12/26/2023
Our Utilization Management (UM) program provides BCBSTX information supporting the care you render our members. Our preservice review process, including required prior authorizations or optional recommended clinical reviews, use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan, care and place of setting options.
Member benefits where to begin
Before rendering care or services, always check eligibility and benefits first, via Availity® Essentials or your preferred web vendor. In addition to verifying membership and coverage status, this step returns information on prior authorization requirements and utilization management, depending on the vendor.
Note: If you deliver care or services without a prior authorization when one is required, a post service medical necessity review will be conducted and you, not the member, would be responsible for any non-covered charges.
Reminders as you render care to BCBSTX members
- Leverage information on UM website explaining various review types needed or suggested that can help with timely payment, reduce delays and denials.
- Review member benefits for prior authorization requirements and recommended clinical reviews as they may vary based on services rendered and benefit plan
- Refer to code lists and details on how to submit.
- Reference review requirements and recommendations as they may vary based on services rendered and individual/group policy elections.
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 third party vendors.