PEAQ^SM Program Adds New Specialties for Cost Efficiency Analysis

As of Jan. 1, 2025, the Physician Efficiency, Appropriateness, & Quality^SM program includes 23 new specialties for the cost efficiency component. Learn how this change affects what members see when searching for information on Provider Finder^®.

New Prior Authorizations Are Required for Home Health Care

Prior authorizations secured during 2024 for home health care services for our commercial members expired Dec. 31, 2024. Request new authorizations for 2025 through Availity^® Essentials or by phone.

Remind Billing Agencies to Correctly Submit Claim Review Requests

Agencies may submit requests using our claim review form or, for faster processing, submit requests electronically through Availity Essentials. Learn tips on how to complete submissions and avoid returned requests.

ClaimsXten^TM Quarterly Update

We’ll implement first quarter code updates for the ClaimsXten auditing tool on or after March 17, 2025.

Prior Authorization Changes

Effective April 1, 2025, prior authorization requirements are changing to reflect new, replaced or removed codes. Learn about the changes for commercial and Medicare Advantage members.

Medical Records Needed to Support Quality Care

You may receive requests in 2025 for our members’ medical records. We collect data for Healthcare Effectiveness Data and Information Set (HEDIS^®) measures to track quality of care. Learn how you can help by promptly providing complete records for Federal Employee Program^® and Medicare Advantage members.

Follow‑Up Care Is Recommended for Children Prescribed ADHD Medication

Attention‑deficit/hyperactivity disorder is one of the most common behavioral health disorders affecting children. To support quality care, we gather data on follow‑up visits for children using ADHD medication.

Remind Our Members About Cervical and Breast Cancer Screenings

Regular screening tests can help detect cancer early when it’s easier to treat. Learn about documenting these screenings in members’ medical records and other tips to close gaps in care.

New Gene Therapy Solutions Helps Monitor Results

We launched gene therapy solutions on Jan. 1, 2025, to support access to care while protecting against high treatment costs for our commercial group members. To help track clinical outcomes, we may ask you for information about the effectiveness of gene therapy treatments prescribed for our members.

New Part D Quality Measures Track High‑Risk Medication Combinations

The Centers for Medicare & Medicaid Services added two quality measures to its Star Ratings for Medicare prescription drug plans. Learn more about the measures and the risks of concurrent use.

Medicare Providers May Treat Members of Blue Cross Group Medicare Advantage Open Access (PPO)^SM

This open access, national PPO plan is for retirees of employer groups. If you’re a Medicare provider, you may treat these members even if you don’t participate in our Medicare Advantage or other networks.

Appointment Wait Time Standards for Commercial Members Are Changing

Learn about National Committee for Quality Assurance requirements for behavioral health services, routine primary care and non‑urgent specialty care.

Medicare‑Like Rates to Apply to Claims for Some Self-Funded Tribal Plans

Hospitals must accept Medicare‑like rates as payment in full for services provided to beneficiaries of some self‑funded Tribal organizations that have new benefit plans.

Ensure Your Office Is Providing Your Most Current Information

When seeking care, our members may contact your office or search our online Provider Finder for information such as your appointment availability for new patients. Learn how to ensure our members can access the most up‑to‑date information.

Keep Your Contact Information Updated to Receive Recredentialing Reminders

Providers credentialed with us are required to recredential every three years. Keep your information updated with us and the Council for Affordable Quality Healthcare to receive reminders and ensure we’re able to obtain your recredentialing application with CAQH.

Looking for Help? Contact Your Network Representative

Do you know the fastest way to get a response on prior authorizations? Are you aware of the latest pharmacy drug updates? Maybe you have other questions. Many of these answers are in our News and Updates, but if you need more information, our provider network representatives are here. Email us or call 800‑722‑3730 and select Option 2 for Network.

Clinical Payment and Coding Policy Updates

New or revised clinical payment and coding policies are on our Clinical Payment and Coding Policies page. These policies provide billing, coding and documentation guidelines. Visit our site regularly to ensure you’re up to date on any changes or new policies.

Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month under the Standards and Requirements tab. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.