November 2016

Physician Payment Policies for Members Enrolled in Blue Cross Medicare Advantage HMO^SM and Blue Cross Medicare Advantage PPO^SM

Effective Feb. 1, 2017, Blue Cross and Blue Shield of Texas (BCBSTX) will enhance our review and application of our physician payment policies applicable to Blue Cross Medicare Advantage PPO and Blue Cross Medicare Advantage HMO.

There are no changes required by providers. The payment policies for the Blue Cross Medicare Advantage plans will continue to be based on nationally accepted means of claims payment, which include:

• Medicare’s:
• National bundling edits, including the Correct Coding Initiative (CCI)
• Modifier usage
• Global surgery rules
• AMA CPT coding guidelines
• Regional Medicare policies
• National specialty academy guidelines (coding and clinical).

 As a valued provider, please continue to render services to our members and submit your claims accordingly. The goals of this endeavor are to:

• Enable you and your billing staff to more readily understand our payment of claims given the widespread use of these policies and source criteria utilized above.
• Identify that the service or drug being requested is medically necessary and appropriate by following up-to-date medical recommendation treatment plans that are not duplicated

This is one of many things we are doing to make the health care system work better by focusing on improving health care delivery. We want our members to receive the best health outcomes for all of the dollars spent on their care.