There are important updates to the Prior Authorization Lists for patients enrolled in Medicare Advantage plans offered by Blue Cross and Blue Shield of Texas (BCBSTX) effective Jan. 1, 2022. These updates are the result of new, replaced or removed codes implemented by the American Medical Association (AMA) .
Use Availity® or your preferred vendor to check eligibility and benefits, to determine if you are in–network for your patient and to determine whether any prior authorization or prenotification is required. Availity allows you to determine if prior authorization is required based on the procedure code. Refer to Eligibility and Benefits under the Claims and Eligibility tab on the BCBSTX provider website for more information on Availity.
The updated Blue Cross Medicare Advantage Prior Authorization Lists are posted on the BCBSTX provider website on the Claims and Eligibility page under Utilization Management (Prior Authorizations and Predeterminations). Next select Quick Link for Prior Authorization Lists for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (PPO)SM. Payment may be denied if you perform procedures without obtaining prior authorization when prior authorization is required. If this happens, you may not bill your patients.
If you need assistance or do not have internet access, please contact your BCBSTX Network Management Representative.
eviCore is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.
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 Blue Cross and Blue Shield of Texas.
BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore or AIM. 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.
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.