How to Request Prior Authorization or Prenotification and View Statistical Data

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 BCBSTX Medical Management

Services requiring prior authorization through Magellan Healthcare®:

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

Services requiring prior authorization through eviCore®:

Services requiring prior authorization or RQI prenotification through AIM Specialty Health® (AIM):

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

Approval Process & Statistics

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 BCBSTX Medical Management or the authorizing vendor.

Prior authorization approval or denial statistics for the previous preceding calendar year for fully-insured members is are available for review:

 

Prior Authorization Approval or Denial Statistics*

Medical Data History

Drugs Data History

Behavioral Data History

*Blue Cross and Blue Shield of Texas has a reporting cycle of a calendar year from January 1st to December 31st. Appeals outside the calendar year in review are not included. Note, some appeals may relate to denials reported in prior year reporting cycles.

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

AIM Specialty Health (AIM) is an operating subsidiary of Anthem and an independent medical benefits management company that provides utilization management services for 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 Blue Cross and Blue Shield of Texas.

BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore or AIM. 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 checking 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.