Prior Authorizations & Predeterminations
Refer to the COVID-19 Preparedness page for temporary information related to servicing members in response to COVID-19.
Health care providers may need to request prior approval in advance of medical, mental health/substance abuse and pharmacy health care services for our member/participants.
What is Prior Authorization
Prior Authorization, preauthorization, prospective review, prenotification or prior approval refer to the prior assessment that proposed services are medically necessary, appropriate and a covered medical expense of the member/participant contract.
A prior authorization is not a guarantee of benefits or payment. Actual availability of benefits is always subject to other requirements of the Plan, such as limitations and exclusions, payment of premium, and eligibility at the time services are provided. The applicable terms of a member/participant’s plan control the benefits that are available. At the time the claims are submitted, they will be reviewed in accordance with the terms of the Contract.
Many of our groups utilize Health Advocacy Solutions and Wellbeing Management Programs for the services that require prior authorization.
Responsibility for Prior Authorization
Usually, health care providers are responsible to request prior authorization before they perform a service. However, a member/participant’s plan may also require them to obtain prior authorization for certain services.
If prior approval is not obtained the costs may not be covered by BCBSTX, billed to the patient and/or the patient’s cost-share may be impacted. If a service or medication is not authorized and the health care provider is out-of-network, the patient will likely pay more out of pocket. The applicable terms of a their plan control the benefits that are available.
What is a Predetermination of Benefits
A predetermination of benefits is a written request for verification of benefits before rendering services. Learn more about Predetermination of Benefits Requests.
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.
How to Submit a Prior Authorization
Prior authorization may be required via BCBSTX's medical management, eviCore® healthcare, AIM specialty Health® or Magellan Healthcare®. You can review how to submit each request as well as statistical data here.
Prior Authorization Lists
Refer to the following for services and/or procedure codes that may require prior authorization:
- 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.
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.