SA Modifier and Midlevel Provider Contracting Update  |  view in Web Browser


Blue Review

A newsletter for physician, professional, facility, ancillary and Medicaid providers

June 2021


Monthly News for Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR), STAR Kids and CHIP Providers

Read this month’s Medicaid news to learn about:

Notices & Announcements

COVID-19 Provider Preparedness Updates

As the COVID-19 crisis evolves, we’re continuing to make updates on our COVID-19 Preparedness and our COVID-19 Related News pages. Be sure to check these pages frequently for updates including COVID-19: Texas Provider FAQsAdobe Acrobat Icon and COVID-19: FAQs for Medicare ProvidersAdobe Acrobat Icon.

SA Modifier and Midlevel Provider Contracting Update

On Jan. 19, we posted an article about contracting and credentialing midlevel providers and the upcoming implementation of the ClaimsXtenTM edit of the SA modifier for non-payable services resulting in the SA modifier being non-reimbursable. This edit has not been implemented and there are currently no plans for future implementation of this edit.

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Update to Telemedicine Code List

Review the codes we’ve updated in the Telemedicine Code List; these codes were effective Jan. 1.

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Newsletter Readership Survey: Your Feedback Is Important

Blue Review strives to deliver important information each month to our contracted providers. To provide the content that’s most relevant, we need your feedback. You will soon receive a survey via email that will only take a few minutes to complete. As a thank you for your time, we’re providing an opportunity to win one of three, $25® gift certificates. (Note: Government employees are not eligible.)

Behavioral Health

Free CME Webinar on Depression

Join our board-certified psychiatrists and behavioral health medical directors for a one-hour webinar, Depression in a Primary Care Setting. The webinar is Wednesday, June 16 at 8 a.m. CT. It is free to all providers. Those who attend will earn one continuing medical education credit (CME) or continuing education unit.

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Claims & Eligibility

Prepayment Reviews on BlueCard® Inpatient DRG Claims

Beginning July 1, the Blue Cross and Blue Shield Association will require us to review select, inpatient diagnosis-related group (DRG) claims for services rendered to any hosted BlueCard member. Hosted BlueCard members are members of any Blue Cross and Blue Shield plan outside Texas receiving health care services in Texas.

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Professional Provider Fee Schedule via Availity®

Starting May 27, participating professional providers are able to access fees for up to 20 procedure codes using the online Fee Schedule Viewer Tool via the Availity Provider Portal.

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Clinical Payment and Coding Policy Updates

The Clinical Payment and Coding Policies describe payment rules and methodologies for CPT®, HCPCS and ICD-10 coding for claims submitted as covered services. This information is a resource for our payment policies; it is not intended to address all reimbursement-related issues. We regularly add and modify clinical payment and coding policy positions as part of our ongoing policy review process. The following have been recently added or updated:


Clinical Resources

Keys to Diabetes Management

In late 2020, we asked BCBSTX providers to tell us what works best to manage diabetes. Read their responses and also learn about the programs we offer to close the gaps in care for managing diabetes.

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Health & Wellness

To support quality care, we are providing information to providers and members to encourage discussions on health topics. Watch for more on health care quality in News and Updates and our Wellness Can’t Wait web page.

Catch Up Now on Child and Adolescent Vaccinations

Due to COVID-19, children and adolescents have fallen behind on receiving recommended vaccines. The CDC recommends that children get caught up now with vaccinations so that they’re protected when they return to in-person learning. We’re encouraging providers to schedule catch-up vaccinations as soon as possible and prepare for COVID-19 vaccine protocols.

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Treating Substance Abuse

We encourage providers to talk with our members about the signs of substance abuse disorders and how alcohol can affect them. Learn about closing the health care gaps related to substance abuse and review tips to consider when urging a member to seek help.

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Medicare Advantage Plans



Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2021 – Part 1

This pharmacy update includes changes/updates to the drug list, dispensing limits, the Utilization Management program, benefit coverage for select high-cost claimants and HIV pre-exposure prophylaxis coverage. It also includes reminders about the Split Fill program and the HDHP/HAS Preventive Drug program.

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Prior Authorization


Utilization Management

New Location for Utilization Management on Provider Website

Utilization Management information, which includes Prior Authorizations, is now located under Claims and Eligibility on our provider website. This change was designed to enhance your experience for the entire claim cycle, from the moment a member walks into your office, from reviewing prior authorization requirements to processing claims for covered services you provide.

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Utilization Management Decisions

We are dedicated to serving our customers through the provision of health care coverage and related benefit services. Utilization Management (UM) determinations are made by licensed clinical personnel based on the:

  • benefits policy (coverage) of a member’s health plan,
  • evidence-based medical policies and medical necessity criteria, and the
  • medical necessity of care and service.

All UM decisions are based on the appropriateness of care and service and the existence of coverage. We prohibit decisions based on financial incentives, nor do we specifically reward practitioners or clinicians for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. The criteria used for UM determinations are available upon request. Please call the Customer Service number on the back of the member’s ID card.


Regulatory & Requirements (formerly Did You Know?)

This section includes additional items related to regulatory requirements and operational processes to assist provider offices with servicing our members. Access this month’s articlesAdobe Acrobat Icon.

We are required to provide certain notices in all published correspondence with health care providers. For the latest updates, visit the News and Updates section on the BCBSTX provider website.

Printable PDF

View a printable PDFAdobe Acrobat Icon of the non-Medicaid information in this newsletter.

Contact Us

View our quick directory of contacts for BCBSTX.

Update Your Information

Do you need to update your location, phone number, email or other important details on file with BCBSTX or want to receive the Blue Review by email? Use our online form to request information changes.

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an Independent Licensee of the Blue Cross and Blue Shield Association

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