Quality Measures Help Track Our Members’ Heart Health

Heart disease and stroke are among the leading causes of death in the U.S. We track measures related to our members’ blood pressure control and statin therapy. Learn steps to help identify and close care gaps.

Avoid Inappropriate Use of Antipsychotic Medication for Anxiety Disorders

Most antipsychotic medications aren’t approved for the treatment of anxiety disorders. We encourage prescribing providers to carefully assess symptoms, risks and benefits when considering medications for our members with anxiety disorders.

Postponed: Updates to Behavioral Health Substance Use Criteria for Utilization Management

We’ll continue to apply criteria from the American Society of Addiction Medicine’s third edition in our medical necessity reviews for substance use services for adults and adolescents.

Prior Authorization Changes

Effective April 1, 2025, prior authorization requirements are changing to reflect new, replaced or removed codes. Learn about the changes for commercial and Medicare Advantage members.

Contracted Providers Must File Claims

Contracted providers are required to file claims to us and only collect the patient share at the time of service.

Check Status of Your Prior Authorization Exemptions

Refer to Availity^® Essentials to determine if your prior authorization exemption was reinstated effective Jan. 1, 2025.

Annual Surveys Monitor Our Members’ Health Care Experiences

Every year, some of our members receive surveys about their experiences with their health care providers and plans. Learn about survey topics for these members:

• Commercial

• Medicaid

• Medicare Advantage

Earn Continuing Education Credit in Courses on Maternal Mental Health

You can access March of Dimes^® e‑learning modules on maternal mental health and perinatal loss at no cost through May 13, 2025.

Help Us Fight Fraud, Waste and Abuse

Every year, our analysts and investigators review claims data, industry trends and investigative results to identify potential areas of fraud, waste and abuse. We share this information with you by mail to remind you to comply with our policies and requirements. Refer to our fraud and abuse page for more information and to learn how to report potential fraud, waste and abuse.

Prior Authorization Required for Kisunla Therapy for Alzheimer’s Disease

As of Jan. 1, 2025, Kisunla procedure code J0175 is a benefit of Texas Medicaid. Effective Feb. 1, 2025, the Texas Health and Human Services Commission requires prior authorization for J0175.

Medicaid Providers Must Collect Information on Hospital Costs Related to Immigration Status

Hospitals began collecting the information on immigration status Nov. 1, 2024, and will begin quarterly reporting on March 1, 2025, to the Texas Health and Human Services Commission.

Stay Updated on Medicaid News

You can find information for STAR, STAR Kids and CHIP on our Medicaid News and Updates page.

Patients in the Qualified Medicare Beneficiary Program Should Not Be Billed

QMB patients are eligible for both Medicare and Medicaid. If you participate in Blue Cross Medicare Advantage^SM, you may not bill our members enrolled in the QMB program. Learn precautions to take to avoid billing these members.

Hospitals Must Provide Notice to Members Under Outpatient Observation for More Than 24 Hours

Hospitals and critical access hospitals are required to give the standardized Medicare Outpatient Observation Notice to Medicare Advantage plan members who are under outpatient observation for more than 24 hours. The notice explains why the members aren’t inpatient and their cost‑sharing obligations.

Pharmacy Program Quarterly Update – Part 2

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

Clinical Payment and Coding Policy Updates

Our clinical payment and coding policies describe payment rules and methodologies for Current Procedural Terminology (CPT^®), Healthcare Common Procedure Coding System and ICD-10 coding for claims submitted as covered services. 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:

• Policy Revised on Revenue Codes Requiring Supporting Codes for Outpatient Facility Claims, Effective April 14, 2025

• CPCP041 Sepsis Policy Updated, Effective April 1, 2025

• CPCP006 Preventive Services Policy Updated, Effective Feb. 1, 2025