Frequently Asked Questions



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Please select from the categories below to find the section that best fits the subject matter of your question(s):




Q. Does Verification apply to BlueCard?
A.

No

Q. In an emergency, if a member’s ID card is not available can we call BCBSTX for the alpha prefix?
A.

No. Unfortunately, BCBSTX does not maintain membership information for out-of-state plans. You would need to contact the patient or employer group for claim filing information.

Q. Is there a certain alpha prefix to designate a traditional BlueCard member?
A.

No. The alpha prefix is assigned to multiple BCBS plans and there is not a specific prefix to designate traditional plan members.

Q. Where do we send an appeal for a BlueCard claim?
A.

(BlueCard) out-of-state appeals should be filed to the same address that the claim was filed. Generally, Texas Providers send appeals to BCBSTX and will coordinate with the members plan.

Q. Where do I send an out-of-state claim when the ID card does not have a three digit alpha prefix?
A.

You would need to contact the patient or employer group for claim filing information.

Q. Why do some BCBS member’s ID cards reflect a suitcase and some do not?
A.

If an ID card reflects a suitcase with PPO on the inside, it generally means the member is enrolled in a PPO plan. In order for them to obtain the highest level of benefits, they would need to seek services from an in-network Physician. Effective 01/01/06 all non PPO BlueCard member ID cards must include the designated blank suitcase logo.

Q. Who is responsible for benefit determinations?
A.

The member’s BCBS plan will notify BCBSTX on how to apply the member’s benefits to the claim.

Q. Why don’t (BlueCard) out-of-state claims go directly to the member’s plan?
A.

By filing with your BCBSTX plan, this enables the member to obtain their maximum benefits while allowing the provider to receive their contracted rate.

Q. Is BlueCard a different entity?
A.

No. BlueCard is a program of the BlueCross BlueShield Association.

Q. How do I know what the benefits are for (BlueCard) out-of-state claims?
A.

As with any member, benefits should be obtained prior to providing services. For (BlueCard) out-of-state members you should call 1-800-676-BLUE (2583), voice the alpha prefix at which time you will be transferred to the member’s plan where they can disclose the member’s eligibility and benefits.

Q. When we call BCBSTX for claim status and they are unable to assist, where do we call?
A.

If your claim was filed to BCBSTX, most inquiries will be handled by the Texas Provider Customer Service Department.

Q. Do I file all claims to BCBSTX?
A.

Yes, unless advised otherwise when obtaining eligibility and benefits.

Q. Why do I receive Provider Claim Summaries advising me to send my claim to the member’s BCBS plan?
A.

At times BCBSTX is unable to process the claim through the (BlueCard) out-of-state program, and it must be filed directly to the member’s BCBS plan. Generally, BCBSTX will manually forward your claim to the appropriate BCBS plan. You may contact BCBSTX to establish if your claim was forwarded.

Q. Is the current remittance based on our BCBSTX contract?
A.

Yes

Q. Is there something on the (BlueCard) out-of-state ID card to determine if the member is an HMO, PPO, or Traditional member?
A.

For PPO members, the letters “PPO” will appear inside the suitcase. Most other products (POS, HMO or Traditional) will reflect an empty suitcase logo on the ID card.

Q. Which claims are mailed to the Dallas address?
A.

All claims should be filed electronically when possible. All paper claims should be mailed to the Dallas address unless instructed by the member’s BCBS plan to file directly to them.

Q. What is the Dallas address where claims need to be filed?
A.

BCBSTX, P.O. Box 660044, Dallas, TX 75266-0044

Q. What number do I call for In-Patient authorization?
A.

The phone number on the back of the member’s ID card.

Q. Is there a list of groups or states that require filing claims to out of state plans?
A.

For members without an alpha prefix, follow the claim filing instructions on the back of the member’s ID card.

Q. Can a secondary COB BlueCard claim be filed directly to BCBSTX?
A.

Yes

Q. Are (BlueCard) out-of-state claims subject to the Texas Prompt Pay Legislation?
A.

No

Q. When Specialty Care Providers are involved and the member’s plan is out-of-state who should be contacted for claims assistance?
A.

Contact the Provider's servicing plan for assistance and/or direction.

Q. Is a alpha prefix used across the board?
A.

It is unique. Each plan that participates in the (BlueCard) out-of-state program is assigned prefixes by the Blue Cross Association (BCA).

Q. Do all Texas members have alpha prefixes?
A.

Yes

Q. If the Patient’s ID card does not have an alpha prefix what should we do?
A.

Make sure you have the most current copy of the member’s ID card. Usually, there are filing instructions on the back of the ID card. If not, contact the Provider Customer Service Department at the telephone number found on the member’s ID card.

Q. How long should a BlueCard appeal take?
A.

(BlueCard) out-of-state appeals generally are handled in the same time frame as a BCBSTX claim appeal.

Q. On (BlueCard) out-of-state claims where Medicare is primary, should I file directly with BCBSTX?
A.

Yes, all secondary (BlueCard) out-of-state claims, including secondary to Medicare, may be filed directly to BCBSTX. However, Medicare secondary claims should only be filed after confirmation that the claim was not included in the Medicare crossover process.

Q. Does the alpha prefix need to be in all caps when submitted on the claim?
A.

It is recommended to use the ID number exactly as it appears on the member’s ID card. Texas does accept either caps or lower case.

Q. If BCBSTX can identify plans and claims, why can’t BCBSTX publish a list of alpha prefixes?
A.

Changes and updates are periodically made to the alpha prefixes assigned to the various BCBS plans. It is extremely important to utilize the most current information at all times.

Q. Does BCBS have 4 digit alphas?
A.

No. Alpha Prefixes will always be three digits.

Q. Are (BlueCard) out-of-state claims forwarded to the member’s benefit plan electronically or via paper?
A.

Claim information is transmitted to a member’s plan electronically. In addition, BCBSTX can submit electronic inquiries on behalf of our providers to the member’s plan.

Q. We have a previous claims inquiry and a Provider Claim Summary in hand. The automated system states there is no claim on file for this patient. What should we do?
A.

The automated (VRU) system has been recently enhanced to include more (BlueCard) out-of-state claims. If the VRU is unable to locate the claim you should opt out to speak with a Provider Customer Service Representative who can assist you.

Q. Why are checks for (BlueCard) out-of-state adjustments never issued?
A.

(BlueCard) out-of-state adjustment payments should be generated in the same manner as an original claim or any other Texas adjusted claim payment.

Q. Can eligibility for (BlueCard) out-of-state members be obtained on-line?
A.

No. Information for out-of-state members is not currently available at the BCBSTX web site.

Q. BCBSTX is moving away from using the member’s Social Security number as an identifier. Are other states doing the same?
A.

Yes. All BlueCross BlueShield plans have replaced their member’s Social Security number with a Unique Identifier.

Q. There is a problem with out-of-state claims having different denial codes than BCBSTX supplies.
A.

BCBSTX is currently addressing this issue and will provide updates in future editions of the Blue Review Quarterly Newsletter.

Q. When I call 1-800-676-BLUE, I always get transferred? Why can’t I be given the telephone number instead?
A.

Calls are answered in a central office and transferred to the actual plan based on the alpha prefix provided.


Q. Where do we send claim reviews?
A. You should send your request to the same address you filed the claim, which will be BCBSTX in most instances. They should be sent with a completed Claim Review Form  attached on the top. If you are instructed to file your claim direct to another plan, then all correspondence to include claim reviews should be sent directly to that plan also.

Q. Do we have to file a corrected claim in its entirety or just the line item?
A. Complete the Claim Review Form  with your corrected claim attached. The comments section should state what is being corrected on the claim.

Q. Do we have to use the Claim Review Form?
A. Yes, the BCBSTX Claim Review Form  is required for all claim reviews.

Q. We have problems when we send in claim reviews. We are told that BCBSTX has no record of the claim review. Why? 
A. Using the Claim Review Form  will help ensure your request is routed to the appropriate area for processing. The form and instructions can be located in the Downloadable Forms section on the BCBSTX Provider website.

Q. Is a claim number required on the Claim Review Form?
A. Yes, the claim number should be listed in the appropriate box. This eliminates the need for you to submit a paper copy of your claim when submitting a claim review.

Q. When we request a claim review and the claim continues to deny, can BCBSTX give a specific reason?
A. Process improvements are being made in this area. However, if no additional information is received with your claim review, BCBSTX may continue to uphold the original payment determination without specific details.


Claims/Benefits

Q. Is there a deadline for filing claims?
A.

All HMO Blue Texas claims must be filed within 180 days of the date of service. PPO/POS and ParPlan claims must be filed within 365 days of the date of service.

Q. How do I request a medical policy?
A.

To view a medical policy go to the General Reimbursement section, select Medical Policy, review/approve disclaimer. You can then search for a medical policy using a CPT, HCPCS, ICD-9 code, policy title, or view the table of contents. To print a medical policy use the printer friendly version option located in the upper right corner. If you are unable to find the Medical Policy you are looking for, complete and submit the Single Edit Request Form.

Q. How do I request bundling logic?
A.

Clear Claim ConnectionTM (CCC), a Web-based code auditing reference tool, is now available to all contracted BCBSTX physicians and professional providers. You may access this tool through the BCBSTX Provider Web site.

Q. Are individual plan riders (exclusions) for the entire life of the policy?
A.

Some riders are in effect for a specific period of time, while others are in force for the duration of the policy. You may contact Provider Customer Service to determine the duration of the rider/exclusion.

Q. When calling for benefits, BCBSTX ends with a disclaimer. Why?
A.

All services are subject to medical necessity, contract limitations and exclusions (e.g. payment of premium). This is a standard statement to remind the caller of such.

Q. Are you going to start sending patient information to patients in Spanish?
A.

Some of our materials are already available in Spanish upon request. We are continuing to evaluate what additional materials may be offered in Spanish in the future.

Q. When we get a Medicare statement it is not clear if it has been sent electronically. Should we drop to paper?
A.

If Medicare submits your claim to a secondary payer it will be reflected in the message code on your Medicare EOMB.

Q. We have situations where every claim for a specific patient denies for COB information. Is the patient responsible for providing this information?
A.

Yes. The patient is responsible for providing COB information or notifying BCBSTX they have no other coverage. Several attempts are made to obtain this information.

Q. Can you call to stop a claim from processing?
A.

Generally once a claim is received it will be processed. You are required, however, to submit a corrected claim or notify us in writing should the claim have been filed in error to avoid any liability.

Q. How does timely filing affect secondary payments?
A.

You must file your secondary claim to HMO Blue Texas within 180 days after the primary carrier paid or denied services. For the PPO/POS product, the primary carrier's payment starts the clock and timely filing varies according to the contract, generally 365 days from the date of service.

Q. Which claims are mailed to the Dallas address?
A.

Claims should be filed electronically whenever possible. All paper claims should be mailed to the Dallas address as follows: BCBSTX, P.O. BOX 660044, Dallas, TX 75266-0044.

Q. When you send a denial for terminated coverage, can you provide a specific date?
A.

At the present time we are unable to provide the coverage termination date on the Provider Claim Summary. However, you may request this information by contacting Provider Customer Service.

Q. What happens when claims are sent to BCBSTX from Medicare that are part of delegated HMO IPA?
A.

Crossover claims from Medicare may not automatically be forwarded to the IPA. You will receive an EOB message directing you to refile to the appropriate IPA.

Q. What is an ASO Plan?
A.

ASO stands for “Administrative Services Only.” These groups are self-funded and not subject to Texas prompt pay legislation. However, they are often subject to certain federal legislative requirements.

Q. Which network do PPO and POS members use?
A.

Generally, all PPO and POS plans utilize the BlueChoice network of physicians and providers.

Q. How long does it take to change a PCP?
A.

For HMO Blue Texas members, they may call member customer service anytime during the month and the change will take effect the first of the following month. For the POS product, the change takes effect on the day of the call, or any day thereafter, based on the member's request.

Q. We have a financial agreement with our patients to be responsible for whatever insurance does not cover. Are we able to demand payment from the member?
A.

The Provider Claim Summary or EOB indicates the patient share. You cannot bill the patient in excess of the coinsurance, deductible and non-covered charges.


Contracting/Network Participation

Q. What is required for me to join BCBSTX’ managed care networks?
A.

You must obtain from Blue Cross and Blue Shield of Texas (BCBSTX) a provider record by calling Provider Administration at (972) 996-9610. View more information regarding your provider record with BCBSTX, completion of a credentialing application as well as contracts for the networks in which you wish to participate.

Q. Is applying for a provider record with BCBSTX the same as applying for participation in your PPO/HMO networks?
A.

No. You cannot apply to the PPO/HMO networks until you are issued a provider record with BCBSTX. Obtaining a provider record only loads you in the system for claims processing purposes. Participation in the PPO/POS and HMO networks requires contracting and credentialing.

Q. How can I request an application for network participation?
A.

Request an application online or contact your local Professional Provider Network office.

Q. On the contracts/agreements with IPAs, is the physician’s or other professional provider’s effective date based on delegation?
A.

No. The physician’s or other professional provider’s effective date is based on BCBSTX’ assigned effective date.

Q. What is the length of time that a physician or other professional provider can be out of the network before they have to be fully credentialed again?
A.

BCBSTX does not allow more than a 30 day gap in credentialing. If it has been over 30 days, then the physician or other professional provider will need to be fully credentialed again.

Q. Are the physician and other professional provider fee schedules/reimbursement percentages available on the BCBSTX Web site?
A.

To access BCBSTX general reimbursement information policies, request forms for allowable fees and fee schedule information, visit the General Reimbursement Information section of the site. To request a sample of maximum allowable fees or if you have any questions, contact your local Professional Provider Network office.

Q. How do I request a fee schedule?
A.

Complete the fee schedule request form, or send the request in writing (by mail or fax) to your local Professional Provider Network office. Be sure to include your NPI number and the schedules you are requesting (ParPlan, BlueCHoice and/or HMO Blue Texas).

Q. Can you obtain the full fee schedule?
A.

Generally we provide an “ample sample” which covers the more frequently billed CPT codes. General Reimbursement Information is also available on the Web site. If you have specific CPT codes you would like information and cannot locate on the Web site, please include these in your request.

Q. How long does it take to get information regarding fee schedule requests?
A.

Normally, most requests are processed within seven to 10 business days. Full fee schedule requests take longer.

Q. Medicare changed our Medicare provider number. Do we need to notify BCBSTX?
A.

No.

Q. We have a financial agreement with our patients to be responsible for whatever insurance does not cover. Are we able to demand payment from the member?
A.

The Provider Claim Summary indicates the patient's share. You cannot bill the patient in excess of the coinsurance, deductible and non-covered charges.

Q. What is ParPlan?
A.

ParPlan is a BCBSTX payment agreement under which health care professionals agree to:

  • File all claims for BCBSTX patients through BCBSTX
  • Accept the BCBSTX allowable amount
  • Only bill BCBS subscribers for deductibles, cost-share (coinsurance) and medically necessary services which are limited or not covered either at the time of service or after BCBSTX has reimbursed you
  • Not bill BCBSTX for experimental, investigative or otherwise unproven or excluded services
  • Not bill either BCBSTX or the subscribers for covered services which are not medically necessary

The ParPlan obligation of the physician or other professional provider applies to subscribers of any BCBS plan.


ID Cards

Q. How can you tell which IPA the HMO member’s PCP participates with?
A.

The Physician Organization Code (POrg) appears on the front of all HMO Blue Texas member's ID cards.

Q. Can BCBSTX put the employer name on the ID card?
A.

Certain Administrative Services Only (ASO) groups request the group name to be added to the card. This may be the specific employer or the parent company. Most fully insured cards do not currently reflect the employer's name.

Q. Hospital based providers often do not receive the patient’s date of birth from the hospital information. Can the patient's date of birth be put on the ID card?
A.

Due to HIPAA, this information will not be printed on the member’s ID card.

Q. Anesthesiologists don't see patients' ID cards. How will they know the patient's unique ID number?
A.

Most hospital and ancillary facilities supply the patient’s healthcare information to providers involved with the patient’s care during the hospital confinement. The information may also be obtained by contacting the patient directly.

Q. How can you tell if a member is subject to Texas prompt pay legislation? 
A.

The letters TDI (Texas Department of Insurance) appear at the bottom center on the front of the ID card.


Legislative Information

Q. Is there an indicator on the ID card that shows if a group is subject to Texas Prompt Pay Legislation?
A. Yes, the letters “TDI” will be on the front of the member’s ID card beginning with cards issued January 15, 2004. The indicator will be added to cards as new groups enroll or existing groups renew.

Q. Does Texas Prompt Pay Legislation apply to out-of-network providers?
A. Out-of-network providers (i.e., non-preferred providers) who provide emergency services as those are defined in the Texas Prompt Pay Legislation and out-of-network providers who provide specialty or other medical care on a referral basis because the services are not available from a BCBSTX network providers are entitled to prompt payment of their clean, timely submitted claims under the Texas Prompt Pay Legislation. The provisions of the legislation relating to verification of medical care also apply. However, such providers are not entitled to penalties under the Texas Prompt Pay Legislation, as such penalties are only available to preferred providers. Please see the Texas Department of Insurance's Prompt Pay FAQ for more information.

Q. Are Wal-Mart employees subject to Texas Prompt Pay Legislation?
A. Wal-Mart is excluded based on criteria established by the Texas Department of Insurance.

Q. Will groups currently excluded from TDI jurisdiction ever become subject to their jurisdiction?
A. Groups are subject to TDI jurisdiction for different reasons including their funding arrangement. If circumstances change, the group may then become subject to TDI jurisdiction. Groups not covered under TDI jurisdiction generally fall under federal regulations.

Q. Does TDI have jurisdiction over HMOs?
A. Yes, TDI does have jurisdiction over the HMO Blue Texas plan.

Q. Where can I find Texas Department of Insurance (TDI) information online?
A. For additional TDI information, please visit the Texas Department of Insurance site . TDI Regulation/Legal page  of the Texas Department of Insurance site.

Q. We were told that if we send a complaint to the Texas Department of Insurance (TDI), we will not receive a response from BCBSTX. Is that correct?
A. Complaints filed directly with TDI receive a response directly from TDI. To clarify, the complaint process for TDI is as follows: TDI forwards a copy or your complaint to BCBSTX for review and/or resolution. We respond to TDI, which in turn will notify you directly of the outcome. BCBSTX will not respond directly to you once a complaint has been received from TDI.

Q. What is the claims filing deadline?
A. All HMO Blue Texas claims must be filed within 180 days of the date of service. POS/PPO and ParPlan claims must be filed within 365 days of the date of service.

Q. Can carriers delay or deny claims processing if they are waiting on information from the member?
A. For members subject to Prompt Pay Legislation, BCBSTX can request information from the treating physician without finalizing claim payment. If there is any other information needed from another source, we will not delay payment. Upon receipt of the additional information from the other source, if the information alters our decision, additional payment of refund notice will be issued accordingly.


Q: What coding manual does BCBSTX use?
A: BCBSTX utilizes CPT and HCPCS manuals for coding and ClaimCheck as our code auditing software.

Q: Our office recently received clinical information from the AMA that would help in an argument to change claim check (bundling) edits. Can we expect BCBSTX to make those changes?
A: BCBSTX does take AMA information into consideration when reviewing our bundling logic. In addition, BCBSTX requests the recommendation of Physicians/Professional Providers within a specific specialty to provide details regarding multiple procedures and how they should be considered.

Q: Does BCBSTX use McKesson software?
A: Yes, BCBSTX currently utilizes a version of McKesson Information Solutions’ ClaimCheck for code editing.

Q: BCBSTX does not recognize CCI rules. Does BCBSTX recognize all modifiers established in the Medicare guidelines?
A: Our code auditing software, ClaimCheck is consistent with many CCI edits. Although BCBSTX accepts all standard modifiers, not all modifiers impact reimbursement.

Q: We have codes that are bundling together even though we submit a separate diagnosis for each code. Is this correct?
A: Bundling edits are primarily determined from CPT or other procedure codes submitted with a claim. They are only secondarily affected by diagnosis codes and also take into account the most likely clinical scenario and/or the most comprehensive procedure performed.

Q: We have a physician who is billing two different procedures; however, we commonly receive a denial for one of the procedures billed. Our appeals are also denied for bundling. The office is following CCI, why are these not being reimbursed separately?
A: BCBSTX utilizes a version of McKesson Information Systems’ ClaimCheck, not CCI. Although ClaimCheck often follows CCI, it does not always mirror CCI. For an appeal or additional consideration, BCBSTX recommends you include details, including medical records where appropriate, to substantiate each procedure being considered independently for reimbursement.

Q: Where can you obtain a copy of the bundling edits?
A: The vendor licensing agreement prohibits us producing spreadsheets, tables or mass lists of all bundling edits in the software. Clear Claim ConnectionTM (CCC), the web-based code auditing reference tool, is now available to all contracted Blue Cross Blue Shield of Texas (BCBSTX) providers. CCC mirrors the ClaimCheck® auditing rules that BCBSTX has adopted as part of its claim adjudication process. It provides easy access to ClaimCheck payment policies and rules along with clinical rationales, clarification and source information for ClaimCheck edits.

Q: When I bill a vaccine with an office visit or a preventive care visit, why does my visit deny?
A: Verify usage of the correct administrative code of a vaccine for the specific age range. Please refer to the CPT manual section entitled "Immunization Administration for Vaccines/Toxoids."


   Q:    What do I need to do if I am changing my tax ID?    A:    Contact Provider Administration at 972-996-9610 and request a solo or group provider record application. You should request a group application if your practice is a corporation or a partnership.

   Q:    What do I need to do if I am changing my address and how do I add additional addresses to the provider directory?    A:    

At least 30 days in advance of the change,

  1. Complete the "Change Your Information" form on the BCBSTX Provider Web site, or
  2. Contact Provider Administration at 972-996-9610.
   Q:    My demographic information (specialty, practice information/status, board certification, etc.) is not correct on the Web site or I have added a sub-specialty. How do I correct this?    A:    

At least 30 days in advance of the change,

  1. Complete the "Change Your Information" form on the BCBSTX Provider Web site, or
  2. Contact Provider Administration at 972-996-9610.
   Q:    How do I apply for a provider record with BCBSTX?    A:    Contact Provider Administration at 972-996-9610 to request a provider record application.
                           

Are you a non-contracting provider in need of the allowable amounts for proposed procedures? If you answered yes to this question, this article will assist you in obtaining the allowable amounts for any proposed procedures you plan to render to our member.

Blue Cross and Blue Shield of Texas (BCBSTX) will need you to gather the following information prior to contacting Customer Service:

  • Member’s Group and Subscriber ID Number
  • Your National Provider Identifier (NPI) Number
  • Provider Specialty (Only if your NPI Number is not registered with BCBSTX)
  • Proposed CPT/HCPCS procedure codes
  • Proposed Diagnosis Code
  • Proposed Place of Treatment
  • Proposed Date of Service
  • Proposed Billed Charges


Upon calling Provider Customer Service you will need to enter the appropriate information at the prompts to obtain benefits for the member. Once the benefits have been quoted, you will have the option to speak with a Customer Advocate.

Once you are on the line with a Customer Advocate, you will need to let them know you are a non-contracting provider and would like to obtain the allowable amounts for proposed services.

The Customer Advocate will request the information listed above. Be sure to leave your call back number with the Customer Advocate. The inquiry will then be sent to the appropriate area to obtain the allowable amounts. It may take up to three business days to obtain the pricing and call you back with the allowable amounts you have requested. Once the pricing has been obtained, a Customer Advocate will contact your office. Before the Customer Advocate can release the allowed amounts to you, there is a disclaimer that must be read to you. Once the disclaimer has been read, the Customer Advocate will give you the allowed amount for each procedure code as requested.

The allowable amounts quoted are based on BCBSTX allowables for non-contracted providers rendering services. Please be aware that if the member’s health benefit plan is held in another state, the allowable amounts actually paid may be different once the claim is received and processed. The member’s home plan has the final decision on the allowed amounts for services that are rendered.


Q. Is there a limit to how far back BCBSTX will request a refund?
A. As of August 16, 2003, for those groups or accounts subject to Texas Prompt Pay Legislation, BCBSTX is limited to 180 days from the date payment is received in your office. For our self-funded Administrative Services Only (ASO) agreements, it is contingent upon the group’s guidelines and notification to BCBSTX.

Q. Where do I send refunds?
A. Refunds should be submitted using the Provider Refund Form  found on our BCBSTX Provider website, and sent to the address found in the upper left hand corner of that form.

Q. Can a provider notify BCBSTX of an overpayment and request a recoupment?
A. Yes. The provider may fill out the Provider Refund Form . Instead of issuing a refund, you may request an offset (recoupment) on the form at the time of notification. You will receive a confirmation in the form of a refund request letter shortly preceding the actual offset (recoupment).

Q. Why do we have to suffer denial of payment when BCBSTX retroactively terminated eligibility on the patient’s plan when we confirmed eligibility and benefits at the time we provided services?
A. We are reviewing our current membership processes and working with our employer groups to update their eligibility information as quickly as possible. Unfortunately there are occasions for which BCBSTX may process a retroactive termination. Please keep in mind that BCBSTX provides the most current information possible at the time of each inquiry. In addition, if the member is subject to Texas Prompt pay Legislation you may request a Verification which is a guarantee of payment regardless if their coverage changes retroactively.

Q. Why does BCBSTX take money from another patient’s payment?
A. Recoupments cannot always be applied to the same patient for which the overpayment applies. To avoid a recoupment, you may refund the balance due by following the instructions found in the notice you receive.

Q. Why do we not always receive a reason for the refund request?
A. Process improvements have recently been made in this area and you should now be receiving more detailed information in your refund request notices.

Q. Is there a limit on refund amounts, (i.e. 50 cents)?
A. Generally BCBSTX will not request refunds on individual claims where the paid amount is $50.00 or less. However, if we identify that an overpayment was made on more than one claim, even though the amount owed on each is less than $50.00 if the total amount owed is greater than $50.00, we will request a refund for each individual claim. This may differ for our self-funded Administrative Services Only (ASO) agreements. Refunds are requested for HMO Blue Texas claims regardless of the amount. At the request of the physician/provider, refunds will be processed for any amount owed.


Q. What is available online through this website?
A.

You can access information regarding Provider Finder, Medical Policies, Downloadable Forms, Blue Review, iEXCHANGE Online, Pharmacy & Prescribing Guidelines, Wellness Guidelines, General Reimbursement Information, Provider Manuals, Electronic Commerce and Credentialing/Contracting, and The Availity Health Information Network.

Q. Are the provider fee schedules/reimbursement percentages available on the BCBSTX Provider website?
A.

Yes. This information may be located in the Reimbursement Schedules section of the General Reimbursement Information portion of the website.

Q. How do I request the medical policy and/or bundling logic?
A.

Medical policies are available in the Medical Policy section of this site. To request bundling logic, complete the Single Edit Request Form or register with RealMed to access Clear Claim Connection or bundling.

Q. Can I access iEXCHANGE online for referrals and preauthorizations?
A.

Yes. You will need to sign up for a password on the iEXCHANGE section of this site.

Q. Where can I get instructions on how to fill out the Claim Review Form?
A.

The form  and instructions  are available on this site under Downloadable forms.

Q. Can I file claim reviews online?
A.

Not at this time. However, BCBSTX continuously reviews possible enhancements to our existing processes. Should this option become available in the future, BCBSTX will notify you via our Blue Review newsletter and a notice on our website.

Q. Can you check BCBSTX eligibility if you do not use Availity as your clearinghouse?
A.

Yes. The BCBSTX eligibility and benefit information can be obtained on the Availity web portal even if you use another clearinghouse for your electronic claims. Availity Enrollment Information can be obtained by visiting the Availity Web site at www.availity.com  or by clicking on the following link, http://www.availity.com/providers/registration-details/ .

Q. Can we go online to get verifications?
A.

Verification is not currently available online. You will need to call the BCBSTX Provider Customer Service areas for this information.

Q. Where can I find information on changes and updates within the medical field and with Blue Cross and Blue Shield of Texas?
A.

These can be found in the Blue Review section of our Provider website.