1. What are the functions of the Utilization Management (UM) Department?
2. Should we use the iEXCHANGE Web application or iEXCHANGE IVR system for Precertification of inpatient admissions or outpatient services?
3. What is the difference between Precertification and Verification?
4. Does outpatient surgery require Precertification?
5. Where can we get a listing of the Precertification Requirements?
6. Does a member's ID card show if they need a referral?
7. 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.)
8. 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?
9. In a Specialty Care Physician's/Professional Provider's office, who is responsible for obtaining the referral? The patient, the PCP, who?
10. 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?
11. 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?
12. If a patient is admitted as an inpatient to the hospital; does the hospitals' Inpatient Precertification cover the physician?
13. 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 Behavioral Health, Inc. (Behavioral Health Provider) as well?
14. Can Referrals be done for a year at a time?
15. Is there a limit on the number of visits that can be requested for a Referral?
16. How long can a Referral be backdated for an HMO Blue® Texas member in iEXCHANGE? HealthSelectSM member? Or BlueChoice POS member?
17. What will happen if the wrong office location is chosen for the Referral? Do they need to do a new Referral or can the current one be corrected?
18. How long are referral records kept in the iEXCHANGE System?
19. Can I access the iEXCHANGE Web application for Precertifications and Referrals?
20. If a referral is requested through the IVR will it show up in iEXCHANGE Web and vice versa?
21. Can an extension on Referrals & Inpatient Precertifications be completed through the iEXCHANGE Systems?
22. How do specialists inquire about a Referral if they do not have the Case ID #?
23. What does it mean when I receive a message that my Referral or Inpatient Precertification has been pended?
24. Why does iEXCHANGE not let us set up a Referral or Inpatient Precertification online for certain procedures and diagnoses?
25. Can a Precertification go through iEXCHANGE without a Referral to the specialist if one is required?
26. Can a retroactive Inpatient Precertification be entered in iEXCHANGE? If so, within how many hours/days?
27. For iEXCHANGE is there a way to pull a listing by user of all Inpatient Precertifications and/or Referrals that were entered in a single day by that individual?
28. Can the physician, professional provider or facility complete an Inpatient Precertification for an HMO Blue Texas member whose PCP is with a delegated IPA or Medical Group?

Q1. What are the functions of the Utilization Management (UM) Department?
The Utilization Management (UM) Department reviews Referrals and Inpatient Precertifications not completed in iEXCHANGE. The UM Department may be reached at 1-800-441-9188, select 1 (English), then select 3 (preauthorizations & referrals), then select 3 (preauthorizations & referrals) again, then select 2 (Medical/Surgical). Telephones are answered by UM personnel from 6:00 AM to 6:00 PM, CST, Monday through Friday and non-legal holidays and 9:00 AM to 12:00 PM (noon) CST, Saturday, Sunday and legal holidays. Messages may be left in a confidential voice mailbox after business hours.
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Q2. Should we use the iEXCHANGE Web application or iEXCHANGE IVR system for Precertification of inpatient admissions or outpatient services?

For Inpatient Admissions - All inpatient admissions must be initiated through the iEXCHANGE IVR or Web application. 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, your case will be referred to the Utilization Management Department for review.
For Outpatient Services - Outpatient services do not require Precertification. View detailed list of Precertification Requirements.
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 Q3. What is the difference between Precertification and Verification?
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.
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Q4. Does outpatient surgery require Precertification?
No. For a detailed list of the Precertification Requirements, please click on the Precertification Requirements link below for the services that require precertification.
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 Q5. Where can we get a listing of the Precertification Requirements?
The Precertification Requirements Lists for all products may be found on the BCBSTX Web site at www.bcbstx.com/provider.
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 Q6. Does a member's ID card show if they need a referral?
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.
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Q7. 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.)
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.
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 Q8. 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?
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.
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 Q9. In a Specialty Care Physician's/Professional Provider's office, who is responsible for obtaining the referral? The patient, the PCP, who?
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.
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 Q10. 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?
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.
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 Q11. 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?
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.
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Q12. If a patient is admitted as an inpatient to the hospital; does the hospitals' Inpatient Precertification cover the physician?
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.
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Q13. 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 Behavioral Health, Inc. (Behavioral Health Provider) as well?
No. Primary Care Physician visits are generally reimbursed under the member's/subscriber's medical benefits.
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Q14. Can Referrals be done for a year at a time?

For the IVR & Web application - both systems will allow up to one year.
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Q15. Is there a limit on the number of visits that can be requested for a Referral?
For the IVR & Web applications - Referrals should be entered with no more than 999 visits.
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Q16. How long can a Referral be backdated for an HMO Blue® Texas member in iEXCHANGE? HealthSelectSM member? Or BlueChoice POS member?
HMO Blue Texas Member - Yes, up to 60 days
HealthSelect Member - Yes, up to 60 days
BlueChoice POS Member - Yes, up to 60 days
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Q17. What will happen if the wrong office location is chosen for the Referral? Do they need to do a new Referral or can the current one be corrected?
For the IVR & Web applications, the transaction cannot be changed in iEXCHANGE. They will need to enter a new Referral with the correct information.
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Q18. How long are Referral records kept in the iEXCHANGE System?
Referral records are kept for seven years.
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Q19. Can I access the iEXCHANGE Web application for Precertifications and Referrals?
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.

Q20. If a referral is requested through the IVR will it show up in iEXCHANGE Web and vice versa?
Yes, regardless of the point of entry, cases are available in both areas.
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Q21. Can an extension on Referrals & Inpatient Precertifications be completed through the iEXCHANGE Systems?
The Extension Functionality to extend an existing Referral or an Inpatient Certification is not currently available for the IVR or Web applications.
For Referral Extensions, you will need to enter a new referral.
For Inpatient Precertification Extensions, please contact the Utilization Management (UM) Department at 1-800-441-9188, select 1 (English), then select 3 (preauthorizations & referrals), then select 3 (preauthorizations & referrals) again, then select 2 (Medical/Surgical).
Note: Facilities can view Inpatient Precertification extensions in the Treatment Search section of the Web application.
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Q22. How do specialists inquire about a Referral if they do not have the Case ID #?
For the IVR - they have to know the Member ID & Case ID #. Note: The specialist could call the PCP to obtain the information.
For the Web application - they can inquire if they are the provider rendering the service and they can perform this function with only the Member ID and dates of service.
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Q23. What does it mean when I receive a message that my Referral or Inpatient Precertification has been pended?
For the IVR, If you need to speak with the UM Department, call 1-800-441-9188, select 1 (English), then select 3 (preauthorizations & referrals), then select 3 (preauthorizations & referrals) again, then select 2 (Medical/Surgical).
For the Web application, this means that your case is being reviewed by the UM Department. You can check the status through the Search feature in the Web application for any updates. Generally, you should see an update by the end of the following business day. Please refer to the Web Reference Guide. If you need to speak with the UM Department, call 1-800-441-9188, select 1 (English), then select 3 (preauthorizations & referrals), then select 3 (preauthorizations & referrals) again, then select 2 (Medical/Surgical).
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Q24. Why does iEXCHANGE not let us set up a Referral or Inpatient Precertification online for certain procedures and diagnoses.
BCBSTX's business needs will continue to require certain procedures and diagnoses to be reviewed by our clinical staff for medical necessity (i.e. focus review, experimental and investigational, etc.) iEXCHANGE will continue to support BCBSTX's business need.
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Q25. Can a Precertification go through iEXCHANGE without a Referral to the specialist if one is required?
No. If a Referral is required, i.e. HMO Blue Texas, the Precertification will not go through. If the Referral is optional, i.e. BlueChoice POS, the Precertification will go through but out-of-network benefits will apply. For BlueChoice PPO, a Referral is not required.
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Q26. Can a retroactive Inpatient Precertification be entered in iEXCHANGE? If so, within how many hours/days?
Yes. Retro Inpatient Precertifications are allowed up to 3 days in both the iEXCHANGE IVR and Web applications.
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Q27. For iEXCHANGE is there a way to pull a listing by user of all Inpatient Precertifications and/or Referrals that were entered in a single day by that individual?
No.
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Q28. Can the physician, professional provider or facility complete an Inpatient Precertification for an HMO Blue Texas member whose PCP is with a delegated IPA or Medical Group?
iEXCHANGE does NOT allow Referrals or Inpatient Precertifications for HMO Blue Texas members with a PCP participating in an IPA/Medical Group identified by PORG “KELS” or “RNPO”.
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Q29. Will I be able to do an inquiry or treatment search in the iEXCHANGE Systems?
Yes, you will be able to perform treatment searches or inquiries for Referrals and Inpatient Precertifications in both the IVR and Web applications.
For the IVR - To search for an existing treatment, select the Treatment Search option from the main menu. You will be prompted to enter the Member ID and a Case ID number. (Please note - the Case ID number includes a dash. Refer to the entry instructions under “Special Character” on page 4 of the iEXCHANGE IVR Reference Guide). When the iEXCHANGE IVR finds one or more treatments matching the search criteria you have entered, you are able to listen to a summary of each treatment.
For the Web application - The Web application offers inquiry through the Treatment Search or Treatment Update options. A Case ID is not required to search the Web application. Please refer to the Web Reference Guide.
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revised 03/2010