Update to Additional Detail for BCBSTX Preauthorization Requirements Beginning January 1, 2019

December 26, 2018

Posted November 16, 2018 Updated December 26, 2018 (Note: no additional preauthorization services added.)

Effective January 1, 2019, benefit plans, managed by Blue Cross and Blue Shield of Texas (BCBSTX), will be updating preauthorization and prenotification requirements.

Patient eligibility and benefits should be verified prior to every scheduled appointment. Eligibility and benefit information includes membership validation, coverage status and, preauthorization requirements. To obtain fast, efficient, detailed information for BCBSTX members, please access the Availity® Eligibility and Benefits Tool . You must be registered with Availity to gain access to this free online tool. Additional tip sheets are available on the Claims and Eligibility section of the BCBSTX provider website. Procedure code-specific preauthorization verification is now available on Availity.

Below is a list of the impacted care categories that may need preauthorization for various networks effective January 1, 2019:

  • Molecular and genomic testing
  • Radiation therapy
  • Advanced Imaging
  • Cardiac (heart related)
    • Cardiac advanced imaging services (MRI, MRA, PET, PET-CT, CT, CTA, Nuclear Medicine)
  • Sleep Medicine
    • Sleep studies and sleep durable medical equipment (DME)
  • Orthopedic (Musculoskeletal)
    • Artificial intervertebral disc
    • Autologous chondrocyte implantation (ACI) for focal articular cartilage lesions
    • Femoroacetabular impingement (FAI) syndrome
    • Functional neuromuscular electrical stimulation (FNMES)
    • Joint and spine surgery
    • Lumbar spinal fusion
    • Meniscal allografts and other meniscal implants
    • Orthopedic applications of stem cell therapy
  • Pain Management
    • Occipital nerve stimulation
    • Surgical deactivation of headache trigger sites
    • Interventional pain management
    • Percutaneous and implanted nerve stimulation and neuromodulation
    • Spinal cord stimulation
  • Surgical Procedures
    • Mastopexy; breast lift
    • Orthognathic surgery; face reconstruction
    • Reduction mammoplasty; breast reduction
  • Ear, Nose and Throat (ENT)
    • Bone conduction hearing aids
    • Cochlear implant
    • Nasal and sinus surgery
  • Gastroenterology (Stomach)
    • Gastric Electrical Stimulation (GES)
  • Neurological
    • Deep brain stimulation,
    • Sacral nerve neuromodulation/stimulation,
    • Vagus nerve stimulation (VNS)
  • Wound Care
    • Hyperbaric oxygen (HBO2) therapy
  • Non-Emergent Fixed Wing Air Ambulance
  • Specialty Pharmacy including Infusion Site of Care

Not all requirements apply to each BCBSTX network (Blue Choice PPOSM, Blue EssentialsSM, Blue PremierSM or Blue Advantage HMOSM). It is imperative that providers check eligibility and benefits and verify preauthorization requirements through Availity or their preferred vendor. If preauthorization is required, this step will determine who to contact.

A 2019 BCBSTX Outpatient Preauthorization Requirements by Procedure Code PDF Document list as well as a list of services that may require preauthorization or prenotification is available under Clinical Resources then Preauthorizations/Notifications/Referral Requirements on the BCBSTX provider website. The list of procedure codes is not exhaustive of all services that may require preauthorization. Not all requirements apply to every BCBSTX plan.

The AIM Specialty Health® prenotification process will continue for Blue Choice PPO if the member's group has not selected to require preauthorization through eviCore for Advanced Imaging services. If the AIM Radiology Quality Initiative (RQI) program applies to the member, you will continue to contact AIM for the RQI.

Watch for updates on the provider website including available training sessions. If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. Aerial, iExchange and Medecision® are trademarks of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity or Medecision. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.

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. Benefit determination will occur when a claim is received and will be based on other things such as the member’s eligibility and terms of the member’s certificate of coverage applicable on the date of services when renders.