What’s Changing: Blue Cross and Blue Shield of Texas (BCBSTX) is changing prior authorization requirements for Medicare members to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association (AMA). A summary of changes is included below.
Medicare: Refer to Prior Authorization Lists on the Utilization Management section of our provider website. The revised lists can be found on the Prior Authorization Lists for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM page.
Changes effective 04/01/2023 include:
- Addition of lab codes to be reviewed by eviCore
- Addition of musculoskeletal codes to be reviewed by eviCore
- Addition of radiation oncology codes to be reviewed by eviCore
- Removal of a musculoskeletal code previously reviewed by eviCore
- Addition of a Specialty Pharmacy code to be reviewed by BCBSTX
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 2022 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.
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSTX.
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