December 2016

Reminder: Announcing a New Change for Rehabilitative and Habilitative Services for Members Enrolled in QHPs under the Affordable Care Act

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 applies to Blue Advantage HMO^SM, Blue Advantage Plus^SM HMO and Blue Choice PPO^SM members enrolled in qualified health plans under the Affordable Care Act.

Note: This change only includes the above products; it does not apply to other BCBSTX plans.

The change impacts 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 that 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 eligibility and 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 is strongly recommended that providers ask to see the member’s ID card for current information and a photo ID to guard against medical identity theft. When services might not be covered, members should be notified that they may be billed directly.