Prior Authorization Requirements for Blue Cross Medicare Advantage (Texas)
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Defines prior authorization and notification requirements for Blue Cross Medicare Advantage members in Texas, including services managed via eviCore and Blue Cross and Blue Shield of Texas; affects network and out-of-network providers and members covered under the Medicare Advantage plans.
No material clinical or coverage changes in this revision.
Coverage and Prior Authorization Criteria
Coverage criteria sets
Coverage and prior authorization requirements vary by service and member contract; many services require prior authorization or referral to the procedure code list/grid. Covered services and exceptions are summarized below.
Services requiring referral to procedure code list or prior authorization
- Allergy care (tests and serum) — refer to prior authorization requirements grid.
- Bariatric surgery — Prior authorization = Yes.
- Blepharoplasty — Prior authorization = Yes.
- Botox injections — Prior authorization = Yes.
- Chemotherapy and radiation therapy — Prior authorization = Yes.
- Dental care — Prior authorization = Yes.
- DME, medical supplies, orthotics and prosthesis — refer to the procedure code list for benefit prior authorization requirements.
- Home health care and intravenous services — refer to the procedure code list for benefit prior authorization requirements.
- Injections — refer to the procedure code list for benefit prior authorization requirements.
- Laboratory, X-ray, EKGs, medical imaging services, and other diagnostic tests — refer to the procedure code list for benefit prior authorization requirements.
- Minor surgeries — refer to the procedure code list for benefit prior authorization requirements.
- Podiatry (foot and ankle) services — refer to the procedure code list for benefit prior authorization requirements.
- PET, MRA, MRI, and CT scans — refer to the procedure code list for benefit prior authorization requirements.
- Special rehabilitation services (physical therapy, occupational therapy, speech therapy, cardiac rehabilitation, pulmonary rehabilitation) — refer to the procedure code list for benefit prior authorization requirements.
- Surgery including assistant surgeon, anesthesiologist, organ transplants — refer to the procedure code list; all transplants and pre‑transplant evaluation require prior authorization.
- Transcranial Magnetic Stimulation — Prior authorization = Yes.
Inpatient admission requirements
- Planned (elective) inpatient hospital admissions — prior authorization is required; authorization must be obtained before admission.
- All inpatient stays (facilities/hospitals) are addressed; stays with services managed by eviCore will be reviewed through the eviCore grid.
Unplanned admissions and notifications
- Unplanned or emergency inpatient admissions — notification is required within one business day.
Network participation and out-of-network providers
- Out‑of‑network providers must seek prior authorization for all services.
Exceptions to out‑of‑network prior authorization
- Emergency services
- Emergency ambulance services
- Stabilization services
- Services provided by Indian Health Services
Routing to eviCore and contact channels
- Certain services (e.g., radiology, molecular genetics, musculoskeletal, sleep, specialty drug programs) are routed to eviCore for prior authorization; use the eviCore portal or specified eviCore contact methods.
- Presence of a code on the procedure code list does not necessarily indicate coverage under the member benefits contract; refer to the comprehensive prior authorization grid for specific code requirements.
Procedure Codes and Authorization Notes
| Procedure code lists referenced for benefit prior authorization requirements (comprehensive prior authorization grid). |
Prior Authorization Entry Points, Network Rules, and Admission Notifications
Prior Authorization Entry Points and Contacts
Prior Authorization Required. Use the eviCore Healthcare Web Portal as the primary entry point to initiate prior authorization cases for Radiology, Molecular Genetics, Musculoskeletal (Spine/Joint/Pain), Sleep, Specialty Drug, and other services managed by eviCore. The portal allows providers to initiate cases, check case status, review clinical guidelines, and view existing authorizations and eligibility. For Sleep services or when portal use is not possible, call eviCore toll-free at 855-252-1117 between 7 a.m. and 7 p.m. local time, Monday through Friday. For Specialty Drug inquiries, eviCore phone support is available Monday–Friday (TX) between 6 a.m. and 6 p.m. Central Time and limited weekend hours; refer to eviCore for exact weekend availability. For Medicare Advantage Medical/Surgical/Behavioral Health prior authorization and predetermination information, contact Blue Cross and Blue Shield of Texas toll-free at 877-774-8592 between 8 a.m. and 8 p.m. Central Time, Monday through Friday except holidays. For a full list of services and program-specific entry points, visit the Blue Cross and Blue Shield of Texas Clinical Resources webpage and select Prior Authorizations and Predeterminations.
- Use eviCore Healthcare Web Portal to initiate and manage authorization cases (preferred method).
- Radiology, Molecular Genetics, Musculoskeletal (Spine/Joint/Pain), Sleep, Specialty Drug and other eviCore-managed services require prior authorization through eviCore.
- Sleep prior authorization by phone: eviCore 855-252-1117, 7 a.m. – 7 p.m. local time, Mon–Fri.
- Specialty Drug phone hours (TX): Mon–Fri 6 a.m. – 6 p.m. CT; limited weekend hours — check eviCore for details.
- Medicare Advantage prior authorization/ predetermination: BCBS Texas 877-774-8592, 8 a.m. – 8 p.m. CT, Mon–Fri (except holidays).
- Visit BCBS Texas Clinical Resources > Prior Authorizations and Predeterminations for full service lists and program details.
Network Participation and Prior Authorization for Out-of-Network Providers
Out-of-network providers must obtain prior authorization for all services except emergency services, emergency ambulance services, stabilization services, and services provided by Indian Health Services. This requirement applies to all lines of business unless a specific program or network adequacy exception is documented.
- Out-of-network providers: prior authorization required for all non-exempt services.
- Exceptions: emergency services, emergency ambulance, stabilization, and Indian Health Services.
Inpatient Admission Prior Authorization and Notification
Prior authorization is required for all planned (elective) inpatient hospital admissions (surgical, non-surgical, behavioral health, and substance abuse). Elective admissions must have authorization completed before the admission occurs. For all unplanned inpatient hospital admissions (surgical, non-surgical, behavioral health, and substance abuse), the facility must notify Blue Cross and Blue Shield of Texas within one business day of the admission. Notification requirements also apply to admissions to skilled nursing facilities, long-term acute care hospitals, rehabilitation facilities, and residential treatment programs; follow payer-specific instructions for authorization or notification as applicable.
- Planned (elective) inpatient admissions require prior authorization before admission.
- Unplanned inpatient admissions: notify the payer within one business day of admission.
- Admissions to SNF, LTACH, rehabilitation, and residential treatment programs require authorization or timely notification per payer instructions.
Definitions and Exceptions
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