Oct. 28, 2019
As a reminder, checking eligibility and benefits electronically through the Availity® Provider Portal or your preferred web vendor is the quickest way to access coverage and prior authorization/preauthorization information for Blue Cross and Blue Shield of Texas (BCBSTX) members.
However, if you need to use the Interactive Voice Response (IVR) phone system instead, as of Oct. 21, 2019, providers can now verify procedure code prior authorization requirements for outpatient, office and home services when calling the IVR for most* BCBSTX members. This IVR enhancement will improve provider administrative efficiencies and ultimately reduce call and/or hold time with BCBSTX. Checking procedure code(s) in the IVR is for prior authorization determination only and is not a code-specific quote of benefits.
*Checking code-specific prior authorization in the IVR is not available for the following members:
- Federal Employee Program® (FEP®)
- Blue Cross Medicare Advantage (HMO)SM and Blue Cross Medicare Advantage (PPOSM
- Texas Medicaid STAR, STAR Kids and CHIP
How to determine procedure code prior authorization requirements via IVR phone system:
- If calling BCBSTX (1-800-451-0287) to verify eligibility and benefits for outpatient, office or home services, the IVR provides an optional prompt to "check preauthorization by procedure code" after eligibility and benefits are quoted.
- If calling BCBSTX (1-800-441-9188) to initiate and submit an outpatient, office or home prior authorization request, the IVR will request a procedure code to determine if the specific code(s) requires prior authorization before initiating the request.
- IVR quotes prior authorization requirements based on the code(s) entered.
- Confirmation number for the quote is provided to the caller.
- Callers can request a faxed response of the IVR quote once completed.
- You may verify up to five procedure codes during the IVR quote.
- If you do not have a procedure code when the IVR prompts for it, say "I don't have one" and the system will quote prior authorization requirements based on the benefit category instead (i.e., physical therapy, surgical, etc.).
- If no prior authorization is required, you will be returned to the main menu in the IVR.
For step-by-step IVR navigational assistance, refer to the Eligibility and Benefits Caller Guide or Outpatient Preauthorization Caller Guide located on our Provider website.
If you need additional support or have further questions, contact our Provider Education Consultant team at PECS@bcbstx.com.
Checking eligibility and/or benefit information 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 any questions, please call the number on the member's ID card.
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.