Preauthorization/Prior Authorization Rules and Retrospective Reviews for Medical Necessity

October 30, 2017

There are certain services that require preauthorization/prior authorization and the requirements are specific to each Blue Cross and Blue Shield of Texas (BCBSTX) network. BCBSTX posts the Preauthorizations/ Notifications/Referral Requirements Lists for all its networks (e.g., Blue Advantage HMOSM, Blue EssentialsSM and Blue PremierSM, etc.) on the BCBSTX provider website under Clinical Resources.

Preauthorizations/Prior Authorization are required to allow for medical necessity review. Claims for services rendered without preauthorization/prior authorization for services requiring it will be denied and provider will be held responsible. Please be aware, retrospective reviews for medical necessity will not be performed for any HMO plans except in limited special circumstances.