Multiple Procedure Payment Reduction Claims Review
Blue Cross and Blue Shield of Texas (BCBSTX) will be conducting post pay claim reviews of certain diagnostic cardiovascular and ophthalmology services to ensure reimbursement adheres to BCBSTX reimbursement policy for Multiple Procedure Payment Reduction (MPPR) of the Technical Component (TC) of Certain Diagnostic Cardiovascular and Ophthalmology Procedures effective June 1, 2021.
What this means to you: If you submit claims with multiple diagnostic cardiovascular or ophthalmology services performed for the same member, on the same day, you may have been paid 100% for the technical component of each service. This is most common when services are submitted on separate claims for the same day and same member. If this occurred, services may be overpaid and a refund for an overpayment may be requested. This could also impact the member’s cost-share.
To avoid overpayment, please submit services for same member on the same day on a single claim.
MPPR policy applies to the following plans:
- Blue Advantage HMOSM and Blue Advantage PlusSM HMO
- Blue Choice PPOSM
- Blue EssentialsSM and Blue Essentials AccessSM
- Blue PremierSM and Blue Premier AccessSM
- PAR Plan
View the MPPR policy here or go to the BCBSTX website under Standards and Requirements, General Reimbursement Information, Reimbursement Schedules and Related information. The information is secure and requires a password to access. Contact your BCBSTX Network Management Representative, you need the password or have additional questions.
Please be advised that the reimbursement information being disclosed within this notice contains confidential information proprietary to BCBSTX. The use and disclosure of this information is restricted under Texas Insurance Code Section 1301.136(b), Texas Insurance Code Section 843.321(b) and the terms of your BCBSTX agreements.