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National Coordination of CareSM Program for Group Medicare Advantage PPO Members

December 18, 2019

Beginning Jan. 1, 2020, we will participate in a new Blue Cross and Blue Shield Association National Coordination of Care program to help improve care and services for Blue Cross Group Medicare Advantage (PPO)SM (MA PPO) members nationwide. This program also will help streamline administrative processes for providers.

As we announced in October, Blue Cross Group Medicare Advantage (PPO)SM is the new name of Blue Cross Medicare Advantage (PPO)SM for Blue Cross and Blue Shield of Texas (BCBSTX) members who purchase MA PPO coverage through their employers or other groups. While the name has changed, the program retains its traditional PPO network that allows members to seek care in-network and out-of-network, typically providing cost savings for in-network care.

Through the National Coordination of Care program, BCBSTX will collaborate with you to identify gaps in care and retrieve medical records for claims you submit to BCBSTX for Group MA PPO members living in Texas. This includes BCBSTX members with Group MA PPO coverage, as well as Group MA PPO members enrolled in other BCBS Plans who are living in Texas.

You will receive requests only from BCBSTX or our vendor when medical records are needed, or when potential gaps in care or risk adjustment gaps are identified related to claims submitted to BCBSTX for these members. You will no longer receive these requests from multiple BCBS plans or their vendors.

This program is part of our ongoing initiative to support our members in receiving the right care at the right time and place. As a result of concerns about gaps in care, this program may help encourage members to come into your practice more frequently, allowing for greater continuity of care. For out-of-area members with Group MA PPO coverage, this program will help BCBSTX give these members’ BCBS Plans a fuller understanding of their members’ health status.

Questions? Call the Customer Service number on the member’s ID card.

Important Reminders

  • Per your contract, you are required to respond within the requested timeframe to requests for risk adjustment, Healthcare Effectiveness Data and Information Set (HEDIS®) and other government-required activities including this program.
  • Use Availity® or your preferred vendor to check eligibility and benefits for Group MA PPO members. Eligibility and benefit quotes include membership confirmation, coverage status, copayment, coinsurance, deductible amounts and applicable benefit prior authorization requirements.
  • Ask to see the member’s BCBSTX ID card and a driver’s license or other photo ID to help guard against medical identity theft. See our Eligibility and Benefits page for more details.
  • Consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any other applicable laws and regulations, BCBSTX or BCBSTX’s vendor is contractually bound to preserve the confidentiality of members’ protected health information (PHI) obtained from medical records and provider engagement on Stars and/or risk adjustment gaps. You will only receive requests from BCBSTX or BCBSTX’s vendor that are permissible under applicable law. Consistent with your current practices, patient-authorized information releases are not required in order for you to fulfill medical records requests and support closure of Stars and/or risk adjustment gaps received through this care coordination program.

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 the vendor, you should contact the vendor directly.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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. If you have any questions, call the number on the member’s ID card.

HEDIS® is a registered trademark of NCQA