Health Plan News

TMA payment specialists know how difficult it is to keep up with health plans’ constant changes. We are here to help you stay informed about the latest news from the major payers. Check back frequently for billing, coding, and health plan policy updates.

• Maternity Care CPT Codes Will Move Away from Global Payment in 2027
  On June 8, the American Medical Association announced a new batch of CPT codes that will let physicians bill for certain maternal care services individually across four separately identified phases of care: antepartum, labor management, delivery, and postpartum. The new coding model is effective Jan. 1, 2027.

  As of this writing, insurers have not yet adopted the new set of codes. If payers adopt the codes, physicians will be required to use them when documenting maternal care. TMA is monitoring for updates.

  Currently, physicians are paid for maternity care through one global, bundled payment representing nine months of care as a single service. To help physicians prepare to implement the coding revisions, AMA is providing early education and resources on the revisions. Find more information in Texas Medicine Today.

• Here’s Your 2026 Billing and Coding Checklist
  TMA’s Physician Payment Resource Center works year-round with member physicians and health plans to resolve certain insurance payment issues. They suggest these practical actions you can take at the start of 2026 to keep your billing and collections on track throughout the year.

• Updates Coming Soon!
  

• Physicians Joining BCBSTX’s Network Must Submit Certain Onboarding Documents Starting Aug. 1
  Starting Aug. 1, Blue Cross and Blue Shield of Texas (BCBSTX) will require physicians applying to join the payer’s network to submit additional tax documentation with their onboarding application, including a W-9 with their legal name and, if applicable, a Doing Business As (DBA) name when operating under an alias different from the physician’s legal or registered name. The health plan will also require physicians to submit official IRS documentation verifying their tax identification number (TIN), such as SS-4 or 147C forms, with their application.

  Current in-network physicians do not need to take any action unless they are updating their information, such as to change their name or TIN. If a physician needs to update their legal or DBA name or TIN, BCBSTX asks they submit their updated W-9 and official IRS documentation via its updated physician onboarding application.

  Per BCBSTX, physicians that are not in network with the health plan may submit organizational changes through its demographic change form or contact their network representatives with questions. 

• BCBSTX to Reduce Prior Authorization Response Times for Medicare Patients
  As of Jan. 1, Blue Cross and Blue Shield of Texas (BCBSTX) has begun accelerating prior authorization decisions for nonurgent preservice and concurrent prior authorization and admission notification. The payer says the change will reduce response times to up to seven calendar days. The previous response time was up to 14 calendar days.

  According to BCBSTX, the change was made to better align with guidelines from the Centers for Medicare & Medicaid Services (CMS) and to “ensure timely access to medical care.”.  BCBSTX may extend the response time up to an additional 14 days (not calendar days) when:

  • A patient or clinician requests an extension; and
  • The health plan requests additional clinical information for prior authorization processing.
    
    
  If the response time is extended, BCBSTX says it will send notification letters to physicians and patients explaining the delay. The notices will include information on a patient's right to file an expedited grievance if the member disagrees with the extension. For more information, see CMS’ appointment wait time FAQs.

• BCBSTX May Ask Physicians Who Provide Services to Medicare Advantage Members for Medical Records
  Blue Cross and Blue Shield of Texas (BCBSTX) and its vendor Advantmed may request medical records from physicians who provide services to Medicare Advantage members as part of the Centers for Medicare & Medicaid Services’ (CMS) Risk Adjustment Data Validation Audit that began in June 2025. The audit is performed on a sample of patients enrolled in Medicare Advantage plans to evaluate chronic conditions, HEDIS measures, and to support risk-adjustment code accuracy. BCBSTX may request all records from the sampled year, which includes dates of service from 2018 through 2023.

  BCBSTX says physicians who have patients included in the audit will receive a letter from Adventmed with an attached medical records request. Per the payer, these requests are time sensitive and provide CMS information about patients’ health statuses. According to BCBSTX, physicians do not need to seek patient authorization to release these records, since their collection and review is considered a part of health care operations under HIPAA.

  For more information about the audit, contact BCBSTX’s RADV department.

• BCBSTX : Document Out-of-Network Referrals
  Be sure to fill out the appropriate Blue Cross and Blue Shield of Texas (BCBSTX) form when you refer a Blue Choice PPO or Blue Advantage HMO* patient to an out-of-network physician or provider, you are a participating BCBSTX physician, and an in-network option for referral is available.

  As applicable, fill out the Out-of-Network Care – Enrollee Notification form for regulated business (look for “TDI” on the patient’s ID Card) or for nonregulated business (no “TDI” on the patient’s ID card).

  Then give a copy of the completed form to your patient and keep a copy in the patient’s medical record files.

  *for Blue Advantage Plus point-of-service benefit plan

• Updates Coming Soon!

• Humana Changing Policy on Excludes 1 Notes for Medicare Advantage
  Humana has announced that as of March 5, for its Medicare Advantage plans statewide, it will not issue payment on certain diagnosis codes that fall under the guidelines for Excludes 1 notes in the ICD-10-CM Manual issued by Centers for Medicare & Medicaid Services (CMS).

  An Excludes 1 note flags two medical conditions that cannot occur together and therefore should not be paired on a claim. Under an example from the manual, an Excludes 1 note would be used if both a congenital condition and an acquired form of the same condition were billed at the same time, but both can’t be used, since such a condition would either be congenital or acquired.

  Humana clarified this will affect physicians and other health care professionals as well as inpatient and outpatient facilities.

• HHSC Delays CLIA Claims Denials Date

  The Texas Health and Human Services Commission (HHSC) has delayed when it will begin denying Texas Medicaid claims for laboratory services when a physician’s Clinical Laboratory Improvement Amendments (CLIA) certification information in the Provider Enrollment Management System (PEMS) is missing or inaccurate.

  Previously, HHSC planned to start issuing denials for missing CLIA-related information starting June 1. Now, HHSC has directed managed care organizations to issue warning edits for missing or inaccurate CLIA certifications in PEMS, since HHSC has not yet determined a new effective date to deny claims. Some MCOs have begun that process.

  Physicians should confirm that all applicable CLIA certification information has been properly entered and present in PEMS and maintain updated CLIA certification information in the system as those certifications are renewed.

  For guidance, physicians can visit the Texas Medicaid Healthcare Partnership Licenses/Certifications Accreditations webpage.

• Texas Medicaid Overhauls Login System

  The Texas Medicaid & Healthcare Partnership (TMHP) announced its new IAMOnline platform, providing a secure, single-entry point for the Provider Enrollment and Management System and four other TMHP applications. The agency sent physicians participating in Medicaid and the Children’s Health Insurance Program a June 8 email with details on how to change their logins, including picking one of three multifactor authentication options, by June 15 to avoid losing access to the system. Physicians can contact the Electronic Data Interchange Help Desk at 888-863-3638 with questions and can learn more from Texas Medicine Today.

• Certain Texas Medicaid PCNs May Incorrectly Appear Ineligible
  The Texas Medicaid & Healthcare Partnership (TMHP) says newly issued Texas Medicaid patient control numbers (PCNs) may appear ineligible in certain TMHP systems. The agency advises physicians who have a Medicaid PCN beginning with the number nine to check the Medicaid Client Portal to verify their eligibility. TMHP also recommends physicians refer to the agency’s resource, the Medicaid Client Portal Job Aid for Providers, for directions on accessing the Medicaid Client Portal and to verify client eligibility. For more information, call the TMHP Contact Center at 800-925-9126.

• Texas Physicians Must Provide Medicaid Enrollment Info to New Mothers
  As of Jan. 1, per a new state law, health care professionals providing prenatal care to a pregnant woman during gestation or at delivery must inform her of Medicaid coverage extending to a newborn child. Newborns are automatically eligible for coverage and Texas House Bill 3940 specifies that a mother must be informed her Medicaid identification number may be used on claims for services provided to her newborn child “until the child is enrolled in Medicaid and assigned a separate Medicaid identification number.” Physicians must document that they provided this information in medical records.

  The law also requires the Texas Health & Human Services Commission (HHSC) to annually share that information with managed care organizations and health care facilities (including hospitals) that regularly care for pregnant women and newborn children in Medicaid.

  To help health care professionals meet their obligation, the Texas Department of State Health Services published a document available in English and Spanish.

  More information is available in this Texas Medicine Today story.
  

• CMS Guidance Out for Physicians Offering Telehealth from Their Homes
  A COVID-19 pandemic-era waiver allowing physicians to provide telehealth services from their homes without needing to report their address on their Medicare enrollment – while continuing to bill from their currently enrolled location – has been made permanent by the Centers for Medicare & Medicaid Services (CMS).

  To help physicians comply with billing requirements when servicing telehealth from their homes, CMS has released guidance on scenarios when a physician would need to enroll a new practice location or update their Medicaid enrollment to bill correctly. This includes information on what to do when telehealth services are provided at:

  • A physician’s home, billed under the home’s address, even when a physician has their own private practice;
  • A physician’s home, but billed under the address of their group’s brick and mortar office (including when that office is not in the state the physician resides); and
  • A physician’s home, billed under the home’s address because their group does not have a physical location, such as when a physician provides virtual telehealth services only.

• Physicians Must Voluntarily Refund Medicare Overpayments, Novitas Warns
  Novitas Solutions, the Medicare administrative contractor (MAC) overseeing Texas, recommends physicians promptly refund incorrect payments when they occur, such as when a service or treatment is uncovered or erroneously billed.

  “Otherwise, an overpayment, which is a debt due to the Medicare program, will be established when the error is identified by the MAC,” the MAC’s notice said.

  TMA staff caution that overpayments must be reported and repaid within 60 days of being identified, or by the date any corresponding cost report is due. If not repaid within 30 days of notification, interest may accrue.

  The MAC also warns physicians to ensure proper billing practices to avoid such instances, especially as the federal government may still pursue criminal, civil, or administrative remedies arising from or relating to claims made in error.

  Read this Texas Medicine Today story for more information.

• Remote Patient Monitoring Still a Priority for Medicare
  Physicians who use remote patient monitoring (RPM) services in Medicare must meet compliance and billing standards, says the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS).  

  In 2024, OIG found that 43% of patients who received RPM services did not receive all three components of it. Citing the survey, OIG is once again asking physicians to ensure they are using RPM correctly by satisfying all three components:  

  • Treatment management: The patient has a chronic or acute condition and the physician reviews the health data and uses it to manage the patient’s condition;
  • Device Supply: The patient has an internet-connected device approved by the Food and Drug Administration that collects and transmits health data for at least 16 days out of  30-days (i.e., health data is transmitted a majority of the days over a 30-day period); and
  • Enrollee education and device setup: The patient is educated about how to use the device and transmit the health data.
    
    

  Physicians who bill Medicare for RPM services must use procedure codes 999453 – 99091, which cover one of three components to RPM. For more information, see the Centers for Medicare & Medicaid Services’ Remote Patient Monitoring webpage and Telehealth & Remote Monitoring booklet. And read this Texas Medicine Today article for more.

• Medicare Modifier 25 Usage Addressed in Federal Report
  A recent federal audit revealed many claims lack supporting documentation for evaluation and management (E/M) services billed with modifier 25 when provided on the same day as an eye injection, emphasizing the need for proper use and documentation.

  Using modifier 25 indicates the patient’s condition required a significant, separately identifiable E/M service that is above and beyond the work normally associated with the procedure performed and lets the payer know the separately identifiable E/M service was addressed on the same day.

  The May 2025 U.S. Department Health and Human Services’ (HHS’) Office of Inspector General (OIG) report found that billing for nearly half of the procedures used modifier 25 in tandem with E/M services. In its most recent audit, of the 24 sampled E/M services billed with modifier 25 and provided on the same day as intravitreal injections using the modifier, 22 were found to be improper, as the use of modifier 25 was not supported by documentation. OIG recommended in the report that the Centers for Medicare & Medicaid Services update Medicare requirements for billing E/M services provided on the same day as intravitreal injections to promote better understanding of how to bill using modifier 25.

  Find additional information in this Texas Medicine Today story.

• Novitas Updates Reflect HCPCS and CPT Changes
  Novitas Solutions, Texas’ Medicare Administrative Contractor (MAC), has updated 18 articles to reflect annual changes to the Healthcare Common Procedural Coding System (HCPCS) and Current Procedural Terminology (CPT) for 2026. All updated articles are viewable via the Novitas website. TMA staff recommend physicians regularly check the Novitas news sections for their specific jurisdiction (JH for Texas.) for the latest revised articles and fee schedule updates.
  

• Collect Medicare Info to Bill for Medicare Advantage COVID-19 Vaccine Administration
  Physicians contracted with Medicare Advantage plans should submit to original Medicare – not to the plan carriers – claims for administering a COVID-19 vaccine to their Medicare Advantage patients. To submit the claim to Medicare through Novitas Solutions, the Medicare payer for Texas, your practice will need to have on file your Medicare Advantage patient’s original Medicare card or Medicare ID number. Be sure to have your staff collect this when Medicare Advantage patients make appointments to receive a COVID-19 vaccine.
  
  Bill only for the vaccine administration when you’ve received the COVID-19 vaccine doses from the  government for free; don’t include the vaccine codes on the claim. Any other services you provide the patient on the same date should be filed to the Medicare Advantage plan. 

• Updates Coming Soon!

• Superior Launches APM for Trauma-Informed Care in STAR Health Plans
  Superior HealthPlan has announced the launch of a new alternative payment model (APM) for physicians and other behavioral health therapy professionals who use trauma-informed care to treat STAR Health members (i.e., Medicaid managed care for children and adolescents in foster care) with trauma-related behavioral health issues and symptoms. Superior’s five approved treatment modalities allow for an additional 10% payment to a submitted claim, if the claim includes proof of certification in one or more of those modalities and uses the specified billing modifier.

• Superior Announces Prior Auth Changes for Physical, Occupational, Speech Therapy
  Starting July 1, oversight for prior authorization requests and reviews for Superior HealthPlan Medicaid STAR, STAR+PLUS (non-waiver) and Children’s Health Insurance Program (CHIP) members will move from Evolent Specialty Services, Inc. to Centene Management Company, LLC. Superior’s website provides the required prior authorization request methods, including links to the two online portals, plus the phone number and fax number. Also, starting Aug. 1, Superior is implementing new prior authorization requirements for speech therapy evaluations for all Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP members for services provided on Aug. 1 or later.

• Superior HealthPlan Releases New Plan for Dual Eligibles
  As directed by the Centers for Medicare & Medicaid Services, Superior HealthPlan replaced its STAR+PLUS Medicare-Medicaid Plan (MMP) with its new aligned Dual Special Needs Plan, effective Jan. 1. Like MMP, the new plan is designed for patients who qualify for both Medicare and Medicaid. Per the payer, patients were automatically transitioned into the new Wellcare By Superior HealthPlan.

  Tools and resources regarding the transition can be found on  Superior’s webpage. Physicians who have additional questions about this change, their contract status, or to join Superior’s network, can visit Superior’s resource page or reach out to the payer’s Provider Services at 1-855-445-3572.

• Updates Coming Soon!
  

• UHC to Begin Payment Policies for Monitoring Treatment of Certain Conditions
  Beginning Sept. 1, UnitedHealthcare (UHC) will implement five new payment policies impacting if and how physicians get paid to screen for or monitor certain conditions.

  Per UHC, four of the five new policies will permit physicians to get paid for running specific tests or for delivering and monitoring treatment for certain illnesses, including certain allergy and hormone conditions.

  Each of those four policies also detail circumstances that would make those services unpayable, as well as which tests physicians will not get paid for providing. A fifth new policy mandates that physicians will not receive any payment for certain chemotherapy testing. Read more in Texas Medicine Today.

• United Advises Medicaid Physicians to Upload Current CLIA Certificate to PEMS
  For lab services provided June 1 or later, UnitedHealthcare, in its role as a Texas Medicaid & Partnership (TMHP) managed care organization, will deny claims not meeting TMHP requirements for current Clinical Laboratory Improvement Amendments (CLIA) certificate display. TMHP requires each physician and entity enrolled in its Medicaid program providing laboratory services to upload a current CLIA certificate in the state’s Provider Enrollment and Management System (PEMS). UHC will make sure the CLIA certificate isn’t either: (1) missing in PEMS, or (2) outdated. For laboratories certified to perform only waived tests, UHC advises using the QW modifier on the claim to avoid processing delays.

  Also note that Texas Health and Human Services Commission (HHSC) has delayed when it will begin denying Texas Medicaid claims for laboratory services when a physician’s CLIA information in PEMS is missing or inaccurate.

• United Adjusts Payment Range Under New Global Days Policy
  For procedures June 1 or later, UnitedHealthcare (UHC) changed its Global Days policy for its commercial and Affordable Care Act marketplace plans to align with the Centers for Medicare & Medicaid Services’ (CMS’) designated range of claim payment, which may result in payment reduction for surgeons. Per UHC, the new policy “applies to certain procedures subject to a Global Surgical Package concept whereby all necessary services normally furnished by a physician (before, during and after the procedure) are included in the reimbursement for the procedure performed.”

  UHC says physicians treating patients under its commercial health plans with postoperative complications requiring a return trip to the operating room should use modifier 78 for procedures with a Global Days value of 10 or 90. For those 10-day or 90-day procedures appended by modifier 78, UHC is changing its payment policy from 84% of the CMS-allowed amount (per the CMS physician fee schedule) to anywhere between 60-84%.

  Texas Medical Association staff note that, as UHC follows the CMS’ physician fee schedule for calculating Global Days Values, physicians may wish to use Novitas’ physician fee schedule search tool for confirming which procedures are affected, and its global surgery calculator to determine the 10-day and 90-day global period timeframes.

• United Announces New Payment Range for its Commercial Plans Under a New Global Days Policy
  For procedures starting June 1, United HealthCare is changing its Global Days policy to align with the Centers for Medicare & Medicaid Services-designated range of claim payment, which may result in payment reduction for surgeons.

  Per UHC, the new Global Days policy applies to “all necessary services normally furnished by a physician (before, during and after the procedure)” included in payment for the surgical procedure in question.

  UHC says physicians treating postoperative complications requiring a return trip to the operating room for patients under its commercial health plans should use modifier 78 for procedures with a global days value of 10 or 90. For those 10-day or 90-day procedures appended by modifier 78, UHC is changing its payment policy from 84% of the CMS-allowed amount (per the CMS physician fee schedule) to anywhere between 60-84%.

  Texas Medical Association staff notes that physicians may wish to use Novitas’ physician fee schedule search tool for confirming which procedures are affected, and its global surgery calculator to determine the 10-day and 90-day global period timeframes.

• United Implements New Payment Reduction Policy for Outpatient Hospital Items
  Starting March 1, UnitedHealthcare says it will implement a new payment reduction policy in its commercial plans that aligns with a Centers for Medicare & Medicaid Services payment reduction policy for certain outpatient hospital items and services.

  The Payment Reduction of Off-Campus Provider-Based Departments Billed with Modifier PO Policy, Facility, will apply a 60% reduction when Healthcare Common Procedure Coding System code G0463 is reported with modifier PO. Payment for G0463, when appropriately billed with the modifier, will be considered for payment at 40% of the allowable amount.

  Read this payment reduction policy for a definition of an off-campus department and exclusions.

• United to Enforce New Diagnosis Code Policy March 1
  Starting March 1, UnitedHealthcare (UHC) will implement a new, comprehensive diagnosis code requirement policy that will consolidate multiple diagnosis-related procedures in line with existing ICD-10-CM guidelines related to Excludes 1 guidelines. An Excludes 1 note signifies two medical conditions that cannot exist simultaneously in a single patient, and thus, cannot be paired on a claim.

  Previously, UHC planned for the new policy to apply only to inpatient claims; it will now apply for any outpatient, professional, and facility service.

  If a physician files a claim that does not comply with these requirements, the claim may be edited or denied completely. For additional details, UHC asks physicians to review its updated Diagnosis Code Reimbursement Policy.