05/28/2024
Effective Sept. 1, the following updates will be made related to claim processing for Employee Retirement System of Texas participants:
- Cotiviti
- Diagnosis Code Guideline Policy added to identify multiple scenarios where a diagnosis submitted for a procedure or service is reported in an inappropriate position on professional and/or facility claim line(s).
- Anatomical Modifiers edit will focus on coding the appropriate modifier based on the area or part of the body the procedure is performed and will apply to professional claims and facility claims.
- Emergency Room Evaluation & Management edits to identify miscoded facility and professional claims that were billed at high intensity levels (4 & 5).
- Diagnosis Code Guideline Policy added to identify multiple scenarios where a diagnosis submitted for a procedure or service is reported in an inappropriate position on professional and/or facility claim line(s).
- MultiPlan out-of-area or out-of-network rate negotiations
- We will negotiate charges for covered health care services from out-of-network health care providers to reduce the amount a participant may be liable for and/or help protect participants from balance billing.
For additional information, contact your Blue Cross and Blue Shield of Texas Network Management office.