See Our BlueCard^® Program Checklist for Out‑of‑Area Member Claims

As part of our BlueCard program, you may see members with Blue Cross and Blue Shield Plans from other states. Review our checklist for filing out‑of‑area member claims.

We Will Administer Behavioral Health Benefits for Blue Advantage HMO^SM and MyBlue Health^SM

Effective Jan. 1, 2026, Magellan Healthcare^® will no longer administer benefits for these members. Review how to verify eligibility and benefits and submit claims.

Take Note of Prior Authorization Changes for Commercial and Government Plans

Effective Oct. 1, 2025, prior authorization requirements for certain commercial and government plans are changing to reflect new, replaced or removed codes.

We’re Reviewing New Prior Authorization Exemptions

Effective Sept. 1, 2025, exemption notifications will be available in Availity^® Essentials. Learn how to review results if you qualify for an exemption.

Encourage Pediatric Well‑Child Visits and Immunizations

We track quality measures to help close gaps in our members’ care. See tips for documenting visits and vaccines.

Review New Clinical Practice Guideline on Hepatitis C

We adopted a guideline on testing, managing and treating hepatitis C virus from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America. Learn about the recommendations.

See Resource on ICD‑10 Z Codes to Help Track Members’ Social Needs

We encourage adding ICD‑10‑CM Z codes on claims to document social determinants of health that may affect our members. Refer to our flyer for sample codes.

Explore Learning Opportunities

We offer free training for providers who participate in our networks. Review and sign up for sessions, including courses on Availity Essentials tools.

Help Us Fight Fraud, Waste and Abuse

Every year, our analysts and investigators review claims data, industry trends and investigative results to identify potential fraudulent activity. Learn how to report potential fraud, waste and abuse.

Use Correct Taxonomy Code for Rendering Providers on Claims

The taxonomy code must match what the state Medicaid agency has on file.

Update: Rider 32 to Transition Medicaid‑Only Services for Dual‑Eligible Members

Effective Sept. 1, 2025, providers will be able to bill us directly for Medicaid wrap‑around services provided to members eligible for Medicaid and Medicare.

Encourage Members to Use Virtual Visits for Urgent Care After Hours

If our members enrolled in Medicaid need to receive care after hours or while traveling, they may access MDLIVE^® Virtual Visits for urgent, non‑emergency medical conditions. Consider telling our members about this benefit if they need services when your office isn’t available.

Reminder: Annual Survey Monitors Medicaid Members’ Health Care Experiences

We’re conducting the annual Consumer Assessment of Healthcare Providers and Systems survey with Medicaid members. Learn about survey topics and how you may most impact results.

Stay Updated on Medicaid News

You can find information for STAR, STAR Kids and CHIP in Medicaid News and Updates.

Provide Records to Support Risk Adjustment Data Validation Audit

You may receive medical record requests for the Centers for Medicare & Medicaid Services’ RADV audit. If you receive a letter from us and our vendor, please respond as soon as possible.

Identify Your First-Responder and Sign-Language Services for HealthSelect of Texas^®

Our HealthSelect of Texas Provider Finder tool can now help participants identify providers who specialize in first‑responder care and offer American Sign Language services.

Verify Your Directory Information Every 90 Days

Our members rely on our provider directory for accurate information about your practice. Review and verify your data every 90 days and update it when it changes.

Review Reminder on Billing Point‑of‑Use Convenience Kits

These prepackaged kits include supply items in addition to injectable medicine. We reimburse only the drug component of the kits.

Pharmacy Program Quarterly Update — Part 2

Changes were made to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

Follow Guidelines for Making Physician Referrals for HMO Members

Review steps to follow when members with Blue Advantage HMO^SM, Blue Advantage Plus^SM HMO, Blue Essentials^SM and MyBlue Health request a referral.

Learn About Updates to Clinical Payment and Coding Policies

We regularly add and modify CPCPs as part of our ongoing policy review. See which policies were updated and when.

Review Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.