Prior Authorizations & Predeterminations



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Prior authorization, pre-notification, pre-certification or preauthorization are all names referring to the requirements that a provider's plan of treatment may need to meet medical necessity review under the applicable health benefits plan. Predeterminations are written requests for verification of benefits before rendering services.


Eligibility and Benefits Reminder: It is imperative that providers obtain eligibility and benefits first to confirm membership, verify coverage, determine if you are in-network for the member's policy and determine whether preauthorization is required through Availity® or their preferred vendor. Availity allows preauthorization determination by procedure code. Refer to the Blue Cross and Blue Shield of Texas (BCBSTX) Eligibility and Benefits page for more information on Availity.





Confirm using Availity or your preferred vendor that a preauthorization/prenotification is necessary and if it needs to be obtained through BCBSTX, eviCore® or AIM Specialty Health® (AIM), Once you determine where to obtain the preauthorization/prenotification for your services, use the following information to make your request:

Services requiring preauthorization through BCBSTX:

  • Submit via iExchange®, a web-based automated tool. To learn more, visit iExchange on the provider website..
  • Preauthorization through BCBSTX may also be requested by calling the phone number listed on the member/participant’s ID card.

Services requiring preauthorization through eviCore®:

Services requiring RQI prenotification through AIM Specialty Health® (AIM):


Predetermination of Benefits Are

  • Written requests for verification of benefits before rendering services
  • Recommended when the service may be considered experimental, investigational or cosmetic
  • Approved or denied often based on BCBSTX Medical Policies Learn more about third-party links
  • Not a substitute for the eligibility and benefits verification process

How to Submit a Request for Review

  • Complete the Predetermination Request Form  and fax to BCBSTX
  • This form also may be used to request review of a previously denied Predetermination of Benefits
  • You will be notified when an outcome has been reached

General Information For Preauthorizations/Notifications/Referrals

  • Preauthorization General Information PDF Document
  • Most benefit plans require the member or provider to pre-certify inpatient hospital admissions (acute care, inpatient rehab, skilled nursing, hospice, long term acute care/sub-acute care,etc.)
  • Procedures on posted preauthorization lists may require preauthorization or prenotification by either BCBSTX or eviCore Healthcare®. These lists are not exhaustive. The presence of codes on these lists does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply
  • All Out-of-Network/Out-of-Plan Services require preauthorization.
  • The following outpatient services may require Referrals, Preauthorization or Prenotification depending on BCBSTX product:

OUTPATIENTSERVICES:

  • Dialysis
  • Occupational Therapy
  • Drug/Alcohol Treatment
  • Physical Therapy
  • Durable Medical Equipment
  • Obstetrical Care
  • Home Health
  • Oral and Dental Procedures and Surgery
  • Home Infusion
  • Speech Therapy
  • Hospice
  • Prosthetics and Orthotics
  • Mental Health Behavioral Health
  • Transplant Evaluations
  • High tech Diagnostic Radiology Procedures (Some Blue Choice PPOSM plans require RQI through AIM Specialty Health® (AIM). Contact AIM at 1(800) 859-5299)
  • Please note: Not all requirements above apply to each BCBSTX product (Blue Choice PPOSM, Blue EssentialsSM, Blue PremierSM or Blue Advantage HMOSM).

 

Prior Authorization/Notifications/Referral Lists


Our members and employers are looking for partners that can help them effectively manage their health care investment. This means we will be offering products that provide a holistic view of health management and wellness. Health advocacy solutions and Wellbeing Management are innovative product benefits that take a high-touch, tailored approach to enriching a member’s health care journey and reducing health care costs.

  • Groups can customize benefits and chose which services require preauthorization or prenotification to best fit their members. Therefore, it is important to check eligibility and benefits and preauthorization requirements before any member visits.
  • Services such as advanced imaging, cardiology, musculoskeletal, molecular and genetic testing, radiation therapy and sleep medicine may require preauthorization review.