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Provider Tools

Refer to the COVID-19 Preparedness page for temporary information related to servicing members in response to COVID-19.

At Blue Cross and Blue Shield of Texas (BCBSTX), we are committed to providing support to physician practices. We've designed useful tools for health care providers. Whether doing research or streamlining billing, these tools can help you evaluate costs, save time, improve service and more.

Availity^® Attachments: Submit Predetermination of Benefits Requests Online

Attachments is an online tool in the Availity Provider Portal that allows you to submit electronic predetermination of benefits requests handled by Blue Cross Blue Shield of Texas (BCBSTX). Learn More

Availity^® Authorizations & Referrals

Authorizations & Referrals is an online tool in the Availity Provider Portal that allows you to submit prior authorization and/or referral requests handled by Blue Cross and Blue Shield of Texas (BCBSTX). Learn More.

Availity Eligibility and Benefits

It is important to verify membership and check coverage details for every patient at every visit, before you administer treatment.

To obtain fast, efficient, detailed benefits information for Blue Cross and Blue Shield members, you can use Availity's Eligibility and Benefits tool. This free online tool can provide you with co-payment, co-insurance, deductible, and other important information. Learn More.

Blue Distinction^®

The Blue Distinction Specialty Care Program is a national designation program recognizing healthcare providers that demonstrate expertise in delivering quality specialty care safely, effectively, and cost-efficiently. The goal of the program is to help consumers find both quality and value for their specialty care needs, while providing a credible foundation for employers to design benefits tailored to meet their quality and cost objectives.

Blue Distinction Specialty Care has eleven areas of specialty care: bariatric surgery, cancer care, cardiac care, knee and hip replacement, maternity care, spine surgery, substance use treatment and recovery, transplants, fertility care, cellular immunotherapy, and gene therapy.

For specific information please select the Blue Distinction website.

Claim Inquiry Resolution (CIR) Tool

Our Claim Inquiry Resolution tool is available via a tab in our Electronic Refund Management (eRM) system. By providing a method for online assistance with specific inquiries on finalized claims, the CIR tool can help save your staff time by reducing the need for phone calls and written correspondence. Learn More

Claim Status Tool

The Availity^® Claim Status Tool offers enhanced, real-time claim status functionality to help you manage and resolve claims processed by BCBSTX. Learn More

Clear Claim Connection™

Clear Claim Connection (C3) is a web-based code auditing tool, designed by McKesson Information Solutions, Inc., that enables BCBSTX to disclose our claim auditing rules and clinical rationale to our contracting provider network. C3 "mirrors" how BCBSTX's current code auditing software evaluates code combinations during the adjudication of a claim. Learn More

Clinical Quality Validation (CQV) Application

Clinical Quality Validation (CQV) is a web-based application in the Availity^® Provider Portal that allows providers to quickly comply with Healthcare Effectiveness Data and Information Set (HEDIS^®) measures. Providers can electronically document their patient’s care and assessments to close quality HEDIS care gaps for BCBSTX members using CQV. Learn More

CoverMyMeds^®'

CoverMyMeds is an online tool for electronic completion and submission of benefit prior authorization (PA) requests for prescription drugs that are part of the Blue Cross and Blue Shield of Texas (BCBSTX) pharmacy PA program. Learn More

DNoA Connect

DNoA Connect is a provider self-service tool where dental offices can conveniently connect to patient information for members with BlueCare Dental^SM. It was designed to help providers manage their administrative tasks as quickly and efficiently as possible. Learn More

Electronic Claim Submission via Availity^® Provider Portal

Availity’s Claim Submission tool allows providers to quickly submit electronic Professional (ANSI 837P) and facility, or Institutional (ANSI 837I) claims or encounters to Blue Cross and Blue Shield of Texas (BCBSTX), at no cost. Learn More

Electronic Clinical Claim Appeal Request via Availity^®

The Dispute Claim option allows providers to electronically submit appeal requests for specific clinical claim denials through the Availity Portal. Learn More

Electronic Quality and Risk Adjustment Medical Records Requests

The Availity^® Medical Attachment tool allows providers to receive electronic quality and risk adjustment medical record requests from Blue Cross and Blue Shield of Texas (BCBSTX). Learn More

Electronic Refund Management (eRM)

Electronic Refund Management (eRM) is an online tool that can help simplify your overpayment reconciliation and related processes. Learn More

Eligibility and Benefits Inquiry (HIPAA 270/271)

An eligibility and benefits inquiry should be completed for every patient at every visit to confirm membership, verify coverage and determine other important information, such as the patient's co-pay, co-insurance and deductible amounts. Learn More

Fee Schedules via Availity^® (Professional Providers)

The Availity Fee Schedule tool allows professional providers participating with BCBSTX to electronically request a range of up to 20 procedure codes and immediately receive the contracted price allowance for the patient services you perform. Learn More

National Drug Code (NDC) Units Calculator Tool via Availity^®

The National Drug Code (NDC) Units Calculator is a user-friendly online tool that allows providers to convert applicable classified or specified Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT^®) codes to NDC units. Learn More

OptiNet^®' Assessment Tool

OptiNet is an online assessment tool developed by AIM Specialty Health_®' (AIM)_' to collect modality-specific data from imaging providers. This tool is as an enhancement to our Radiology Quality Initiative (RQI) program, which AIM^®' administers for BCBSTX. Learn More

Patient Care Summary

The Patient Care Summary tool uses claim-based information to provide you with a consolidated view of a patient's health care history at the point of care. This electronic health record can help you identify gaps in care, missed prescription refills and possible drug interactions, and other "clinical flags" and treatment opportunities. Learn More.

Patient Cost Estimator

The Patient Cost Estimator is a member liability estimator tool. This free online tool can provide you with a real-time, estimated member share amount at the time of service, while the patient is still in your office, prior to claim submission. Learn More.