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It defines how “Commercial plans” should be interpreted and organizes monthly topics across regulatory needs, benefits and eligibility, claims tools, clinical resources, and electronic options. Key sections address billing and documentation requirements, claim filing obligations, after-hours access expectations, and medical policy disclosure timelines and effectiveness rules.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/regulatory-requirements-july-2022/288885/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/regulatory-requirements-july-2022/288885.png","ImageObject",442,249,{"name":88,"@type":89},"Hazel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What billing and documentation changes does BCBSTX implement for provider requirements?","Question",{"text":108,"@type":109},"BCBSTX implemented changes to clarify existing billing and documentation requirements for Commercial, Blue Cross Medicare Advantage (PPO), and Blue Cross Medicare Advantage (HMO) plans. The updates are reflected in specific provider manuals under Section F Filing Claims.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"When must contracted providers file claims with BCBSTX?",{"text":113,"@type":109},"Providers must file claims for covered services rendered to patients enrolled in a BCBSTX health plan. Arrangements offering cash discounts in lieu of filing claims violate the provider contract.",{"name":115,"@type":106,"acceptedAnswer":116},"What after-hours coverage mechanisms are acceptable under BCBSTX requirements?",{"text":117,"@type":109},"Primary and specialty care providers must provide urgent and emergency coverage 24/7 and use a verifiable mechanism to direct patients to appropriate after-hours care. Acceptable options include an answering service, or recorded messages directing patients to call/page the answering service or the on-call physician/provider with a provided phone number.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288885,1789634154,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":125,"read_time":76},137441390410,"https://ap-avatar.wpscdn.com/avatar/2000252f4ab5702993?_k=1776741390130283984","JULY 2022  \nREGULATORY & REQUIREMENTS  \nThe following includes regulatory or mandated information that Blue Cross and Blue Shield of Texas (BCBSTX) is required to provide in all published correspondence with health care providers. It also includes a collection of articles to assist provider offices in servicing BCBSTX patients. For additional information, visit the BCBSTX  provider website.  \nNote: When “Commercial plans” is referenced, it includes Blue Choice PPO® , Blue Advantage HMOSM, Blue Advantage PlusSM, Blue EssentialsSM (including TRS-ActiveCare Primary and TRS-ActiveCare Primary+ participants), Blue Essentials AccessSM, Blue PremierSM, Blue Premier AccessSM, MyBlue HealthSM and Blue High PerformanceSM.  \nNote: When “Commercial plans” is referenced, it includes:  \n• Blue Choice PPO® and Blue High Performance NetworkSM (BlueHPN)  \n• Blue Advantage HMOSM  \n• Blue Advantage PlusSM  \n• Blue EssentialsSM (including TRS-ActiveCare Primary and TRS-ActiveCare Primary+ participants) and Blue Essentials AccessSM  \n• Blue PremierSM and Blue Premier AccessSM  \n• MyBlue HealthSM and Blue High PerformanceSM  \nTopics:  \n•  Regulatory and Requirements Corner  \no  Billing and Documentation Information and Requirements  \no  Contracted Providers Must File Claims  \no After Hours Access Is Required  \no  Medical Policy Disclosure  \no  Rights and Responsibilities Notification  \n•  Benefits & Eligibility  \no No articles this month. Refer to the Claims & Eligibility section or the Provider Manuals section on our provider website.  \n•  Claims  \no  ClaimsXtenTM Quarterly Updates  \no  Cotiviti Code-Auditing Software  \n•  Clinical Resources  \no  BCBSTX HEDIS® Tip Sheets  \no  BCBSTX Lab Guidelines  \n•  Education & Reference  \no No articles this month. Refer to the Education & Reference section on our provider website.  \n•  Electronic Options  \no  Electronic Options Available in Availity® Essentials  \n•  Medicare Advantage  \no  Blue Cross Medicare Advantage (PPO)SM Lab Guidelines  \no  CMS Notifications for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare  Advantage (HMO)SM  \no  Medicare Advantage Prior Authorization Requests through eviCore®  \n•  Pharmacy  \no No articles this month. Refer to the Pharmacy Program section on our provider website.  \n•  Utilization Management  \no  Importance of Obtaining a Prior Authorization/Referral  \no AIM Prior Authorizations and RQI Programs  \n•  Contact Us  \n•  Update Your Information  \nREGULATORY AND REQUIREMENTS CORNER  \nBilling and Documentation Information and Requirements  \nBilling and Documentation Information and Requirements  \nBCBSTX has implemented changes to clarify existing policies related to billing and documentation requirements for the Commercial, Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM plans. These updates are reflected in the Blue Choice PPO and BlueHPN Provider Manual and the Blue Essentials, Blue Advantage HMO, Blue Premier and MyBlue Heath Provider Manual in Section F Filing Claims posted on [bcbstx.com/provider](bcbstx.com/provider) under Standards and Requirements/Manuals.  \nContracted Providers Must File Claims  \nAs a reminder, health care providers must file claims for any covered services rendered to a patient enrolled in a BCBSTX health plan. You may collect the full amounts of any deductible, coinsurance or copayment due and then file the claim with BCBSTX. Arrangements to offer cash discounts to an enrollee in lieu of filing claims with BCBSTX violate the requirements of your provider contract with BCBSTX.  \nNotwithstanding the foregoing, a provision of the American Recovery and Reinvestment Act changed HIPAA (Health Insurance Portability and Accountability Act of 1996) to add a requirement that if a patient self pays for a service in full and directs a provider to not file a claim with the patient's insurer, the provider must comply with that directive and may not file the claim in question. In such an event, you must comply with HI","cbCaisPlV1HitEaZ","https://ap.wps.com/l/cbCaisPlV1HitEaZ","pdf",214244,9,"English","# Regulatory and Requirements Corner\n## Billing and Documentation Information and Requirements\n## Contracted Providers Must File Claims\n## After Hours Access Is Required\n## Medical Policy Disclosure\n## Rights and Responsibilities Notification\n# Claims\n## ClaimsXtenTM Quarterly Updates\n## Cotiviti Code-Auditing Software\n# Clinical Resources\n## BCBSTX HEDIS® Tip Sheets\n## BCBSTX Lab Guidelines\n# Electronic Options\n## Electronic Options Available in Availity® Essentials\n# Utilization Management\n## Importance of Obtaining a Prior Authorization/Referral\n## AIM Prior Authorizations and RQI Programs","[{\"question\":\"What billing and documentation changes does BCBSTX implement for provider requirements?\",\"answer\":\"BCBSTX implemented changes to clarify existing billing and documentation requirements for Commercial, Blue Cross Medicare Advantage (PPO), and Blue Cross Medicare Advantage (HMO) plans. The updates are reflected in specific provider manuals under Section F Filing Claims.\"},{\"question\":\"When must contracted providers file claims with BCBSTX?\",\"answer\":\"Providers must file claims for covered services rendered to patients enrolled in a BCBSTX health plan. Arrangements offering cash discounts in lieu of filing claims violate the provider contract.\"},{\"question\":\"What after-hours coverage mechanisms are acceptable under BCBSTX requirements?\",\"answer\":\"Primary and specialty care providers must provide urgent and emergency coverage 24/7 and use a verifiable mechanism to direct patients to appropriate after-hours care. Acceptable options include an answering service, or recorded messages directing patients to call/page the answering service or the on-call physician/provider with a provided phone number.\"}]","Regulatory & Requirements - July 2022 | PDF"]