Correction to the New Preauthorization Requirements through eviCore effective June 1, 2017 for Blue Cross Medicare Advantage HMO SM and Blue Cross Medicare Advantage PPO SM
Blue Cross and Blue Shield of Texas (BCBSTX) previously notified providers that it has contracted with eviCore healthcare (eviCore)*, an independent specialty medical benefits management company to provide Utilization Management services for new preauthorization requirements outlined below for the Blue Cross Medicare Advantage HMOSM and Blue Cross Medicare AdvantageSM PPO provider networks.
A correction was made to the preauthorization list, that will be effective 6/1/2017, regarding codes E0748 and 22614. Preauthorization of codes E0748 and 22614 will be handled by eviCore instead of BCBSTX. Refer to information below on how to contact eviCore to preauthorize these services.
In addition, the Cardiac Rhythm Implantable Device (CRID) implementation has been delayed and will not be part of the eviCore program on 6/1/2017. Please look for updates regarding the CRID implementation in the near future.
As a reminder, below is the list of the specialized clinical services that eviCore will manage for preauthorization for Blue Cross Medicare Advantage HMO and Blue Cross Medicare Advantage PPO effective 6/1/2017:
- Outpatient Molecular Genetics
- Outpatient Radiation Therapy
- Physical and Occupation Therapy
- Speech Therapy
- Spine Surgery (Outpatient/Inpatient)
- Spine Lumbar Fusion (Outpatient/Inpatient)
- Interventional Pain
- Outpatient Cardiology and Radiology
- Abdomen Imaging
- Cardiac Imaging
- Chest Imaging
- Head Imaging
- Neck Imaging
- Obstetrical Ultrasound Imaging
- Oncology Imaging
- Pelvis Imaging
- Peripheral Nerve Disorders (Pnd) Imaging
- Peripheral Vascular Disease (Pvd) Imaging
- Spine Imaging
- Outpatient Medical Oncology
- Outpatient Sleep
- Outpatient Specialty Drug
The Blue Cross Medicare Advantage HMO Preauthorization Requirements List and Blue Cross Medicare Advantage PPO Preauthorization Requirements List posted under Clinical Resources on the BCBSTX website have been updated to include the above services that require preauthorization through eviCore for dates of service beginning June 1, 2017. A detailed list of CPT codes that apply to the above services, are listed on the BCBSTX Medicare eviCore implementation site .
To obtain preauthorization through eviCore you may use one of the following methods:
- The eviCore HealthCare Web Portal will be available 24x7. After a one-time registration, you can initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
- Texas Providers can call toll-free at 855-252-1117 between 6 a.m. to 6 p.m. (central time) Monday through Friday and 9 a.m. to noon on Saturdays, Sundays and legal holidays.
eviCore will be conducting training sessions for Blue Cross Medicare Advantage plans May 16 - May 31.
For all other services (not listed above), that require a referral and/or preauthorization, providers should refer to the telephone numbers on the members'ID card or physicians, professional providers and facilities contracted with BCBSTX can access iExchange. To learn more or set up a new account for iExchange go to www.bcbstx.com/provider/tools/iexchange.html.
Services performed without preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek reimbursement from the member.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.
* eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSTX.
** Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.