Prior Authorization (PA) Services for:

- Fully Insured* & Certain

Administrative Services Only Groups

- All Other Administrative Services Only (ASO)

The procedures or services on the below lists may require prior authorization or prenotification by BCBSTX Medical Management, Carelon Medical Benefits Management (Carelon) or Magellan Healthcare^®. Services not subject to a required prior authorization may still be reviewed for medical necessity.

These lists:

May not necessarily be covered under the member benefits contract.**
May periodically be updated to comply with American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) guidelines including procedure code updates as well as updates to BCBSTX medical policies or clinical guidelines.
New or amended prior authorization requirements will be posted to the provider website, 60 days prior to the effective date unless they are less burdensome or removed, which may be subject to shorter notice.

**Providers should check eligibility and benefits through Availity^® or your preferred vendor, check the member/participant benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.

Fully Insured Plans & Certain ASO Groups

*Fully insured plans will have “TDI” indicated on the ID Card.

Refer to the PA lists for ASO groups included.

Services Lists

Prior Authorization Services List for Fully Insured and Certain ASO Groups Effective 01/01/2024
Prior Authorization Services List for Fully Insured and Certain ASO Groups Effective 01/01/2023

Procedure Code Look Up

Locate procedure codes that may require prior authorization for Fully Insured Members Only using the following:

Digital Lookup Tool

Select the appropriate category below to find out if a member’s procedure may require prior authorization:

Medical Procedure

Behavioral Service

Procedure Code Lists

Prior Authorization Procedure Codes List for Fully Insured Plans and Certain ASO Groups Effective 01/01/2024 (Includes changes effective 07/01/2024)

Prior Authorization Procedure Codes List for Fully Insured Plans and Certain ASO Groups Effective 01/01/2023 -12/31/2023 (Includes changes effective 10/01/2023)

Other Administrative Services Only (ASO) Groups

Administrative Services Only (ASO) groups will NOT have “TDI” indicated on the ID Card.

Services Lists

Prior Authorization Services List for Other ASO Groups Effective 01/01/2024
Prior Authorization Services List for Other ASO Groups Effective 01/01/2023

Procedure Code Lists

Prior Authorization Procedure Codes List for Other ASO Plans Effective 01/01/2024 (Includes changes effective 07/01/2024)
Prior Authorization Procedure Codes List for Other ASO Plans Effective 01/01/2023 – 12/31/2023 (Includes changes effective 10/01/2023)

Related Links

Availity® Authorization & Referrals
Blue ApprovR^SM
MCG^TM Care Guidelines: Providers can access these in the BCBSTX-branded Payer Spaces section in Availity^® under the Resources tab. Use CTRL+F to locate specific criteria within the MCG Care Guidelines.
Medical Policies
Prior Authorization Exemptions
Recommended Clinical Review

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

BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore or Carelon. The vendors are solely responsible for the products or services they offer.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or received a recommended clinical review 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.