Correction: New Genetic Testing and Revised Sleep Study Prior Authorization Requirements for H-E-B Partners with Blue Choice PPOSM

July 10, 2019

Updated July 10, 2019 Posted April 29, 2019

Correction: The "H-E-B Members Only Additional Prior Authorization Procedure Code List Effective 8/1/2019" was updated to indicate genetic testing code 81212 will require prior authorization through eviCore. Procedure code 81213 previously required prior authorization through BCBSTX and will no longer require any prior authorization.

There are important changes to the prior authorization requirements for your Blue Cross and Blue Shield of Texas (BCBSTX) patients who are H-E-B partners and have the Blue Choice PPO health plan.

Effective Aug. 1, 2019, you will need to obtain prior authorization for an expanded list of molecular and genetic lab procedures through eviCore healthcare (eviCore) an independent specialty medical benefits management company. Also, procedure codes 81211, 81213, 81214, and 95805 that previously required prior authorization through BCBSTX for genetic testing or sleep studies have been removed.

The list of procedures* that will require prior authorization through eviCore as of Aug. 1, 2019, as well as the codes related to Knee/Hip/Spine, Sleep Study/Sleep Apnea and Specialty Drugs that will continue to require prior authorization through BCBSTX for H-E-B members is on our provider website under Clinical Resources then Prior Authorizations/Notifications/Referral Requirements and refer to “H-E-B Members Only Additional Prior Authorization Procedure Code List Effective 8/1/2019”.

*This list is not exhaustive of all codes. It is imperative to use Availity® or your preferred vendor to check eligibility and benefits, determine if you are in-network for your patient and whether prior authorization or prenotification is required. Availity allows you to determine if prior authorization is required based on the procedure code. Refer to “Eligibility and Benefits” on the provider website for more information on Availity.

H-E-B partners can be identified by employer group #091043 on their BCBSTX identification cards. Payment may be denied if you perform procedures without authorization. If this happens, you may not bill your patients.

Once you have determined your service requires prior authorization through eviCore, use one of the following methods to obtain authorizations:

  • Go online to the eviCore web portal. After a one-time registration, you can initiate a case, check status, review guidelines, view authorizations and eligibility and more. This is the quickest, most efficient way to obtain information.
  • Call eviCore at 1-855-252-1117 toll-free between 6 a.m. to 6 p.m. CT, Monday through Friday and 9 a.m. to noon CT, Saturday, Sunday and legal holidays.

For other services requiring prior authorization through BCBSTX, continue to use iExchange® to preauthorize those services. For more information or to set up an iExchange account, visit iExchange on the provider website.

If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.