Blue Advantage HMOSM and Blue PremierSM Changes to Preauthorization Requirements Effective Jan.1, 2018

October 2, 2017

Beginning January 1, 2018, providers will be required to obtain preauthorization through Blue Cross and Blue Shield of Texas (BCBSTX) or eviCore for certain procedures as noted below. These new preauthorization requirements will apply to the fully insured members with Blue Advantage HMO and Blue Premier plans.

The new preauthorization requirements care categories for fully insured members in Blue Advantage HMO and Blue Premier are listed below:

  • Cardiology
  • Ear, nose and throat (ENT)
  • Gastroenterology
  • Musculoskeletal (MSK)
  • Neurology
  • Non emergent Air ambulance
  • Outpatient surgery
    • Orthognathic Surgery
    • Mastopexy
    • Reduction Mammaplasty
  • Sleep Studies
  • Wound Care

The updated, applicable Preauthorization/Referral Requirements Lists will be available in the Clinical Resources section of our provider website.

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 and preauthorization requirements. 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. Services performed without preauthorization may be denied for payment. You may not seek reimbursement for denied payments from members. Please note, a member penalty may also apply based on the benefit plan. When services may not be covered, members should be notified that they may be billed directly.

To obtain preauthorization through BCBSTX for the care categories noted above, you will continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSTX. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our provider website.

Preauthorization for care categories authorized through eviCore can be obtained by accessing or calling 855-252-1117.

Our goal is to provide our members with access to quality, cost-effective health care. If you have any questions or if you need additional information, please contact your Network Management Representative.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member's ID card.

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

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.