Bcbs of texas medical policy guidelines 001 Policy Effective Date 12/01/2021 Policy End Date 04/30/2023 . CPCPs are not intended to provide billing or These manuals provide detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Policy Number SUR717. The purpose of this document is to clarify the payment policy for covered Applied Behavior Analysis (ABA). Gender Assignment Surgery and Gender Reassignment Surgery with Related Services . Medical record documentation is frequently required to determine the medical necessity for services described in Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policies. Other Clinical Resources Programs: Clinical Practice Guidelines. *Current Policy See medical policy #422, RSV Immunoprophylaxis (RSV-IVIg) Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Note: All requests for indications listed and not listed on the medical policy guidelines may be submitted to BCBSMA Pharmacy Operations by completing the Prior Authorization Form on the last page of this Our medical policies include evidence-based treatment guidelines and address common medical situations. Additional sources are used and can be provided upon request. 1, 2021. A legible physical or electronic signature is required. Medical record documentation should be relevant to the member’s medical condition for the Medical Necessity Criteria. In line with new U. Policies may be archived due to the technology being obsolete or discarded, the technology For HealthSelect SM of Texas, Consumer Directed HealthSelect SM of Texas, HealthSelect SM and Consumer Directed HealthSelect SM Out-of-State, the prior authorization requirement is waived for preventive colonoscopies performed by in-network providers when the intent of the procedure is preventive and billed with modifier 33, regardless of the findings. Plan Effective Date: July 15, 2021 (Blue Cross and Blue Shield of Texas) Description This policy serves as a general reference claim submission guideline for appending modifiers to the appropriate procedure codes. Clinical Practice Guidelines for Texas Commercial, Marketplace, Medicare and Medicaid plans. To view medical policies, go to 05/15/2023. Our guide can help. To find out which services are covered under your policy at any facility, please call the customer service phone number on the back of your Blue Cross and Blue Shield of Texas member ID card. Provider Manual - Filing Claims – Billing Requirements. 154 (“MED207. Assistance The Provider Manuals are reference tools for providers. The viscosupplement products on the Select Medication List will be updated effective Nov. Implant Payment and Coding Policy Policy Number: CPCP007 Version: 1. Recommendations from other national entities may vary. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and B lue Shield Association. com . Effective Date: December 1, 2021 (Blue Cross and Blue Shield of Texas) This policy applies to professional health care providers submitting reimbursement for the code(s) that correctly describe health care services rendered for multiple procedures. The policies contained in the FEP Medical Policy Manual are developed to assist in administering contractual benefits and do not constitute medical advice. If there are any draft medical policies to review, these documents will be made available for your review around the 1st and the 15th of each month with a review periodof approximately two weeks. Medical Policies are used as guidelines for coverage must include a preventive diagnosis code, a preventive procedure code, meet medical policy review criteria, and fall within the guidelines issued by the USPSTF, ACIP, HRSA, or Bright Futures. Healthcare providers can find the resources they need to check prior authorization requirements, make requests, and reference medical policies for AZ Blue members. In this Section. Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policies are based on scientific and medical research. Claim submissions are subject to claim review including but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinical payment and coding policies as well as We may conduct a post-service utilization management review, which may include requesting medical records and review of claims for consistency with: Medical policies; State and federal requirements; Member’s benefits; Other clinical guidelines; Prior Authorization Exemptions (Texas House Bill 3459) BlueCard Program Claim Filing Guidelines. 154”), including appropriate medical record documentation. You can find provider manuals, reimbursement documents and procedures. Claims are subject to the code edit protocols for services/procedures billed. What's Changing Your Member Guide; BCBSTX Plan Benefits; Learn About Pharmacy Benefits; Member Tools. Quality Improvement Tip Sheet When submitting electronic claims, if the modifier requires submission of medical records, fax the medical records to one of the following numbers listed below within 72 hours of submitting your claims (include a note indicating the member’s group number and member ID number including the 3-character prefix and state ”Medical records for Alacura Medical Transportation Management. 2. 0 Enterprise Clinical Payment and Coding Policy Committee Approval Date: July 20, 2021 (NCCI) Policy Manual, CCI table edits and other CMS guidelines. Service Resource(s) Last Reviewed / Approved; Asthma: 2007 National Heart, Lung, and Blood Institute (NIH) EPR-3 Guidelines for the Diagnosis and Management of Asthma (includes: 2008 edits to the 2007 guideline): Last The Blue Cross medical and behavioral health policy team develops evidence-based medical and behavioral health policies. These records and claims must be retained for a minimum of five years from the date of service (DOS) or until the audit questions, appeals, hearings, investigations, or court cases 01/29/2024. Current and retired/replaced policies are available. g. The proposed new and revised Medical policies will become effective 90 calendar days from the date listed on the bulletin. 1, 2022, we will begin recommending some preferred drugs over other drugs through our medical policies, when clinically appropriate, to improve access to more affordable care for our members. Providers have the opportunity to review The following resources provide you with the information needed to administer Blue Cross and Blue Shield of Texas (BCBSTX) plans for your patients. GLMA: Health Professionals Advancing LGBT Equality is the world's largest and oldest association of healthcare professionals committed to providing individuals with health care services regardless of sexual orientation, gender identity or Behavioral Health Guidelines. These documents are not to be used to determine benefits or reimbursement. 0 Physicians and other health care providers are expected to exercise their medical judgment in providing the most appropriate care. SEARCH FOR MEDICAL POLICIES: CPA/SEPA DE NENY WNY WPA/NEPA WV; Medicare Advantage Policy Search Highmark adheres to the Centers for Medicare and Medicaid Services (CMS) coverage determinations for Medicare Advantage (MA Clinical payment and coding policies are based on using healthcare professionals and industry standard guidelines. The recommendations are not intended as medical advice nor meant to be a substitute for the individual medical judgment of a health care provider. 2024 QHP Small Group Actual Policy Documents; 2023 Policy Documents. 2024 Policy Documents. These guidelines are designed to assist clinicians by providing a framework for evaluation, and treatment of patients and is not intended to either replace a clinician’s judgment or For the best results, search on the medical policy site by category, policy number, procedure code, or alphabetically. 02/29/2024. org and search Have the three character prefix ready to find medical policy, pre-certification and pre-authorization information (for out-of-area members). Benefit plans vary in coverage and some BCBSWY plans may not provide coverage for certain services discussed in the medical policies. The online Medical Policy Reference Manual contains approved medical policies and operating procedures for all products offered by CareFirst. They are not intended to replace or substitute for the independent medical judgment Medical Policy Medical Records Documentation Guidelines . To view the Federal Employee Program Medical Policy Manual, please visit FEPblue. (NCCI) Policy Manual, CCI table edits and other CMS guidelines. To help ensure submission of medical record documentation is pertinent, accurate, complete July 21, 2021. We are also the largest provider of health benefits in Texas, serving more than 10. Health care providers (facilities, physicians and other health care professionals) are expected to exercise 11/12/2024 Follow CMS Guidelines for Appointment Wait Time Standards. 2024 Schedules effective 2/1/24; 2020 Schedules effective 3/1/20 - 1/31/24; 2017 Schedules effective 10/1/17 - CPCP023 Modifier Reference Guideline Update. What’s changing: When submitting a prior authorization (PA) request for certain drugs, you will Medical policies address the medical need for new services or procedures and new applications of existing services or procedures. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association When the subscriber's health benefits Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent To streamline the medical policy review process, you can view draft medical policies and provide your feedback online. Cultural Diversity and Mental Health: Considerations for Policy and Practice (2018) Frontiers Public Health; Electroconvulsive Therapy. What is new. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers. This policy is not intended to impact care decisions or medical practice. Claim submissions are subject to claim review including but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinical payment and coding policies as well as Medical Policies. We have FEP-specific medical policies that should be used to guide the care of our Federal Employee Program members. 0 Clinical Payment and Coding Policy Committee Approval Date: September 16, 2022 Plan Effective Date: December 26, 2022 (Blue Cross and Blue Shield of Texas Only) Description This policy is to help ensure submission of medical record documentation is pertinent, 1 Virtual Visits may be limited by plan. Machine Readable Files for Transparency in Coverage; 2025 Policy Documents. Transcranial Magnetic Stimulation as a BCBSTX publishes and disseminates evidence-derived Preventive Care Guidelines based upon the recommendations of recognized sources such as professional medical associations, specialty societies, professional consensus panels, national task forces, and governmental entities. The medical policies generally apply to all Blue Each of these categories may be further divided based on certain information, such as whether your policy is a qualified health plan (QHP) or grandfathered plan, or whether the group health plan has a standard benefit design or a custom benefit design. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations. org. If you cannot complete your eligibility/benefits inquiry online, please contact us at 800-842-5975. Coverage Policy Guidelines Description Rationale Coding References Policy History . com. Introduction . 0 Medical Policy Review Committee Approval Date: April 22, 2022 Clinical Practice Guidelines. Quality Improvement Tip Sheet Blue Cross and Blue Shield of Texas adopts Clinical Practice Guidelines as the foundation for our Behavioral Health Care Management Program. Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) Policy Number: CPCP028 Version: 3. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Clinical Practice Guidelines. For this to occur, we believe it is important for our members’ Primary Care Provider (PCP) to oversee all medical care, even when members are referred to another provider for services. Health care providers are expected to exercise independent medical judgment As a result of the calendar year (CY) 2024 policy and technical changes to theMedicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly, changes have been made to the Blue Cross and Blue Shield of North Carolina Blue Medicare Advantage ℠ medical policies. Claim submissions are subject to claim review including but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinical payment and coding policies as well as coding Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Revised: 09172020 Clinical Practice Guidelines (CPGs) BLUE CROSS AND BLUE SHIELD OF TEXAS (BCBSTX) Not all requirements apply to each BCBSTX network (Blue Choice PPO. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. Recently Blue Cross and Blue Shield of Texas updated our Medical Policy page and link. 0 Clinical Payment and Coding Policy Committee Approval Date: 10/17/2019 Plan Effective Date: November 1, 2019 (Blue Cross and Blue Shield of Texas Only) Description . This will be for some of our commercial members. Carelon is a specialty health benefits company that works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent clinical guidelines, tests and treatments, helping to promote care that is appropriate, safe and affordable. Note that while a publish date is enterprise-wide, the implementation date may differ depending on notification requirements. Coverage decisions are subject to all terms and conditions of the applicable benefit [] Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policies are based on scientific and medical research. Access Behavioral Health Provider Resources. The Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policy manual contains Medical Policies used by Blue Cross Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Preventive Services Task Force (USPSTF) recommendations, Blue Cross and Blue Shield of Texas (BCBSTX) recommends that colorectal cancer screening for our members begin at age 45 rather than 50. This policy may be updated and is therefore subject to change. View Clinical Medical Policies. Please refer to the plan Provider Newsletter for more information relating to implementation dates. They are often used as guidelines for coverage determinations in health care benefit programs. , Milliman Care Have the three character prefix ready to find medical policy, pre-certification and pre-authorization information (for out-of-area members. The Medical Policy . 50. Effective February 1, 2024, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM) in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook to update changes in the Continuous Glucose Monitoring (CGM) policy. Blue Cross and Blue Shield of TX has revised the following Clinical Payment and Coding Policies (CPCP) effective July 15, 2021 and has been posted to the provider website: Clinical payment and coding policies are based on using healthcare professionals and industry standard guidelines. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, For information on FEP Medical Policies and Utilization Management Guidelines, please visit www. 02/29/2024 CPCP033 Telemedicine and Telehealth/Virtual Health Care Services Policy Updated Effective 05/01/2024. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue 04/29/2022. Observation Services Policy Clinical Payment and Coding Policy . Health care providers are expected to exercise independent medical judgment in providing care to patients. Blue Cross and Blue Shield of Texas has revised the Clinical Payment and Coding Policy (CPCP) for the CPCP023 Modifier Reference Policy effective April 19, 2024. Alacura Medical Transportation Management. These policies may impact your reimbursement and your patients’ benefits. Please check with your health care provider for individualized advice on the recommendations provided. Refer to Medical Necessity Criteria - Behavioral Health for information utilized by BCBSTX for its group, retail and government products. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. Be sure to change your bookmark to the updated link. You can review our medical policies online any time. MCG Health national guidelines and the CMS Provider Reimbursement Manual. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Medical Record Documentation Policy Number: CPCP029 Version 1. Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policies are based on scientific and medical research. . To view medical policies, go 04/01/2019 (Blue Cross and Blue Shield of Texas Only) Description: This policy is to provide a guideline on the coding and documentation requirements for the reimbursement of drug testing. Procedure Codes End-dating August 31, 2017 x Treatment procedure codes 97039, 97139, and S8990 will be end-dated for dates of Blue Cross and Blue Shield of Texas adopts Clinical Practice Guidelines as the foundation for our Behavioral Health Care Management Program. Guidelines are designed to support the decision-making processes in patient care. Medical Policies. typicallyServices are requested for up to 40 hours per week (see Medical Policy PSY 301. For providers licensed in New Mexico and the District of Columbia, urgent care service is limited to interactive online video. Blue Cross and Blue Shield of Texas has revised the Clinical Payment and Coding Policy for the CPCP033 Telemedicine and Telehealth/Virtual Health Care Services Policy effective May 1, 2024. Updated 12/19/2024 Page F (c) – 1. Joint Medical Policies are a source for BCBSM and BCN medical policy information only. If validity testing is abnormal then subsequent testing of the Medical technology is constantly evolving and these medical policies are subject to change. Clinical Practice Guidelines (CPGs) and Preventive Care Guidelines are adopted by Blue Cross and Blue Shield of Texas (BCBSTX) and are the foundation for selected Condition Management Programs. The medical policies generally apply to all Blue These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks. 2 Preventive Health Guidelines for Children Age Birth to 18 Years 4 Part I: Neonates (Birth to 1 Month) Guidelines for Coverage Decisions BCBSWY has developed medical policies that serve as one of the sets of guidelines for coverage decisions. Disclaimer . For Plan Brochures, select “Tools and Resources Physicians, the American Cancer Society and the United States Preventive Services Task Force. --Select Category-- BCBSM Only BCBSM and BCN BCN Only Medications- Healthcare Administered Quantity Limit Policies Retired or Replaced Medicare Advantage Clinical Payment and Coding Policy Committee Approval Date: November 25, 2020 Plan Effective Date: March 3, 2021 (Blue Cross and Blue Shield of Texas Only) Description The purpose of this document is to clarify the payment policy for covered Applied Behavior Analysis (ABA). S. The Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policy manual contains Medical Policies used by Blue Cross Blue Shield of Texas, a Division of Health Care Service Clinical payment and coding policies (CPCPs) are based on criteria developed using These manuals provide detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks. Clinical Practice Guidelines Find everything you need to help your patients understand their health insurance as it relates to medical and pharmacy benefits and policies here. These guidelines are based on 01/18/2024. Our medical policies include evidence-based treatment guidelines and address common medical situations. Medical policies for Medicare Advantage members: We are required to make coverage determinations for services through the CMS National Coverage View the current policies below: For Clinical Payment and Coding policy effective dates for in-network providers, please refer to the effective date listed on the policy. , Milliman Care Guidelines) and the CMS Clinical payment and coding policies (CPCPs) are based on criteria developed using healthcare professionals and industry standard guidelines. , Milliman Care Guidelines) and the CMS Provider Reimbursement Manual. 0 Enterprise Clinical Payment and Coding Policy Committee Approval Date: July 6, 2020 Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Archived medical policies are inactive and no longer updated. 1, 2024. 8, “Treatment Note” for documentation requirements. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Medical Policy Medical Records Documentation Guidelines . Carefully check state regulations and/or the member contract. Medical Record Documentation Guideline Effective 12/01/2021- Note: – policy now includes same Medical Record Documentation as listed in the current CPCP020 Drug Testing Clinical Payment and Coding Policy Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association o MCG care guidelines (mental health disorders) o American Society of Addiction Medicine’s ASAM Criteria (addiction disorders) BCBSTX Medical Policies and The Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policy manual contains Medical Policies used by Blue Cross Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve The specific effective date will be noted for each medical policy that is posted. Email us at MedicalPolicy@bcbstx. The team presents medical and behavioral health policies to the Blue Cross Medical and Behavioral Health Policy Committee and the Blue Cross Medical Pharmacy & Therapeutics Committee, which are made up of practicing physicians, pharmacists and other payment and coding policies as well as coding software logic. After reviewing and agreeing to the disclaimer, the new page provides navigation on the left-hand panel to: medical policies, clinical payment and coding policies as well as coding software logic. Quality Improvement Tip Sheet Premera medical policy should be used as a guide in evaluating the medical necessity of a particular service or treatment. SM, Blue Essentials Category Procedure Code Description Medical Policy Number Medical Policy Title Updates. View Medical Policies. Claim submissions are subject to claim review including but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinical payment and coding policies as well as coding Each of these categories may be further divided based on certain information, such as whether your policy is a qualified health plan (QHP) or grandfathered plan, or whether the group health plan has a standard benefit design or a custom benefit design. Since medical technology is dynamic, the Company reserves the Alacura Medical Transportation Management. Number: CPCP001 Version 2. Updates to CPGs are reviewed and adopted every two years. Table of Contents . Clinical payment and coding policies are based on using healthcare professionals and industry standard guidelines. A physician may delegate with appropriate supervision, the months. 01/21/2025 Quality Measures Help Track Our Members’ Heart Health 01/17/2025 Pharmacy Program Quarterly Update Changes Effective Jan. These guidelines are based on Medical Policy and Pre-Certification/Prior Authorization Information for Out-of-Area Members To view the out-of-area Blue Plan's medical policy or general pre-certification/prior authorization information, please select the type of information requested, enter the first three characters of the member's identification number on the Blue Cross 2021-2022 Magellan Healthcare Guidelines Guideline: Transcranial Magnetic Stimulation Treatment – for non-Medicare Blue Cross and Blue Shield of Texas (under Health Care Service Corporation) plans that cover TMS Effective Date: Feb. 2025 QHP Small Group Actual Policy Documents Last Review Date — the date a medical policy or clinical UM guideline was reviewed and approved. Learn about different plans, get clear answers and make an informed decision. Quality Improvement Tip Sheet Clinical Payment and Coding Policy Committee Approval Date: August 24, 2021 . If you want to receive notification by email or mail, complete the Prior Authorization Exemption Communication Preference Questionnaire by 01/31/2025. 694). Effective Aug. Learn more about clinical practice guidelines. Last Updated: Oct. Medical Policies are based on Medical record documentation is frequently required to determine the medical necessity for services described in Blue Cross Blue Shield of Texas (BCBSTX) Medical Policies. Providers have the opportunity to review claim review including but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinical payment and coding policies as well as coding software logic. In most cases, they are used as guidelines for coverage determinations in health care benefit programs. necessity for services described in Blue Cross Blue Shield of Texas (BCBSTX) Medical Policies. Reimbursement Inform ation: Billing guidelines for urine drug testing, with a few exceptions, are intended to be consistent with those Important: 01/21/2025 Our next review for PA Exemptions will be effective 03/01/2025 and notifications will be available in the Provider Correspondence Viewer on our BCBSTX-branded Availity ® Payer Spaces page. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Qualitative or presumptive drug screening must meet medical policy criteria, established in Medical Policy MED207. If there are any draft medical policies to review, these documents will be made available for your review around the 1st and the 15th of each month with a review period of approximately two weeks. 01. Health Care Costs; Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation Preventive Care Guidelines/Patient Wellness Guidelines; Quality Care – Partner With Your Patients clinical payment and coding policies, provider manuals and/or benefit and medical policy changes which may impact claim payments. We are updating our Preventive Care Guidelines and our claims processing to reflect this change. Medical Record Documentation Guidelines Policy Number: CPCP0 29 Version 5. 10, 2023. For more than 95 years, we’ve provided our members with comprehensive, affordable health plans, Policy Documents. Other Criteria In addition to the documents Empire BlueCross BlueShield maintains for coverage decisions, we may adopt criteria developed and maintained by other organizations. The medical record should be signed at the time services are rendered. For out-of-network providers in Texas, the CPCP is effective as of the date the policy is posted to the BCBSTX provider website. Providers should not add late signatures to the medical record beyond the short delay that occurs during the contract language, medical policies, clinical payment and coding policies as well as coding software logic. 21, 2022 Blue Shield of California Medical Policy 2. 4 million members in all 254 counties across the state. You may search for topics by Keyword, Procedure Code or Policy Bulletin Number. Medical policies for Federal Employee Program members: Find them on fepblue. Medical Policies are used as guidelines for coverage Find comprehensive medical policy guidelines for all of Highmark’s medical-surgical products, including managed care. Dental Information; Medical Policies (Medical Coverage Guidelines) Medication Guides; Medical Policy, Pre-Certification, Pre-Authorization; Part B Step Therapy; Payment Policies; Pharmacy Utilization Blue Cross and Blue Shield of Texas (BCBSTX) wants members enrolled in Medicaid Managed Care to receive the best possible care. Medical record documentation should be relevant to the member’s medical condition for the Alacura Medical Transportation Management. 2021-2022 Preventive Care Guidelines. *Current Policy Durable Medical Equipment (DME) providers must disclose the following records to the Texas Health and Human Services Commission (HHSC) or its designee on request. Be sure to include the complete ID number including the three-character prefix as it appears on the member's ID card when submitting claims. Screening should continue until age 75. Medical technology is constantly evolving and these medical policies are subject to change. If there are any draft medical policies to review, these documents will be made available for your review around the 1st and the 15th of Overview. Assistance contract language, medical policies, clinical payment and coding policies as well as coding software logic. Additional medical policies may be developed from time to time and some may be withdrawn from use. 1, 2025 – Part 2. ST Prior Authorization/Step Therapy Program 6 of 18 (NCCI) Policy Manual, CCI table edits and other CMS guidelines. Blue Choice PPO SM, Blue Essentials SM, Blue Premier SM, Blue Advantage HMO SM, MyBlue Health SM,Blue High Performance SM, ParPlan Schedules. Medical Policies are used as guidelines for coverage 01/23/2025 Patients in the Qualified Medicare Beneficiary Program Should Not Be Billed 01/23/2025 Hospitals Mu st Provide Notice to Members Under Outpatient Observation for More Than 24 Hours. Learn To aid in the decision-making for the development of these Medical Policies (Medical Coverage Guidelines), we consult expert sources, such as the views of physicians practicing in the relevant clinical area, review of clinical studies published in respected scientific journals and the opinions from various specialty medical organizations. Clinical UM Guidelines adopted by Empire BlueCross BlueShield. Health To streamline the medical policy review process, you can view draft medical policies and provide your feedback online. Validity testing is included in the base testing code and may not be billed separately. Disclosure notices subject to Title 28 of the Texas Administrative Code are posted at least 90 days in advance of the effective date of the change. This policy does not apply to rapid Medical Policies: We Want Your Feedback. Medical record documentation should be relevant to the member’s medical condition for the service(s) requested and should always include any specific documentation requirements as outlined in the coverage section of the applicable medical policy. Quality Improvement Tip Sheet The Behavioral Health Clinical Practice Guidelines are applicable to all BCBSTX Behavioral Health (BH) product lines including Texas Government Programs. Please reference the appropriate certificate or contract for benefit information. BCBSTX Clinical Payment and Coding Policies are based on criteria developed by specialized professional societies, national guidelines (e. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. Clinical Practice Guidelines (CPGs) adopted by Blue Cross and Blue Shield of Texas (BCBSTX) are the foundation for the Behavioral Health Care Management Programs. Medical Policies are based on BCBSTX Clinical Payment and Coding Policies are based on criteria developed by specialized professional societies, national guidelines (e. 2021 Medical Surgical Procedures Requiring Prior Authorization. Upon request, the provider is urged to submit any additional documentation. Policy Number: CPCPG001 Version 1. These manuals provide detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks. Preventive Care Guidelines/Patient Wellness Guidelines These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks. 2025 Prescription Drug Changes; Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Blue Cross and Blue Shield of Texas (BCBSTX) expects all providers to follow Current Procedural CPT Code 95165 is defined as “Antigen Therapy Services" (2019, American Medical Association CPT Professional Edition, p. Medical Policy . Use these alphabetical lists to find Blue Shield medical policies, and review requirements and criteria for new technologies, devices and procedures. Changes to this Preventive Services policy are based on compliance with the United States Preventive Services Task Force updates and/or may be the result of American Medical Association procedure code Medical Policies. org and select the Policies & Guidelines link at the bottom of the page. 01/16/2025 Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association They are often used as guidelines for coverage determinations in health care benefit programs. To streamline the medical policy review process, you can view draft medical policies and provide your feedback online. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Explore more about Medical Policies . 021). 12/07/2023 Care Guidelines for Medicare Advantage Members’ Availability and Access Standards. Insurance Basics. BCBSMT recognizes the rapid changes of technological development and welcomes comments on all medical policies. • Signature requirements- Each medical record must be signed and dated by the clinician performing the service. Prior Authorization Requirements. If you have any questions about the CPGs adopted by BCBSTX, email us at BH Quality Improvement. View clinical policies and procedures These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks. Obtain a copy of member's most current identification (ID) card. July 5, 2021. The Company adopts these policies after careful review of published and peer-reviewed scientific literature, national guidelines and local standards of practice. Clinical utilization management (UM) guidelines focus on selection criteria, length of stay, and location for generally accepted technologies or services. We review and adopt updates to guidelines at least every two years. Publish Date — the date a medical policy or clinical UM Alacura Medical Transportation Management. fepblue. Behavioral Health service requires video for the initial visit but may use video or audio for follow-up visits, based on the provider’s clinical judgment. Archived policies will remain available for a period of one year. Refer to the Texas Medicaid Provider Procedures Manual, Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook, subsection 5. Medical Policy Router (out-of-area members) Search for Blue Cross Blue Shield of Michigan and Blue Care Network medical policies, including policies for medical benefit medications. Medical policies, both new and revised, are used as guidelines to determine health care benefits for most Blue Cross and Blue Shield of Texas (BCBSTX) members, unless otherwise indicated. Blue Cross and Blue Shield of Oklahoma (BCBSOK) uses evidence-based clinical guidelines from nationally recognized sources to guide our quality and health management programs. Medical Policies are based on research that provides evidence of scientific merit for a particular medical technology. The Clinical Payment and Coding Guidelines are not intended to provide billing or coding advice, but to serve as a reference. Find medical policy for Blue Shield of California plans. 0 Clinical Payment and Coding Policy Committee Approval Date: September 22, 2021 12/22/2023. Medical policy guidelines for all of Highmark's medical-surgical products, including managed care. Blue Cross and Blue Shield of Texas has updated the Clinical Payment and Coding Policy (CPCP) for CPCP006 Preventive Services Policy effective Jan. If validity testing is Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association and/or clinical guidelines and/or clinical studies and according to dosing recommended in product labeling. Behavioral Health Care Management Program; Carelon Clinical Practice Guidelines; eviCore Prior Authorization Program; Health Equity and Social Determinants of Health (SDoH) Preventive Care Guidelines/Patient Wellness Guidelines; Quality Care – Partner With Your Patients. Please forward any questions or comments regarding proposed new or revised medical policies to TexasMedicaidNetworkDepartment@bcbstx. The American Medical Many of these clinical and reimbursement guidelines are automated in our claims processing system. The member’s plan may require prior authorization for The purpose of the Blue Cross and Blue Shield of Montana (BCBSMT) Medical Policy is to guide coverage decisions and is not intended to influence treatment decisions. This update has been posted to the provider website. Select the Medical Policy type to be viewed: Highmark Medical Policy. Point-of-Care Ultrasound Examination Policy Policy Number: CPCP030 Version 1. Please keep in mind that: BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. 05/15/2023 Medical Policy Updates. NOTE: Qualitative or presumptive drug screening must meet medical policy criteria, established in Medical Policy MED207. Medical Record Documentation Guidelines . Learn more. jlvb lnewxk gywtt ltcfgi wzju rqysld aoj nhvmfzt mgwoc zggv