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 to Reduce Prior Authorization Response Times for Medicare Patients
  As of Jan. 1, Blue Cross and Blue Shield of Texas (BCBSTX) has begun accelerating prior authorization decisions for nonurgent preservice and concurrent prior authorization and admission notification. The payer says the change will reduce response times to up to seven calendar days. The previous response time was up to 14 calendar days.

  According to BCBSTX, the change was made to better align with guidelines from the Centers for Medicare & Medicaid Services (CMS) and to “ensure timely access to medical care.”.  BCBSTX may extend the response time up to an additional 14 days (not calendar days) when:

  • A patient or clinician requests an extension; and
  • The health plan requests additional clinical information for prior authorization processing.
    
    
  If the response time is extended, BCBSTX says it will send notification letters to physicians and patients explaining the delay. The notices will include information on a patient's right to file an expedited grievance if the member disagrees with the extension. For more information, see CMS’ appointment wait time FAQs.

• BCBSTX to Review Existing Prior Auth Exemptions (i.e., Gold Cards)
  Blue Cross and Blue Shield of Texas (BCBSTX) is reviewing prior authorization exemptions for certain health care services in effect for at least a year, determining whether those exemptions will be continued. BCBSTX will contact physicians to request medical records to facilitate reviews, asking that they promptly reply to those requests.

  For each physician under review, BCBSTX will select at least five claims at random processed after that physician’s prior auth exemption was in effect. If at least 90% of the claims were medically necessary, the exemption will be renewed for the service in question. If less than 90% were medically necessary, the exemption will be rescinded. The review is aligned with requirements under Texas House Bill 3812, effective Sept. 1, 2025, which mandates an evaluation of exemptions at least once every year.

  Starting Jan. 30, results are available on BCBSTX’ Provider Correspondence Viewer. Physicians providing an alternate email or mail communication method for prior authorization exemptions on BCBSTX’s questionnaire will also get notice sent via those preferred routes.

• BCBSTX May Ask Physicians Who Provide Services to Medicare Advantage Members for Medical Records
  Blue Cross and Blue Shield of Texas (BCBSTX) and its vendor Advantmed may request medical records from physicians who provide services to Medicare Advantage members as part of the Centers for Medicare & Medicaid Services’ (CMS) Risk Adjustment Data Validation Audit that began in June 2025. The audit is performed on a sample of patients enrolled in Medicare Advantage plans to evaluate chronic conditions, HEDIS measures, and to support risk-adjustment code accuracy. BCBSTX may request all records from the sampled year, which includes dates of service from 2018 through 2023.

  BCBSTX says physicians who have patients included in the audit will receive a letter from Adventmed with an attached medical records request. Per the payer, these requests are time sensitive and provide CMS information about patients’ health statuses. According to BCBSTX, physicians do not need to seek patient authorization to release these records, since their collection and review is considered a part of health care operations under HIPAA.

  For more information about the audit, contact BCBSTX’s RADV department.

• 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

• Updates Coming Soon!

• Humana Changing Policy on Excludes 1 Notes for Medicare Advantage
  Humana has announced that as of March 5, for its Medicare Advantage plans statewide, it will not issue payment on certain diagnosis codes that fall under the guidelines for Excludes 1 notes in the ICD-10-CM Manual issued by Centers for Medicare & Medicaid Services (CMS).

  An Excludes 1 note flags two medical conditions that cannot occur together and therefore should not be paired on a claim. Under an example from the manual, an Excludes 1 note would be used if both a congenital condition and an acquired form of the same condition were billed at the same time, but both can’t be used, since such a condition would either be congenital or acquired.

  Humana clarified this will affect physicians and other health care professionals as well as inpatient and outpatient facilities.

• Texas Physicians Must Provide Medicaid Enrollment Info to New Mothers
  As of Jan. 1, per a new state law, health care professionals providing prenatal care to a pregnant woman during gestation or at delivery must inform her of Medicaid coverage extending to a newborn child. Newborns are automatically eligible for coverage and Texas House Bill 3940 specifies that a mother must be informed her Medicaid identification number may be used on claims for services provided to her newborn child “until the child is enrolled in Medicaid and assigned a separate Medicaid identification number.” Physicians must document that they provided this information in medical records.

  The law also requires the Texas Health & Human Services Commission (HHSC) to annually share that information with managed care organizations and health care facilities (including hospitals) that regularly care for pregnant women and newborn children in Medicaid.

  To help health care professionals meet their obligation, the Texas Department of State Health Services published a document available in English and Spanish.

  More information is available in this Texas Medicine Today story.
  

• Physicians Must Voluntarily Refund Medicare Overpayments, Novitas Warns
  Novitas Solutions, the Medicare administrative contractor (MAC) overseeing Texas, recommends physicians promptly refund incorrect payments when they occur, such as when a service or treatment is uncovered or erroneously billed.

  “Otherwise, an overpayment, which is a debt due to the Medicare program, will be established when the error is identified by the MAC,” the MAC’s notice said.

  TMA staff caution that overpayments must be reported and repaid within 60 days of being identified, or by the date any corresponding cost report is due. If not repaid within 30 days of notification, interest may accrue.

  The MAC also warns physicians to ensure proper billing practices to avoid such instances, especially as the federal government may still pursue criminal, civil, or administrative remedies arising from or relating to claims made in error.

  Read this Texas Medicine Today story for more information.

• Remote Patient Monitoring Still a Priority for Medicare
  Physicians who use remote patient monitoring (RPM) services in Medicare must meet compliance and billing standards, says the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS).  

  In 2024, OIG found that 43% of patients who received RPM services did not receive all three components of it. Citing the survey, OIG is once again asking physicians to ensure they are using RPM correctly by satisfying all three components:  

  • Treatment management: The patient has a chronic or acute condition and the physician reviews the health data and uses it to manage the patient’s condition;
  • Device Supply: The patient has an internet-connected device approved by the Food and Drug Administration that collects and transmits health data for at least 16 days out of  30-days (i.e., health data is transmitted a majority of the days over a 30-day period); and
  • Enrollee education and device setup: The patient is educated about how to use the device and transmit the health data.
    
    

  Physicians who bill Medicare for RPM services must use procedure codes 999453 – 99091, which cover one of three components to RPM. For more information, see the Centers for Medicare & Medicaid Services’ Remote Patient Monitoring webpage and Telehealth & Remote Monitoring booklet. And read this Texas Medicine Today article for more.

• Medicare Modifier 25 Usage Addressed in Federal Report
  A recent federal audit revealed many claims lack supporting documentation for evaluation and management (E/M) services billed with modifier 25 when provided on the same day as an eye injection, emphasizing the need for proper use and documentation.

  Using modifier 25 indicates the patient’s condition required a significant, separately identifiable E/M service that is above and beyond the work normally associated with the procedure performed and lets the payer know the separately identifiable E/M service was addressed on the same day.

  The May 2025 U.S. Department Health and Human Services’ (HHS’) Office of Inspector General (OIG) report found that billing for nearly half of the procedures used modifier 25 in tandem with E/M services. In its most recent audit, of the 24 sampled E/M services billed with modifier 25 and provided on the same day as intravitreal injections using the modifier, 22 were found to be improper, as the use of modifier 25 was not supported by documentation. OIG recommended in the report that the Centers for Medicare & Medicaid Services update Medicare requirements for billing E/M services provided on the same day as intravitreal injections to promote better understanding of how to bill using modifier 25.

  Find additional information in this Texas Medicine Today story.

• Novitas Updates Reflect HCPCS and CPT Changes
  Novitas Solutions, Texas’ Medicare Administrative Contractor (MAC), has updated 18 articles to reflect annual changes to the Healthcare Common Procedural Coding System (HCPCS) and Current Procedural Terminology (CPT) for 2026. All updated articles are viewable via the Novitas website. TMA staff recommend physicians regularly check the Novitas news sections for their specific jurisdiction (JH for Texas.) for the latest revised articles and fee schedule updates.
  

• 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!

• Superior HealthPlan Releases New Plan for Dual Eligibles
  As directed by the Centers for Medicare & Medicaid Services, Superior HealthPlan replaced its STAR+PLUS Medicare-Medicaid Plan (MMP) with its new aligned Dual Special Needs Plan, effective Jan. 1. Like MMP, the new plan is designed for patients who qualify for both Medicare and Medicaid. Per the payer, patients were automatically transitioned into the new Wellcare By Superior HealthPlan.

  Tools and resources regarding the transition can be found on  Superior’s webpage. Physicians who have additional questions about this change, their contract status, or to join Superior’s network, can visit Superior’s resource page or reach out to the payer’s Provider Services at 1-855-445-3572.

• Updates Coming Soon!
  

• United Implements New Payment Reduction Policy for Outpatient Hospital Items
  Starting March 1, UnitedHealthcare says it will implement a new payment reduction policy in its commercial plans that aligns with a Centers for Medicare & Medicaid Services payment reduction policy for certain outpatient hospital items and services.

  The Payment Reduction of Off-Campus Provider-Based Departments Billed with Modifier PO Policy, Facility, will apply a 60% reduction when Healthcare Common Procedure Coding System code G0463 is reported with modifier PO. Payment for G0463, when appropriately billed with the modifier, will be considered for payment at 40% of the allowable amount.

  Read this payment reduction policy for a definition of an off-campus department and exclusions.

• United to Enforce New Diagnosis Code Policy March 1
  Starting March 1, UnitedHealthcare (UHC) will implement a new, comprehensive diagnosis code requirement policy that will consolidate multiple diagnosis-related procedures in line with existing ICD-10-CM guidelines related to Excludes 1 guidelines. An Excludes 1 note signifies two medical conditions that cannot exist simultaneously in a single patient, and thus, cannot be paired on a claim.

  Previously, UHC planned for the new policy to apply only to inpatient claims; it will now apply for any outpatient, professional, and facility service.

  If a physician files a claim that does not comply with these requirements, the claim may be edited or denied completely. For additional details, UHC asks physicians to review its updated Diagnosis Code Reimbursement Policy.
• 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.