May 22, 2020
Below is a summary of billing and documentation information and requirements for the BlueChoice® PPO, Blue Advantage HMOSM, Blue EssentialsSM, Blue PremierSM, MyBlue HealthSM, Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM, as reflected in the Provider Manuals in Section F Filing Claims posted on the provider website under Standards and Requirements/Manuals.
Permissible Billing
BCBSTX does not permit pass-through billing, splitting all-inclusive bills, under-arrangement billing, and any billing practices where a provider or entity submits claims by or for another provider not otherwise provided for in the provider’s agreement or in this policy.
Pass-through Billing
Pass-through billing occurs when the ordering health care provider requests and bills for a service, but the service is not performed by the ordering health care provider.
The performing health care provider is required to bill for the services they render unless otherwise approved by BCBSTX. BCBSTX does not consider the following scenarios to be pass-through billing:
- the service of the performing health care provider is performed at the place of service of the ordering physician or professional provider and billed by the ordering physician or professional provider;
- the service is provided by an employee of a physician, professional provider, facility or ancillary provider (i.e., physician assistant, surgical assistant, advanced nurse practitioner, clinical nurse specialist, certified nurse-midwife or registered first assistant who is under the direct supervision of the ordering physician or professional provider); and
- the service is billed by the ordering physician or professional provider.
The following modifiers should be used by the supervising physician when he/she is billing for services rendered by a Physician Assistant (PA), Advanced Practice Nurse (APN) or Certified Registered Nurse First Assistant (CRNFA):
AS modifier: A physician should use the AS modifier when billing on behalf of a PA, APN or CRNFA, including that provider’s National Provider Identifier (NPI), for services provided when the PA, APN, or CRNFA is acting as an assistant during surgery. Modifier AS is to be used ONLY if the PA, APN or CRNFA assists at the surgery.
SA modifier: A supervising physician should use the SA modifier when billing on behalf of a PA, APN or CRNFA for nonsurgical services. Modifier SA is to be used when the PA, APN, or CRNFA is assisting with any other procedure that DOES NOT include surgery.
Under Arrangement Billing
Under-arrangement billing and other similar billing or service arrangements are not permitted by BCBSTX. Under-arrangement billing refers to situations where services are performed by a physician, facility, or ancillary provider but the services are billed under the contract of another physician, facility or ancillary provider, rather than under the contract of the physician, facility, or ancillary provider that performed the services.
All Inclusive Billing
Any testing performed on patients treated by a physician, professional provider, facility, or ancillary provider that is compensated on an all-inclusive rate should not be billed separately by the facility or any other provider. The testing is a part of the per diem or outpatient rates paid to a facility for such services. The Physician, professional provider, facility or ancillary provider may, at their discretion, use other providers to provide services included in their all- inclusive rate, but remain responsible for costs and liabilities of those services, which shall be paid by the facility and not billed directly to BCBSTX.
For all-inclusive billing, all testing and services that share the same date of service for a patient must be billed on one claim. Split billing is a violation of network participating provider agreements.
Other Requirements and Monitoring CLIA Certification Requirement
Facilities and private providers who perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Therefore, any provider who performs laboratory testing, including urine drug tests, must possess a valid CLIA certificate for the type of testing performed.
Review of Codes
We may monitor the way test codes are billed, including the frequency of testing. Abusive billing, insufficient or lack of documentation to support the billing, including a lack of appropriate orders, may result in action taken against the provider's network participation and/or 100% review of medical records for such claims submitted.
Limitations and Conditions
Reimbursement is subject to:
- Medical record documentation, including appropriately documented orders
- Correct CPT/HCPCS coding
- Member Benefit and Eligibility
- Applicable BCBS Medical Policy(-ies)
Obligation to notify BCBSTX of Certain Changes
Physicians, facilities, and ancillary providers are required to notify BCBSTX of material changes that impact their contract with BCBSTX including the following:
- Change in ownership
- Acquisitions
- Change of billing address
- Change in billing information
- Divestitures
Assignment
As a reminder, no part of the contract with BCBSTX may be assigned or delegated by a physician, facility or ancillary provider without the express written consent of both BCBSTX and the contracted provider. If you have any questions or if you need additional information, please contact your local BCBSTX Network Management Office