What’s Changing: Blue Cross and Blue Shield of Texas (BCBSTX) is changing prior authorization requirements for Medicare Advantage members to reflect new, replaced or removed codes due to updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association (AMA) or Healthcare Common Procedure Coding System (HCPCS) changes from the Centers for Medicaid & Medicare Services.
Medicare: Refer to Prior Authorization Lists on the Utilization Management section of our provider website. The revised lists can be found on the Prior Authorization Lists for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM page.
Changes effective Jan. 1, 2023 include
- Addition of Sleep drug codes to be reviewed by eviCore
- Addition of a Radiation Oncology code to be reviewed by eviCore
- Addition of Specialty Drug codes to be reviewed by eviCore
- Addition of prior authorization codes to be reviewed by BCBSTX
- Removal of prior authorization codes previously reviewed by BCBSTX
Check Eligibility and Benefits: To identify if a service requires prior authorization for our members, check eligibility and benefits through Availity® or your preferred vendor.
Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
CPT copyright 2021 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 healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for 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.