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CLAIMS & ELIGIBILITY |
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ClaimsXtenTM Quarterly Update Effective June 17
We will implement our second-quarter code updates for the ClaimsXten auditing tool on or after June 17. Code updates may include additions, deletions and revisions to:
- Current Procedural Terminology (CPT®) codes
- Healthcare Common Procedure Coding System codes
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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 policies were added or updated:
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EDUCATION & REFERENCE |
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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 outlined in the MCG Care Guidelines . Claims for observation services are subject to post-service review, and we might request medical records for the determination of medical necessity. |
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HEALTH & WELLNESS |
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Continuity and Coordination of Eye Care
When a PCP refers a diabetic patient to an eye care specialist, that specialist needs to share the details about the care the patient received with the referring PCP. Learn how. |
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Caring for Substance Use Disorders
Providers can play an important role in our members’ care by discussing the signs of substance use disorder and encouraging help, when appropriate. We track quality measures related to SUD to monitor our members' treatment and follow-up care. |
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MEDICARE ADVANTAGE PLANS |
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Webinar on Coding for Medicare Advantage Annual Wellness Visits
Join us on April 12 for a webinar on coding annual wellness visits for Medicare Advantage members. Topics will include:
- Components of annual health assessments and wellness visits
- Documentation standards and general coding requirements
- Coding for chronic conditions
- Common coding errors
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Reminder
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MEDICAID |
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Access all 2023 and 2024 news and updates for BCBSTX Medicaid (STAR), STAR Kids and CHIP providers.
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Reminders
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PHARMACY |
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Pharmacy Program Quarterly Update, Part 1: Changes Effective April 1, 2024
Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes. |
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Reminder
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STANDARDS & REQUIREMENTS |
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Medical Policy Updates
When Policies are Posted
New or revised medical policies, when approved, may be posted on our provider website (under Standards and Requirements) on the 1st or 15th of each month. Medical policies requiring disclosure will become effective 90 days from the posting date. Medical policies that do not require disclosure will become effective 15 days after the posting date. The specific effective date will be noted for each medical policy that is posted. To streamline the review process, you can view medical policy drafts and provide your feedback online. When there are draft medical policies to review, they will be posted around the 1st or 15th of each month with a review period of approximately two weeks.
Related Information
To request a review of your services (before rendering the service), refer to the Recommended Clinical Review Option webpage. Also, other policies and information regarding payment can be found on the Clinical Payment and Coding Policies webpage. |
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UTILIZATION MANAGEMENT |
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Recommended Clinical Review Services, and Code List Changes for Certain Members
Periodically, we update our lists of services and procedure codes that require Recommended Clinical Review (for some commercial members) to reflect new, replaced or removed codes. Review how to access RCR lists, and make sure to check eligibility and benefits before rendering services. |
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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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