Claims and Eligibility

This section presents an introduction to doing business with Blue Cross and Blue Shield of TX (BCBSTX), along with an overview of options and resources that may help you maximize administrative efficiencies in your office.

The pages in this section are designed to follow the claim cycle — from the moment a BCBSTX member walks into your office, through processing and payment for covered services you provide.

BlueCard® Program

The BlueCard Program links participating health care providers and the independent Blue Cross and Blue Shield Plans across the country and around the world through a single electronic network for claims processing and reimbursement. Learn more about BlueCard.

Electronic Commerce Solutions 

Say goodbye to paper shuffle and say hello to increased operational efficiencies and improved turnaround on payments. BCBSTX is your source for e commerce transactions. Learn more about Electronic Commerce Solutions.

Eligibility and Benefits

Patient eligibility and benefits should be verified prior to every scheduled appointment. Learn more.

Eligibility and Benefits Inquiry (HIPAA 270/271)

Utilize the online tools in order to quickly and efficiently check eligibility and benefits for every patient at every visit. Using the HIPAA 270/271 transaction you can confirm membership, verify coverage and determine other important information, such as the patient's copay, coinsurance and deductible amounts. Learn more.

Utilization Management

Review information related to Utilization Management (Prior Authorizations & Predeterminations)

Claim Filing Tips

At Blue Cross and Blue Shield of Texas, we are committed to fast and efficient claim processing. In order to prevent delays, billing errors and other potential setbacks, we’ve put together valuable tips and information to help you manage and submit claims.

Claim Status

After submitting a claim, you can check the status online through Availity® or your preferred vendor or via Provider Customer Service's automated phone system Learn more.

Claim Review Process

After claim adjudication, additional evaluation may be necessary. Learn more.

Interactive Voice Response (IVR) System

Enjoy the convenience of self-service inquiry resolution. Learn more.

Medicare Advantage Private Fee-for-Service

If you provide care to a Medicare Advantage Private Fee-for-Service (PFFS) member from an out-of-area Blue Cross and Blue Shield (BCBS) Plan, you may use the Web Finder Tool.

Out-of-Network Provider Surprise Billing Senate Bill (SB) 1264

Effective 1/1/2020, Texas SB1264 was implemented to protect members from surprise medical bills from out-of-network providers. Learn More.

Patient Cost Estimator

The Availity® Patient Cost Estimator (PCE) tool is an online member liability estimator that can help professional and institutional providers estimate a patient’s potential out-of-pocket costs in real-time for office, inpatient and outpatient services provided to BCBSTX members. Learn more