Claim Editing Enhancements Coming Feb. 23, 2022 for Medicaid and CHIP

January 27, 2022

Effective February 23, 2022, Blue Cross and Blue Shield of Texas (BCBSTX) will enhance our claims editing and review process with Cotiviti, Inc. for some of our Medicaid members to help ensure accurate coding of services and that services are properly reimbursed.

What this means for you: The enhancements require you to continue to follow generally accepted claim payment policies. With your help, the enhanced claims review process will help our members get the right care at the right time and in the right setting.

Note: Inaccurately coded claims will result in denied or delayed payment.

About the guidelines: BCBSTX will continue to follow claim payment policies that are global in scope, simple to understand, and come from recognized sources, including:

ICD-10 coding guidelines
The Healthcare Common Procedure Coding System (HCPCS)
Current Procedural Terminology (CPT^®) codes as documented by the American Medical Association (AMA)
Correct Coding Initiatives (CCI)
Post-Operative Period Guidelines as outlined by the Centers for Medicare and Medicaid Services (CMS)

Using these guidelines will help ensure a more accurate review of all claims.

What’s changing: Components of the editing and review enhancements include:

Emergency Transport Modifiers – According to the Texas Medicaid guidelines, emergency transport (A0427, A0429, A0999) must be reported with ET modifier (Emergency transport services).
Emergency Transport Diagnosis Code Guidelines - According to the Texas Medicaid guidelines, emergency transport (A0427, A0429, A0999) must be reported with one of the emergency medical conditions.
Additionally, ambulance transport (A0382, A0398, A0422, A0424-A0425, A0430-A0431, A03433- A0436) when appended with modifier ET (Emergency transport services) must be reported with one of the emergency medical conditions.

More Information: View the Medicaid and CHIP Cotiviti, Inc Edit Descriptions for additional guidance. To edit or correct a denied claim, refer to the Provider Appeal form, Reconsideration Request Form sections under forms on our provider website. Watch News and Updates for future updates.

For additional information, please visit the TMHP website for full detailed information.

Cotiviti, Inc. is an independent company that provides medical claims administration for BCBSTX. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.

References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.