Procedure Code Updates for Prior Authorization

June 29, 2020

On Sept. 1, 2020, Blue Cross and Blue Shield of Texas (BCBSTX) will update its list of Current Procedural Terminology (CPT®) codes to comply with changes from the American Medical Association (AMA) Learn more about third-party links. These changes are the result of new, replaced or removed codes implemented by the AMA

What Should You Do

Providers will need to utilize the new list of procedure codes under on the Utilization Management - Prior Authorization & Predetermination page when determining if a service requires prior authorization Sept. 1, 2020, and after. You should also use Availity® or your preferred vendor for prior authorization requirements. Payment may be denied if you perform procedures without authorization. If this happens, you may not bill your patients.

Plans Affected

The following plans are affected by these changes:

  • Blue Choice PPOSM
  • Blue EssentialsSM and Blue Essentials AccessSM
  • Blue PremierSM and Blue Premier AccessSM
  • Blue AdvantageSM and Blue Advantage HMOSM Plus
  • MyBlue HealthSM

Check Eligibility and Benefits: Before rendering services, providers should check eligibility and benefits through Availity® or your preferred vendor to confirm membership, check coverage, determine if you are in-network for the member's policy and determine whether prior authorization is required. Availity allows prior authorization determination by procedure code. Locate How to Submit Prior Authorizations on the Utilization Management - Prior Authorizations and Predeterminations page to determine how to submit requests when it is determined if BCBSTX Medical Management, Magellan Healthcare®, eviCore Healthcare® or AIM Specialty Health® handles prior authorization or prenotification for your services or procedure codes.

More Information: Check the AMA website Learn more about third-party links for more information on CPT code changes. If you have questions, contact your Network Management Office location.

CPT copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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

eviCore® is a trademark of CareCore National, LLC, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Texas

AIM Specialty Health is an independent medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas (BCBSTX).

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.

As a reminder, it is important to check eligibility and benefits before rendering services. This step will help you determine if 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.