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Verify Prior Authorization Requirements via Availity®

September 2, 2020

Providers can electronically verify Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) code-specific prior authorization requirements and submit prior authorization requests handled by Blue Cross and Blue Shield of Texas (BCBSTX) all within the Availity Provider Portal.

Checking patient eligibility and benefits is an imperative first step to confirm coverage and prior authorization requirements prior to rendering services. The Availity Eligibility and Benefits Inquiry allows you to quickly obtain prior authorization requirements by procedure code, along with contact information for the prior authorization entity. As a reminder, the procedure code inquiry option is for prior authorization determination only and is not a code-specific quote of benefits.

Step 1 – Determine code-specific prior authorization requirements via Availity:

  • Complete the eligibility and benefit inquiry entry (ANSI 270) by selecting a benefit/service type and/or enter a valid CPT/HCPCS code(s) and the associated place of service. Providers may enter up to eight CPT/HCPCS codes in the inquiry.
  • The eligibility and benefit inquiry response (ANSI 271) displays specific prior authorization requirements in the Pre-Authorization Info tab for the benefit/service type and/or CPT/HCPCS codes entered in the inquiry.

Note: If a benefit/service type is not selected, the place of service and at least one CPT/HCPCS code is required. If a CPT/HCPCS code is not entered, the place of service and benefit/service type is required.

Exceptions
CPT/HCPCS code inquiry for prior authorization is not yet supported for the following lines of business:

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

Step 2 – Submit required prior authorization requests handled by BCBSTX via Availity:

  • Select the Patient Registration menu option, choose Authorizations & Referrals, then Authorizations
  • Select Payer BCBSTX, then select your organization
  • Select Inpatient Authorization or Outpatient Authorization
  • Enter preauthorization request
  • Review and submit

Important Reminders

The process of submitting benefit prior authorization requests through eviCore® healthcare (eviCore) or other vendors has not changed.

For More Information

Refer to the educational Availity Eligibility and Benefits user guide , Availity Authorizations user guide and Availity Referrals user guide located under the Provider Tools section of our website. Additionally, you can visit our Provider Training page to register for upcoming online training sessions.

Have additional questions or need customized training? Email our Provider Education Consultants for assistance.

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 or contract 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 2020 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 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.