Utilization management is at the heart of how we can help members continue to access the right care, at the right place and at the right time. In this section, we will review the different types of reviews.
What is Utilization Management Review
A utilization management review determines whether a benefit is covered under the health plan using evidence-based clinical standards of care. Utilization management includes:
- Required Prior Authorization (including initial and concurrent review)
- Recommended Clinical Review Option
- Inpatient Services (including initial and concurrent review)
- Outpatient Services (formerly Predetermination)
- Post-Service Reviews
What is a Required Prior Authorization
Required prior authorizations are a pre-service medical necessity review. A prior authorization is a form of prospective utilization review where we review the requested service or drug to see if it is medically necessary and covered under the member’s health plan. Not all services and drugs need prior authorization. A prior authorization is not a guarantee of benefits or payment. The terms of the member’s plan control the available benefits.
Who Requests Prior Authorization
The provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider.
Most out-of-network services require utilization management review. If the provider or member does not get prior authorization for out-of-network services, the claim may be denied or will be subject to a post-service medical necessity review. Emergency services are an exception.
Reminder: 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
Why Obtain a Prior Authorization
If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists:
- Prior authorization may be required as a condition of payment
- The service or drug may not be covered and the ordering or servicing in-network provider will be responsible.
- We may conduct a post-service utilization management review, which may include requesting medical records and review of claims for consistency with:
- Medical policies
- State and federal requirements
- Member’s benefits
- Other clinical guidelines
Prior Authorization Exemptions (Texas House Bill 3459)
Under Texas House Bill 3459, providers may qualify for an exemption from submitting prior authorization requests for particular health care service(s) for all fully insured and certain Administrative Services Only (ASO) groups beginning no later than Oct. 1, 2022. Only services subject to required prior authorizations are eligible for an exemption. Learn More
What is a Notification
Providers can submit notifications for inpatient services that are not subject to prior authorizations. By submitting a notification, the plan in turn will let the provider know what days or units are covered initially so that concurrent review is submitted when required for additional days or units. When a provider submits a notification for a service that is exempt from required prior authorizations, no review is conducted on that service.
How to Submit a Prior Authorization or a Notification and View Prior Authorization Statistical Data
Prior authorization (PA) may be required via BCBSTX's medical management, eviCore® healthcare, Carelon Medical Benefits Management or Magellan Healthcare®. You can review how to submit PA or Notification requests and view PA statistical data here.
Recommended Clinical Review Option
The optional Recommended Clinical Review of medical necessity is submitted before services are completed for a Covered Service that does not require prior authorization and helps limit the situations where a service may be denied based upon medical necessity retrospectively. Learn More
Predetermination of Benefits (See Recommended Clinical Review Option)
Eligibility and Benefits Reminder
Health care providers must obtain eligibility and benefits through Availity® or a preferred vendor first to confirm membership, check coverage, determine if you are in-network for the member/participant's policy, determine whether prior authorization is required and where to submit the request. Availity allows prior authorization determination by procedure code and providers can submit requests on Availity using the Authorization & Referral tool. Learn more about Eligibility and Benefits and Availity.
What is Post-Service Utilization Management Review
A post-service utilization management review occurs after the service occurs. During a post-service utilization management review, we review clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan. We may ask you for the information we do not have.
We may also elect to conduct a post-service utilization management review if you do not obtain a required prior authorization. Some claims may be denied based on the member’s benefit plan without post-service review.
Prior Authorization Lists
Refer to the following for services and/or procedure codes that may require prior authorization:
- Behavioral Health Services
- Prior Authorization Lists for Fully Insured and Administrative Services Only (ASO) Plans
- Prior Authorization Lists for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM
- Prior Authorization Lists for Designated Groups
- Employee Retirement Groups of Texas (ERS)
eviCore is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.
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, 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 Carelon. 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.