Verification Processing

Blue Cross and Blue Shield of Texas and HMO Blue^® Texas implemented a verification process to support prompt pay legislation enacted in 2003. Providers of service have the right to request verification guaranteeing that a particular service will be paid by the insurance carrier.

Verification Definition

The Texas Department of Insurance (TDI) defines verification as “a guarantee by an HMO or preferred provider carrier that the HMO or preferred provider carrier will pay for proposed medical care or health care services if the services are rendered within the required timeframe to the patient for whom the services are proposed”.

Exclusions From Prompt Pay Legislation

Verification is not applicable for all enrollees or providers. A sample list of those health benefits plans excluded from prompt pay legislation include:

• Self-funded ERISA (Employee Retirement Income Security Act)
• Self-funded governmental, school and church health plans including:
  
  1. Federal Employee Program
  2. Employee Retirement System (Health Select – Group 38000)
  3. Texas Health Insurance Pool (THIP)
  4. The Teacher Retirement System of Texas (TRS-ActiveCare – Group 85000)
  5. The University of Texas System (UT SELECT – Group 71778)
• Out-of-state Blue Cross and Blue Shield plans
• Out-of-network (non-participating) providers

Identification Card Requirements

To assist in recognizing those subject to prompt pay legislation, the letters “TDI” will appear on the front of the BCBSTX subscriber or HMO Blue Texas member identification card when the subscriber/member is subject to prompt pay legislation.

TDI Required Data Elements

Before submitting a request for verification, please be prepared to provide all of the TDI required data elements at the time of your request.

The TDI required data elements are:

1. patient name
2. patient identification number (exactly as shown on the current ID card)
3. patient date of birth
4. name of enrollee or subscriber
5. patient relationship to enrollee or subscriber
6. presumptive diagnosis, if known, otherwise presenting symptoms
7. description of proposed procedure(s) or procedure code(s)
8. place of service code where services will be provided and if place of service is other than provider’s office or provider’s location, name of hospital or facility where proposed service will be provided
9. proposed date of service
10. group number
11. if known to the provider, name and contact information of any other carrier including:

    a) other carrier’s name
    b) address
    c) telephone number
    d) name of enrollee
    e) plan or identification number
    f) group number (if applicable)
    g) group name (if applicable)

  12. name of the provider providing the proposed service(s)

  13. provider’s federal tax identification number

Verification Procedure

For telephone requests, please contact the appropriate Provider Customer Service Department and select the option for verification:

• BlueChoice (PPO/POS): 1-800-451-0287
• HMO Blue Texas: 1-877-299-2377

Upon completion of processing, telephonic requests for verification will receive a fax notice followed by a written notice via U.S. Mail.

For those providers who prefer to submit a written request, please complete the Provider Request for Verification Form and submit to the following address:

BCBSTX or HMO Blue Texas
Request for Verification
P.O. Box 833908
Richardson, TX 75083

Upon completion of processing, written requests for verification will receive a written notice via U.S. Mail.

Reasons Why a Declination Notice Would Be Issued

Verification is voluntary and may not be available to all subscribers/members and/or providers. Some examples of reasons for declination may include, but are not limited to:

• No coverage or change in eligibility, including individuals not eligible, not yet effective or canceled
• Premium payment timeframes that prevent verifying eligibility for a 30-day period
• Policy deductible, specific benefit limitations or annual benefit maximum
• Benefit exclusions
• Pre-existing condition limitations
• BCBSTX/HMO Blue Texas is the secondary carrier

A declination notice simply means that a guarantee of benefit cannot be issued in advance, not a determination that a claim will not be paid. Please be advised that routine eligibility and benefit information may be obtained when verification is not applicable or a declination has been issued.

Additional Information

Please refer to the on-line provider manuals for more information about verification.

Should you have any questions, please contact your local Professional Provider Network office.