How to Request Prior Authorization 

The following outlines the process providers take to submit requests for prior authorizations or prenotifications.

Submitting Prior Authorizations

Confirm Requirements

Confirm if prior authorization/prenotification is required using Availity® or preferred vendor. This first step will also determine if prior authorization/prenotification will be obtained through BCBSTX or a dedicated vendor.

How to Submit

Obtain prior authorization/prenotification as follows:

Services requiring prior authorization through Medical Management at BCBSTX

  • Use BlueApprovRSM to request prior authorization for some inpatient and/or outpatient, medical and surgical services and specialty pharmacy drugs. Visit our BlueApprovR page for information.
  • Submit via Authorizations & Referrals an online tool in Availity® Essentials. To learn more, visit Availity Authorizations & Referrals.
  • Call the phone number listed on the member's ID card.

Services requiring prior authorization through Magellan Healthcare®:

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

.Services requiring prior authorization through eviCore®:

Services requiring prior authorization through Carelon Medical Benefits Management:

Medical Transportation Services Managed by Alacura:

What You Need

Be prepared to provide the following information for the request:

  • Patient’s medical or behavioral health condition
  • Proposed treatment plan
  • Date of service, estimated length of stay (if the patient is being admitted)
  • Patient ID and name/date of birth
  • Place of treatment
  • Provider NPI, name and address
  • Diagnosis code(s)
  • Procedure code(s) (if applicable)

Renewal of an existing prior authorization can be requested up to 60 days before the expiration of the existing prior authorization.

Reminder: Submit your prior authorization requests with the appropriate documentation and level of urgency. An urgent or expedited request is appropriate when treatment that, when delayed:

  • could seriously jeopardize the life and health of the member or the member’s ability to regain maximum function.
  • would subject the member to severe pain that cannot be adequately managed without the requested care or treatment
  • would subject the member to adverse health consequences without the care or treatment that is the subject of the request

Approval Process

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.”

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

Related Resources

 

eviCore is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.

Carelon Medical Benefits Management is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

Alacura Medical Transportation Management, LLC. is an independent company that has contracted with Blue Cross and Blue Shield of Texas to provide utilization management services for members with coverage through BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.

Please note that checking of eligibility and benefits information, and/or the fact that any pre-service review has been conducted, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered.