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BEHAVIORAL HEALTH |
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Updates Coming to Behavioral Health Substance Use Disorder Criteria for Utilization Management
Effective Jan. 1, we’ll begin using ASAM’s new Criteria 4.0 for our behavioral health medical necessity reviews for substance use disorders for adults.
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CLAIMS & ELIGIBILITY |
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Important Benefit Changes for Fully Insured Texas Group Plans
Review important benefit changes for Fully Insured group plans, effective Jan. 1, 2025, including:
- Outpatient lab claims
- Claims for services performed in an outpatient setting
- Any claims that meet criteria relevant to one or more of the applicable lab services included in this article
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Reminders
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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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Check ID Cards for New Coupe Health Plan Members
As a reminder, providers in our commercial PPO network and Blue High Performance Network® can treat members with our new Coupe Health benefit plan. This plan streamlines the payment process for your office and our members.
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HEALTH & WELLNESS |
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Risk Identification and Outreach Program Supports Member Safety
Our Risk Identification and Outreach Program focuses on medical and behavioral safety, opioid education, and follow-up care after treatments and emergency room visits.
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Encourage Annual Eye Exams for Members with Diabetes
Early detection and treatment can greatly lower the chance of vision loss for our members living with diabetes. Learn about the important role annual eye exams play and tips for closing gaps in care. |
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MEDICARE ADVANTAGE PLANS |
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Medicare Prescription Payment Plan Launching Jan. 1, 2025
Members will be offered a new payment plan for Medicare Advantage Part D to pay for prescriptions via monthly payments.
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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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NETWORK PARTICIPATION |
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MyBlue HealthSM Network Expansion
Effective Jan. 1, 2025, we’re expanding the MyBlue Health network to Jefferson and Nueces Counties. |
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PHARMACY |
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Pharmacy Program Quarterly Update Changes Effective Oct. 1, 2024 – Part 2
Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes. |
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30-Day Supply Limit: Select Commercial Members Have New Pharmacy Benefit for GLP-1 and/or Anti-Obesity Drug Therapy
Effective Sept. 1, a 30-day supply limit went into effect for certain members who are prescribed GLP-1 and/or anti-obesity drug therapy medications. |
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UTILIZATION MANAGEMENT |
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Medical Transportation Utilization Management for Some Members Updated
Effective Jan. 1, 2025, Alacura Medical Transportation Management will manage air and ground medical transportation, prior authorization, recommended clinical review and retrospective claim reviews for our Fully Insured members and certain ASO groups. |
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Prior Authorization Code Changes for Commercial Members Effective Jan. 1, 2025
We’re updating our lists of codes requiring prior authorization for some commercial members on Jan. 1, 2025. A summary of changes is included. |
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Reminder
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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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