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ClaimsXten™ October 2014 Update

July 30, 2014

Blue Cross and Blue Shield of Texas (BCBSTX) reviews new and revised Current Procedural Terminology (CPT®')and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson 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 McKesson and will confirm the effective date on the BCBSTX website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will continue to be posted on the BCBSTX Provider website.

Beginning on or after October 28, 2014, BCBSTX will enhance the ClaimsXten code auditing tool by adding two new rules into our claim processing system.

The first rule is CPAP/BiPAP Supply Frequency. This rule identifies supply codes, submitted from all providers for the same member, associated with the Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BiPAP) therapy that are being submitted at a frequency that exceeds CMS Local Coverage Determination policy for CPAP Supplies. Quantities of supplies greater than those described in a CMS LCD policy will be denied.

The second rule is Obstetrics Package Rule. This rule audits claim lines to determine if any global obstetric care codes (defined as containing antepartum, delivery and postpartum services) were submitted with another global OB care code OR a component code during the average length of time of the typical pregnancy of 280 days and/or pregnancy plus postpartum period of 322 days.

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management. BCBSTX will continue with the modifier 59 exempt program through ClaimsXten. This program is based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI).

NCCI guidelines state, "Each NCCI edit has an assigned modifier indicator. A modifier indicator of "0" indicates that NCCI associated modifiers cannot be used to bypass the edit." BCBSTX will continue to use ClaimsXten as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimsXten database will NOT be added. 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. Refer to our website at bcbstx.com/provider for additional information on gaining access to C3.

For updates on ClaimsXten, watch the News and Updates on our Provider website, as well as 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 it products and services.

CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.