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Announcing a New Change for Rehabilitative and Habilitative Services for Members Enrolled in Qualified Health Plans under the Affordable Care Act

September 28, 2016

Effective Jan. 1, 2017, Blue Cross and Blue Shield of Texas (BCBSTX) will implement a change for rehabilitative and habilitative services that are essential health benefits (EHB) and billed by Physical Therapy, Speech Therapy, and Occupational Therapy providers as well as any other providers that may bill for these services. This new change will apply to Blue AdvantageSM and Blue Advantage PlusSM, and Blue Choice PPOSM members enrolled in qualified health plans under the Affordable Care Act (Note: this does not apply to other BCBSTX plans).

The change does impact visit limits for rehabilitative and habilitative services and devices. Each rendered service should be billed separately since these plans provide coverage for 35 visits per calendar year each for habiliatitve services and for rehabilitative services. As a result of this change, only claims for habilitative services should be submitted with a CPT modifier of SZ. This modifier will be used to identify applicable procedures as habilitative for claims adjudication. This requirement does not impact how rehabilitative services are currently billed.

Reminders:

  • Habilitative services are health care services and devices that help a person keep, learn, or improve skills and assist with functioning for daily living. These services could include devices that are provided for a person to attain, maintain, or prevent deterioration of a skill or function never learned or acquired due to a disabling condition. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
  • Rehabilitative services which include devices are provided to help a person regain, maintain, or prevent deterioration of a skill or function that has been acquired but then lost or impaired due to illness, injury, or a disabling condition.
  • When submitting claims for habilitative services, please submit procedure codes with a CPT modifier of SZ. Refer to your applicable billing policies and procedures for more information regarding applicable rehabilitative and habilitative procedure codes.

Member benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It's strongly recommended that providers ask to see the member's ID card for current information and photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

If you have any questions or if you need additional information, please contact your Network Management Representative. For your convenience, the telephone and fax numbers of our Network Management offices are listed below:

Network Management OfficeTelephone NumberFax Number
Austin 512-349-4847 512-349-4853
Corpus Christi 361-878-1623 361-852-0624
Dallas 972-766-8900 /
800-749-0966
972-766-2231
El Paso 915-496-6600 915-496-6614
Houston, Beaumont, East Texas 713-663-1149 /
800-637-0171
713-663-1227
Lubbock, Amarillo 806-783-4610 806-783-4666
Midland, Abilene, San Angelo 432-620-1406 432-620-1428
San Antonio 361-878-1623 361-852-0624