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Postponed: ClaimsXten™ November 2014 Update

August 5, 2014

Updated Aug. 7, 2014

The deployment of these two rules will be postponed until on or after Dec. 8, 2014.

Beginning on or after Nov. 3, 2014, Blue Cross and Blue Shield of Texas (BCBSTX) will enhance the ClaimsXten code auditing tool by adding two new rules into our claim processing system.

The first rule is Medically Unlikely Edit (MUE) of Durable Medical Equipment (DME). This rule identifies claim lines where the MUE value has been exceeded for a Current Procedural Terminology (CPT®') or HCPCS code, reported by the same or multiple providers, for the same member, on the same date of service. This rule audits professional claims utilizing the DME Supplier Services MUE table data published quarterly by the Centers for Medicare & Medicaid Services (CMS). The DME Supplier Services MUE table contains assigned MUE values for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

The second rule is Durable Medical Equipment (DME) Maximum Payment Rule. This rule calculates the total payments for the DME item being rented to own or for the DME item being purchased new or used and determines if the total payments exceed the plan DME maximum allowance.

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management.

BCBSTX will continue with the modifier 59 exempt program through ClaimsXten. This program is based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI).

NCCI guidelines state, "Each NCCI edit has an assigned modifier indicator. A modifier indicator of "0" indicates that NCCI associated modifiers cannot be used to bypass the edit." BCBSTX will continue to use ClaimsXten as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimsXten database will NOT be added. To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim Connection™ (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSTX's code-auditing software. Refer to our website at bcbstx.com/provider for additional information on gaining access to C3.

For updates on ClaimsXten, watch the News and Updates on our Provider website, as well as upcoming issues of the Blue Review.


Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for it products and services.

CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.