Prior Authorization Code Changes for Administrative Services Only Members

June 2, 2020

What's Changed

We have updated the procedure code list for services requiring prior authorization for administrative services only (ASO) members effective April 20, 2020. These code changes were a result of new, replaced or removed codes implemented by the American Medical Association (AMA). The Prior Authorization Procedure Codes List for ASO Members Effective 4/20/2020 is located on the Utilization Management - Prior Authorizations & Predeterminations page under Prior Authorization Procedure Codes List for Administrative Services Only.

What Providers Need to Do:

Use Availity® or your preferred vendor to check eligibility and benefits, determine if you are in-network for your patient and whether any prior authorization is required for your patient. Availity allows you to determine if prior authorization is required through BCBSTX medical management or another vendor such as eviCore healthcare®, based on the procedure code. Refer to How to Request Prior Authorization or Prenotification section on the Utilization Management - Prior Authorizations & Predeterminations page for information on submitting the prior authorization request. Payment may be denied if you perform procedures without authorization. If this happens, you may not bill your patients.

If you need assistance, view the list of our Network Management offices to contact.

As a reminder, it is important to check eligibility and benefits before rendering services. This step will help you determine if benefit prior authorization is required for a member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on Blue Cross and Blue Shield of Texas (BCBSTX's) provider website.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been prior authorized 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.

eviCore is a trademark of eviCore healthcare, LLC, an independent company that provides utilization review for select health care services on behalf of BCBSTX.

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.

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.