Posted 12/20/2022 Updated 02/22/23
What’s Changing
Beginning April 16, 2023, Blue Cross and Blue Shield of Texas (BCBSTX) will begin reviewing claims as they are received to verify the claim is billed consistent with its prior authorization, including number of days by level. Claims will only pay for the days billed at the level approved on the prior authorization.
Previously this review was done on a post-payment basis, resulting in refund requests when claims were inconsistent with the prior authorization. Now, the Provider Claim Summary (PCS) will explain how the claim was paid upon adjudication.
Reconciliation Process
The following are examples of how the claim may be adjudicated to match the prior authorization:
Example 1
- Provider’s prior authorization is approved for authorization for a Level II NICU bed for 10 days
- Provider bills 10 of Level III NICU
- The system will allow 10 days of Level II NICU instead of the Level III NICU billed
Example 2
- Provider’s prior authorization is approved for authorization for a Level IV NICU bed for 5 days and 5 days at Level III NICU
- Provider bills 10 of Level IV NICU
- The system will allow 5 days of Level IV NICU instead of 10 that was billed and allow the additional 5 days at Level III NICU
In both examples, a message will appear on the PCS indicating that the claim was paid at the level authorized, not the level that was billed.
Please note, if there is no prior authorization on file for NICU services, the claim will follow normal no authorization processing guidelines.
When qualified, providers can submit an appeal if you do not agree with the payment.
Check eligibility and benefits electronically through Availity®, or your preferred Web vendor. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is 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. If you have any questions, please call the number on the back of the member’s ID card.