Claims/Benefits

All HMO Blue Texas and Blue Medicare PPO claims must be filed within 180 days of the date of service. PPO/POS and ParPlan claims must be filed within 365 days of the date of service.

To view a medical policy go to the General Reimbursement section, select Medical Policy, review/approve disclaimer. You can then search for a medical policy using a CPT, HCPCS, ICD-9 code, policy title, or view the table of contents. To print a medical policy use the printer friendly version option located in the upper right corner. If you are unable to find the Medical Policy you are looking for, complete and submit the Single Edit Request Form.

Clear Claim Connection^TM (CCC), a Web-based code auditing reference tool, is now available to all contracted BCBSTX physicians and professional providers. You may access this tool through the BCBSTX Provider Web site.

Some riders are in effect for a specific period of time, while others are in force for the duration of the policy. You may contact Provider Customer Service to determine the duration of the rider/exclusion.

All services are subject to medical necessity, contract limitations and exclusions (e.g. payment of premium). This is a standard statement to remind the caller of such.

Some of our materials are already available in Spanish upon request. We are continuing to evaluate what additional materials may be offered in Spanish in the future.

If Medicare submits your claim to a secondary payer it will be reflected in the message code on your Medicare EOMB.

Yes. The patient is responsible for providing COB information or notifying BCBSTX they have no other coverage. Several attempts are made to obtain this information.

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Generally once a claim is received it will be processed. You are required, however, to submit a corrected claim or notify us in writing should the claim have been filed in error to avoid any liability.

You must file your secondary claim to HMO Blue Texas within 180 days after the primary carrier paid or denied services. For the PPO/POS product, the primary carrier's payment starts the clock and timely filing varies according to the contract, generally 365 days from the date of service.

Claims should be filed electronically whenever possible. All paper claims should be mailed to the Dallas address as follows: BCBSTX, P.O. BOX 660044, Dallas, TX 75266-0044.

At the present time we are unable to provide the coverage termination date on the Provider Claim Summary. However, you may request this information by contacting Provider Customer Service.

Crossover claims from Medicare may not automatically be forwarded to the IPA. You will receive an EOB message directing you to refile to the appropriate IPA.

ASO stands for “Administrative Services Only.” These groups are self-funded and not subject to Texas prompt pay legislation. However, they are often subject to certain federal legislative requirements.

Generally, all PPO and POS plans utilize the BlueChoice or BlueChoice Solutions network of physicians and providers.

For HMO Blue Texas members, they may call member customer service anytime during the month and the change will take effect the first of the following month. For the POS product, the change takes effect on the day of the call, or any day thereafter, based on the member's request.

The Provider Claim Summary or EOB indicates the patient share. You cannot bill the patient in excess of the coinsurance, deductible and non-covered charges.

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