Blue Cross to Adjust Denied ERS Claims
By David Doolittle

Update April 19: Blue Cross Blue Shield this week said it will review and adjust as appropriate for payment all applicable Employees Retirement System of Texas claims that 1) were denied for lack of prior authorization; and 2) include any outpatient procedures that no longer require prior authorization.  

“Additionally, BCBSTX will review any appeals and grievances to determine if an appeal or grievance is no longer appropriate,” health plan officials said.

 BCBS_ERSOriginal story: Thanks to Texas Medical Association advocacy, a major new hassle for treating state employees, retired employees, and their dependents has gone away. 

Blue Cross and Blue Shield will no longer require prior authorization for outpatient surgery in an office setting for several Employees Retirement System (ERS) of Texas plans, the insurer has announced.

TMA notified the insurer of physicians’ complaints about these unnecessary and burdensome prior authorization requirements and asked that the company review the policy. 

The change, which will be implemented retroactively to Sept. 1, 2017, will affect participants in ERS HealthSelectSM of Texas, Consumer Directed HealthSelectSM, and ERS out-of-state plans. Prior authorizations will still be required for all other ERS plans.

“Office surgery claims are currently being re-adjudicated if they were previously denied for no prior authorization,” Blue Cross and Blue Shield said in announcing the change. “No action is needed by the providers for the previously submitted claims.”

“I am grateful for the work your team has done on this,” Heather Willingham, billing manager at Lakeland Medical Associates in Athens, said in an email to TMA. “In-office procedures at a [primary care physician’s] office are regularly performed, and it was insane to expect our staff to stop what they were doing to get a prior authorization as well as ask our patients to come back for another appointment after the authorization was acquired. It takes more than an hour at this time to get an authorization for any service, let alone a procedure that might need to be done that day.”

The updated prior authorization requirements can be found on the Clinical Resources page on the insurer’s website.

Practices whose claims are not reprocessed in a timely manner should contact TMA at paymentadvocacy[at]texmed[dot]org.

Last Updated On

May 02, 2018

David Doolittle


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Dave Doolittle is editor of Texas Medicine and Texas Medicine Today. Dave grew up in Austin, where he attended culinary school as well as the University of Texas. He spent years covering Central Texas for the Austin American-Statesman newspaper. He is the father of two girls, a proud Longhorn, and an avid motorsports fan.

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