Tag: Blue Cross Blue Shield (BCBS)
ERISA or maybe TPA?
Let’s play pretend:
Some one gives you this card and wants to make an appointment.
They seem to want an answer right now.
You know your physician takes Blue Choice, but have never seen this card before. How would you know?
Look at the front of the card. Blue Cross is written all over it. BCBS must be the insurer? STOP!
Do you see any insurance regulation language? Is “TDI” or “DOI” on this card?
NO. This is your 1st clue. The employer may be the insurer.
Scan the front of the card intently. Are there any other clues. Look for what you know, not what you don’t know.
If not flip it over. What do you see? READ ALL THE TINY WRITING.
On this card: phone numbers, addresses, where to file, prior auth info. But what else?
“This coverage is self-funded Excellus BlueCross BlueShield, and independent licensee of the BlueCross BlueShield Association provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.”
What does that mean:
- The employer is the insurer (self-funded plan)
- Excellus BCBS is acting as a Third-Party Administrator (TPA)
Is this a Lease Network?
Very likely — yes.
On the front of the card it says:
“To verify participation, please call the BlueCard Provider Network.”
That suggests:
- The plan is using the BlueCard network
- Excellus is providing network access + claims processing. The employer is leasing the BCBS network
That’s what we commonly call a lease network arrangement.
But — this is important — don’t assume, Verify
Why you may still get a “Yes” when you call
When you call provider services:
- The rep may simply see “In Network”
- They may not understand lease networks
- They may not understand the difference between:
- Payor
- TPA
- Repricer
- Network administrator
So we need to ask better questions.
Instead of just asking “Is Dr. Smith in network?”
Tell the representative you would like to check network participation.
Ask:
- Is this plan self-funded? (if it is self-funded it is not a lease network)
- Is Excellus the payor, or the administrator?
- Is this a leased network?
- Who bears the financial risk?
- Is Excellus repricing the claims?
- What network applies to this patient?
And always get:
✔ Representative name
✔ Date/time
✔ Call reference number
If the claim denies, that reference number becomes your leverage.
Why this matters
In lease network plans:
- The employer controls the benefits.
- The employer may carve out services.
- The employer may override network rules.
- The plan can be patient-specific.
Basically they can make up their own rules.
In practical terms — They have more flexibility than a fully insured DOI-regulated plan.
Protect Yourself when speaking to the patient.
Never speak in absolutes.
Use language like:
- “It looks like this is a self-funded plan…”
- “Based on the card wording…”
- “According to the representative I spoke with…”
- “At the time of verification…”
Never say:
- “Yes, you are definitely covered.”
- “This will pay.”
- “You are in network.”
NEW BCBSTX fee schedule coming
ATTENTION PROVIDERS
BCBSTX has notified POET that a NEW Fee Schedule for Blue Choice and Blue Essentials will be effective May 1, 2026.
Once POET receives the new fee schedule and completes its review, OPT-IN / OPT-OUT packets will be sent to physician offices for participation decisions.
Please watch for additional communication once the review process is complete
Employer Group PPO/EPO Hybrid
Interpreting insurance cards has never been easy, but with the constant changes in today’s insurance landscape, it has become nearly impossible.
Every week seems to bring a new insurance company—or an established insurer that has acquired several others, rebranded, and rewritten the rules.
On top of that, there are hybrid plans like POS and EPO, along with discount cards, medical cost-sharing programs, limited-benefit plans, and the growing model of Direct Primary Care.
The one pictured below is an ultimate example!
It takes hybrid to a new level of complexity.
By mixing the rules of PPO and EPO in one plan.
Therefore, I, Sir Seymore, have taken my red pen in hand in an effort to make sense of it all.
Feel free to download this card for your records.
BCBS Pharmacy Qtrly Updates for January 2026
Pharmacy Program Quarterly Update Changes Effective Jan. 1, 2026 – Part 1
BCBS CIR Cheat Sheet
“The Claim Inquiry Resolution (CIR) tool within the Electronic Refund Management (eRM) portal accessed via Availity® Essentials only accepts inquiry submissions related to High-Dollar, Pre-Pay Review requests for most Host (BlueCard® out-of-area) claims (Medical Records and/or Itemized Bills). The other inquiry options that were available via CIR have transitioned to the Availity Claim Status Tool’s Dispute Claim or Message This Payer features.” Per BCBS Provider Education.
WHAT CAN BE DOWNLOADED TO eRM?
See Example Below —
TRS 2025-2026 Plan Year
Products for 2025-2026 Plan Year
Please be aware the Retiree Plans are Calendar Year
ERS 2025-2026 Plan Year
Products for 2025-2026 Plan Year
Please be aware the Retiree Plans are Calendar Year
Health Plan Representatives Updated 8/4/2025
The Health Plan Representatives List has been updated. This is a good tool to print and have close by when you have an issue.
The biggest change for claims issues will be HealthSpring (HCSC) formerly Cigna MA. Here is how:
- Email ALL claims issues to [email protected]
2. HealthSpring has supplied the spreadsheet that MUST be used. A link is provided below, or you may call POET, we will be glad to email you an electronic copy.
Only the columns with Red Lettering, need to be filled out by the Physician’s office.
4. Always feel free to copy [email protected] if you would like POET to be in the loop.
5. If you have a time sensitive, special, or just an issue you would like to discuss with POET, please call (936) 637-7638.
A Familiar Name Returns to Healthcare
In a landscape cluttered with brand mashups, logo overload, and forgettable names—WellThis, WellThat, PlusThis, PlusThat, and the never-ending bowl of Alphabet Soup—clarity is a breath of fresh air. Amidst the noise, we’re proud to reintroduce a name that brings familiarity, trust, and simplicity back into focus: HealthSpring
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How to Search the BCBS Fee Schedule for Quarterly HCPCS (Updated)
Choose “Standards and Requirements”
Then “General Reimbursement Information”
Scroll to the Bottom and enter the password “Manual”, then click submit
Read the Policies Disclaimer or scroll to the bottom and click “Continue”
Then choose “Blue Choice PPO, Blue Essentials, Blue Premier, Blue Advantage HMO, MyBlue Health, Blue High Performance Network Schedules”
Directly under that, select “2024 Schedules effective 2/1/2024”
Scroll down to “CPT/HCPCS Drug Schedule” click
The schedule will open in a PDF. You may search by using “CTRL F”
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