eviCore Preauthorization Requirements
Blue Cross and Blue Shield of Texas (BCBSTX) contracts with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to administer preauthorization requirements for select specialized services and products for BCBSTX members.
For a detailed list of the services that require authorization through eviCore, refer to the eviCore implementation site .
To determine which specialized clinical services require preauthorization/prior authorization through eviCore for your member, providers should check eligibility, benefits and preauthorization requirements through Availity® or your preferred vendor. Also, reference the Preauthorization/Referral/Notification page on the BCBSTX provider website. Services performed without authorization may be denied for payment and you may not seek reimbursement from members.
Note: Some plans may require inpatient musculoskeletal surgery medical necessity authorization through eviCore and the provider will be required to supply the eviCore preauthorization number to BCBSTX to obtain a BCBSTX preauthorization number for the inpatient stay.
eviCore authorizations can be obtained using one of the following methods:
- Use the eviCore healthcare web portal , which is available 24/7. After a one-time registration, you can initiate a case, check status, review guidelines, view authorizations and eligibility, and more. The web portal is the quickest, most efficient way to obtain information.
- Call eviCore at 855-252-1117 toll-free between 6 a.m. - 6 p.m. CT, Monday through Friday and 9 a.m. – noon CT, Saturday, Sunday and legal holidays.
For all other services that require a referral and/or authorization through BCBSTX, continue to use iExchange®. iExchange is accessible to all physicians, professional providers and facilities. You can learn more about iExchange or set up a new account on the BCBSTX provider website.
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. 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.