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Blue Review

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

January 2022


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:

COVID-19 News and Updates
COVID-19 Moderna and Janssen (Johnson & Johnson) Vaccine Booster DoseAdobe Acrobat Icon
COVID-19 Pfizer Vaccine Update, Age Change and ComirnatyAdobe Acrobat Icon
COVID-19 Reimbursement Rate for Vaccine Administration Code 0004A Effective Sept. 22, 2021Adobe Acrobat Icon
Addressing Social Determinants of Health to Improve Maternal Health Outcomes
Six Factors that Affect Childhood Obesity
Register Now for Jan. 25 Webinar for Texas Medicaid Autism Services PolicyAdobe Acrobat Icon
Check Out Our New Podcast: Medicaid SimplifiedAdobe Acrobat Icon
Prior Authorization Code Update Effective April 1, 2022, for Medicaid Members


COVID-19 Provider Preparedness Updates

Check for continuing updates to our COVID-19 Preparedness, COVID-19 Provider Information for ERS Participants and COVID-19 Related News pages.

New Look Ahead for Provider Website

Our provider website will have a new streamlined design by early next year. We’re making changes to enhance your online experience and help you easily find the information you need. Information will be in the sections you’re used to seeing, such as Claims and Eligibility and Education and Reference. Please watch for future updates.


Claim Editing Enhancements Coming April 1, 2022

Effective April 1, 2022, we will enhance our claims editing and review process with Cotiviti, Inc. for some of our commercial members. Learn what these changes will mean for you.

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2022 Federal Employee Program® (FEP®) Prior Authorization and Benefit Updates

Effective Jan. 1, there will be changes to their prior authorization requirements and benefits for FEP. Review prior authorization updates and benefit changes.

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Chiropractic & Mixed Therapy Benefits Contained in IVR Phone System as of Jan. 3, 2022

Beginning Jan. 3, the option to speak to a Customer Advocate will be removed from the chiropractic and mixed therapy benefit category within our automated Interactive Voice Response (IVR) phone system. The IVR quotes the same level of patient eligibility and benefits information that a Customer Advocate provides. Remain assured that our Customer Advocates will continue to be available for more complex benefit quotes.

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Availity® Tools to Support Providers in 2022

As a reminder, the Availity Provider Portal helps providers and us quickly and securely share information, including information defined by the Consolidated Appropriations Act. Review the many self-service tools you can access through the Availity portal, instructional user guides and important tips.

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Clinical Payment and Coding Policy Updates

The Clinical Payment and Coding Policies on our website 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:

Coordinated Home Care/Private Duty Nursing PolicyAdobe Acrobat Icon – Effective 12/01/2021
Applied Behavior AnalysisAdobe Acrobat Icon  – Effective 03/01/2022
Emergency Department Evaluation and Management (E/M) Services Coding – Facility ServicesAdobe Acrobat Icon  – Effective 03/20/2022


Rural Health Clinics and Federally Qualified Health Centers May Meet Quality Measure

Starting Jan. 1, 2022, Rural Health Clinics and Federally Qualified Health Centers may meet the requirements for the quality measure Follow-up After Hospitalization for Mental Illness (FUH). Review why FUH matters and the criteria for the Psychiatric Collaborative Care Model must meet to qualify.

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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.


COVID-19 Vaccine Billing for Medicare Advantage Members

Starting Jan. 1, 2022, we will cover the cost of COVID-19 vaccines and their administration for Blue Cross Medicare AdvantageSM members instead of the original Medicare program (also known as Fee-for-Service Medicare).

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New Flexible Medicare Advantage PPO Plan

The Blue Cross Medicare Advantage Flex (PPO)SM plan is an open-access plan that allows members to see any provider accepting Medicare, including Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM contracted providers. Members can see providers inside or outside the plan service area or plan network, at no additional cost. Learn about the value to members and what this means for you.

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Hospitals Must Provide Medicare Outpatient Observation Notice

Hospitals and Critical Access Hospitals (CAH) are required to give the standardized Medicare Outpatient Observation Notice (MOON) to our Blue Cross Medicare Advantage members who are under outpatient observation for more than 24 hours. The notice explains why the members aren’t inpatient and what their coverage and cost-sharing obligations will be. Review the steps to complete the MOON.

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Qualified Medicare Beneficiary Program Patients Should Not Be Billed

If you participate in Blue Cross Medicare Advantage networks, you may not bill cost-sharing or out-of-pocket costs to our members enrolled in the Qualified Medicare Beneficiary (QMB) program, a federal Medicare savings program. Review tips to avoid billing QMB patients.

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Blue Cross Medicare Advantage Prior Authorization Code Update Effective April 1, 2022

We are changing prior authorization requirements for Blue Cross Medicare Advantage members to reflect new, replaced or removed procedure codes due to updates from Utilization Management or the American Medical Association. A summary of changes is included.

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Medicare Advantage Provider Manual Supplements Update

Be sure to check out the updated Medicare Advantage PPO and HMO Provider Manual Supplements posted on the Provider Manuals page on the BCBSTX provider website. In addition, throughout the year, keep current on changes by visiting the provider website for News and Updates and the Blue Review newsletter. You and your staff can also directly receive the newsletter by submitting your email address(es) using the Demographic Change Form. Refer to the User Guide for instructions on which fields to complete.


2022 Blue Cross Medicare Advantage Expansion Service Areas


Pharmacy Program Updates Effective Jan. 1, 2022

Pharmacy programs have numerous updates effective Jan. 1, 2022. Some members may have new pharmacy networks and/or changes within their current network. You can refer to our News and Updates page to review the Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2022 – Part 1Adobe Acrobat Icon for details on the changes.


Prior Authorization Code Update Effective April 1, 2022, for Commercial Members

We will be updating our lists of procedure codes requiring prior authorization for some commercial members. Review the changes effective April 1.

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Revision to Prior Authorization Codes for Commercial Members

Regulatory & Requirements

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

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 PDF 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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