Prior Authorization

Sometimes you may need to get approval from Blue Cross and Blue Shield of Texas (BCBSTX) before we will cover certain inpatient, outpatient and home health care services and prescription drugs. This is called prior authorization, preauthorization or prior approval. These terms all refer to the requirements that you may need to meet before treatment may begin.

During this process, BCBSTX reviews the requested service or drug to see if it:

  • is covered by your plan, and
  • meets your health plan’s definition of "medically necessary."

This review does not replace the advice of your provider.

When BCBSTX is contacted with a prior authorization request, we will ask for the following:

  • Your name, subscriber ID number and date of birth
  • Your provider’s name, address and National Provider Identifier (NPI)
  • Information about your medical or behavioral health condition
  • The proposed treatment plan, including any diagnostic or procedure codes (your provider can help you with these)
  • The date you’ll receive service and the estimated length of stay (if you are being admitted)
  • The place you’re being treated
  • Your provider’s name, address and National Provider Identifier (NPI)

Usually, your health care providers will take care of prior authorization before they perform a service. But, it is always a good idea to check if your providers have gotten the needed approval. If your providers are not in network, they will not request prior authorization. You will be responsible for getting this approval. If you do not get this approval via the prior authorization process, the costs may not be covered by BCBSTX.

Effective Jan. 1, 2020, you or your provider can request a renewal of an existing prior authorization up to 60 days before the expiration of the existing prior authorization.

These services and drugs require prior authorization from BCBSTX. Except as otherwise noted, these prior authorization requirements are effective on January 1, 2020.

Note: The requested service or treatment must meet your plan's definition of medical necessity to be eligible for benefits under your plan. The prior authorization process is not a substitute for the medical advice of a health care provider. The final decision to receive any medical service or treatment is between you and your health care provider.

If you are unsure which health care services or medications need prior authorization, call the Customer Service number on the back of your BCBSTX member ID card.

How Your Health Care Provider Requests Prior Authorization

As noted above, your health care provider will usually take care of requesting prior authorization. But, this may not happen if your provider is not in network. What’s more, if you visit a doctor or a hospital that is not in network, you may be responsible for the full cost of your care. To make sure your provider is in network, check Provider Finder®

You can also check with BCBSTX to see if your provider has requested prior authorization before you get any services.

When your provider requests prior authorization, he or she may need to work through us or another company. This depends on the type of service requested. BCBSTX contracts with eviCore® healthcare and Magellan Healthcare for certain prior authorization services.

How You Can Request Prior Authorization

If your health care provider has not requested prior authorization for you, you can request it. To do so, call the number on the back of your BCBSTX member ID card. Our Customer Service will help you begin the process.

How You Can Track Your Prior Authorization Status

You can check if a prior authorization has been submitted or approved. Log in to your Blue Access for MembersSM account or call the number on the back of your member ID card. You can also log in to your BAM account to see the benefits your plan covers.

How BCBSTX Responds to All Prior Authorization Requests

We keep track of how many prior authorization requests we receive each year. This includes how many requests we approve and deny. Below, you will find these numbers.

*To see if you are fully insured, check your member ID card. "TDI" will be printed on your card if you are fully insured. If you do not see "TDI" printed, check your benefit booklet to see your list of services that require prior authorization. If you still have questions, please call the Customer Service number on the back of your BCBSTX member ID card.

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