New Genetic Testing and Revised Sleep Study Preauthorization Requirements for H-E-B Partners with Blue Choice PPOSM
Updated July 31, 2019 and Posted April 29, 2019
Update 7/31/2019: There has been a delay in transitioning preauthorization requirements for your Blue Cross and Blue Shield of Texas (BCBSTX) patients who are H-E-B partners and have the Blue Choice PPO health plan. The previous effective date of Aug. 1, 2019, for requesting preauthorization from BCBSTX to eviCore healthcare (eviCore), an independent specialty medical benefits management company, has been delayed until Aug. 31, 2019.
Correction 7/10/2019: The H-E-B Members Only Additional Preauthorization Procedure Code List Effective 8/1/2019” was updated to indicate genetic testing code 81212 will require preauthorization through eviCore. Procedure code 81213 previously required preauthorization through BCBSTX and will no longer require any preauthorization.
There are important changes to the preauthorization requirements for your Blue Cross and Blue Shield of Texas (BCBSTX) patients who are H-E-B partners and have the Blue Choice PPO health plan.
Effective Aug. 31, 2019, you will need to obtain preauthorization for an expanded list of molecular and genetic lab procedures through eviCore healthcare (eviCore) an independent specialty medical benefits management company. Also, procedure codes 81211, 81213, 81214, and 95805 that previously required preauthorization through BCBSTX for genetic testing or sleep studies have been removed.
The list of procedures* that will require preauthorization through eviCore as of Aug. 31, 2019, as well as the codes related to Knee/Hip/Spine, Sleep Study/Sleep Apnea and Specialty Drugs that will continue to require preauthorization through BCBSTX for H-E-B members is on our provider website under Clinical Resources then Prior Authorizations & Predeterminations and refer to “H-E-B Members Only Additional Preauthorization Procedure Code List Effective 8/31/2019” .
*This list is not exhaustive of all codes. It is imperative to use Availity® or your preferred vendor to check eligibility and benefits, determine if you are in-network for your patient and whether preauthorization or prenotification is required. Availity allows you to determine if preauthorization is required based on the procedure code. Refer to “Eligibility and Benefits” on the provider website for more information on Availity.
H-E-B partners can be identified by employer group #091043 on their BCBSTX identification cards. Payment may be denied if you perform procedures without authorization. If this happens, you may not bill your patients.
Once you have determined your service requires preauthorization through eviCore, use one of the following methods to obtain authorizations:
- Go online to the eviCore web portal . After a one-time registration, you can initiate a case, check status, review guidelines, view authorizations and eligibility and more. This is the quickest, most efficient way to obtain information.
- Call eviCore at 855-252-1117 toll-free between 6 a.m. to 6 p.m. CT, Monday through Friday and 9 a.m. to noon CT, Saturday, Sunday and legal holidays.
For other services requiring preauthorization through BCBSTX, continue to use iExchange® to preauthorize those services. For more information or to set up an iExchange account, visit iExchange on the provider website.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.