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2017 Updates to the Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM Preauthorization Lists

September 29, 2016

Blue Cross and Blue Shield of Texas (BCBSTX) has updated the list of procedures requiring preauthorization for our Blue Cross Medicare Advantage (PPO) PDF Document and Blue Cross Medicare Advantage (HMO) PDF Document plans. Both updated preauthorization lists will be effective January 1, 2017. If you are not participating in the Blue Cross Medicare Advantage (PPO) network or Blue Cross Medicare Advantage (HMO) network, disregard the information pertaining to that plan.

BCBSTX will require notification of inpatient admission for post stabilization care within one (1) business day following treatment of an emergency medical condition. Failure to timely notify BCBSTX and obtain pre-approval for further post-stabilization care services may result in denial of the claim(s) for such post-stabilization care services, which cannot be billed to the member pursuant to your provider agreement with BCBSTX.

Additionally, when a Blue Cross Medicare Advantage (PPO) or Blue Cross Medicare Advantage (HMO) member arrives at the facility for an elective admission, providers should notify the BCBSTX Utilization Management Department in order to assist in patient care coordination.

Attached are the updated preauthorization lists. They are also located under the Standards & Requirements tab, General Reimbursement Information area at bcbstx.com/provider.

As a reminder, – iExchange, our automated referral and preauthorization tool, is available 24 hours a day, seven days a week (with the exception of every third Sunday of the month when the system will be unavailable from 11 a.m. to 3 p.m. CT). iExchange is accessible to physicians, professional providers and facilities contracted with BCBSTX. For more information or to set up a new account, complete and submit the online enrollment form located at http://www.bcbstx.com/provider/tools/iexchange.html.

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