Blue Cross Medicare Advantage HMO SM and Blue Cross Medicare Advantage PPO SM New Preauthorization Requirements through eviCore effective June 1, 2017
Blue Cross and Blue Shield of Texas (BCBSTX) has contracted with eviCore healthcare (eviCore)*, an independent specialty medical benefits management company to provide Utilization Management services for new preauthorization requirements outlined below.
These new preauthorization requirements apply to the Blue Cross Medicare Advantage HMOSM and Blue Cross Medicare AdvantageSM PPO provider network.
Effective June 1, 2017, eviCore will manage preauthorization for the following specialized clinical services:
• Outpatient Molecular Genetics
• Outpatient Radiation Therapy
° Physical and Occupational Therapy
° Speech Therapy
° Spine Surgery (Outpatient/Inpatient)
° Spine Lumbar Fusion (Outpatient/Inpatient)
° Interventional Pain
• Outpatient Cardiology & Radiology
° Abdomen Imaging
° Cardiac Imaging
° Chest Imaging
° Cardiac Rhythm Implantable Device (Crid)
° Head Imaging
° Neck Imaging
° Obstetrical Ultrasound Imaging
° Oncology Imaging
° Pelvis Imaging
° Peripheral Nerve Disorders (Pnd) Imaging
° Peripheral Vascular Disease (Pvd) Imaging
° Spine Imaging
• Outpatient Medical Oncology
• Outpatient Sleep
• Outpatient Specialty Drug
The Blue Cross Medicare Advantage HMO Preauthorization Requirements List and Blue Cross Medicare Advantage PPO Preauthorization Requirements List have been updated to include the services listed above that require preauthorization through eviCore, for dates of service beginning June 1, 2017. For a detailed list of CPT codes that apply to the above services, please go to Specialty UM Pre-Authorization Program Code Listing . The updated preauthorization lists will be located on the applicable Blue Cross Medicare Advantage HMO Network Participation and Blue Cross Medicare Advantage PPO Network Participation pages.
To obtain preauthorization through eviCore you may use one of the following methods:
• The eviCore HealthCare Web Portal will be available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines,
view authorizations/eligibility and more. The Web Portal is the quickest,
most efficient way to obtain information.
• Texas Providers can call toll-free at 855-252-1117 between 6 a.m. to 6 p.m. (central time) Monday through Friday and 9 a.m. to noon on Saturdays,
Sundays and legal holidays.
BCBSTX and eviCore will be providing additional information, including eviCore website and training opportunities in the future, on the BCBSTX
Provider website and in Blue Review.
Services performed without preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek reimbursement from the member.
For all other services (not listed above), that require a referral and/or preauthorization, providers will continue to use the current telephone and fax numbers as noted on the preauthorization/referral requirements list, including those for iExchange and Availity. iExhange is accessible to physicians, professional providers and facilities contracted with BCBSTX. Go to iExchange to learn more or set up a new account.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.
* 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 BCBSTX.
** Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.