Important Benefit Changes to 2023 Fully Insured Group Plans


Blue Review

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

February 2023


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

Reminder: Texas Medicaid STAR, CHIP, and STAR Kids Provider ManualAdobe Acrobat Icon on our BCBSTX Medicaid provider website under Education and Reference.

Reminder: BCBSTX Appointment Accessibility Standards
Updates to Texas Health and Human Services Commission Policy Flexibility for Member Appeals Ending March 31
Collaborative Care Model Provider Attestation Form, Effective Jan. 1
Collaborative Care Model in Texas Medicaid Computer-Based Training
Clinical Practice Guidelines for Texas Medicaid Plan
BCBSTX Medicaid Emergency Disaster Plan
Supporting Heart Health Equity
Are You Using These Shared Decision-Making Aids?
Reminder to Encourage Medicaid Members to Renew CoverageAdobe Acrobat Icon


Important Benefit Changes to 2023 Fully Insured Texas Group Plans

Texas law permits insured group contracts to be modified during coverage renewal if the modification is effective uniformly among all employer groups covered by the benefit plan. Since all BCBSTX Fully Insured group health plans were amended on Jan. 1, some laboratory services may not be covered.

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FEP® Annual Medical Record Data Collection for Quality Reporting – HEDIS®

To meet the Federal Employees Health Benefits Program requirements, our BCBS FEP Team will soon collect medical records using internal resources and the independently contracted third-party vendor, Episource. The collection process runs from February to the end of April. If you receive a request for medical records, we ask that you reply within five (5) business days.

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Annual HEDIS/QRS Reports

Because our Quality Improvement Program aims to monitor and improve the care and services our members receive, we’re providing a chart that summarizes how we’re performing on selected HEDIS and Quality Rating System (QRS) measures, along with key interventions and key accomplishments.

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Psychiatry Reimbursement Increase

Effective Jan. 1, 2023, we increased the maximum allowable standard fee schedule reimbursement for the following specialties (for commercial members) in certain networks:

Child & Adolescent Psychiatry
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ClaimsXtenTM Quarterly Update, Effective April 17, 2023

We will implement our first quarter code update for the ClaimsXten Auditing Tool on or after April 17. Code updates may include additions, deletions or revisions to:

Current Procedural Terminology (CPT®) codes
Healthcare Common Procedure Coding System (HCPCS) codes
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Prior Authorization and Claim Reconciliation for Neonatal Intensive Care Unit Services

Beginning March 20, we will begin reviewing claims when they are received for Neonatal Intensive Care Unit (NICU) services with the approved services on the prior authorization. This real-time verification will reconcile the claim to the authorization, including the number of days by level with what the provider submits for payment on their claim.  Examples of claim adjudication are included.

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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 policies were added or updated:

CPCP006 Preventive ServicesAdobe Acrobat Icon – effective Jan. 1, 2023
CPCP028 Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)Adobe Acrobat Icon – effective Jan. 1, 2023
CPCP019 Home InfusionAdobe Acrobat Icon – effective Jan. 5, 2023
CPCP036 Paravertebral Facet Injection Procedure Coding & Billing PolicyAdobe Acrobat Icon – effective Jan. 6, 2023
CPCP028 Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)Adobe Acrobat Icon – effective April 1, 2023
CPCP026 Therapeutic, Prophylactic and Diagnostic Injection and Infusion CodingAdobe Acrobat Icon – effective April 5, 2023


2023 Holiday Schedule Reminders (for 835 and 837 transactions)

We’re providing the 2023 holiday schedule to help plan around scheduling variances that may affect electronic claims (837) and/or electronic claims payment and remittance (835) transactions. We encourage you to download, keep and distribute the PDF calendar (embedded in the Read More link) to the appropriate staff.

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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.

Supporting Heart Health Equity

Social determinants of health are non-medical factors that influence health outcomes (like heart disease). We encourage you to ask our members about their needs related to social determinants of health. On claims, you can include ICD-10 Z codes (for social determinants of health) so we can help address barriers.

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Inflation Reduction Act to Impact Insulin and Vaccine Costs for Medicare Members

Since Jan. 1, 2023, the Inflation Reduction Act of 2022 changed the cost of insulin (and adult vaccines) for Medicare members. Therefore, some Medicare members may be charged more than $35 per month for covered insulin. If that happens, we will reimburse members for any amount paid over $35 via a mailed check no later than Jan. 31, 2023. FAQs are included.

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Correction: Prior Authorization Codes for Commercial Members Updated, Effective April 1, 2023

Please note, corrections were made to the prior authorization lists below. Be sure to review the lists for changes.

Addition of Specialty Pharmacy: Site of Care codes to be reviewed by BCBSTX
Addition of a Medical Oncology code to be reviewed by AIM Specialty Health®
Replacement of Medical Oncology codes to be reviewed by AIM
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‘Predetermination’ Is Changing to ‘Recommended Clinical Review’

On Oct. 1, 2022, we introduced Recommended Clinical Review (RCR) for inpatient services that no longer require prior authorization. Then on Jan. 1, 2023, we also changed the name of our longstanding outpatient preservice review from “Predetermination” to “Recommended Clinical Review.” Key points and the RCR submission process are included.

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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 PDF Adobe Acrobat Icon of the non‑Medicaid information in this newsletter.

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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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