Prior Authorization Services for Other Administrative Services Only (ASO) Members
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Defines prior authorization requirements, review processes, and services that require authorization for ASO accounts of Blue Cross Blue Shield of Texas; applies to providers treating ASO members and administrative staff managing authorization workflows.
No material clinical or coverage changes in this revision.
Services and Prior Authorization Criteria
Prior authorization criteria and notes
Services requiring prior authorization (examples and categories):
ALL of the following
- Acute care hospital (hospice, maternity, medical, surgical, transplant)
- Long term acute care / sub-acute
- Skilled nursing facility
- Rehabilitation facility
- Operational note
Inpatient services are a recommended clinical review for certain ASO accounts; seek clinical review within 48 hours of unplanned inpatient admission to avoid post-service adverse determinations (verify via Availity/Utilization Management resources).
ALL of the following
ANY of the following
- Advanced imaging (radiology, cardiology)
- Molecular genetic lab testing
- Musculoskeletal procedures (joint, spine surgery, musculoskeletal pain)
- Radiation therapy / radiation oncology
- Sleep services
ALL of the following
- Cardiology: lipid apheresis
- Gastroenterology
- Ear, nose and throat
- Neurology
- Outpatient surgery (examples: breast, deactivation of headache triggers, jaw)
- Pain management
- Wound care
ALL of the following
- Durable medical equipment (varies by plan design)
- Home health services including home private duty nursing (PDN)
- Home infusion therapy (HIT)
- Home hospice
- Home hemodialysis
- Non-emergent air ambulance
ALL of the following
- Specialty pharmacy medications covered by medical benefits
Infusion site-of-care medical necessity review may be required for therapy and place of infusion; oncology/supportive care drugs require medical necessity review through Carelon when supported by an oncology diagnosis.
- Provider-administered drug therapies (medical benefit) - medical necessity review required for therapy only
- Some pharmacy benefit drugs require prior authorization—check the drug list/guide for ASO members
ALL of the following
- Inpatient and residential treatment center (RTC) admissions
- Outpatient services including Applied Behavioral Analysis (ABA), electroconvulsive therapy (ECT), intensive outpatient treatment (IOP), partial hospitalization
- Psychological testing / neuropsychological testing
- Inpatient behavioral health services are a recommended clinical review for certain ASO accounts
ANY of the following
- Transplant evaluations and transplants require prior authorization
- Out-of-network / out-of-plan services require prior authorization
- Outpatient elective surgery received in an out-of-network hospital or ambulatory surgical center requires prior authorization
ANY of the following
- Downloadable lists of outpatient procedure, mental health, and medication codes that require prior authorization are referenced; specific codes are not included in this document
See provider resources to view or download the procedure and mental health code lists and the Prior Authorization/Step Therapy Program information for pharmacy prior authorization requirements.
ALL of the following
- Prior authorization decisions reference evidence-based guidelines and medical policies including MCG Care Guidelines, DrugDex, NCCN, ASAM, and Texas Department of Insurance standards
- Providers must verify eligibility, benefits, and prior authorization requirements through Availity Essentials and the Utilization Management page on the provider website
- Seek clinical review within 48 hours of unplanned inpatient admission to avoid post-service adverse determinations
Procedure and Pharmacy Coding Notes
| Document notes that a downloadable list of outpatient procedure codes requiring prior authorization for Other ASO members is available; specific codes not provided in this document. |
Authorization Verification, Timelines, and Provider Requirements
Verify authorization and timing via Availity; seek clinical review within 48 hours for unplanned admissions
Verify member eligibility, benefits, and whether prior authorization is required using Availity Essentials and the Utilization Management page on the provider website. For all unplanned inpatient hospital admissions (surgical, non‑surgical, mental health and/or substance use), seek clinical review within 48 hours of admission to avoid post‑service medical necessity reviews that may result in an adverse determination.
- Use Availity Essentials to determine if a service requires prior authorization.
- Refer to the Utilization Management page on the provider website for additional guidance.
- Seek clinical review within 48 hours for all unplanned inpatient hospital care.
Prior authorization required for inpatient admissions and many home/durable services
Obtain prior authorization for inpatient admissions (acute care hospitals including hospice, maternity, medical, surgical, transplant), long‑term acute care/sub‑acute, skilled nursing facility, and rehabilitation facility stays. Prior authorization also applies to many home and durable medical services (e.g., durable medical equipment, home health including PDN, home infusion therapy, home hospice, home hemodialysis). Inpatient services are a recommended clinical review for certain ASO accounts.
- Inpatient settings requiring authorization include acute care hospitals, LTAC/sub‑acute, skilled nursing facilities, and rehabilitation facilities.
- Home services and durable medical equipment may require prior authorization depending on plan design.
- Certain ASO accounts should treat inpatient services as recommended clinical review.
Prior authorization for select outpatient specialty services and specialty pharmacy/infusion therapies
Obtain prior authorization for select outpatient specialty services and for certain pharmacy‑managed services; some of these services are managed through Carelon and others through BCBSTX as indicated. Examples include advanced imaging, molecular genetic testing, musculoskeletal (joint/spine) surgeries, radiation therapy, sleep services, specialty pharmacy medications covered by medical benefits, infusion site‑of‑care reviews, provider‑administered drug therapies, and oncology/supportive care drugs.
- Carelon manages advanced imaging, molecular genetic testing, musculoskeletal surgery, radiation therapy, and sleep services where indicated.
- Specialty pharmacy medications covered by medical benefits and provider‑administered drug therapies require medical necessity review; infusion site‑of‑care may be reviewed.
- Check the Prior Authorization/Step Therapy Program information and drug list guide to determine pharmacy PA requirements for specific medications.
Prior authorization required for out‑of‑network services and transplant evaluations/transplants
Obtain prior authorization for out‑of‑network/out‑of‑plan services, outpatient elective surgery performed in an out‑of‑network hospital or ambulatory surgical center, and for transplant evaluations and transplants.
- Outpatient elective surgery received in an out‑of‑network hospital or ambulatory surgical center requires prior authorization.
- Transplant evaluations and transplants require prior authorization.
- Out‑of‑network or out‑of‑plan services require prior authorization.
Use evidence‑based guidelines and medical policies for clinical review decisions
Prior authorization and clinical review decisions reference evidence‑based guidelines and BCBSTX medical policies; reviewers may use MCG Care Guidelines, DrugDex, NCCN, ASAM criteria, Texas DOI standards, FDA labeling, and other authoritative references for drug and clinical determinations.
- Clinical criteria sources include MCG Care Guidelines, DrugDex, NCCN, and ASAM.
- Texas Department of Insurance standards and FDA‑approved labeling, package inserts, and nationally recognized references are used where applicable.
- Carelon evidence‑based guidelines and BCBSTX medical policies inform reviews; provider‑administered drug therapy reviews may leverage compendia such as NCCN and DrugDex.
Key Terms and Review References
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