Prior Authorizations & Predeterminations



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Health care providers may need to obtain prior approval for Blue Cross and Blue Shield of Texas (BCBSTX) members in advance of medical, mental health/substance abuse and pharmacy health care services.


Prior Authorization also referred to as preauthorization, prospective review, prenotification or prior approval are all names referring to the prior assessment that proposed services are medically necessary, are an appropriate treatment for a Blue Cross and Blue Shield of Texas (BCBSTX) member and are a covered medical expense of the member contract. A prior authorization is not a guarantee of benefits or payment. At the time the member’s claims are submitted, they will be reviewed in accordance with the terms of the Contract.


Usually, the member’s health care providers are responsible to request prior authorization before they perform a service. However, a member’s plan may also require the member to obtain prior authorization for certain services.


If prior approval is not obtained via the prior authorization process the costs may not be covered by BCBSTX, billed to the member and/or the member cost-share may be impacted. Prior Authorization is not a guarantee of payment of benefits. Actual availability of benefits is always subject to other requirements of the Plan, such as limitations and exclusions, payment of premium, and eligibility at the time services are provided.


Predeterminations are written requests for verification of benefits before rendering services.


Eligibility and Benefits Reminder: It is imperative that health care providers obtain eligibility and benefits first to confirm membership, check coverage, determine if you are in-network for the member's policy and determine whether prior authorization is required through Availity® or their preferred vendor. Availity® allows prior authorization determination by procedure code and providers can submit requests on Availity using the Authorization & Referral tool. Refer to the BCBSTX Eligibility and Benefits page for more information on Availity.


Prior authorization that a service is medically necessary is not a guarantee of coverage. If a service or medication is authorized, if the health care provider is out-of-network, the member will likely pay more out of pocket. The applicable terms of a member’s plan control the benefits that are available.





“TDI” is indicated on the ID Card for Fully Insured members


Prior Authorization Services List 1/1/2020 For Fully Insured PDF Document


Prior Authorization Procedure Codes list for Fully-Insured Members. 1/1/20


Note: Procedures or services on posted prior authorization lists may require prior authorization or prenotification by BCBSTX, eviCore Healthcare®, Magellan or AIM Specialty Health® (AIM). 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.


Note: ID card for ASO members will NOT indicate “TDI”


Prior Authorization Services List for ASO Members Effective 1/1/2020 PDF Document


Prior Authorization Procedure Codes List for ASO Members Effective 1/1/2020 PDF Document


Specialty Drugs Prior Authorization List for ASO Members Effective 1/1/2020 PDF Document


Note: Procedures or services on posted prior authorization lists may require prior authorization or prenotification by BCBSTX, eviCore Healthcare®, Magellan or AIM Specialty Health® (AIM). 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.


Step 1: Providers must confirm if prior authorization/prenotification is required using Availity® or their preferred vendor. This first step will also determine if prior authorization/prenotification will be obtained through BCBSTX or a dedicated vendor.


Step 2: Obtain prior authorization/prenotification as follows:


Services requiring prior authorization through BCBSTX Utilization Management:

Services requiring prior authorization through Magellan Health Services:

  • Call the number on the back of the member’s ID card
  • Refer to the Behavioral Health page for additional information

Services requiring prior authorization through eviCore®:

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


Step 3: Be prepared to provide the following information for the request:

  • Information about the patient’s medical or behavioral health condition
  • The proposed treatment plan
  • Date of service, estimated length of stay (if the patient is being admitted)
  • Member information - subscriber ID and name/date of birth
  • Place of treatment
  • Provider information - NPI, name and address
  • Diagnosis code(s)
  • Procedure code(s) (if applicable)

After the request is submitted, the service or drug is reviewed to determine if it:

  • is covered by the health plan, and
  • meets the health plan’s definition of “medically necessary.”

Effective Jan. 1, 2020, a renewal of an existing prior authorization can be requested up to 60 days before the expiration of the existing prior authorization.


The prior authorization is then completed accordingly, and the results are sent to the provider. If you have questions regarding the response, contact BCBSTX Utilization Management or the authorizing vendor.


Information regarding prior authorization approval or denial statistics for the preceding calendar year is available for review:


View Medical Prior Authorization Statistical Data


View Behavioral Health Statistical Data


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 Prior Authorizations, Prenotifications or Referrals

  • Prior Authorization General Information PDF Document
  • Most benefit plans require the member or provider to prior authorize inpatient hospital admissions (acute care, inpatient rehab, skilled nursing, hospice, long term acute care/sub-acute care, etc.)
  • Procedures or services on posted prior authorization lists may require prior authorization 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 prior authorization.
  • The following outpatient services may require Referrals, Prior Authorization or Prenotification depending on BCBSTX product:

    Please Note: Not all requirements below apply to each BCBSTX Commercial or Retail Plan (Blue Choice PPOSM, Blue EssentialsSM, Blue PremierSM, Blue Advantage HMOSM or MyBlue HealthSM).

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)

 

Prior Authorization/Notifications/Referral Lists


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