Update to Prior Authorization Codes for Commercial Members, Effective July 1, 2023


What’s New: Blue Cross and Blue Shield of Texas (BCBSTX) will be updating its lists of codes requiring prior authorization, for some commercial members, to reflect new, replaced or removed codes. These changes are based on updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association (AMA) or Healthcare Common Procedure Coding System (HCPCS) changes from the Centers for Medicaid & Medicare Services.

Changes effective July 1, 2023 include:

  • Addition of Medical Oncology* codes to be reviewed by Carelon Medical Benefits Management (Carelon) formerly AIM Specialty Health®
  • Replacement and removal of Musculoskeletal Joint and Spine codes reviewed by Carelon
  • Addition of Genetic Testing codes to be reviewed by Carelon
  • Replacement of an Infusion Site of Care drug code reviewed by BCBSTX
  • Addition of Advanced Imaging codes to be reviewed by Carelon

*Watch our provider website for training sessions beginning in May 2023 related to enhancements to Medical Oncology prior authorization submissions to the Carelon Provider Portal.

More Information: 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.

Note: Effective July 1, 2023, the prior authorization list will include a link to the medical policy website for review of the specific medical policies associated with the procedure code rather than listing the medical policy number and title for each code. The list will continue to include information on whether prior authorization for the procedure code is managed by BCBSTX or Carelon.

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 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.

Carelon Health Benefits Management (Carelon) is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.

The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.