12/12/2022
Blue Cross and Blue Shield of Texas (BCBSTX) is expanding members enrolled in Blue Cross Group Medicare Advantage (PPO)℠ programs effective Jan. 1, 2023. These members will require prior authorization from eviCore healthcare® for certain services as shown below. Services performed without authorization may not be reimbursed for these healthcare services and you may not seek reimbursement from members.
Authorization is required for:
- Advanced Radiology Imaging
- Musculoskeletal – Pain/Joint/Spine
- Outpatient Medical Oncology
- Outpatient Radiation Therapy
- Outpatient Sleep
- Outpatient Specialty Drug
- Lab Management Solutions – Molecular and Genomic Lab Testing
Services performed in conjunction with an inpatient stay, 23-hour observation, or emergency room visit are not subject to authorization requirements.
As of December 9th, 2022, providers can submit eviCore prior authorization requests for services for dates of service Jan. 1, 2023 and after.
To request an authorization:
- Log onto (preferred method)
- Call: 1-855-252-1117 (7 am – 7 pm local time, M-F)
- Fax: 1-800-540-2406
For urgent requests: If services are required in less than 48 hours due to medically urgent conditions, please submit a request online at eviCore and indicate the procedure is NOT routine/standard. Providers can also request urgent requests by calling the toll-free number at 1-855-252-1117. Be sure to tell the representative the request is for medically urgent care.
We recommend ordering physicians request authorization and pass the approval information to the rendering facilities at the time of scheduling. Authorizations contain approval numbers and one or more CPT codes specific to the services authorized. If the service requested and/or performed is different than what was initially authorized, the rendering facility must contact eviCore to make revisions to the authorization prior to claim submission.
Have questions about requesting authorizations? Attend on online orientation session!
The orientation schedule and program training resources are available on the eviCore resources site then select Blue Cross Blue Shield of Texas from drop down list.
eviCore healthcare’s Clinical Guidelines and request forms are available on the eviCore website. Please call Client and Provider Services department at 1(800) 646-0418 (Option 4) if you have any questions or need more information.
eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.
Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any Prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.