10/27/2023
Blue Cross and Blue Shield of Texas (BCBSTX) will enhance our claims editing and review process with Cotiviti for emergency department (ED) evaluation and management (E&M) for some of our commercial members. These editing enhancements for facility and professional claims will help ensure accurate billing and proper reimbursement.
As we told you earlier this year, for dates of service beginning Nov. 1, 2023, we will edit applicable professional claims to help ensure accurate billing and proper reimbursement.
Now, for dates of service beginning Dec. 15, 2023, we will edit applicable facility claims to help ensure accurate billing and proper reimbursement.
What’s changing: when we review your claim your reimbursement may be processed at a lower level of service if we cannot validate the level of E&M services billed. We will follow the American Medical Association guidelines for level of service and medical decision making.
What happens next: if you agree with the level of service reimbursed, no further action is needed. If you do not agree with the level of service reimbursed, you may submit additional medical records to support your claim.
Learn More: For more information on revisions to our ED claims editing process, please review our Clinical Payment and Coding Policies web page – see our revised CPCP003 Emergency Department Evaluation and Management (E/M) Services – for Facility Services policy and our new CPCP042 Emergency Department Evaluation and Management (E/M) Services Coding – for Professional Services policy.
Cotiviti, INC. is an independent company that provides medical claims administration for BCBSTX. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.