Clinical Payment and Coding Policies
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Clinical payment and coding policies (CPCPs) are based on criteria developed using healthcare professionals and industry standard guidelines.
- CPCPs are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.
- CPCPs are neither intended to address every aspect of a reimbursement situation nor cover all issues related to reimbursement for services rendered to Blue Cross and Blue Shield of Texas enrollees. BCBSTX reserves the right to modify a CPCP at any time by publishing a new version.
- Certain CPCPs may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If a conflict arises between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.
- If a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern.
- “Plan documents” include, but are not limited to, Certificates of Health Care Benefits, Benefit Booklets, Summary Plan Descriptions, and other enrollee benefit Coverage Documents. Blue Cross and Blue Shield of Texas (BCBSTX) (the Plan) may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSTX has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.
- Claims should be coded appropriately according to industry-standard coding guidelines. For Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes that have been replaced by a new code(s), or the criteria for the codes has materially changed, Providers must submit the new code(s) which accurately reflects the services provided.
- For CPCP effective dates for in-network BCBSTX providers, please refer to the effective date listed on the CPCP. For out-of-network providers in Texas, the CPCP is effective as of the date the policy is posted to the BCBSTX provider website.
View the current policies below:
For Clinical Payment and Coding policy effective dates for in-network providers, please refer to the effective date listed on the policy. Disclosure notices subject to Title 28 of the Texas Administrative Code are posted at least 90 days in advance of the effective date of the change. All other disclosures will be provided with as much notice as is practicable and in compliance with applicable law. For out-of-network providers, the policy will be effective on the date the policy is posted to the provider website.
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