June 27, 2019
Blue Cross and Blue Shield of Texas (BCBSTX) has updated the list of procedures requiring prior authorization for our Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM plans. The updated prior authorization list is effective May 1, 2019. Prior Authorization/Referral Requirements Lists have been updated to include the services that require prior authorization through BCBSTX and eviCore. BCBSTX has contracted with eviCore® healthcare (eviCore), an independent specialty medical benefits management company to provide utilization management services for certain specified prior authorization requirements.
In addition, some changes were due to American Medical Association (AMA) procedure code updates. The updated Blue Cross Medicare Advantage Prior Authorization Requirements List is located on bcbstx.com/provider under Clinical Resources. For specific codes that apply, refer to the Blue Cross Medicare Advantage CPT Prior Authorization Procedure Code List. Requests for prior authorization for ongoing care may be submitted as early as seven days before the requested start date.
To authorize services requiring prior authorization through eviCore, please visit the eviCore Healthcare Web Portal or call 1-855-252-1117. As a reminder, iExchange, our automated referral and prior authorization tool, is available 24 hours a day, seven days a week (except for every third Sunday of the month when the system will be unavailable from 11 a.m. to 3 p.m. CT) for those services requiring prior authorization through BCBSTX. iExchange is accessible to physicians, professional providers and facilities contracted with BCBSTX. For more information or to set up a new account, complete and submit the iExchange online enrollment form.
Failure to timely notify BCBSTX and obtain pre-approval for listed procedures may result in denial of the claim(s) for care services, which cannot be billed to the member pursuant to your provider agreement with BCBSTX.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Consultant.
eviCore® is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Texas.
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. Aerial, iExchange and Medecision® are trademarks of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity or Medecision. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.
Please note that verification 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.
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