We are changing the prior authorization requirements for Blue Cross Medicare AdvantageSM members to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association (AMA) effective July 1, 2022.
- Addition of one Outpatient Sleep code to be reviewed by eviCore® healthcare (eviCore)
- Addition of two Outpatient Specialty Drug codes to be reviewed by eviCore
- Addition of Outpatient Specialty Drug, Susvimo, reported with codes J3590 or C9399 to be reviewed by eviCore
- Addition of Outpatient Specialty Drugs, Cortophin and Vyvgart reported with codes J3490, J3590, or C9399 to be reviewed by eviCore
Refer to the Utilization Management section of our provider website for access to the Prior Authorization Lists. 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.
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.
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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.
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.