What’s New: Blue Cross and Blue Shield of Texas (BCBSTX) will be updating its lists of procedure codes requiring prior authorization, for some commercial members, to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association (AMA).
Changes include the following:
- Specialty Pharmacy code J0897 – Previously this code was reviewed only by AIM Specialty Health®. As of 8/1/22, if the drug requested is not associated with an oncology diagnosis, it will be reviewed by BCBSTX. It will continue to be reviewed by AIM if supported by an oncology diagnosis.
- Medical/Surgical codes 23130 and C9757 are being removed effective 7/1/2022.
More Information: Refer to Prior Authorization Lists on the Utilization Management section of our provider website. Revised lists can be found on Prior Authorization Lists for Fully Insured and Administrative Services Only (ASO) Plans.
Check Eligibility and Benefits: To identify if a service requires prior authorization for our members, check eligibility and benefits through Availity® Essentials or your preferred vendor.
Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
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.
AIM Specialty Health (AIM) is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.
BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.