Musculoskeletal, Cardiology Expansion and other Prior Authorization Code Changes for Commercial Members, Effective Jan. 1, 2024


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 include:

  • Jan. 1, 2024 – Expansion of the Musculoskeletal Joint & Spine category to include arthroscopy codes to be reviewed by Carelon Medical Benefits Management (Carelon)
  • Jan. 1, 2024 – Expansion of the Cardiology category reviewed by Carelon
  • Jan. 1, 2024 – Addition of Specialty Pharmacy codes to be reviewed by BCBSTX
  • Jan. 1, 2024 – Addition of Medical Oncology drug codes to be reviewed by Carelon
  • Jan. 1, 2024 – Addition of Genetic Testing lab codes to be reviewed by Carelon

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.

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.

CPT copyright 2022 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits 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 of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.

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.

Carelon Medical 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.

BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore or Carelon Medical Benefits Management.