Utilization Management/Precertifications & Referrals

Precertifications and Referrals

Q. Can I access the iEXCHANGE Web application for precertifications and referrals?
A. Yes. You will need to sign up for an iEXCHANGE ID, User ID and password. Instructions are located in the iEXCHANGE section of the Blue Cross and Blue Shield of Texas (BCBSTX) Web site at www.bcbstx.com/provider.

Q. How do I get signed up for the iEXCHANGE Web application?
A. Select iEXCHANGE under the UM/QI/Medical Management section on the BCBSTX Web site at www.bcbstx.com/provider, then select Getting Started with iEXCHANGE.

Q.How long is a password good for in the iEXCHANGE Web application?
A. Passwords for the iEXCHANGE Web application expire every 90 days for security reasons. After 90 days, the iEXCHANGE Web application will prompt you to choose a new password. The iEXCHANGE office administrator in your office is responsible for adding, changing or resetting passwords.

Q. Who do I call if I am having problems using the iEXCHANGE Web application or iEXCHANGE IVR system?
A. The Texas iEXCHANGE Support Desk is available Monday through Friday, 8 a.m. to 5 p.m. CST by calling 1-800-441-9188, select 1, then select 4.

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Precertifications

Q. Should we use the iEXCHANGE Web application or iEXCHANGE IVR system for precertification of outpatient or inpatient stays?
A. All outpatient and inpatient stays should be initiated through iEXCHANGE. Often the transaction can be authorized based on a few data elements without additional information being required. In the event your case is not immediately approved by iEXCHANGE, you will be referred to the Utilization Management Department for review.

Q. What is the difference between Precertification and Verification?
A. Precertification is completed by the Utilization Management Department to ensure medical necessity and/or the appropriate place of treatment for the services being provided. Verification is a guarantee of payment obtained through the Provider Customer Service Department. Verification includes eligibility, benefits and precertification, for those services which require precertification.

Q. Does outpatient surgery require precertification?
A. No. For a detailed list of the Precertification Requirements, please click on the link below for the services that require precertification.

Q. Where can we get a listing of the Precertification Requirements?
A. The Precertification Requirements Lists for all products may be found on the BCBSTX Web site at www.bcbstx.com/provider.

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Referrals

Q. Does a member's ID card show if they need a referral?
A. A Primary Care Physician (PCP) designation on the member's/subscriber's ID card represents a referral is required for most Specialty Care Physician/Professional Provider services to be payable or to receive the highest level of benefits available.

All HMO Blue Texas members must have a referral for specialty care services, excluding those services received by an OB/GYN, for services to be payable.

For all BlueChoice POS subscribers, a referral must be completed in order for the subscriber to receive the highest level of benefits available, excluding those services received by an OB/GYN.

Q. As a Primary Care Physician (PCP) are we required to fax confirmation to the specialist's office? (Some Specialty Care Physicians/Professional Providers are requiring the confirmation before they see the patient.)
A. Once a referral is completed, the Specialty Care Physician's/Professional Provider's (SCP's) office automatically receives written confirmation from BCBSTX advising them of the number of visits and timeframe. SCPs may also access iEXCHANGE directly to confirm if a referral has been completed. SCPs should not routinely be contacting your office to confirm referral completion.

Q. Once the referral is established, if the servicing Specialty Care Physician/ Professional Provider (SCP) recommends that the patient see another specialist, does the Primary Care Physician (PCP) need to get involved to refer to the other Specialty Care Physicians/ Professional Providers?
A. Yes. For both BlueChoice POS subscribers and HMO Blue Texas members, the PCP is responsible for directing the member's/subscriber's care; therefore, he or she needs to be made aware of any additional treatment recommendations and coordinate care with the new Physician/Professional Provider. The PCP must complete referrals for other Specialty Care Physicians/Professional Providers.

Q. In a Specialty Care Physician's/Professional Provider's office, who is responsible for obtaining the referral? The patient, the PCP, who?
A. For the HMO Blue Texas member, it is the PCP's responsibility to initiate the referral as he/she is responsible for directing the patient's care. In addition, it is the responsibility of the contracting Specialty Care Physician/Professional Provider to ensure the referral is in place prior to providing services.

For the BlueChoice POS subscriber, it is the PCP's responsibility to initiate the referral as he/she is responsible for directing the patient's care. However, unlike the HMO, the subscriber does have some responsibility to make sure this referral was completed, as the subscriber may receive a reduced level of benefit if the referral is not in place at the time services are provided.

Q. We have a large group of physicians. If one physician sees a patient but the referral was issued under another physician, will the visit still be paid in-network?
A. Generally if the physicians are all in the same group/clinic and specialty, it should not be a problem. If they are not in the same group/clinic and specialty, they would have to obtain a separate referral.

Q. Is it possible for another Physician/Professional Provider to see the patient and be paid if the Specialty Care Physician/Professional Provider, who has the referral, is out-of-the-office?
A. Yes, if they are both under the same clinic/group and specialty and are loaded in the BCBSTX system as a covering Physician/Professional Provider.

Q. If a patient is admitted as an inpatient to the hospital; does the hospitals' Inpatient Certification cover the physician?
A. The admitting and/or attending physician is required to obtain an inpatient precertification for an inpatient hospital confinement. Once complete, the inpatient precertification does cover all services provided within the approved authorization period for the level of care authorized.

Q. A Primary Care Physician (PCP) is seeing a patient and prescribing medication for Attention Deficit Disorder or Depression. Does the PCP visit have to be approved by Magellan/Inroads (Behavioral Health Provider) as well?
A. No. Primary Care Physician visits are generally reimbursed under the member's/subscriber's medical benefits.

For additional iEXCHANGE information

Updated 01/2008