How to Request Prior Authorization 

The following outlines the process providers take to submit requests for prior authorizations or prenotifications.

How to Request Prior Authorization 
The following outlines the process providers take to submit requests for prior authorizations or prenotifications.

Confirm Requirements
Check eligibility and benefits using Availity® Essentials or your preferred vendor prior to rendering services. This step will confirm if prior authorization or prenotification is required and where to submit your request. 

Submit Your Request
For some services for our members, prior authorization or prenotification may be required through Blue Cross and Blue Shield of Texas. For other services and members, prior authorization or prenotification may be required through a dedicated vendor. 

Medical Management at BCBSTX

  • Use the BlueApprovRSM integrated process through Availity Authorizations to request prior authorization for behavioral health services. Refer to Availity Authorizations and BlueApprovR for more information.
  • Submit your request using the Availity Authorizations & Referrals tool.
  • Call the phone number listed on the member's ID card.

EviCore:

  • Online – Visit the EviCore Web Portal.
  • Call EviCore toll-free at 855-252-1117.
  • Refer to EviCore  for more information.

Carelon Medical Benefits Management:

Alacura Medical Transportation Management, LLC:

What You'll 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, name and date of birth
  • Place of treatment
  • Provider name, address and National Provider Identifier
  • Diagnosis codes
  • Procedure codes, if applicable

Renewal of an existing prior authorization can be requested up to 60 days before the expiration of the existing prior authorization.

Submit your prior authorization requests with the appropriate documentation and level of urgency. An urgent or expedited request is appropriate when treatment that, when delayed:

  • Could seriously jeopardize the life and health of the member or the member’s ability to regain maximum function.
  • Would subject the member to severe pain that cannot be adequately managed without the requested care or treatment
  • Would subject the member to adverse health consequences without the care or treatment that is the subject of the request

Approval Process

After the request is submitted, the service or drug is reviewed to determine if it:

  • It's covered by the health plan, and
  • It meets the health plan’s definition of “medically necessary.”

You’ll receive results once the review is completed. If you have questions regarding the response, contact Medical Management at BCBSTX or the authorizing vendor.

Related Resources

EviCore is an independent specialty medical benefits management company that provides utilization management services for BCBSTX.

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.

Alacura Medical Transportation Management, LLC. is an independent company that has contracted with Blue Cross and Blue Shield of Texas to provide utilization management services for members with coverage through BCBSTX.

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

Please note that checking 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.