Can Referrals be done for a year at a time?
For IVR & Web - both systems will allow up to one year.
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Is there a limit on the number of visits that can be requested for a Referral?
For the IVR & Web - Referrals should be entered with no more than 999 visits.
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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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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 IVR & Web, the transaction cannot be changed in iEXCHANGE. They will need to enter a new Referral with the correct information.
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How long are referral records kept in the iEXCHANGE System?
Referral records are kept for seven years.
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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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Can an extension on Referrals & Inpatient Certifications 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 Certification Extensions, please contact Medical Care Management at 1-800-441-9188, select 1, then select 3.
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What are the functions of the Medical Care Management Department?
Medical Care Management reviews Referrals and Inpatient Certifications not completed in iEXCHANGE. The Medical Care Management Department may be reached at 1-800-441-9188, select 1, then select 3. Telephones are answered by Medical Care Management 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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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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What does it mean when I receive a message that my Referral or Inpatient Certification has been pended?
For the IVR, if you receive a message that your case has pended - this means that your case is being reviewed by the Medical Care Management Department. If you need to speak with the Medical Care Management Department, call 1-800-441-9188, select 1, then select 3.
For the Web application, this means that your case is being reviewed by the Medical Care Management 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 Medical Care Management Department, call 1-800-441-9188, select 1, then select 3.
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Why does iEXCHANGE not let us set up a Referral or Inpatient Certification online for certain procedures and diagnoses.
BCBSTX' 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' business need.
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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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Can a retroactive Inpatient Certification be entered in iEXCHANGE? If so, within how many hours/days?
Yes. Retro Inpatient Certifications are allowed up to 3 days in both the iEXCHANGE IVR and Web applications.
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For iEXCHANGE is there a way to pull a listing by user of all Inpatient Certifications and/or Referrals that were entered in a single day by that individual?
No.
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Can the physician, professional provider or facility complete an Inpatient Certification for an HMO Blue Texas member whose PCP is with a delegated IPA or Medical Group?
iEXCHANGE does NOT allow Referrals or Inpatient Certifications for HMO Blue Texas members with a PCP participating in an IPA/Medical Group identified by PORG “KELS” or “RNPO”.
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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 Certifications 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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Posted 07/30/08
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