Laboratory Benefit Cost-Share Change
Currently, Blue Cross and Blue Shield of TX (BCBSTX) covers many non-preventive lab services without any member cost-share when billed with a preventive diagnosis.
Beginning Jan. 1, 2020, or upon a member's renewal date, non-preventive labs will no longer be covered at the no member cost-share level for some BCBSTX PPO and HMO members but will instead be treated as a standard medical benefit regardless of diagnosis code. Any applicable cost-sharing (copay, coinsurance and deductible) may apply, based on the member's health plan.
What does this mean for you?
- You may have to seek payment from both BCBSTX and the member.
- You may want to alert members that they could have to pay any applicable cost share (copayment, coinsurance, deductible) for laboratory services.
Please refer to the Clinical Payment and Coding Policies page on the provider website for the Preventive Services Policy which contains the list of lab procedures that are considered preventive and will process at the no cost share benefit level when billed with a preventive diagnosis.
As a reminder, it is important to check member eligibility and benefits through the Availity® Provider Portal or your preferred vendor before every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as an applicable copayment, coinsurance and deductible amounts. Checking eligibility and benefits also helps providers confirm benefit prior authorization requirements. Providers must also ask to see the member's ID card for current information and a photo ID to help guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly. Obtaining benefit prior authorization is not a substitute for checking member eligibility and benefits.
To confirm how a lab will process if it's not identified on the Preventive Clinical Payment and Coding Policy, please call the number on the member's ID card and ask about their non-ACA (Affordable Care Act) wellness benefit.
Note: This information does not apply to members who have BCBSTX Medicaid or Medicare Advantage plans.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third-party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.
Checking eligibility and/or benefit information is 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. If you have any questions, please call the number on the member's ID card.