Blue Cross Reverses Preauth Requirements — Payer Newsletter Excerpt
By Ellen Terry


 The Texas Medical Association’s payment specialists continuously review health care payment plans’ newsletters and updates for items important to Texas physicians. Texas Medicine Today periodically publishes key excerpts from those newsletters that you might have missed.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit for more resources and information.

As a result of “feedback from the provider community,” Blue Cross and Blue Shield of Texas (BCBSTX) has removed 111 procedure codes from its preauthorization requirements related to additional care categories of codes. 

The deleted codes were among a list of nearly 300 BCBSTX had designated for preauthorization starting Jan. 1. An updated list showing all the codes added Jan. 1 indicates in red which ones BCBSTX has since dropped from the preauthorization requirement. It also lists which benefit plans are affected.  

New hours for EDI help

BCBSTX’s Electronic Commerce Services Center has new hours: Monday through Thursday, 8 am-4:30 pm, and Friday, 8:30 am-3 pm (CT). Contact the center at (800) 746-4614 or ecommerceservices[at]bcbstx[dot]com if you have questions or problems with electronic data interchange (EDI) transactions or online tools. Visit the BCBSTX Electronic Commerce page to learn more about EDI and other electronic options. To learn about the payer’s Availity web portal, catch a free online seminar March 28, 11 am-noon (CT). (Source: BCBSTX Blue Review, February 2018.)

Which plans require referrals?

Some BCBSTX HMO plans require primary care provider selection and referrals, and some don’t. BCBSTX has created a chart, with some added reminders, you might what to print out to help remember which is which.

Tips for coding for colonoscopies

When the initial reason for a colonoscopy is to screen for colorectal cancer, bill that procedure using modifier 33 (preventive service) for BCBSTX commercial health plans because it is a preventive service under the Affordable Care Act.   

  • If the purpose of the procedure is to screen for colorectal cancer and the service becomes diagnostic during the procedure, you may use modifier 33.
  • Do not use modifier 33 for nonscreening colonoscopies, such as those done to evaluate or follow up on signs, symptoms, or preexisting conditions, or for other nonpreventive procedures.
  • A colonoscopy procedure claim will process at the no-cost sharing benefit level as long as modifier 33 is present.
  • Colonoscopies not billed with the preventive modifiers will not be processed as a preventive screening.  

Note that currently for BCBSTX HealthSelect of Texas, Consumer Directed HealthSelect of Texas, HealthSelect, and Consumer Directed HealthSelect Out-of-State, the prior authorization requirement is waived for preventive colonoscopies performed by in-network physicians when the intent of the procedure is preventive and the claim is billed with modifier 33, regardless of the findings. However, you should always refer to the current BCBSTX preauthorization/prior authorization requirements lists to find out if authorization is required for colonoscopies. See the BCBSTX website for FAQs about preventive colonoscopies. (Source: BCBSTX Blue Review, December 2017.) 

Last Updated On

April 19, 2018

Ellen Terry

Project Manager, Client Services

(512) 370-1391

Ellen Terry has been writing, editing, and managing communication projects at TMA since 2000. She hails from Victoria, Texas; has a journalism degree from Texas State University; and loves to read great fiction. Ellen and her husband have two grown sons and a couple of cats.

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