Preauthorizations/Notifications/Referral Requirements



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Preauthorizations/Notifications/Referral Requirements are also known as prior authorization, pre-notification, pre-certification or preauthorization. These requirements may indicate that a provider's plan of treatment meets medical necessity review under the applicable health benefit plan.


Eligibility and Benefits Reminder: It is imperative that providers obtain eligibility and benefits first to confirm membership, verify coverage and determine whether preauthorization is required through Availity® or their preferred vendor. Availity allows preauthorization determination by procedure code. Refer to the Blue Cross and Blue Shield of Texas BCBSTX Eligibility and Benefits page for more information on Availity.


2019 Commercial and Retail Plan Services Requiring Preauthorization/Prenotification

(For Government Programs and Employee Retirement of Texas Employees see AdditionalPreauthorizations/Notification/Referral Requirements Lists section below)

  • The following services may require Preauthorization or Prenotification:

ALL INPATIENT CARE

  • Hospital
  • Rehab
  • Skilled Nursing
  • Hospice
  • Long Term Acute Care / Sub-acute

OUT-OF-NETWORK/OUT-OF-PLAN SERVICES

OUTPATIENTSERVICES:

Dialysis

Occupational Therapy

Drug/Alcohol Treatment

Physical Therapy

Durable Medical Equipment

Obstetrical Care

Home Health

Oral and Dental Procedures and Surgery

Home Infusion

Speech Therapy

Hospice

Prosthetics and Orthotics

Mental Health Behavioral Health

Transplant Evaluations

High Tech Diagnostic Radiology Procedures (Some Blue Choice PPOSM plans require RQI through AIM Specialty Health® (AIM) - Contact AIM at 1(800) 859-5299)


Please note: Not all requirements above apply to each BCBSTX product (Blue Choice PPOSM, Blue EssentialsSM, Blue PremierSM or Blue Advantage HMOSM).

  • Additional Outpatient Preauthorization Requirements by Procedure Code
    • Procedures on the list below may require preauthorization or prenotification by either BCBSTX or eviCore Healthcare® effective 1/1/19. This list is not exhaustive. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply. Providers may also check eligibility and benefits through Availity® or their preferred vendor to determine if a preauthorization is required.
    • If your procedure code is listed, providers need to obtain eligibility and benefits and determine who to contact for specific preauthorization requirements through Availity® or their preferred vendor: For more information on checking eligibility, benefits and preauthorization requirements, refer to the BCBSTX Claims and Eligibility page.

    2019 BCBSTX Outpatient Preauthorization Requirements by Procedure Code PDF Document


General Information For Preauthorizations/Notifications/Referrals

Preauthorization General Information PDF Document


How to Request Preauthorization:

Confirm using Availity or your preferred vendor that a preauthorization is necessary and if it needs to be obtained using BCBSTX or eviCore. Once you determine where to obtain the preauthorization for your procedure, use the following information to make your request:

Services requiring preauthorization through BCBSTX:

  • For the convenience of our providers, services preauthorized by as indicated in Availity may be submitted via iExchange®, a web-based automated tool. To learn more, visit iExchange on the provider website..
  • Preauthorization through BCBSTX may also be requested by calling the phone number listed on the member/participant’s ID card.

Services requiring preauthorization through eviCore®:

Services requiring RQI through AIM Specialty Health® (AIM):

  • Contact AIM at 1(800) 859-5299)

For more information regarding Preauthorization requirements, please refer to your BCBSTX participating provider agreement or the provider manual.


Health advocacy solutions and Wellbeing Management:
Our members and employers are looking for partners that can help them effectively manage their health care investment. This means we will be offering products that provide a holistic view of health management and wellness. Health advocacy solutions and Wellbeing Management are innovative product benefits that takes a high-touch, tailored approach to enriching a member’s health care journey and reducing health care costs. Groups that enroll in health advocacy solutions and Wellbeing Management can customize services that require preauthorization or prenotification.


Additional Preauthorizations/Notifications/Referral Requirements Lists

Providers should review the Preauthorizations/Notifications/Referral Requirements Lists below to assist in determining when preauthorization or prenotification is required for:

  • 2018 Services Requiring Preauthorization for Commercial and Retail Plans
  • Medicare Advantage Plans
  • Employee Retirement System of Texas
  • H-E-B Members



(Does not apply to Government Programs or Employee Retirement System of Texas)

Below are lists of newly effective procedure codes, as of Jan. 1, 2018, for the care categories requiring preauthorization as posted Oct. 2, 2017 on the BCBSTX provider website for the plans indicated:

 

2018 Newly Effective Preauthorization Procedure Codes PDF Document for the following plans:

  • Blue Advantage HMO and Blue Advantage Plus HMO - Fully Insured Members
  • Blue Choice PPO - Fully Insured Members
  • Blue Essentials and Blue Essentials Access - Fully Insured Members
  • Blue Premier and Blue Premier Access - Fully Insured Members

2018 Newly Effective Preauthorization Procedure Codes for Premier Health Advocacy Solutions PDF Document for the following plan:

  • Blue Choice PPO With Health Advocacy Solutions Premier Package

2018 Newly Effective Preauthorization Procedure Codes for Primary and Advanced Health Advocacy Solutions PDF Document for the following plans:

  • Blue Choice PPO with Health Advocacy Solutions Primary Package
  • Blue Choice PPO with Health Advocacy Solutions Advanced Package

Refer to the member/participant’s plan below to review the applicable Preauthorizations/Notifications/Referral Requirements List:

Note:

  • Fully Insured member ID cards will indicate "TDI".
  • The back of the member's ID card for Blue Choice PPO Self-Insured with health advocacy solutions (Primary, Advanced or Premier) will indicate: Providers: This is a _______________(Primary, Advanced or Premier) package and/or will indicate Health Advocate phone number