Date: July 15, 2011
To: SPA Physicians
From: Bruce Landes, M.D.
President & CEO
Re: Blue Cross Blue Shield of Texas HMO/Blue Choice (PPO/POS) Opt-In/Opt-Out
Blue Cross Blue Shield of Texas (“BCBSTX”) has notified SPA, in accordance with the terms of the
BCBSTX/SPA agreement that, effective September 1, 2011, BCBSTX will implement a change in
their fee schedules for their HMO (HMO Blue) and PPO/POS (Blue Choice) products.
BCBSTX will not be applying Geographic Practice Cost Indices (“GPCI”) in their reimbursement
schedules. The new fee schedule will not consistently be related to the 2011 National Medicare fees.
Because of this approach, even fees in the same CPT categories will not be the same percentage of
Dallas Medicare allowable rates. In order to know the exact contracted price for any given CPT
code that is not listed on the enclosed sample of fees it will be necessary to use SPA Compare.
BlueChoice PPO/POS and HMOBlue services will differentiate in its payment rates between services
performed within the physician’s office or performed outside the office (i.e. hospital or outpatient
facility). Effective September 1, 2011, BCBSTX will pay different rates to primary care
physicians (family practice, internal medicine, pediatrics, and general practice) than to
specialists (all others) for Evaluation and Management (E&M) codes.
A sample fee schedule is enclosed. The entire BCBSTX reimbursement schedule is available through
the SPA web site’s SPA Compare, in the member password-protected site. If you do not yet have your
password for SPA Compare, please contact Debby McLain at SPA at 214-346-6624. The password
will only be given to the SPA member.
Effective September 1, 2011, for Blue Choice, HMO Blue and ParPlan, if a claim (or claims)
from the same physician, for the same date of service, for the same patient includes both a
procedure (see list of procedures included with this mailing) and a general Ophthalmological CPT
service code (CPT codes 92002-92014) or an Evaluation and Management CPT service code
(CPT codes 99201-99499), the general Ophthalmological service or Evaluation and Management
service will be considered as the primary service and payable at 100% of the allowable amount
and the procedure will be considered the secondary service payable at 95% of the allowable
Effective September 1, 2011, physicians who bill for diagnostic imaging supplies and services
will see a multiple procedure payment reduction for the technical component (TC) of certain
diagnostic imaging procedures. The reduction applies to both TC-only services and the TC
portion of global services. A listing of imaging procedures covered by this change is included
with this mailing.
Effective December 1, 2011, BCBSTX will begin reimbursing claims submitted with the
National Drug Code (NDC) along with the applicable HCPCS procedure code(s) in accordance
with the NDC schedule. The NDC must be in the proper format (11 numeric characters, no
spaces or special characters); the NDC must be active for the date of service; and, the appropriate
qualifier, unit of measure, number of units, and price per unit also must be included. Electronic
and Paper Claim Guidelines for submitting NDC are included with this mailing.
Blue Cross Blue Shield of Texas Opt-in/Opt-out
Page 2 of 3
Unlisted codes, Drug Codes (i.e. J codes), supplies and other HCPCS codes will be reimbursed in
accordance with the BCBSTX fee schedule. Drug codes, supplies and other HCPCS codes will
be updated on 9/1/2011, 12/1/2011, 3/1/2012 and 6/1/2012. These updates are available on the
Blue Cross website or contact SPA.
All non-stat lab services, including Pap Smears, for HMOBlue must go to Quest. Enclosed with
this opt-in/opt-out there is a listing of reimbursable lab services that BCBSTX will reimburse on a
fee-for-service basis if performed in the physician’s office. BCBSTX strictly enforces pass-
through billing. This means that if the physician does not directly perform the service and the
service is rendered by another provider, only the rendering provider can bill for those services.
Reference lab (i.e. blood specimens) for BlueChoice (PPO/POS) may be sent to Quest (the
preferred lab per BCBSTX), LabCorp, or CPL Laboratories. Pathology (i.e. Pap Smears) for
Blue Choice (PPO/POS) may be sent to any Blue Cross Blue Shield participating pathologist or to
any in-network national or regional laboratory.
Claims for both the HMO and PPO must be filed electronically or on CMS 1500 forms or its
successor form to Blue Cross Blue Shield of Texas, PO Box 660044, Dallas, TX 75266-0044.
The BCBSTX Provider Manual can be found on the BCBSTX website (www.bcbstx.com). The
password to access the Provider Manual is “Manual.” The password is not case-sensitive.
HMOBlue requires pre-authorization from American Imaging Management (“AIM”) before
scheduling outpatient, non-emergency, MRI/MRA, CT, PET scans and Nuclear Cardiology
services. Pre-authorized radiology services must be obtained from the current AIM network.
MRI/MRA, CT, PET procedures cannot be provided in the office. Nuclear Cardiology may
only be provided in the office if the provider is contracted with AIM.
PPO/POS products require a prior Radiology Quality Initiative (“RQI”) authorization from
AIM for non-emergency outpatient diagnostic MRI/MRA, CT, PET scans and Nuclear
Cardiology procedures. PPO/POS products also require a prior RQI authorization number
for diagnostic MRI/MRA, CT, PET scans and Nuclear Cardiology procedures provided in the
The current AIM outpatient radiology network, required pre-authorizations and RQI numbers
may be accessed on the AIM website at www.americanimaging.net or call 1-800-859-5299.
For out of state Blue Cross plans (i.e. Blue Cross of Michigan) contact that out of state plan
(referred to as “The Home Plan”) for any pre-authorization requirements.
Urgent Care, DME, Home Health Providers: For a complete listing of Urgent Care facilities,
DME, Home Health and other ancillary providers, refer to Provider Finder on the Blue Cross website:
If you are not currently participating in BCBSTX through SPA and opt into this offer,
you will be notified in writing of your SPA effective date with BCBSTX as soon as it
becomes available from BCBSTX. The effective date of this reimbursement schedule
change is not your effective date. If you are not currently participating in BCBSTX at
all, opting into this agreement does not guarantee your acceptance by BCBSTX.
Blue Cross Blue Shield of Texas Opt-in/Opt-out
Page 3 of 3
If SPA does not receive a response from you by the close of business on Monday,
August 15, 2011, and you currently participate in BCBSTX through SPA, OR, if your
response to this offer has been to “opt-out,” and SPA is in receipt of your response by
the close of business on Monday, August 15, 2011, then your agreement with BCBSTX
through SPA will expire effective 11:59 p.m., Wednesday, August 31, 2011.
PLEASE COMPLETE AND FAX THE NOTICE TO 1-877-889-9084 REGARDLESS OF
WHETHER OR NOT YOU WISH TO PARTICIPATE IN BLUE CROSS BLUE SHIELD OF
TEXAS THROUGH SPA.
If you have any questions, contact SPA Physician Services at (214) 346-6621, (214) 346-6622,
or (214) 346-6628, or e-mail email@example.com.
SPA DOES NOT ENDORSE ANY CONTRACT OR ADVISE YOU TO
PARTICIPATE OR NOT TO PARTICIPATE IN ANY SPECIFIC CONTRACT.
This memo is not a contract or an offer to contract. A copy of the contract is
available on request.
Summary checklist 2011.xls
Click here for Contract Summary: