To support Texas prompt pay legislation, Blue Cross and Blue Shield of Texas (BCBSTX) has a verification of benefits process. Providers have the right to request a verification of benefits guaranteeing that a particular service will be paid by the insurance carrier for applicable BCBSTX members.
The Texas Department of Insurance (TDI) defines verification as “a guarantee by an HMO or preferred provider carrier that the HMO or preferred provider carrier will pay for proposed medical care or health care services if the services are rendered within the required timeframe to the patient for whom the services are proposed.”
Exclusions From Prompt Pay Legislation
Verification is not applicable for all enrollees or providers. A sample list of those health benefits plans excluded from prompt pay legislation include:
- Self-funded ERISA (Employee Retirement Income Security Act)
- Self-funded governmental, school and church health plans including:
- Federal Employee Program
- Employee Retirement System of Texas
- Texas Health Insurance Pool (THIP)
- Teacher Retirement System of Texas
- University of Texas System
- Out-of-state Blue Cross and Blue Shield plans
- Out-of-network (non-participating) providers
Identification Card Requirements
To assist in recognizing those subject to prompt pay legislation, the letters “TDI” will appear on the front of the BCBSTX member identification card when the member is subject to prompt pay legislation.
TDI Required Data Elements
Before submitting a request for verification, please be prepared to provide all of the following TDI required data elements at the time of your request.
- Patient name
- Patient identification number (exactly as shown on the current ID card)
- Patient date of birth
- Name of enrollee or subscriber
- Patient relationship to enrollee or subscriber
- Presumptive diagnosis, if known, otherwise presenting symptoms
- Description of proposed procedure(s) or procedure code(s)
- Place of service code where services will be provided and if place of service is other than provider’s office or provider’s location, name of hospital or facility where proposed service will be provided
- Proposed date of service
- Group number
- Name of the provider providing the proposed services(s)
- Provider's federal tax identification number
- If known to the provider, name and contact information of any other carrier including:
- Other carrier's name
- Telephone number
- Name of enrollee
- Plan or Identification number
- Group Number (if applicable)
- Group Name (if applicable)
For telephone requests, please contact the appropriate Provider Customer Service Department number on the back of the member ID card or call 1-800-451-0287 .
Upon completion of processing, telephonic requests for verification will receive a fax notice followed by a written notice via U.S. Mail.
For those providers who prefer to submit a written request, please complete the Provider Request for Verification Form and submit to the following address:
Request for Verification
P.O. Box 833908
Richardson, TX 75083
Upon completion of processing, written requests for verification will receive a written notice via U.S. Mail.
Verification is voluntary and may not be available to all members and/or providers. Some examples of reasons for declination may include, but are not limited to:
- No coverage or change in eligibility, including individuals not eligible, not yet effective or canceled
- Premium payment timeframes that prevent verifying eligibility for a 30-day period
- Policy deductible, specific benefit limitations or annual benefit maximum
- Benefit exclusions
- Pre-existing condition limitations
- BCBSTX is the secondary carrier
A declination notice simply means that a guarantee of benefit cannot be issued in advance, not a determination that a claim will not be paid. Please be advised that routine eligibility and benefit information may be obtained when verification is not applicable or a declination has been issued.
Please refer to the on-line provider manuals for more information about verification.