CurrentBlue Cross Blue Shield - TexasPolicy N/A

Prior Authorization Services for Other Administrative Services Only (ASO) Members

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.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization Services for Other Administrative Services Only (ASO) Members

Policy CodePolicy N/A

Change TypeTechnical update (no material clinical changes)

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionCheck eligibility and benefits via Availity Essentials and seek clinical review within 48 hours for unplanned inpatient admissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48+service types listed

48 hrsclinical review timeframe

Carelon, Magellan, Alacuravendor partners

MCG, BCBSTX, ASAM, TDIcriteria sources named

Clinical and Screening Criteria

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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

Provider Verification, Authorization, and Admission Actions

Prior Authorization

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.

Prior Authorization

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)

Prior Authorization

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.

Prior Authorization

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).

Prior Authorization

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

Provider Administered Drug Therapy Reviews

DefinitionProvider Administered Drug Therapy Reviews are medical necessity reviews that leverage BCBSTX medical policies plus authoritative references such as package inserts, DrugDex, and NCCN.

Evidence baseReviews rely on medical policies which are based on current peer-reviewed scientific literature, FDA‑approved labeling, and nationally recognized authoritative references (e.g., MCG, DrugDex, NCCN, professional society guidelines, CMS coverage).

Review focusFor drug therapy, the proposed dose, frequency, and duration must be consistent with recommendations in at least one authoritative source to be considered appropriate.

PurposeTo determine medical necessity and ensure requested therapies are proven effective for the relevant diagnosis or procedure according to referenced guidelines and labeling.

Medical policies

DefinitionMedical policies are written guidelines that support current standards of practice and are based on current peer‑reviewed scientific literature.

Role in reviewThey are used to determine whether a requested therapy is proven effective for the relevant diagnosis or procedure and to guide appropriate dosing, frequency, and duration.

Supporting referencesMedical policies are supported by FDA‑approved labeling and nationally recognized authoritative references (e.g., MCG, DrugDex, NCCN, professional society guidelines, CMS coverage).

ApplicationMedical policies inform clinical screening criteria applied during prior authorization and Provider Administered Drug Therapy Reviews.

OpenPayer

Prior Authorization Services for Other Administrative Services Only (ASO) Members

Clinical and Screening Criteria

Codes and Pharmacy Prior Authorization

Provider Verification, Authorization, and Admission Actions

Key Definitions