More Access for Medicare Patients and Providers


Blue Review

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

July 2023


Access all 2023 news and updates for Blue Cross and Blue Shield of Texas (BCBSTX) Medicaid (STAR), STAR Kids and CHIP Providers. Highlights include:

Catch Up on Routine Vaccines and Well-Child Visits
Reminder Texas Medicaid Providers Help Out Members Get Ready for RedeterminationAdobe Acrobat Icon
Reminder: Primary Care Physicians (PCP) Appointment Accessibility Standard AvailabilityAdobe Acrobat Icon
Reminder: New Form for OB/GYN Compliance Challenges with Prenatal Appointment AvailabilityAdobe Acrobat Icon
Texas Medicaid Claims Editing EnhancementsAdobe Acrobat Icon
Additional Changes to Prior Authorization Codes for Medicaid Members Effective July 1, 2023
Reminder: Survey to Assess Medicaid Provider ExperiencesAdobe Acrobat Icon
Medicaid Members Can’t be Balanced Billed


Annual Notice of Provider and Member Rights and Responsibilities

As a participating provider in our provider networks, you are required to comply with our Provider Rights and Responsibilities and understand our Member Rights and Responsibilities that may affect your practice.

The Physician Performance Insight (PPI) Reports Coming Soon

The Physician Efficiency, Appropriateness, and QualitySM (PEAQ) program evaluates physician performance in a transparent and multidimensional way. Physicians who meet inclusion requirements are provided with PPI reports that show how they compare to their peers and information to improve future performance.

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Ground and Air Ambulance Overpayment Error


New Availity® Eligibility & Benefits Experience

As a result of provider feedback, the Availity Eligibility and Benefits Tool has a refreshed point of entry. And now the response screens provide a clearer and more concise workflow, as well as flexible options for adding providers, expanding sections, and other toggle/filtering options.

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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. 

Medical Necessity Review of Observation Services

As a reminder, it is our policy to provide coverage for observation services when determined to be 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.

ClaimsXtenTM Announces Software Version Upgrade

Beginning on or after July 10, 2023, we will upgrade our ClaimsXten system software from version 6.0 to 7.0. Key enhancements include a new look for the Clear Claim ConnectionTM (C3) tool with new data fields for greater claim specificity. The ICD code set default will now be ICD-10. Note: Clinical edit clarifications and related sources will continue to be available. Refer to our Clear Claim Connection Provider Tools web page for more details regarding ClaimsXten, including a user guide, rule descriptions and other details.


Clinical Payment and Coding Policy Updates

Our website’s 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 and does not address all reimbursement-related issues. During our policy review process, we regularly add and modify clinical payment and coding policy positions. The following policies were added or updated:

Update of CPCP028 Non-Reimbursable Experimental, Investigational and/or Unproven Services Update, 04/01/2023 & 07/01/2023
CPCP011 Applied Behavioral Analysis Updated, Effective 09/01/2023
CPCP028 Non-Reimbursable Experimental, Investigational and/or Unproven Services Update, 09/01/2023
New CPCP041 Sepsis Policy, Effective 09/06/2023


Webinars on Cross-Cultural Care Offer Continuing Education Credit

If you haven’t completed our webinars on cross-cultural care, there’s still time to register and earn continuing education credit. We offer these webinars at no cost through Quality Interactions, a separate company that supplies cultural awareness training to health care professionals.

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Medicare Advantage Annual Wellness Visits: Webinar and Resources

Join us for a free webinar to learn about components of wellness visits, documentation standards, general coding requirements, and more. Our Coding Compliance team will present information from the official ICD-10-CM Coding Guidelines, the American Hospital Association Coding Clinic and the Centers for Medicare & Medicaid Services. Visit our provider website for more training opportunities.

Date: July 10
Time: Noon to 12:30 p.m. CT
Register hereLeaving Site Icon (If you cannot access the registration site, try clearing your web browser history.)

Provider Learning Opportunities

We offer free webinars for contracted providers who serve our members. Trainings focus on electronic options and other helpful tools and resources. Review upcoming training sessions – including the topics below – on our Provider Training Webinars page. Also, if you are a new provider or have new staff, refer to our Provider Orientation information.

Availity Essentials Orientation – Save Time and Go Online
Availity® Essentials Authorization and Referral Tools
Availity Essentials Claim Status, Clinical Claim Appeals & Message This Payer
Remittance Viewer & Reporting On-Demand via Availity Essentials
eviCore® Healthcare Training
CarelonTM ProviderPortal Training for Prior Authorizations


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.

Catch Up on Routine Vaccines and Well-Child Visits

Because many children missed routine childhood immunizations and well-child visits during the last few years, we’re providing tips to make it easier for you and your staff to encourage families to get caught up.

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BCBS Medicare Advantage PPO Network Sharing

All Blue Cross and Blue Shield Medicare AdvantageSM (BCBS MA PPO) plans participate in reciprocal network sharing, which allows all BCBS MA PPO members to obtain in-network benefits when traveling or living in the service area of any other BCBS MA PPO plan if the member sees a contracted BCBS MA PPO provider. For more information, refer to the Blue Cross Medicare Advantage (PPO) Provider Supplement. If you have questions regarding the BCBS MA PPO program or products, please contact BCBS MA PPO Customer Service at 1-877-774-8592.

Additional Changes to Prior Authorization Codes for Medicare Members, Effective July 1, 2023

Update: In addition to the prior authorization codes we recently added, we’ve now removed prior authorization requirements for some ultrasound codes and replaced a specialty drug code for Medicare members.

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More Access for Medicare Patients and Providers

As a reminder, if you’re a Medicare provider, you can treat Blue Cross Group Medicare Advantage Open Access (PPO)SM, UT CARETM Medicare PPO (UT CARE) and Blue Cross Medicare Advantage Flex (PPO)SM members regardless of your contract or network status with us.

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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


Additional Changes to Prior Authorization Codes for Commercial Members, Effective July 1

We recently updated our lists of codes requiring prior authorization (for some commercial members) to reflect the replacement of certain medical oncology codes reviewed by Carelon Medical Benefits Management.

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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 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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