Health Plan News

TMA payment specialists know how difficult it is to keep up with health plans’ constant changes. We are here to help you stay informed about the latest news from the major payers. Check back frequently for billing, coding, and health plan policy updates.

• Here’s Your 2026 Billing and Coding Checklist
  TMA’s Physician Payment Resource Center works year-round with member physicians and health plans to resolve certain insurance payment issues. They suggest these practical actions you can take at the start of 2026 to keep your billing and collections on track throughout the year.

• Use Correct Codes for HIV PrEP Services
  Aetna advises physicians billing for tests, services and medications related to HIV preexposure prophylaxis, or PrEP to avoid the general administrative code 96372. Find the correct codes, including associated ICD-10 codes, listed in a table in this OfficeLink Update. 
• 2026 Aetna Smart Compare™ Rankings Coming Soon 
  Aetna announced that evaluation notifications for its 2026 Aetna Smart Compare™ physician rankings, using claims data from 2023 and 2024, will begin in late 2025. The program “evaluates our participating providers, identifying those that meet higher standards of quality and cost-effectiveness,” per its Sept. 2025 bulletin. Physicians seeking to dispute Aetna’s ranking and tiering decisions prior to publication can request reconsideration within 45 days of receiving the written notice. “All reconsiderations begun in the first 45 days may lead to reversing our decision for your practice, regardless of the length of our exchange,” Aetna says in that update.
  
  The payer says it plans to use physician evaluations generated by its Smart Compare™ program in another new Aetna product: Informed Choice. Also launching in 2026, Aetna’s Informed Choice tool seeks to incentivize enrollees to choose certain physicians by offering them a lower copay if they choose a physician designated by Smart Compare™ as providing quality and effective care. As of this writing, Smart Compare™ and Informed Choice apply to physicians in certain specialties outlined its bulletin. 

• BCBSTX Introduces Five New Claims Editing Rules  

  On or after Nov. 16, 2025, Blue Cross Blue Shield of Texas (BCBSTX) says it will update the Lyric software database "to better align coding" with the payment of claim submissions for primary and secondary editing, the latter of which will delineate ineligible reason codes with an alpha character of “L.” BCBSTX says it will implement the following new claims editing rules: 

  • Missing modifier 54: Identifies claims for surgical services provided in an emergency room where the follow-up care isn’t done by the same provider and Modifier 54 wasn’t billed;  
  • Sexually transmitted infection multi-code rebundles; 
  • Intensity modulated radiation therapy: Identifies codes submitted on an outpatient facility or professional claim when planning procedure 77301 is found within 30 days before or on the same date of service for the same provider; 
  • Trauma activation: Identifies claims with revenue code 068X and procedure code G0390 when submitted on an outpatient facility claim with no critical care procedure code 99291 on the same date of service; and 
  • Professional and technical component codes.  

  BCBSTX refers physicians to Clear Claim Connection™ to determine how coding combinations may be evaluated during claim adjudication, and to learn more about ClaimsXten and C3. 

• New Prior Auth Exemptions Reviewed by Blue Cross Blue Shield of Texas 
  Blue Cross Blue Shield of Texas (BCBSTX) says it has reviewed physicians for new prior authorization exemptions for particular health care services (i.e., a “gold card”) to be effective Aug. 29, 2025. Physicians can review their exemption status via the Provider Correspondence Viewer in Availity® Essentials.  Any requests for mail or email preference for prior authorization exemption communications submitted prior to July 18, 2025, will be sent via physicians’ preferences, per BCBSTX. Refer to prior authorization exemptions for more information.  

• BCBSTX : Document Out-of-Network Referrals
  Be sure to fill out the appropriate Blue Cross and Blue Shield of Texas (BCBSTX) form when you refer a Blue Choice PPO or Blue Advantage HMO* patient to an out-of-network physician or provider, you are a participating BCBSTX physician, and an in-network option for referral is available.

  As applicable, fill out the Out-of-Network Care – Enrollee Notification form for regulated business (look for “TDI” on the patient’s ID Card) or for nonregulated business (no “TDI” on the patient’s ID card).

  Then give a copy of the completed form to your patient and keep a copy in the patient’s medical record files.

  *for Blue Advantage Plus point-of-service benefit plan

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• Collect Medicare Info to Bill for Medicare Advantage COVID-19 Vaccine Administration
  Physicians contracted with Medicare Advantage plans should submit to original Medicare – not to the plan carriers – claims for administering a COVID-19 vaccine to their Medicare Advantage patients. To submit the claim to Medicare through Novitas Solutions, the Medicare payer for Texas, your practice will need to have on file your Medicare Advantage patient’s original Medicare card or Medicare ID number. Be sure to have your staff collect this when Medicare Advantage patients make appointments to receive a COVID-19 vaccine.
  
  Bill only for the vaccine administration when you’ve received the COVID-19 vaccine doses from the  government for free; don’t include the vaccine codes on the claim. Any other services you provide the patient on the same date should be filed to the Medicare Advantage plan. 

• Updates Coming Soon!

• Texas Shifts Dual-Eligible Medicaid Services to Managed Care 
  With state-approved Rider 32 implemented on Sept. 1, the Texas Health and Human Services Commission (HHSC) has transitioned Medicaid-only acute care services for dual-eligible individuals (those with both Medicare and Medicaid) from a fee-for-service model to a managed care delivery system. According to HHSC, physicians must submit claims for these services directly to the patient’s managed care organization (MCO), not to Texas Medicaid & Healthcare Partnership (TMHP) as done prior to Sept. 1. If submitted to TMHP in error, TMHP states the claim will be forwarded to the appropriate MCO for processing. Claim responses will show that the claims were forwarded, and TMHP will not generate an Electronic Remittance and Status (ER&S) Report. For a list of the procedure codes that were transitioned to MCOs, please view the Rider 32 Procedure Code List file.

• Updates Coming Soon!
  

• UHC National Gold Card Program Enters Second Year 
  On Oct. 1, UnitedHealthcare (UHC) started the second year of its national “Gold Card” program, which is a separate and distinct program than Texas’ gold-carding law. The insurer says additional provider groups will be eligible for its program this year due to another year of prior authorization submission data and general awareness of the program’s eligibility criteria.  More details, including eligibility rules and status, on the UHC Gold Card are available on the program’s webpage. 
• UHC to Enhance Certain Multiple Procedure Payment Reductions 
  Effective Nov. 1, UnitedHealthcare (UHC) announced it “will enhance” the Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy, Professional. According to its September 2025 Reimbursement Policy Update Bulletin, UHC says it will apply a reduction to certain ultrasound CPT codes to provide consistency with similar codes, and a modifier may be appended, “where appropriate,” to ultrasound procedures to indicate they were performed on the same date of service but in a separate session.