Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)
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Defines procedure and supply codes that Blue Cross Blue Shield of Texas will deny as non-reimbursable because they are considered experimental, investigational, or unproven; applies to claims submitted to BCBSTX and affects providers and members covered under BCBSTX plans.
No material clinical or coverage changes in this revision.
Non-Reimbursable Coverage Criteria
Non-Reimbursable EIU coverage criteria
Coverage stance and application
Non-Reimbursable EIU Codes
| Codes listed on the separate 'Non-Reimbursable EIU Services Code List' which may include CPT Category I, CPT Category III, and HCPCS codes; list is posted under the policy and may not be all inclusive. |
Provider Responsibilities and Claim Actions
Prior notification and reference to code list
Claims for services designated as experimental, investigational, or unproven per this policy will be denied as non-reimbursable and do not require clinical review; providers should consult the separate 'Non-Reimbursable EIU Services Code List' posted under this policy for the specific procedure codes and contact the number on the member's card or Availity for plan-specific coverage.
- EIU procedure codes (CPT Category I, CPT Category III, HCPCS) listed on the separate code list will be denied when submitted on a claim.
- The code list posted under this policy may not be all inclusive; verify plan-specific coverage via member card or Availity.
Documentation responsibilities
Providers are responsible for submitting accurate documentation of services performed and claims coded using valid, industry-standard code sets; upon claim review, additional documentation may be requested.
- Submit claims using HIPAA-approved code sets and follow industry coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG, CCI edits, etc.).
- Be prepared to provide additional documentation upon request as part of claim review or audit.
Key Definitions
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