment periodbegins July 22 and ends August 23.The plan effective date is September 1, 2002.

TRS-ActiveCare participants will have accessto the BlueChoice PPO network and ParPlanproviders and contracting facilities.Physicians may receive inquiries frompatients regarding this new program.

Enrollment assistance includes BCBSTX desig-nated customer service telephone numbers andaccess to printed and online provider directories.More information on TRS-ActiveCare, includingreference guides to the three PPO plan designsand sample ID cards, will be featured in futureeditions of Blue Review.

TRS-ACTIVECARE ENROLLMENT IN PROGRESS

Blue Cross and Blue Shield of Texas (BCBSTX)recently supported a series of TMA workshops forTexas physicians to introduce the HeartCarePartnership (HCP).

The workshop focused on practical patientmanagement strategies within the practice setting.An electronic chart audit tool is now availableonline from the HCP program to improve riskfactor management in patients with cardiovasculardisease.

This audit tool allows HCP participants to enterchart data easily and produce individualizedreports on audit results. The software is free forTexas physicians and hospitals and can be foundon the TMA Web site (www.texmed.org/has/prs/hcp/default.asp).

To learn more about HCP, please contact BridgetButler, Cardiovascular Program Manager at TexasMedical Association, by phone at 1-800-880-1300ext. 1461 or by e-mail at heartcare@texmed.org.

BCBSTX applauds the continuing efforts of TMAand encourages you to participate in a program inyour area.

HEARTCARE PARTNERSHIP: SECONDARY PREVENTION OFCARDIOVASCULAR DISEASE

R E V I E W

BCBSTX CLARIFIES RIDERS ON INDIVIDUAL POLICIESIn response to the TMA carrier meet-ings in April we have taken steps toimprove the identificationof Blue Cross and Blue Shield ofTexas (BCBSTX) individual poli-cies since these policies may havean exclusion or a rider. Riders mayexclude coverage for any furthertreatment due to a pre-existing con-dition. For instance, someone whohas had knee surgery may warrant arider for further treatment of theknee. However, the rider portion of apolicy allows BCBSTXto issue coverage for all other condi-tions, other than the condition therider or exclusion is covering — suchas the knee. Not all conditionsreceive a rider or exclusion sinceit is dependent on the severity ofthe condition.

Riders/Waivers may be applied toeither a standard or lowest ratingcategory. Some applicants may haveconditions for which BCBSTX canapply waivers or riders to the con-tract rather than decline the appli-cant. BCBSTX guidelines allow amaximum of three riders per appli-cant. Riders can be permanent ortemporary and cannot be removedwithout underwriting approval.

When coverage is approved with arider, the applicant is notified inwriting. Following this notification,a contract is issued with the rider(s)attached. If the applicant choosesnot to accept the contract with therider(s), the contract must bereturned within 10 days and any pre-mium submitted will be refunded.Currently, BCBSTX approvesapproximately 85% of applicationssubmitted and over70% of those issued are without rid-ers or exclusions.

Effective June 10, individual policyID cards are being issued with theidentifier “SELECT” on them denot-ing that the coverage is an individualpolicy. This changewill not automatically replaceall old cards. It will only affectnew cards following this issuedate. There will be noreplacement of identificationcards issued prior to June 10.

It is important to understandthat the pre-certification/referral department does nothave access to benefit exclusionson individual riders. To determinewhether or not a rider or qualifierexists on a policy, please contactCustomer Service by calling thenumber on the back of the ID card.There are two ways to determinewhether or not a rider orqualifier exists on a policy:

1) By contacting CustomerService at the number listedon the back of the ID card.If a diagnosis is given toCustomer Service by theprovider, BCTSTX can tellyou the range of the diagnosiscodes that fall into the rangeof rider or exclusion andwhether either has been placedon the patient’s policy.

2) You may choose toask the member sincethe member hasbeen notified twiceduring theunderwriting andpolicy issue process(to confirm adiagnosis given by amember, pleasecontact Customer Service).

NEW FEP BENEFIT PLAN HIGHLIGHTS IN-NETWORK PROGRAM FORMENTAL HEALTH SUBSTANCE ABUSE BENEFITSIn 2001, the Blue Cross and Blue Shield ServiceBenefit Plan offered two different benefit options:High Option and Standard Option. To better serveFEP members, we merged our High Optionenrollees into the Standard Option as of January2002. At the same time, we began offering a newbenefit plan — Basic Option.

Introduction of Basic Option in 2002The Basic Option health benefit plan is anin-network-only benefit program, whichrequires FEP members to use PPO networkproviders to receive coverage. There are no benefitsavailable when a Basic Option member uses anon-PPO network provider. Another change is theaddition of prior approval for mental health andsubstance abuse (MHSA) before any MHSAservices are rendered.

It is important that mental health/substance abuseproviders call 1-800-528-7264 for authorizationprior to treating a Basic Option FEP member forany MHSA services. Basic Option benefits will beavailable only from preferred providers and whenprior approval is granted. Please note that the BasicOption plan office visit copayment for outpatientmental health/substance abuse services is $20.

Standard OptionAlthough Basic Option is new to FEP, the StandardOption health benefit plan remains the same. Thebenefit package offers a PPO program that consistsof a nationwide network including PPO hospitals,

physicians, podiatrists, dentists, pharmacies, mentalhealth facilities and laboratories, along with manyother ancillary and specialty providers. FEP memberswho have the Standard Option Plan must use PPOproviders to receive preferred (network) benefits.Standard Option members may choose to useParPlan or non-participating providers. However,when a non-PPO provider is used, the memberwill not receive preferred benefits.

We recommend that mental health/substance abuseproviders call 1-800-528-7264 at the initiation oftreatment for Standard Option members because amember may have already used all or a portion ofhis or her initial eight sessions with another provider.If a member is seeing both a psychiatrist and atherapist, or is participating in group therapy,sessions from these providers will accumulatetoward the initial eight sessions, after which atreatment plan must be provided for review (priorto the ninth outpatient visit). Please note that theStandard Option office visit copayment for outpatientmental health/substance abuse services is $15.

Claims Filing Questions For additional information, please call BCBSTXCustomer Service at 1-800-442-4607. CustomerService representatives can be reached from 9 a.m.to 4 p.m. (Central time), Monday through Friday.You may also log on to www.fepblue.org orwww.bcbstx.com/fep.

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GROWTH HORMONE ANDINTRAVENOUS IMMUNOGLOBULINFORMS ON WEB SITEBlue Cross and Blue Shield of Texas requires thatthese two custom forms be completed and attachedto your claim when filing growth hormone orintravenous immunoglobulin (IVIG) services.These forms are required in addition to your claimform to meet the definition of a clean claim underthe Texas prompt pay guidelines. To access theseforms, please visit www.provider.bcbstx.com.See the downloadable forms section. Please beaware that growth hormones may be a contractexclusion under some contracts.

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BCBSTX AND HMO BLUE TEXAS CLEAN CLAIMATTACHMENT GUIDELINES

BLUE CROSS ANDBLUE SHIELD OF TEXAS

PROMPT PAYATTACHMENTDISCLOSUREINFORMATION

The Texas Administrative Code provides guidelines to help physicians, providers andinsurance companies work more efficiently together with regard to claims.These guidelines, set forth in 28 Texas Administrative Code (TAC) 21.2801-21.2820,describe what constitutes a “clean claim,” from required information to required fields.Pursuant to these rules, Blue Cross and Blue Shield of Texas and HMO Blue Texasrequirements for attachments are being revised.

• Providers will not have to duplicate required documentation provided at time ofpre-determination or pre-certification (when required). If pre-determination orpre-certification is approved, any requirement for operative report is waived.

• For contracts requiring prior authorization as a condition for benefits, the provision of thedocumentation after the service is rendered, rather than before, may result in penalties orloss of benefits.

• The above does not replace or limit claim adjudication directed to assessingappropriateness of codes used to describe services or allowed fees.

ProcedureRequired Attachments forPPO/POS and HMO Claims

Abdominoplasty and/or • Front and lateral photographs of the abdomenPanniculectomy (please mail photos)

Ambulance — Air/Ground • Mileage• Breakdown of charges filed with an open code• Trip sheet with history and physical/treatment for

physician medical necessity documentation

Assistant Surgeon • Modifier 80• Operative report

Blepharoplasty • Visual fields, history and physical• Eye level photographs (please mail photos)

Breast Implant Removal • Mammography reportand Capsulectomy • Operative and pathology report

• Physical and history• Photographs to support medical diagnosis

(i.e., contractures — please mail photos)

Cochlear Device Implantation • Type of device used

Co-Surgery Surgical Team • Statement of medical necessity of co-surgery surgical teamCharges Modifier 62 or 66 • Operative reports

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ProcedureRequired Attachments forPPO/POS and HMO Claims

Durable Medical • Physician’s prescription with first billing onlyEquipment (DME) • Description of the equipment

• Estimated length of need• Invoice for customized items

Gastroplasty and Other • History and physicalGastric Bypass Procedures • Weight and height and/or Body Mass Index (BMI)

• Documentation of conservative treatment plan for thepast five years

Growth Hormone • Growth Hormone Form — available at www.bcbstx.com(Once growth hormone deficiency has been establishedin childhood with Blue Cross and Blue Shield of Texas, nofurther documentation of need is required through age 18.)

Gynecomastia • Operative and pathology reports• Clinical notes documenting medical symptoms,

failure of conservative treatment• Height, weight and body frame• Endocrine study if performed• Photographs — frontal view (please mail photos)

Home Infusion Therapy • National Drug Code (NDC) for all medications

IVIG Therapy • IVIG form — available at www.bcbstx.com(For continuous treatment, submit form at onset oftreatment. For sporadic treatment, form must besubmitted with each claim.)

Lupron for Non-Cancer Diagnoses • History and physical notesin Either Men or Women • Pathology report if diagnosis is endometriosis

• State size of fibroid if diagnosis is fibroid tumor• Date of surgery, if applicable

Multiple Surgeries • Operative report

Nasal Surgery • Frontal and lateral photographs (please mail photos)• Medical information

Not Otherwise Classified Codes • Description of charges(NOC): (Including Injections) • National Drug Code (NDC), if applicable, or legible copy

of invoice• Dosage if applicable• Statement of medical necessity

R E V I E W

ProcedureRequired Attachments forPPO/POS and HMO Claims

Occupational Therapy • Progress notes to include:a) Plan of treatmentb) Short term goalsc) Long term goals

• Evaluation

Physician Standby Charges • Clinical information to justify medical necessityof standby services

Scar Revision or • Photographs (please mail photos)Keloid Treatment • Documentation of any medical symptoms(Surgical or otherwise) or functional impairment

Sclerotherapy • Medical information documenting patient symptoms,conservative treatment(s)

• Result of the use of elastic stockings• Description of the name and size of vessels to be treated• Which part of the leg is involved• Skin changes such as stasis ulcer or discoloration• Photographs clearly showing varicose veins to be

treated (please mail photos)

Treatment of Obstructive • Complete polysomnogram and CPAP test resultsSleep Apnea or UpperAirway Resistance Syndrome

Surgical Services Only • Operative reportModifier 22

Radioactive Seeds/Wires • Number of seeds/wires• Location of seeds/wires• Legible copy of invoice

Unlisted Procedure Codes • Scientific literature supporting the safety, effectivenessand durability (where applicable) of procedure

• Operative or procedure report• Anesthesia record• Description of charges• National Drug Code (NDC) if applicable, or legible copy

of invoice• Dosage if applicable

SPECIAL HEALTH MANAGEMENT INSERT

The user-friendly guide for diagnosis and treatment ofasthma, based on severity, summarizes the NHLBI guide-lines published in 1997. The material can be saved forlater use to help in the care of patients with asthma.

Reliance upon rescue inhaled bronchodilators as the pri-mary treatment of asthma leads to excessive morbidityand mortality in asthma. Below are three suggestions toconsider in managing your patients with asthma:

• The first anti-inflammatory medication for use inasthmatic patients with persistent asthma should bea low dose of inhaled corticosteroids. Low doseinhaled corticosteroids are safe in pediatric patientsand are extremely powerful in the prevention of thepotentially serious complications of asthma.

• The combination of a long-acting bronchodilator witha low dose of inhaled corticosteroids may improveasthma control and reduce exacerbations requiringphysician encounters or increased doses of corticoids.

• Reducing exposure to cats or house dust mites forsensitive patients with asthma and eliminatingcigarette smoke exposure improves asthma controland reduces the number of medications needed tomanage asthmatic patients.

Recognizing the importance of stayinghealthy and maintaining quality of life,BCBSTX offers four health managementprograms: asthma, diabetes, congestiveheart failure and high risk pregnancy.

Your HMO and selected BlueChoicepatients may receive education toincrease self-management skills, as wellas the individualized support necessaryto maximize health outcomes. Programenrollment is offered based upon eligi-bility, coverage and disease severity.All programs are voluntary and provid-ed at no additional cost to yourpatients.

The programs are designed to support,educate and enhance each patient’sability to maintain better health. Positiveresults of these programs may include:

•Improved quality of life aspatients become more involvedin their own care

•Reduced absenteeism fromwork/school

•Reduced hospitalizations andemergency room visits related toasthma, diabetes, congestive heartfailure or complications of pregnancy

•Reduced frequency and intensity of disease-related symptoms

•Improved compliance with thetreating physician’s care plan

•Increased access to self-monitoringequipment such as a peak flowmeter, spacer, glucometer, scale orpill box, as indicated

•Ongoing support and educationcoordinated through the healthplan via network providers

•Monitoring of key clinical indicators

Call 1-800-462-3275 to enroll eligiblepatients in any of these programs.

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BEHAVIORAL MEDICINE (MENTAL HEALTH AND CHEMICALDEPENDENCY) FOR HMO BLUE TEXAS MEMBERS

HMO Blue Texas has recently implemented arecoupment notification process.

If your account balance is negative at the end of aweekly payment cycle, we will send you our newExplanation of Recoupment Processing (ERP)statement to give you an update of current claimsactivity on your account.

You will only receive an ERP for paymentcycles where you have claims activity.The ERP will only show current paymentcycle activity.

Please do not remit the balance. We will apply anyfuture claim payments toward your balance. Onceyour account balance is $0.00 or greater, you willreceive our standard Explanation of Payment (thatwill include the claims previously reported toyou on an ERP).

Please contact our specially trained CustomerService representatives at 1-866-825-6012 if youhave questions about the HMO Blue Texasrecoupment process.

A RECOUPMENT REMINDER

HMO Blue® TexasH M O B L U E T E X A S N E W S

All HMO Blue Texas services for mental health and chemical dependency treatment by a behavioral healthspecialist and/or facility must be provided by a Magellan behavioral health network provider and authorizedby Magellan.

Contact Magellan at 1-800-729-2422 to obtain authorization of benefits for mental health and chemicaldependency treatment. Benefits for mental health and chemical dependency are available for members bycalling 24 hours a day, seven days a week. The call can be made by the member or by the member’s PCP.Please note that these claims are mailed to:

Magellan Behavioral HealthAttn: ClaimsP.O. Box 1659Maryland Height, MO 63043

Primary care physicians treating Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder(ADHD) and depressive disorders do not require a referral from Magellan. A primary care physician treatingADD, ADHD and depressive disorders who would like to refer to a specialist (i.e., neurologist) can contactUtilization Management for a referral at 1-800-441-9188. Please note that these claims are mailed to:

For HMO Blue Texas and BCBSTX employees/dependents For HealthSelect Plus (ERS)Group 04056H (EXCEPT HealthSelect Plus Group 38000) Group 38000

HMO Blue Texas HealthSelect Plus (ERS)P.O. Box 660044 P. O. Box 833804Dallas, TX 75266-0044 Richardson, TX 75083-3804

Providers who are contracted with an IPA or medical group that pays its own claims must continue to submitall claims to that IPA or medical group for payment. Refer to page 11 of this newsletter.

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CLINICAL PRACTICE GUIDELINES FOR BETA-BLOCKER PROPHYLAXISFOLLOWING AN ACUTE MYOCARDIAL INFARCTIONSince 1995, the American Heart Association hasrecommended beta-blockers as part of acomprehensive program to prevent second heartattacks. According to the American MedicalAssociation Quality Care Alert dated June 7, 2001,“Beta-blockers following an AMI decreasescardiovascular mortality, decreases re-infarctions,and increases the probability of long-term survivalup to 40%.” Below are the HMO Blue Texas clinicalpractice guidelines for beta-blocker prophylaxisfollowing an acute myocardial infarction.

PATIENT GOALS

• Prevent or minimize the incidence ofrecurrent infarction.

• Decrease long-term mortality in patients whohave had an acute myocardial infarction (AMI).

THERAPY

Recommendations for long-term therapy insurvivors of myocardial infarction.

Class I

• All but low-risk patients without a clear contraindication to beta-adrenoceptor blocker.

• Four beta-blockers are specifically indicatedfor treatment of patients who are clinicallystable following an acute myocardial infarction.

Decreased incidence in all but non-Q waveinfarctions have been observed in all age groupsand genders as well as in patients with varyingdiastolic pressure and heart rate. One of thefollowing medications should be started within24 hours or as soon after the AMI (5 — 28 days)as the patient’s condition permits, dosed suchthat the patient’s exercising heart rate does notexceed 75 beats/minute or to the maximumdose, and continued indefinitely (minimum of six months):

> Propranolol (Inderal) — 80 mg/threetimes per day

> Metoprolol (Lopressor) — 100 mg/twotimes per day

> Atenolol (Tenormin) — 100 mg/onceper day

> Timolol (Blocadren) — 10 mg/two timesper day

Beta-blockers with intrinsic sympathomimetic activity(ISA), such as acebutolol, carteolol, pirbuteroland pindolol have not decreased mortality and areinappropriate for post-myocardial infarction treatment.

CONTRAINDICATIONS

• Benefits should be weighed against potential risks in patients with the following conditions:

> IDDM: Beta-blockers can producehypo/hyperglycemia and may mask theeffects of hypoglycemia that may deprivepatients of early awareness of and response to falling blood sugar.

> Congestive Heart Failure: Beta-blockersmay exacerbate CHF initially.

> Asthma, COPD, Bronchitis:Beta-blockers can lead to bronchospasmin some patients.

> Hyperlipidemia: Beta-blockers canincrease serum triglyceride concentrationand can decrease serum density lipoprotein.

• Heart rate less than 60 bpm/Systolic arterial pressure less than 100 mm HG.

• Moderate or severe LV failure/Second — or thirddegree AV block.

• Signs of peripheral hypoperfusion/Severeperipheral vascular disease.

REFERENCESRyan TJ, Antman EM, Brooks NH. Califf RM, Hillis LD, Hiratska LF, Rapaport R,Riegel B, Russell RO, Smith EE III, Weaver WD. 1999 Update: ACC/AHAguidelines for the management of patients with acute myocardial infarction:executive summary and recommendations: a report of the American Collegeof Cardiology/American Heart Association Task Force on Practice Guidelines(Committee on Management of Acute Myocardial Infarction) Circulation.1999; 100:1016-1030. (Initially published in the J Am Coll of Cardiol. 1996;28:1328-1428.)

R E V I E W

In October 2001, HMO Blue Texasperformed an annual statewideAfter-Hours Access PhysicianOffice Survey. Of the sample ofphysicians surveyed, 91% met theafter-hours accessibility standard,which exceeds Blue Cross and BlueShield of Texas’ goal of 90%.

State regulations require HMO healthplans to include after-hours accessprovisions in physician contracts andto monitor physician compliance.

Members should be able to contacttheir primary care physician (PCP)or their PCP’s participating on-calldesignee for medical advice 24 hoursa day, 7 days a week.

If you have any questions concerningafter-hours accessibility requirements,please contact your ProfessionalProvider Network Representative.

AFTER-HOURS ACCESS: ARE YOU AVAILABLE?

Prior to May 1, 2002, non-prescriptivediabetic supplies were covered underHMO Blue Texas basic benefits butwere not covered under the HMOprescription drug rider.

If members obtained diabetic suppliesat a participating pharmacy, they wererequired to pay for these supplies andsubmit a member claim form forreimbursement of eligible expenses.

As of May 1, 2002, non-prescriptiondiabetic supplies are covered underthe HMO prescription drug riderand obtainable at HMO Blue Texasparticipating pharmacies for theapplicable prescription drug copayment.

In order to obtain diabetic supplies atthe prescription drug copay, aprescription for each supply must bepresented to the pharmacy.

HMO BLUE TEXAS NON-PRESCRIPTIONDIABETIC SUPPLIES

The latest update of the HMO Blue Texas Provider Manual can now be foundat www.bcbstx.com/providermanuals (password: manual). Simply view thedocument online or download/print the manual section by section orin its entirety.

Updates to the manual will be made as necessary and posted online,so be sure to check future issues of Blue Review for notices on thelatest revisions.

If you do not have Internet access or experience trouble opening the filesor accessing the site, contact your Professional Provider NetworkRepresentative for either a CD version of the manual or a hard copy.

Please note that this manual is for practitioners. We anticipate that thefacility manual will be available in the near future.

UPDATED HMO BLUE TEXAS PROVIDERMANUAL NOW AVAILABLE ONLINE

H M O B L U E T E X A S N E W S

HMO Blue Texas is committed to providingprompt payment of claims and complying withthe requirements of Texas prompt pay laws andregulations (Texas Insurance Code Article20A.18B and 28 Texas Administrative Code21.2801 — 21.2819). In this regard, it is importantfor providers to submit claims to the appropriateaddresses.

If a member’s primary care physician is affiliatedwith a capitated independent practice association(IPA) or medical group, claims for certain types ofservices must be submitted to the IPA or medicalgroup rather than to the normal address used forHMO Blue Texas claims. If a claim should have

been sent to an IPA or medical group, but wasincorrectly submitted to HMO Blue Texas, the claimwill be rejected and you will receive notice to re-fileit with the appropriate IPA or medical group.

To determine the appropriate IPA or medical groupfor claims submission, refer to the member’sHMO Blue Texas ID card to obtain the physicianorganization (POrg) code. Then refer to the tablebelow for the claims filing address, claims andUtilization Management (UM) phone numbers forthe capitated IPAs and medical groups in your area.

Note: It is important that you have the most currentcopy of the member’s ID card.

CLAIMS PAYMENT

713-965-9444 Claims713-965-9444 UM

713-442-5440 Claims713-442-5339 UM

512-420-2700 Claims512-420-2777 UM

PhysicianOrganization Code

(POrg)

Capitated IPA/MedicalGroup Name

IPA/Medical Group ClaimsFiling Address

HERT Heritage Physician Networks Heritage Physician NetworksP.O. Box 744920Houston, TX 77274

KELS Kelsey-Seybold Clinic Kelsey-Seybold ClinicClaims AdministrationP.O. Box 300368Houston, TX 77230

RNPO Renaissance PhysicianOrganization

Renaissance Physician OrganizationAttention: Claims1235 North Loop West #450Houston, TX 77008

Austin Regional IndependentAssociates

ARCL, ARCN

MediView ClaimsP.O. Box 26727Austin, TX 78755-0727

832-553-3333 Claims832-553-3300 UM

IPA/Medical GroupClaims Inquiry and UM

Phone Numbers

713-986-1600 Claims713-986-1600 UM

HNIN Intercultural Physicians Network(formerly Houston Network, Inc.)

CMS/Cap Management SystemsAttention: ClaimsP.O. Box 27479Houston, TX 77227

713-759-0154 ClaimsExt. 16713-759-0154 UM

PFHC People 1st Health CareNetwork, Inc.

People 1st Health Care Network, Inc.P.O. Box 3687Houston, TX 77253

Health Plans of TexasHHOT Health Plans of TexasP.O. Box 1211Tyler, TX 75710

800-458-4559 Claims800-874-3919 UMContract ends 5/31/02

512-338-1351 Claims512-338-1351 UM

PIPA3445 Executive Center DriveAustin, TX 78731

PIPA Preferred IndependentPhysicians Association

AVOID DELAYS WITH PROPER SUBMISSIONS

HMO BLUE TEXAS

STATEWIDE CLAIMS

FILING ADDRESS

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

HMO BLUE TEXAS

CUSTOMER SERVICE

1-877-299-2377

HEALTHSELECT PLUSSM — ERS

CLAIMS FILING ADDRESS &CUSTOMER SERVICE NUMBER

P.O. Box 833804Richardson, TX 75083-38041-888-585-9393

If the physician organization (POrg) code that appears on the member’s ID cardappears in the table on the previous page, claims for physician/professional servicesand outpatient diagnostic testing should be filed with the IPA or medical group.If the POrg code that appears on the member’s ID card does not appear in the tableor if the claim is not for the services listed above, the claim should be filed withHMO Blue Texas or HealthSelect Plus (Group #38000) at:

Claims for HMO Blue Texas EXCEPT HealthSelect Plus (Group #38000):

HMO Blue TexasP.O. Box 660044 • Dallas, TX 75266-0044

1-877-299-2377

Claims for HealthSelect Plus (Group #38000):

HealthSelect Plus (ERS)P.O. Box 833804 • Richardson, TX 75083-3804

1-888-585-9393

If you have questions about which services should be filed with the capitated IPA ormedical group and which services should be filed with HMO Blue Texas, call yourlocal area provider network office.

Note: Behavioral health claims, regardless of the member’s PCP or physician POrgcode, should be sent to Magellan Behavioral Health Providers of Texas, Inc. at:

Magellan Behavioral HealthAttention: Claims

P.O. Box 1659 • Maryland Heights, MO 630431-800-729-2422

Claims Payment — continued

NEW GROUP ACCOUNTSGROUP ALPHA GROUP EFFECTIVE TYPE OF HOME

PREFIX NUMBER DATE COVERAGE PLAN

GreenLeaf GLC-PPO 89304-PPO 6/1/02 PPO-CMM Michigan BCBSAcquisition GLG-CMM 89305-CMM

GLI-Medicare CMM 89306 Medicare CMM

RWDSU RSU 19108 5/1/02 PPO Alabama BCBS

BlueChoice®

B L U E C H O I C E N E W S

R E V I E W

Blue Review

Published quarterly for BlueChoice®, ParPlan and HMO Blue® Texas contracting physiciansand other health care providers. Ideas for articles and letters to the editor are welcome.

Please mail to: Corporate Communications, Blue Review Editor, Blue Cross and Blue Shield of Texas, P.O. Box 655730, Dallas, Texas 75265-5730.

© 2002 Health Care Service Corporation 8709.325-602

P.O. Box 655730Dallas, TX 75265-5730

PRSRT STDU.S. POSTAGE

PA I DDallas, TexasPermit No. 6010

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company★Southwest Texas HMO, Inc.★ d/b/a HMO Blue® Texas ★Independent Licensees of the Blue Cross and Blue Shield Association® Registered Marks of the Blue Cross and Blue Shield Association

BCBSTX Clarifies Riders on Individual Policies ................................................................................. Page 3Improved identification of BCBSTX individual policies

Growth Hormone and Intravenous Immunoglobulin Forms ........................................................ Page 4These forms now available online

BCBSTX and HMO Blue Texas Clean Claim Attachment Guidelines ......................................... Page 5This will help physicians and insurance companies work more efficiently together

After-Hours Access ....................................................................................................................................... Page 10Are you available?

Claims Payment .............................................................................................................................................. Page 11Avoid delays with proper submissions

ITEMS OF INTEREST IN THIS ISSUE

CONTAINS REQUIRED DISCLOSURES CONCERNING BLUE CROSS AND BLUE SHIELD OF TEXAS

AND HMO BLUE TEXAS CLEAN CLAIM REQUIREMENTS