ClaimsXtenTM New Specialty Pharmacy Rule – Notification of Postponement

June 1, 2016

On April 18, 2016 Blue Cross and Blue Shield of Texas (BCBSTX) announced the upcoming implementation of the ClaimsXtenTM Speciality Pharmacy Rule for dates of service on or after July 18, 2016. This notification is to announce that the implementation of this new rule has been postponed and the rule now will apply to professional and outpatient facility claims with dates of service on or after August 15, 2016 for all lines of business except Federal Employee Program (FEP). FEP will implement this new rule September 26, 2016. The new rule is summarized below:

The Specialty Pharmacy Knowledge Pack rule will audit professional and outpatient facility claims involving specialty pharmaceuticals with 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.