Prior Authorization Services for Other Administrative Services Only (ASO) Members
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Texas policy alerts
Know when Blue Cross Blue Shield - Texas releases new policies or updates existing guidance.
Monitor payer policy activity
This policy describes prior authorization processes and services that require prior authorization for Blue Cross Blue Shield of Texas ASO members and guides providers on verification and clinical review processes.
No material clinical or coverage changes in this revision.
Clinical and Screening Criteria
Clinical screening and operational criteria sources
Clinical and operational screening criteria referenced and how they are applied when evaluating prior authorization requests for ASO members.
ALL of the following
- MCG Care Guidelines
Used for medical/surgical and mental health screening
- BCBSTX Medical Policies
Primary source for medical necessity determinations and provider‑administered drug therapy reviews; medical policies reference authoritative sources such as MCG, DrugDex, NCCN and FDA‑approved labeling
- American Society of Addiction Medicine (ASAM) Criteria
Applied for SUD and certain behavioral health determinations (also referenced by Magellan where applicable)
- Texas Department of Insurance standards for reasonable cost control and utilization review for SUD treatment centers
Applied for SUD services provided in Texas
- Carelon Evidence‑based Guidelines (vendor)
Vendor‑specific evidence‑based guidance used for categories managed by Carelon
- Magellan Healthcare Guidelines (vendor)
Vendor guidelines and ASAM criteria used for plans managed by Magellan
- Pharmacy authoritative sources for Provider Administered Drug Therapy Reviews (package inserts, DrugDex, NCCN, etc.)
Medical policies plus these sources are used to determine appropriate dose, frequency, and duration for drug therapies
ALL of the following
- Providers must verify benefit design and prior authorization requirements through Availity Essentials or the appropriate vendor portal
Not all criteria or vendor requirements apply to every product; verify plan design
- Vendor responsibility: Carelon and Magellan may manage prior authorization and apply their evidence‑based guidelines for specific outpatient categories or plan lines
Refer to vendor routing in the policy for advanced imaging, molecular testing, musculoskeletal/radiation therapy and other vendor‑managed categories
ALL of the following
- MCG, BCBSTX medical policies, ASAM, TDI, Carelon and Magellan guidelines are applied as screening and clinical criteria when reviewing requests
- For drug therapies covered under medical benefits, medical policies are supplemented by package inserts, DrugDex, NCCN and similar authoritative references
ALL of the following
- Providers should confirm whether a specific service or code requires prior authorization for the member's plan; downloadable code lists may be available where indicated
Codes and Pharmacy Prior Authorization
| Document notes that specific codes are not available and refers readers to downloadable lists of outpatient procedure and mental health procedure codes that require prior authorization for Other ASO members. |
Provider Verification, Authorization, and Admission Actions
Verification and Clinical Review Timeframe
Providers must verify member eligibility and benefits and check prior authorization requirements via Availity Essentials before delivering services. For all unplanned inpatient admissions (surgical, non‑surgical, mental health, or substance use), request a clinical review within 48 hours of admission to reduce the risk of post‑service medical necessity denials.
- Check eligibility/benefits and prior authorization requirements through Availity Essentials.
- Seek clinical review within 48 hours for all unplanned inpatient admissions.
Services Requiring Prior Authorization (non‑exhaustive)
The following services (non‑exhaustive) require prior authorization for Other Administrative Services Only (ASO) members. Confirm specific plan design and code lists before rendering services.
- Durable Medical Equipment (varies by plan design)
- Home health services including home private duty nursing (PDN) and home infusion therapy (HIT)
- Home hemodialysis
- Home hospice
- Home infusion therapy (HIT)
- Medical transportation (managed through Alacura Medical Transportation Management)
- Non‑emergency fixed‑wing air ambulance
- Transplant evaluations and transplants
- Out‑of‑network/out‑of‑plan services
- Outpatient elective surgery received in an out‑of‑network hospital or ambulatory surgical center
- Dialysis obtained from an out‑of‑network provider
- Chiropractic services (may be reviewed against benefit limits)
- Occupational/Physical/Speech Therapy (may be reviewed against benefit limits)
- Inpatient admissions (acute, LTAC, skilled nursing facility, rehabilitation) and behavioral health/SUD residential or inpatient admissions
- Specialty pharmacy medications and provider‑administered drug therapies requiring medical necessity review
- Select outpatient behavioral health services (e.g., ECT, ABA, IOP, PHP, psychological/neuropsych testing, rTMS)
Vendor‑Specific Outpatient Prior Authorization Responsibilities
Certain outpatient categories are managed by delegated vendors (Carelon Medical Benefits Management) or by BCBSTX directly. Providers must submit prior authorization requests to the indicated vendor/program for the listed outpatient services.
- Carelon-managed outpatient prior authorization categories: Advanced imaging (radiology, cardiology), Molecular genetic laboratory testing, Musculoskeletal services (joint, spine surgery, musculoskeletal pain), Radiation therapy / radiation oncology, Oncology medications and supportive care medical reviews.
- BCBSTX-managed or other indicated programs: Select outpatient services such as sleep services (Carelon noted for sleep), cardiology lipid apheresis, gastroenterology, ENT, neurology, outpatient surgery (e.g., breast procedures, headache trigger deactivation, jaw), pain management, and wound care — confirm the appropriate manager (Carelon vs BCBSTX) for each service.
- Specialty pharmacy and provider‑administered drugs: Infusion site‑of‑care reviews and medical necessity reviews for therapies are required; many oncology drug reviews are routed through Carelon.
Specialty Pharmacy and Provider‑Administered Drug Review Actions
Specialty pharmacy medications covered under medical benefits and provider‑administered therapies require medical necessity review. Infusion site‑of‑care determinations are required for applicable therapies and place‑of‑infusion reviews may be performed. Oncology drugs and supportive care that are consistent with an oncology diagnosis require review (managed through Carelon where indicated).
- Infusion site‑of‑care medical necessity review required for applicable therapies and infusion locations.
- Medical oncology and supportive care drug reviews managed through Carelon when supported by an oncology diagnosis.
- Provider‑administered drug therapies require medical necessity review; confirm routing for review (Carelon or BCBSTX).
Inpatient and Behavioral Health Prior Authorization Expectations
Admission notification and authorization expectations apply to acute care hospitals (including hospice, maternity, medical, surgical, transplant), long‑term acute care/sub‑acute, skilled nursing facilities, and rehabilitation facilities. Behavioral health and substance use disorder inpatient and residential admissions also require notification and, where applicable, prior authorization and clinical review.
- Notify payer and seek clinical review/authorization for acute inpatient hospital admissions (medical, surgical, maternity, transplant, hospice) as indicated by the ASO account.
- Notify and obtain authorization for long‑term acute care, sub‑acute, skilled nursing facility, and rehabilitation admissions when required by the plan.
- Behavioral health and SUD inpatient and residential treatment center admissions require notification and applicable prior authorization/clinical review.
- For certain ASO accounts, inpatient services are a recommended clinical review — confirm account‑specific requirements.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.