Prior Authorization

Sometimes you may need to get approval from Blue Cross and Blue Shield of Texas (BCBSTX) before we will cover certain inpatient, outpatient and home health care services and prescription drugs. This is called prior authorization, preauthorization or prior approval. These terms all refer to the requirements that you may need to meet before treatment may begin.

During this process, BCBSTX reviews the requested service or drug to see if it:

  • is covered by your plan, and
  • meets your health plan’s definition of "medically necessary."

This review does not replace the advice of your provider.


When BCBSTX is contacted with a prior authorization request, we will ask for the following:

  • Your name, subscriber ID number and date of birth
  • Your provider’s name, address and National Provider Identifier (NPI)
  • Information about your medical or behavioral health condition
  • The proposed treatment plan, including any diagnostic or procedure codes (your provider can help you with these)
  • The date you’ll receive service and the estimated length of stay (if you are being admitted)
  • The place you’re being treated
  • Your provider’s name, address and National Provider Identifier (NPI)

Usually, your health care providers will take care of prior authorization before they perform a service. But, it is always a good idea to check if your providers have gotten the needed approval. If your providers are not in network, they will not request prior authorization. You will be responsible for getting this approval. If you do not get this approval via the prior authorization process, the costs may not be covered by BCBSTX.

Effective Jan. 1, 2020, you or your provider can request a renewal of an existing prior authorization up to 60 days before the expiration of the existing prior authorization.

Search for any medical procedure above that you are looking to inquire about.

For example you can search for “Oral Surgery” or “Cardiology”.
You can also search by description such as: “short-term acute care facility” or “Applied behavior analysis”.

Search for any medical drugs above that you are looking to inquire about.

For example you can search for “Treprostinil” or “Ziconotide”.
You can also search by description such as: “Avastin” or “Duopa”.

Search for any behavioral services above that you are looking to inquire about.

For example you can search for “Applied Behavior Analysis (ABA)” or “Outpatient Electroconvulsive Therapy (ECT)”.
You can also search by description such as: “Psychological testing” or “Mental Health Care”.

Do You Need Prior Authorization?

Are you not sure if you require prior authorization? If so, use the search below to find out if you require prior authorization or not.

Your procedure can fall under one of the 3 categories shown below. Click on the appropriate button below to search if your service requires prior authorization.

Medical procedures are procedures such as; surgeries, transplants, imaging and other tests.

Medical drugs are medicines and prescriptions that you may be taking. ex. Avastin, Duopa.

Behavioral services are services such as; Mental Health, Psychological testing and Psychiatric care.

If you wish to see the full list of services and drugs that require prior authorization, then click below to download a copy of the spreadsheet. Except as otherwise noted, these prior authorization requirements are effective on January 1, 2020.

Note: The requested service or treatment must meet your plan's definition of medical necessity to be eligible for benefits under your plan. The prior authorization process is not a substitute for the medical advice of a health care provider. The final decision to receive any medical service or treatment is between you and your health care provider.

If you are unsure which health care services or medications need prior authorization, call the Customer Service number on the back of your BCBSTX member ID card.

How Your Health Care Provider Requests Prior Authorization

As noted above, your health care provider will usually take care of requesting prior authorization. But, this may not happen if your provider is not in network. What’s more, if you visit a doctor or a hospital that is not in network, you may be responsible for the full cost of your care. To make sure your provider is in network, check Provider Finder®

You can also check with BCBSTX to see if your provider has requested prior authorization before you get any services.

When your provider requests prior authorization, he or she may need to work through us or another company. This depends on the type of service requested. BCBSTX contracts with eviCore® healthcare and Magellan Healthcare for certain prior authorization services.

How You Can Request Prior Authorization

If your health care provider has not requested prior authorization for you, you can request it. To do so, call the number on the back of your BCBSTX member ID card. Our Customer Service will help you begin the process.

How You Can Track Your Prior Authorization Status

You can check if a prior authorization has been submitted or approved. Log in to your Blue Access for MembersSM account or call the number on the back of your member ID card. You can also log in to your BAM account to see the benefits your plan covers.

How BCBSTX Responds to All Prior Authorization Requests

We keep track of how many prior authorization requests we receive each year. This includes how many requests we approve and deny. Below, you will find these numbers.

Search for any medical procedure that you are wanting history of.

For example you can search for “Family Practice” or “Oncology”.

Search for any medical drugs that you are wanting history of.

For example you can search for “Treprostinil” or “Ziconotide”.

Search for any behavioral services that you are wanting history of.

For example you can search for “Mental Health” or “Psychologist”.

How BCBSTX Responds to All Prior Authorization Requests

We keep track of how many prior authorization requests we receive each year. This includes how many requests we approve and deny.

If you’d like to see the statistics of prior authorization health data, click on the appropriate button to search below.

Medical health history includes history data of things such as; Surgeries, Transplants, etc.

Medical drugs history includes history data of things such as; Treprostinil, Ziconotide, etc.

Behavioral health history includes history data of things such as; Mental Health, Psychiatric, etc.

Or if you wish to see the full list of history for all prior authorization data, then click below to download a copy for yourself. You can view data for last 3 years.

*To see if you are fully insured, check your member ID card. "TDI" will be printed on your card if you are fully insured. If you do not see "TDI" printed, check your benefit booklet to see your list of services that require prior authorization. If you still have questions, please call the Customer Service number on the back of your BCBSTX member ID card.

eviCore® is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Texas