ClaimsXtenTM 2nd Quarter 2016 Updates and New Specialty Pharmacy Rule Notification

April 18, 2016

Blue Cross and Blue Shield of Texas (BCBSTX) reviews new and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten code auditing tool software by the software vendor and are not considered changes to the software version. BCBSTX will normally load this additional data to the BCBSTX claim processing system within 60 to 90 days after receipt from the software vendor and will confirm the effective date via the News and Updates section of the BCBSTX Provider website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) also will be posted on the BCBSTX Provider website. 

Beginning on or after July 18, 2016, BCBSTX will enhance the ClaimsXten code auditing tool by adding the second quarter 2016 codes and bundling logic into our claim processing system. BCBSTX will also implement a new Specialty Pharmacy Knowledge Pack rule into our claim processing system. This new rule will apply to professional and outpatient facility claims with dates of service on or after July 18, 2016. The new rule is summarized below: 

The Specialty Pharmacy Knowledge Pack rule will audit professional and outpatient facility claims involving specialty pharmaceuticals utilizing the following parameters: 

  • HCPCS J-code and diagnosis as defined by the U.S. Food and Drug Administration (FDA) labeling
  • HCPCS J-code and maximum billable units
  • HCPCS J-code and age
  • HCPCS J-code and gender
  • HCPCS J-code and place of service
  • HCPCS J-code with any combination of the elements listed above 

This rule will deny claim lines found not payable according to guidelines provided by the FDA and National Comprehensive Cancer Network. 

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSTX’s code-auditing software. For more information on C3 and ClaimsXten, including answers to frequently asked questions, refer to the Clear Claim Connection page in the Education & Reference/Provider Tools section of our Provider website. Information also may be published in upcoming issues of the Blue Review. 

Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. 

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services. 

CPT copyright 2015 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.