May 22, 2020
What's new:
We have updated the procedure code list for services prior authorized by eviCore healthcare (eviCore) for fully insured members effective April 20, 2020. These code changes were a result of new, replaced or removed codes implemented by the American Medical Association (AMA). The procedure code list is located on the Prior Authorizations & Predeterminations page under Prior Authorization Procedure Codes List for Fully-Insured Members Effective 1/1/2020. Refer to the Updates column for the changes.
What Providers Need to Do:
You should use Availity® or your preferred vendor to check eligibility and benefits, determine if you are in-network for your patient and whether any prior authorization is required for your patient. Availity allows you to determine if prior authorization is required through BCBSTX medical management, or another vendor such as eviCore, based on the procedure code. Refer to "Eligibility and Benefits" on the provider website for more information on Availity.
When the procedure, such as these new changes, requires you to prior authorize through eviCore, you can:
- Enter online using the eviCore Healthcare Web Portal, which is available 24/7
- Call 1-855-252-1117 between 6 a.m. to 6 p.m. (CST) Monday through Friday and 9 a.m. - noon Saturday, Sunday and legal holidays.
- Refer to the eviCore implementation site for more information.
Payment may be denied if you perform procedures without authorization. If this happens, you may not bill your patients. If you need assistance, view the list of our Network Management offices to contact.
As a reminder, it is important to check eligibility and benefits before rendering services. This step will help you determine if benefit prior authorization is required for a member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on Blue Cross and Blue Shield of Texas (BCBSTX's) provider website.
Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits 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. If you have questions, contact the number on the member's ID card.
If BCBSTX fails to timely publish, provide notice or respond to a request for prior authorization requirements, BCBSTX must provide an expedited appeal for any medical care or health care service affected.
eviCore is a trademark of eviCore healthcare, LLC, an independent company that provides utilization review for select health care services on behalf of BCBSTX.
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.BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity.
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.