AIM Changes Name to Carelon


Blue Review

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

April 2023


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

End of Continuous Medicaid Coverage Ends March 31, 2023
Provider Enrollment Revalidation Ends May 11, 2023
Reinstatement of CHIP Co-Pays for Medical Office Visits Begins May 12
Primary Care Physicians Appointment Accessibility Standard AvailabilityAdobe Acrobat Icon
Reporting Potential Quality of Care Concerns
Case Management for Children and Pregnant Women Resource Tool
Missed Opportunities to Increase Adolescent Well-Care Visits
Register Now for BCBSTX Claims Billing Provider WebinarAdobe Acrobat Icon


AIM Specialty Health® Changes Its Name to Carelon Medical Benefits Management

As a result of AIM Specialty Health becoming Carelon, we’re updating our website with the new name, including our Utilization Management page and other related resources.

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Medical Necessity Review of Observation Services

As a reminder, it is our policy to provide coverage for observation services when it is medically necessary based on the medical criteria and guidelines outlined in the MCG Care GuidelinesLeaving Site Icon. Claims for observation services are subject to post-service review, and we might request medical records for the determination of medical necessity.

Hospitals, and Routine Services and Supplies

Providers usually include routine services and supplies in charges related to other procedures or services. As such, those services/supplies are considered non-billable for separate reimbursement. The following guidelines identify items, supplies and services that are not separately billable. (Note: This is not an all-inclusive list.)

Any supplies, items and services that are necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine services and not separately billable in the inpatient and outpatient environments.
All items and supplies that may be purchased over the counter are not separately billable. 
All reusable items, supplies and equipment that are provided to all patients during an inpatient or outpatient admission are not separately billable.
All reusable items, supplies and equipment that are provided to all patients admitted to a given treatment area or units are not separately billable.
All reusable items, supplies and equipment that are provided to all patients receiving the same service are not separately billable.


Supporting Behavioral Health Quality Care

We track quality measures related to behavioral health to monitor and improve our members’ care. Below is information about the measures and tips for closing gaps in care.

Screening and Follow-Up Care for Maternal Mental Health
Monitoring Children Using ADHD Medications
Caring for Substance Use Disorders


Technical and Professional Components

Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical components for lab and radiological services. These modifiers should be used in conjunction with the appropriate lab and radiological procedures only. Note: When a health care provider performs both the technical and professional services for a lab or radiological procedure, they must submit the total service, not each service individually.

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 policies were added or updated:

CPCP006 Preventive Services Policy Update – Effective April 1, 2023
Annual Review: TXCPCP003 Surgical and Non-Surgical Services Policy Update – Effective March 9, 2023
Annual Review: CPCP020 Drug Testing Clinical Payment and Coding Policy Update – Effective March 27, 2023
CPCP007 Implant and Coding Policy – Retired March 31, 2023
Update to CPCP023 Modifier Reference Policy – Effective June 26, 2023
Update to CPCP016 Chiropractic Care Services – Effective June 26, 2023
New CPCP040 Physical Medicine and Rehabilitation Services – Effective June 26, 2023
Update to CPCP010 Anesthesia Information – Effective June 26, 2023
Changes to CPCP027 Inpatient Readmissions Policy – Effective July 1, 2023


Earn Continuing Education Credit through Webinar on Opioids

Join us on April 24 or April 26 for a Zoom webinar about opioids where the discussion will focus on:

How opioids have evolved
Risks of opioid misuse
Effects of synthetic opioids and health disparities
Screening tools for opioid use disorder
Treatment trends and follow-up care
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To support quality care, we provide information to providers and members to encourage discussions on health topics. Watch for more on health care quality on our website’s News and Updates section and on our Delivering Quality Care web page.


Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM Annual Health Assessment Incentive FAQs – 2023

Check out FAQs for answers to questions about the Annual Health Assessment incentive including who is eligible, how it works, when payments are made and more.

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Pharmacy Program Quarterly Update, Part 2: Changes Effective Jan. 1, 2023

Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes.

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New for 2023: Specialty Pharmacies Added In-Network

See how we have expanded our specialty pharmacy network, which includes new dispensing options for specialty medications covered under the pharmacy benefit.

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Pharmacy Benefits

As a participating practitioner, you are given a list of drugs that we review and update throughout the year. For certain drugs, we have quantity limits and/or may require prior authorization before we approve any benefits for the drug. Prior approval and quantity limits are in place to ensure we are following current medically appropriate drug guidelines.

For more information, visit the Pharmacy Program section on our provider website. For Federal Employee Program® members, information can be found at We encourage you to check our provider website regularly and watch for updates in this newsletter.

The following information is available on our website: 

Formulary lists, including restrictions and preferences
How to use our pharmacy procedures
An explanation of limits and quotas
How you can provide information to support an exception request
The process for generic drug substitutions, therapeutic interchange and step-therapy protocols

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 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.

Verify and Update Your Information

Verify your directory information every 90 days. Use the Provider Data Management feature on Availity® or our Demographic Change Form. You can also use this form to submit email addresses for you and your staff to receive the Blue Review each month.

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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

1001 E. Lookout Drive, Richardson, TX 75082

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