Jan. 25, 2019
Providers can access prior authorization requirements for specific Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes when conducting an eligibility and benefits inquiry through the Availity® Provider Portal. As a reminder, the CPT/HCPCS code inquiry option is for prior authorization determination only and is not a code-specific quote of benefits. Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized is not a guarantee of payment.
How to determine prior authorization requirements for CPT/HCPCS codes via Availity Portal:
- Eligibility and benefit inquiry entry (270) — Select a benefit/service type and/or enter a valid CPT/HCPCS code(s) and the associated place of service. Providers may enter up to eight CPT/HCPCS codes in the inquiry.
Note: If a benefit/service type is not selected, the place of service and at least one CPT/HCPCS code is required. If a CPT/HCPCS code is not entered, the place of service and benefit/service type is required. - Eligibility and benefit inquiry response (271) — Displays specific prior authorization requirements in the Pre-Authorization Info tab for the benefit/service type and/or CPT/HCPCS codes entered in the inquiry. This information is organized in two sections:
- Requested Procedure Code Authorization — Displays prior authorization information for the procedure codes submitted in the inquiry. If no procedure codes are submitted in the request, this section will not display any prior authorization information.
- Service Level Authorization — Displays prior authorization information for the submitted benefit/service type in the inquiry. This section may also include prior authorization information for procedure codes related to the benefit/service type submitted in the inquiry.
When prior authorization is required for a benefit/service type and/or procedure code, the Pre-Authorization Info tab will display a red “Auth Required” badge. If prior authorization is not required a green “No Auth Required” badge is displayed. In some instances, providers may see a gray “Auth Info Unknown” response for the requested benefit/service type. If prior authorization is required or unknown, contact information for completing the request and other important details are included.
Online CPT/HCPCS code inquiry for prior authorization is not returned for the following Blue Cross and Blue Shield of Texas (BCBSTX) members:
- Federal Employee Program® (FEP®)
- Blue Cross Medicare Advantage (HMO)SM and Blue Cross Medicare Advantage (PPO)SM
- Texas Medicaid STAR, STAR Kids and CHIP
Learn More
BCBSTX invites you to join the complimentary webinar training “Back to Basics: Availity 101” which includes how to verify prior authorization requirements for benefits using procedure codes or contact our Provider eBusiness Consultants at PECS@bcbstx.com for specific training needs or additional information. Please visit the Provider Training page on the BCBSTX provider website to view available training sessions.
Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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 or contract of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.
CPT copyright 2018 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
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. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by independent third-party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.