Starting July 1, Blue Cross and Blue Shield of Texas (BCBSTX) says it will “enhance its claims editing and review process for office, inpatient, and outpatient evaluation and management (E/M) services” for patients in commercial BCBSTX plans.
For dates of service on or after July 1, BCBSTX’s new claims editing and review process will assess whether services billed support the E/M code level as reported on the claim. If the insurer determines that the services billed do not support the reported E/M code level, it will unilaterally lower its payment for those services to that of a lower-level E/M code – a process known as downcoding.
The Texas Medical Association will monitor how the new policy may impact physicians and their practices. At the time this article was written, however, BCBSTX had yet to release policy details. TMA will conduct a broader analysis once it does.
The news follows a similar August 2025 announcement by Cigna , which TMA contested. TMA opposes the practice of unilaterally downcoding, as reflected in its House of Delegates’ policy.
In announcing this policy change, BCBSTX says the new claims editing and review process will follow the American Medical Association’s guidelines for level of service and medical decision-making. If a physician does not agree with the level of service for which they were paid, BCBSTX says they can submit medical records to support their claim.
TMA’s Physician Payment Resource Center is at the ready to help members with billing and coding issues. For coding information and best practices, see TMA’s Billing, Coding, and Payment Resources page.
Last Updated On
May 22, 2026
Originally Published On
May 22, 2026
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469