Update to Prior Authorization Code Changes for Commercial Members Effective April 1, 2024

12/15/2023 Updated 01/08/2024

In addition to the changes effective April 1, 2024 to the Prior Authorization Codes announced on 12/15/2023, the following change is being added:

  • Addition of Gene Therapy codes to be reviewed by BCBSTX for certain member plans

What’s New: BCBCSTX is 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 April 1, 2024 include:

  • Addition of Genetic Testing codes reviewed by Carelon Medical Benefits Management
  • Addition of Infusion Site of Care codes to be reviewed by BCBSTX
  • Addition of Medical Oncology drug codes to be reviewed by Carelon
  • Removal of Medical Oncology drug codes previously reviewed by Carelon
  • Addition of Gene Therapy codes to be reviewed by BCBSTX for certain member plans (Added 01/08/2024)

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 2023 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.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.