July 26, 2019
In a December 2018 News & Updates article, Blue Cross and Blue Shield of Texas (BCBSTX) announced a new online capability that allows providers to verify prior authorization requirements for specific Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes via an eligibility and benefits inquiry in the Availity® Provider Portal. Since this implementation, many updates have been made to improve the process.
HOW TO RECEIVE ACCURATE RESULTS
To ensure code-specific prior authorization requirements are returned online, a valid CPT/HCPCS code(s)* and associated place of service must be submitted in the eligibility and benefits inquiry (270). If a CPT/HCPCS code is not entered, then the place of service and benefit/service type are required. If a benefit/service type is not selected, the place of service and at least one CPT/HCPCS code is required. Additionally, no benefit or prior authorization information will return for the benefit/service type if one is not selected.
*Providers may enter up to eight procedure codes in the inquiry.
The eligibility and benefits inquiry response (271) displays prior authorization requirements in the Pre-Authorization Info tab. In some instances, providers may receive an “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.
As a reminder, the CPT/HCPCS code inquiry option is for prior authorization determination only and is not a code-specific quote of benefits.
EXCEPTIONS
Online code-specific prior authorization information is not yet available for the following 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
RESOURCES
Learn how to successfully verify prior authorization requirements for benefits and procedure online by referencing the General Eligibility and Benefits Expanded Tip Sheet located in the Provider Tools section at on the provider website. For additional assistance, contact the Provider Education Consultants.
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 2019 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 Blue Cross and Blue Shield of Texas (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.