July 22, 2019
There are important changes to the preservice appeals process for patients enrolled in Medicare Advantage plans offered by Blue Cross and Blue Shield of Texas (BCBSTX).
Beginning Nov. 1, 2019, eviCore® healthcare (eviCore), an independent medical benefits management company, will no longer administer the appeals process for denied and partially denied Medicare Advantage prior authorization requests. BCBSTX will assume responsibility for conducting the preservice appeals process, from preservice appeal intake to appeal determination. eviCore will, however, continue its role in administering the initial determination of prior authorization requests. These changes are designed to streamline workflows and lead to an improved member and provider experience.
Note: The medical policies being used for these preservice appeal reviews will not change. Remember when submitting a pre–service appeal to always follow the directions included within the denial letter.
Going forward, it is critical to use Availity® or your preferred vendor to check eligibility and benefits, to determine if you are in–network for your patient and to determine whether any preauthorization or prenotification is required. Availity allows you to determine if preauthorization is required based on the procedure code. Refer to “Eligibility and Benefits” on the BCBSTX provider website for more information on Availity. Providers can also refer to the Prior Authorizations & Predeterminations page on our website for assistance.
Payment may be denied if you perform procedures without obtaining prior authorization when prior authorization is required. If this happens, you may not bill your patients.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Consultant.
As a reminder, it is important to check eligibility and benefits prior to rendering services. This step will help you determine if benefit preauthorization is required for a particular member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSTX’s provider website.
Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized 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.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
eviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSTX. eviCore is wholly responsible for its own products and services. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by eviCore.
iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers.
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 BCBSTX.
BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore, AIM or Medecision. 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.
Plans provided by Blue Cross and Blue Shield of Texas, which refers to HCSC Insurance Services Company (HISC) (PPO plans), and also to GHS Insurance Company (GHS) (HMO, and HMO Special Needs Plans). HISC and GHS are Independent Licensees of the Blue Cross and Blue Shield Association. HISC is a Medicare Advantage organization with a Medicare contract. GHS is a Medicare Advantage organization with a Medicare contract and a contract with the Texas Medicaid program. Enrollment in HISC’s and GHS’ plans depends on contract renewal.