Ground and Air Ambulance Overpayment Error


Blue Review

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

May 2023


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

May highlights include:

Texas Medicaid Providers Help Patients Get Ready for RedeterminationAdobe Acrobat Icon
Update to Prior Authorization Codes for Medicaid Members, Effective July 1, 2023
Texas Health Steps Guidelines Clarified
The CAHPS Survey: We All Play a Role


How to Correctly Use Our Claim Review Form

We’ve revised our Claim Review Form so now is a good time to check out reminders about how to use it correctly.

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Ground and Air Ambulance Overpayment Error

We have identified an overpayment error for some ground and air ambulance claims. As such, this error has been corrected, and we’ve begun requesting applicable overpayments for these claims.

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Behavioral Health Consultations During Hospitalization Can Improve Outcomes

Behavioral health consultations during a hospital stay can help our members who have both physical and behavioral health conditions. Addressing behavioral health care with timely follow-ups can help reduce hospital readmissions and improve health outcomes.

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Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPOSM and Blue Advantage HMOSM (for Blue Advantage Plus)

When a network provider refers a Blue Choice PPO or Blue Advantage HMO member to an out-of-network provider for non-emergency services (when such services are available through an in-network provider), appropriate forms must be filled out and filed.

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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 and does not 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:

Annual Review: CPCP024 Evaluation and Management Coding: Professional Provider Services – Effective 04/20/2023
New CPCP038 Outpatient Services Prior to an Inpatient Admission, Three-day Payment Policy – Effective 08/01/2023
CPCP028 Non-Reimbursable Experimental, Investigational and/or Unproven Services Update – Effective 07/01/2023


Webinar on Coding for Chronic Kidney Disease

Join us on one of three dates for a Teams webinar about coding for chronic kidney disease. The webinar is free to providers and coding professionals, and will focus on:

Specificity, accuracy and completeness in documentation
Coding for CKD with diabetes mellitus, hypertension and hypertensive heart
Closing gaps in care for patients with CKD
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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.

Track Care Visits During and After Pregnancy

Since prenatal and postpartum care contributes to the long-term well-being of new mothers and their infants, we track the quality of care our members receive to assess and improve their care. So, to improve quality, we’re providing tips to close gaps in care.

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New Support Program for Members with Kidney Disease

We’re working with Somatus®, a value-based kidney care organization, to deliver a new, no-cost support program to eligible members living with kidney disease.

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

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

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Update to Prior Authorization Codes for Commercial Members, Effective July 1

We will be updating our lists of codes that require prior authorization to reflect new, replaced or removed codes.

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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. In addition, 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 or health advocate number on the back of a member’s ID card. 


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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