Blue EssentialsSM and Blue Essentials AccessSM Changes to Preauthorization Services Including New Health Advocacy Solutions Service Option Effective Jan. 1, 2018

October 2, 2017

Blue Cross and Blue Shield of Texas (BCBSTX) will be changing the preauthorization requirements for Blue Essentials and Blue Essentials Access members including a new Health Advocacy Solutions service option for Blue Essentials Access self-funded groups. The changes include care categories that require preauthorization through eviCore healthcare (eviCore), an independent specialty medical benefits management company for Blue Essentials Access self-funded groups who have selected the health advocacy solutions service option. Also, there are additional care categories for Blue Essentials and Blue Essentials Access fully insured members that will require preauthorization by BCBSTX.

Effective September 1, 2017 eviCore began managing the pre-service authorization for the following specialized clinical services for Blue Essentials and Blue Essentials Access fully insured members:

  • Molecular and genomic testing
  • Radiation oncology for all outpatient and office services
  • Advanced Radiology Imaging
  • Sleep Studies and Sleep Durable Medical Equipment

Effective January 1, 2018, the above preauthorization requirements will also apply to the Blue Essentials AccessSM self-funded groups who select the health advocacy solutions service option.

Also, effective January 1, 2018, the preauthorization lists should be reviewed for the following care categories for fully insured members with Blue Essentials and Blue Essentials Access to determine if authorization is required through BCBSTX:

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

The updated Blue Essentials and Blue Essentials AccessSM Preauthorization /Referral Requirements List that includes the services listed above which require preauthorization for dates of service beginning January 1, 2018 will be located on the provider website under the Clinical Resources section. Services performed without authorization may be denied for payment and you may not seek reimbursement from member/subscribers.

Preauthorizations for the above services through eviCore can be obtained by accessing or calling 855-252-1117. eviCore will be hosting education sessions December 5th, 6th and 7th, 2017. During these training sessions, BCBSTX will also provide a brief overview of the new health advocacy solutions benefit and AvailityTM roles. Anyone wishing to attend one of the sessions must register in advance.

Sessions are free of charge and will last approximately one hour. You may register on the website under Training Center. Find the orientation sessions named “Blue Cross and Blue Shield of Texas Provider Program Name Orientation Session” and select by Program Name (Radiation Therapy, Genomic Lab, Radiology, Sleep Testing or Sleep DME).Refer to the eviCore website under Training Center Learn more about third-party links for future sessions

For all other services that require a referral, and/or preauthorization, as noted on the Preauthorization/Referral Requirements List, you will continue to use iExchange® Learn more about third-party links. iExchange is accessible to physicians, professional providers and facilities contracted with BCBSTX. You can learn more information about iExchange Learn more about third-party links or set up a new account under Clinical Resources on the provider website.

Check the BCBSTX provider website and the Blue Review newsletter in the coming weeks, for additional information from BCBSTX and eviCore including training opportunities.

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.