Update to Blue Advantage HMOSM and Blue Advantage PlusSM HMO Preauthorization/Referral List – Preauthorization Required for Specific Outpatient Surgeries

September 28, 2016

Effective Jan. 1, 2017, there will be a requirement for a preauthorization for a designated list of surgical CPT codes if performed in an outpatient hospital setting for members enrolled in Blue Advantage HMOSM or Blue Advantage PlusSM HMO. Preauthorization for these services is processed through Medical Management Review, by calling the number on back of the member's ID card.

The updated Blue Advantage HMO/Blue Advantage Plus HMO Preauthorization/Referral Requirements List reflecting the applicable CPT codes will be located in the General Reimbursement Information section of the Blue Cross and Blue Shield of Texas (BCBSTX) provider website.

At BCBSTX, we use preauthorization requirements to help make sure that the service or drug being requested is medically necessary and appropriate, follows up-to-date medical recommendations, is the most economical treatment, is not being duplicated, and is actually helping.

This is one of many things we are doing to make the health care system work better, by focusing on improving health care delivery as well as finding solutions to aid in reducing unnecessary health care costs for everyone. We want our members to receive the best health outcomes for all of the dollars spent on their care.

As noted on the preauthorization requirements list, you can use iExchange®, our automated referral and preauthorization tool for other applicable services. iExchange is available to physicians, professional providers and facilities that are contracted with BCBSTX, and is available 24 hours a day, seven days a week (with the exception of every third Sunday of the month when the system is unavailable from 11 a.m. to 3 p.m. CT). For more information or to set up a new account, complete and submit the iExchange online enrollment form.

Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.