Provider operational requirements and actions regarding prior authorization, documentation submission, and routing for listed CPT/HCPCS codes.
Providers must verify member eligibility and benefits prior to scheduling services; the presence of a code on this list does not guarantee coverage.
Many codes on this list are managed by eviCore Healthcare. When eviCore management is indicated, prior authorization requests and required medical records must be submitted to eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
For Medicare Advantage or other specified plan variations, certain codes may be exempt from prior authorization ("No Prior Auth required") for specific plans and effective dates; providers should confirm plan-specific exceptions and effective dates before submitting.
When medical records or documentation are requested for prior authorization or retrospective review, include the specific items listed for the code (examples below): history and physical, operative report, pre-operative evaluation, plan of care, documentation of conservative measures, transplant evaluation and transplant date (for transplant-related codes), functional status, and a letter of medical necessity when specified.
For durable medical equipment (DME), wheelchair accessories, and complex devices, include a Letter of Medical Necessity that details anticipated duration of use, medical condition, and mobility/functional status when requested.
If a code requires transplant approval on record, submit the transplant approval date; if no transplant approval is on record, submit history and physical, transplant evaluation, and the date of transplant.
Some codes include plan- or state-specific operational notes (for example: "No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21" or "No Prior Auth required for NM Medicare Advantage Plan effective 11/1/18"). Providers must follow those operational exceptions precisely when applicable.
Providers should route prior authorization requests and documentation to eviCore when indicated. If eviCore is not the managing vendor for a member’s plan, route requests per the payer’s standard prior authorization process.
When submitting documentation, ensure all identifying information (member name, ID, date of birth), provider information, and dates of service are included to prevent delays or denials.
Failure to obtain required prior authorization or to supply requested medical records may result in claim denial, payment delay, or additional medical review.
For codes with specific required documents noted (e.g., pre-operative evaluation, operative report, history and physical, plan of care, functional impairment documentation), include those exact documents in the initial submission to avoid requests for additional records.