BCBS Claim Editing Changes
- Jul 6
- 1 min read
What's Happening:
Starting July 1, 2026, BCBS of Texas will enhance its claims editing and review process for office, inpatient, and outpatient Evaluation & Management (E&M) services for commercial plan members.
What’s Changing:
When BCBS reviews your claim for dates of service on or after July 1, 2026:
If the documentation does not support the level of E&M service billed, reimbursement will be adjusted to the validated level of service.
BCBS will follow American Medical Association (AMA) guidelines for level of service and medical decision-making.
How to Prepare Your Practice:
Ensure documentation clearly supports the E&M level billed for each encounter.
Review AMA guidelines for E&M coding and medical decision-making complexity.
Train staff on documentation best practices to reduce potential downcoding.
When to Take Action:
If you agree with the level of service reimbursed, no further action is needed.
If you do not agree with the level of service reimbursed, you may submit medical records to support your claim.
If You Are a Reticle RCM Client:
Reticle will continue to handle first-level appeals for any underpaid claims.
References:
BlueCross BlueShield: Claim Editing Changes for Evaluation and Management Services for Commercial Members, Effective July 1, 2026
BlueCross BlueShield: Evaluation and Management Coding – Professional Provider
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