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NOTICES & ANNOUNCEMENTS |
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New BlueApprovRSM Tool Expedites Prior Authorization and Recommended Clinical Review for Some Medical/Surgical Services
Effective Sept. 11, the new BlueApprovR tool (in Availity®) will streamline the Prior Authorization and Recommended Clinical Review process. It should help reduce your workload by expediting some medical and surgical services approvals. |
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CLAIMS & ELIGIBILITY |
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Reminder for Billing Point-Of-Use (POU) Convenience Kits
We periodically check the pricing of POU kits to manage costs. As a reminder, only the drug component of the kit is reimbursable. |
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ClaimsXtenTM Quarterly Update Effective Dec. 4, 2023
We will implement our Q4 code updates for the ClaimsXten auditing tool on or after Dec. 4. Code updates may include additions, deletions and revisions to:
- Current Procedural Terminology (CPT®) codes
- Healthcare Common Procedure Coding System (HCPCS) codes
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CLINICAL RESOURCES |
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Updates to Clinical Practice and Preventive Care Guidelines
We’ve updated our Clinical Practice Guidelines and Preventive Care Guidelines. The guidelines help direct our quality and health management programs and improve member care. They may help guide your decision-making as you care for our members. We update them no less than every two years or when new significant findings or major advancements in evidence-based care are established. |
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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. We may add and modify clinical payment and coding policies. The following policy was updated:
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HEALTH & WELLNESS |
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To support quality care, we provide information to providers and members to encourage discussions on health topics. Watch for more about health care quality in our website’s News and Updates section and our Delivering Quality Care web page. |
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Supporting Quality Care During Breast Cancer Awareness Month
October is Breast Cancer Awareness Month, so it’s a great time to remind our members about the importance of regular screenings. Tips to reduce gaps in care are included. |
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MEDICARE ADVANTAGE PLANS |
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Medical Records Reminder for Out-of-Area Medicare Advantage Members
If we need medical records for Blue Cross Group Medicare Advantage (PPO)SM members, you will receive requests directly from us or our vendor, Change Healthcare, as part of the Blue Cross and Blue Shield National Coordination of Care program. Please respond quickly to our requests, including requests related to risk adjustment gaps and Healthcare Effectiveness Data and Information Set (HEDIS®) measures. Also, you may receive requests from EXL Health for select inpatient, diagnosis-related group claims for any out-of-area Blue Cross Medicare AdvantageSM members. |
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NETWORK PARTICIPATION |
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Physician Performance Insight Reports Now Available
Physician Performance Insight reports are now in Availity for physicians who met eligibility requirements for the Physician Efficiency, Appropriateness, and QualitySM (PEAQSM) program. |
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MyBlue HealthSM Network Expansion
Effective Jan. 1, 2024, members in Comal, McLennan and Rockwall counties will access care through providers contracted in the MyBlue Health network. |
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PRIOR AUTHORIZATION |
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Notifications for Prior Authorization Exemptions for Jan. 1 to June 30, 2023, Review Period
Effective Sept. 1, providers who met the necessary criteria for prior authorization (PA) exemptions from Jan. 1 to June 30, 2023, were issued a PA exemption. |
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New Location in Availity to Access Prior Authorization Exemption Communications as of Sept. 7, 2023
Effective Sept. 7, there’s a new location on the Availity website where you can access all communications for prior authorization exemptions. |
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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 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.
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Printable PDF
View a printable PDF of the non‑Medicaid information in this newsletter.
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File is in portable document format (PDF). To view this file, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader® which has a built-in screen reader. You can download other tools and learn more about accessibility at adobe.com  .
By clicking this link, you will go to a website/app (“site”). The site may be offered by a vendor or an independent third party. The site may also contain non-Medicare related information. Some sites may require you to agree to their terms of use and privacy policy.
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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
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1001 E. Lookout Drive, Richardson, TX 75082
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