Check Online for Procedure Code-Specific Benefit Preauthorization Requirements

December 3, 2018

As you know, it’s important to check eligibility and benefits first to determine if benefit preauthorization is required for Blue Cross and Blue Shield of Texas (BCBSTX) members. Requesting benefit preauthorization is not a substitute for checking eligibility and benefits. Obtaining benefit preauthorization, if required, may help alleviate claim and back-end process denials.

To help ensure that you have quick access to benefit preauthorization requirements for specific Current Procedural Terminology (CPT/) or Healthcare Common Procedure Coding System (HCPCS) codes, Blue Cross and Blue Shield of Texas (BCBSTX) will soon be implementing an electronic alternative. With this change when you conduct electronic eligibility and benefits inquiries/responses (270/271 transactions) through the Availity® Provider Portal or your preferred web vendor, you will have the option to verify if specific CPT and/or HCPCS codes require benefit preauthorization.

The CPT/HCPCS code inquiry option is for benefit preauthorization determination only and is not a code-specific quote of benefits or eligibility. (To verify if a CPT/HCPCS code is a covered benefit for a specific patient, you may need to speak with a Customer Advocate). Refer to the Eligibility and Benefits Caller Guide for more information.

How to check benefit preauthorization requirements online for CPT/HCPCS codes:

  • Enter the optional CPT/HCPCS code(s) and the associated place of service on the Eligibility and Benefit Inquiry entry screen (270), through the Availity portal or your preferred web vendor.
  • The Pre-Authorization Info tab on the Eligibility and Benefit Inquiry response (271) will display specific benefit preauthorization requirements based on the CPT/HCPCS codes entered.
  • The Pre-Authorization Info tab will also indicate contact information for completing the benefit preauthorization request, and other important details.

Note: To receive an online quote of benefits, make sure you select a Benefit/Service Type when completing the Eligibility and Benefit Inquiry (270). If a Benefit/Service Type is not selected, you will only receive benefit preauthorization requirements for the CPT/HCPCS code entered.

Currently, the online CPT/HCPCS code inquiry option for benefit preauthorization is not available for the following BCBSTX members:

  • Federal Employee Program® (FEP)
  • Blue Cross Medicare Advantage (HMO)SM and Blue Cross Medicare Advantage (PPO)SM
  • Texas Medicaid STAR, STAR Kids and CHIP

For More Information
Watch the News and Updates for implementation announcements and related resources.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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 any questions, please call the number on the member’s ID card.

CPT copyright 2018 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by independent third-party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.