Posted 10/04/2022 - Updated 12/02/2022 & 10/28/2022
Blue Cross and Blue Shield of Texas (BCBSTX) will be updating its lists of Current Procedural Terminology (CPT®) 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).
In addition, to the changes originally posted Oct. 4th and Oct. 28th, 2022, below are additional changes effective Jan. 1, 2023:
- Code list will be updated Jan. 1, 2023 to include codes for the existing PA Transplant Category. There is no change to BCBSTX’s PA requirements.
- Replacement of a Specialty Pharmacy code reviewed by BCBSTX
- Removal of Outpatient Surgery-Obesity codes previously reviewed by BCBSTX
- Removal of Behavioral Health codes previously reviewed by BCBSTX
- Replacement of Behavioral Health codes reviewed by BCBSTX
- Removal of Molecular Genetic Testing codes previously reviewed by AIM
Changes posted Oct. 28, 2022 include:
- Removal of Musculoskeletal – Joint and Spine codes previously reviewed by AIM Specialty Health® (AIM)
- Removal of a Molecular Genetic Lab code previously reviewed by AIM
- Removal of a Specialty Pharmacy code previously reviewed by BCBSTX, that will continue to be reviewed by AIM
- Replacement of a Specialty Pharmacy code reviewed by AIM
- Removal of Orthopedic Musculoskeletal codes previously reviewed by BCBSTX
Changes posted Oct. 4, 2022 include:
- Addition of new Medical Oncology and Supportive Care Current drugs and codes to be reviewed by AIM Specialty Health® (AIM)
- Medical Oncology and Supportive Care codes previously reviewed by BCBSTX to be reviewed by AIM
- Addition of a Radiation Oncology code to be reviewed by AIM
Refer to Prior Authorization Lists on the Utilization Management section of our provider website, Revised lists can be found on the Prior Authorization Lists for Fully Insured and Administrative Services Only (ASO) Plans page.
Check Eligibility and Benefits: To identify if a service requires prior authorization for our members, check eligibility and benefits through Availity® 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.
CPT copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
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 third party vendors and the products and services they offer.